Right Aortic Arch and Kommerell's Diverticulum Repaired without Reconstruction of Aberrant Left Subclavian Artery

Abstract

Right aortic arch with Kommerell's diverticulum is a very rare situation. Surgical treatment is recommended for symptomatic patients or asymptomatic patients with a large diverticulum. However planning the strategy of operation is difficult without a 3D imaging. We report a case of a 57-year-old man with right aortic arch, Kommerell's diverticulum, and aberrant left subclavian artery. After a 3D-CT imaging, the patient underwent descending aortic replacement without reconstruction of aberrant left subclavian artery. After operation, there was no signs or symptoms of ischemia of the left arm. If the reconstruction of the aberrant subclavian artery was too difficult, closing its orifice is an acceptable decision. It has been found advantageous because of a decrease blood loss and a shorter cardiopulmonary bypass duration. If an ischemia of the arm is noticed, additional reconstruction will have to be considered. 3D-CT imaging was very useful to have a proper orientation and plan for the operative strategy.

Figure 1

Enhanced CT showed right aortic arch, Kommerell diverticulum, and aberrant left subclavian artery. There was a 50% stenosis of the orifice of aberrant left subclavian artery (arrows).

Figure 2

3D-CT imaging, scrolling from superficial to deep layer view with chest wall including the ribs, showed the surgical view and the optimal approach through a posterolateral thoracotomy with the fourth intercostal incision.

Figure 3

Postoperative CT revealed enhanced ALSA (arrows) clearly without delay, which was supplied with blood from many branches through very narrow and invisible collateral arteries.