Repair of right aortic arch with aberrant left subclavian artery and left ligamentum arteriosum

A case of right aortic arch with an aberrant left subclavian artery arising from a Kommerell's diverticulum of the descending thoracic aorta with a left ligamentum arteriosum completing a vascular ring about the trachea and esophagus is presented. A posterolateral left thoracotomy alone is sufficient to provide an excellent exposure for the division of the ligamentum arteriosum and the resection of the Kommerell's diverticulum. Furthermore, the development of a subclavian steal syndrome is prevented by the reimplantation of the divided left subclavian artery into the left common carotid artery through this same incision.     

Surgical repair of right aortic arch with aberrant left subclavian artery and left ligamentum arteriosum

Five cases of right aortic arch with aberrant left subclavian artery and left ligamentum arteriosum, with or without Kommerell's diverticulum, are presented. Either right or left thoracotomy with divesion of the aberrant retroesophageal left subclavian artery can be accomplished with good results. However, a right thoracotomy is recommended in the presence of a large Kommerell diverticulum because such a diverticulum should be excised. The development of a subclavian steal syndrome later in life may be prevented by reimplantation of the divided left subclavian artery into the aorta or the left common carotid artery.     

Asymptomatic pseudo-aneurysm of the aortic arch in a patient with aberrant right subclavian artery. A complication of Kommerell's diverticulum?

Kommerell's diverticulum is an aortic arch deformity associated with an aberrant subclavian artery. Symptoms related to compression of adjacent structures, dilatation of the aortic diverticulum or accelerated atherosclerosis leading to increased risks of dissection and rupture represent the indications for surgical treatment. Several surgical strategies have been used for the management of this congenital abnormality. We present the case of a 56-year-old male with a pseudo-aneurysm of a left aortic arch adjacent to a Kommerell's diverticulum at the orifice of a left subclavian artery. The patient also presented an aberrant right subclavian artery originating from the posterior wall of the ecstatic take-off of the left subclavian artery. Our surgical strategy was limited to the resection of the aneurysm without any manipulation of the aortic diverticulum and aberrant right subclavian artery, as the wall of both aorta adjacent to the saccular aneurysm and left subclavian artery was normal, the Kommerell's diverticulum was small and the patient was asymptomatic.     

Diverticula in association with the proximal left subclavian artery: a cause of mediastinal mass lesions.

The case reports of 5 patients with an aortic arch diverticulum associated with the proximal left subclavian artery are presented. In 3 patients, the left subclavian artery arose from a diverticulum off a right aortic arch and traversed the retroesophageal area to the opposite arm. In 1 patient, the left subclavian artery arose from a diverticulum off a left aortic arch; this represents the second instance of this anomaly to be reported in the literature. In 1 patient, the left subclavian artery was not attached to the aorta, and a diverticulum was present in the expected area of attachment. Confusion of these anomalies with solid mediastinal mass lesions and with aortic aneurysms may occur. Treatment is predicted on symptomatology, and resection is usually not indicated. It is necessary to remain cognizant of aortic diverticula and to differentiate them from other mediastinal mass lesions.     

Trends in vascular ring surgery

OBJECTIVE: We sought to review our experience with infants and children with anatomically complete vascular rings (ie, double aortic arch and right aortic arch with left ligamentum) and define perioperative trends in diagnostic imaging, operative techniques, and clinical outcomes. METHODS: From 1946 through 2003, 209 patients (113 with double aortic arch and 96 with right aortic arch) underwent surgical repair. Mean and median ages at the time of the operation were as follows: double aortic arch, 1.4 +/- 2.4 years and 0.75 years, respectively; right aortic arch, 2.7 +/- 3.9 years and 0.9 years, respectively. Fourteen (14.6%) patients with right aortic arch had an associated Kommerell diverticulum. Cardiac diagnoses were present in 26 (12.4%) of 209 patients. RESULTS: There has been no operative mortality since 1959. In the past 30 years, mean hospital stay decreased from 8 to 3 days. Primary means of diagnosis has shifted from barium swallow and angiography to computed tomographic scanning or magnetic resonance imaging. In the past 10 years, 73% of patients had preoperative or intraoperative bronchoscopy. The technique of operation has shifted to a muscle-sparing left thoracotomy without routine chest drainage. In 7 recent patients with right aortic arch and a Kommerell diverticulum, the diverticulum was resected, and the left subclavian artery was transferred to the left carotid artery as a primary procedure. CONCLUSIONS: At our institution, computed tomographic scanning has replaced barium swallow as the diagnostic procedure of choice for vascular ring evaluation. We recommend both preoperative bronchoscopy and echocardiography. Use of a muscle-sparing thoracotomy without routine chest drainage has decreased mean hospital stay. For patients with a right aortic arch and associated Kommerell diverticulum, we recommend diverticulum resection with left subclavian artery transfer to the left carotid artery.     

Surgical repair for aortic dissection accompanying a right-sided aortic arch

Aortic anomaly in which a right-sided aortic arch associated with Kommerell's diverticulum and aberrant left subclavian artery is rare. The present report describes a patient with type-B aortic dissection accompanying aortic anomalies consisting of right-sided aortic arch and the left common carotid and left subclavian artery arising from Kommerell's diverticulum. As dissecting aortic aneurysm diameter increased rapidly, Single-stage surgical repair of extensive thoracic aorta was performed through median sternotomy and right posterolateral fifth intercostal thoracotomy, yielding favorable results. Our surgical procedures are discussed.     

Intermediate to late results of surgical relief of vascular tracheobronchial compression.

Since 1979, a total of 69 infants and children aged 0.1 to 11.9 (median 0.7) years required surgical intervention for: double aortic arch (26), anomalous origin of innominate artery (26), right aortic arch with left ligamentum arteriosum (9), pulmonary artery sling (5), retroesophageal right subclavian artery (3). Before operation, the morbidity was high: 84% of children were symptomatic in the first trimester of life with 24 patients requiring mechanical ventilation. Seven children had an accompanying heart defect. Left thoracotomy was the preferred approach. There were 2 early (asphyxic brain damage, postoperative pneumonia) and 2 late (tracheomalacia, complex heart defect) deaths. Five patients (2 originally operated elsewhere) needed reoperation for persistent symptoms. All 65 survivors are well 1 month to 11.9 (mean 3.9 +/- 3.62) years after surgery. Tracheobronchoscopy, magnetic resonance imaging, and lung function testing were helpful for postoperative evaluation. Minor tracheal compression was revealed in 4 patients despite their good clinical condition.     

Surgical treatment of an aneurysm in the right aortic arch with aberrant left subclavian artery

A saccular aneurysm in the right-sided aortic arch with aberrant left subclavian artery is an uncommon disease, and surgical treatment is complicated. Three patients with Edwards type III-B right aortic arch and enlargement of the Kommerell's diverticulum underwent operations. Right thoracotomy was the preferred approach for this lesion and partial cardiopulmonary bypass is a safe and simple procedure when the aortic arch has mild atherosclerosis.     

Robotic division of an unusual variant of a right aortic arch

Anomalies of the right aortic arch are rare. Right aortic arch with remnants of various components of the left aortic arch and ductus can create a vascular ring resulting in obstruction of the aerodigestive tracts. This case report describes the rare form of retroesophageal left innominate artery with ligamentum between the base of the subclavian artery to the pulmonary artery, and the first time management by the novel robotic approach.     

Retroesophageal Subclavian Artery Aneurysm Arising from Kommerell's Diverticulum

This report describes a novel technique used for management of retroesophageal subclavian artery aneurysm arising from Kommerell's diverticulum. The procedure consists of endoaortic exclusion of the aneurysmal neck, using a prosthetic patch after sternotomy during circulatory arrest, and antegrade cold blood cerebroplegia. The advantages of this technique are avoidance of hemorrhagic complications during clamping of the aneurysmal neck, limiting of the extent of dissection of the aortic arch, and elimination of the risk of inadvertent left recurrent nerve paralysis. Antegrade cold blood cerebroplegia provides good cerebral protection and decreases the duration and consequences of extracorporeal circulation.     

Surgical treatment of vascular ring including right cervical aortic arch

Cervical aortic arch is a developmental entity consisting of persistence of the right or left third branchial arch and regression of the fourth branchial arches. In most cases, the aorta is redundant and crosses behind the esophagus to the opposite side. In the presence of an aberrant subclavian artery contralateral to the side of the aortic arch and a ligamentum arteriosum, a vascular ring is formed around the trachea and esophagus. Two young patients with right-sided cervical aortic arch, aberrant left subclavian artery, and ligamentum arteriosum presented with dysphagia and exertional dyspnea. In one patient, through a left thoracotomy, the ligamentum arteriosum was divided, and the trachea and esophagus were dissected thoroughly above and below the level of the ring. In addition, the aberrant left subclavian artery was divided at its origin from a large diverticulum and implanted into the left common carotid artery; the aortic diverticulum was resected. In the other patient, who had associated 22q11 chromosomal deletion, in addition to left-sided compression of the trachea and esophagus, there was additional marked compression of the right anterolateral trachea by the redundant ascending aorta. Through a median sternotomy, the ligamentum arteriosum was divided, and the trachea and esophagus were widely mobilized; an additional aortopexy of the ascending aorta to the right of the sternum resulted in the absence of tracheal compression. The cases of the two reported patients illustrate the clinical variability of vascular ring, including a right cervical aortic arch and the consequently versatile surgical approach that is needed to successfully address this combination of vascular anomalies.     

Right aortic arch with isolation of the left subclavian artery. A case report

A 58 year old man was admitted to evaluate his swallowing disturbance. Preoperative aortogram demonstrated right aortic arch with isolation of left subclavian artery. Operative findings revealed the absent blood flow through the proximal portion of left subclavian artery which connected to the left pulmonary artery. Abnormal connection was divided and Kommerell's diverticulum was mobilized from the esophagus. His clinical symptom was slightly reduced postoperatively.     

Primary complete repair of partial double aortic arch and Kommerell diverticulum

Tracheal and esophageal stenosis caused by double aortic arch and Kommerell diverticulum is a rare but important pathologic entity in adult patients. Clinical symptoms are caused by esophageal or tracheal stenosis, or both. The present article describes a surgical method of complete repair with division of the rudimentary left arch, resection of the diverticulum, and transposition of the left subclavian artery. This method was transferred from pediatric patients and led to excellent clinical results in 2 consecutive adult patients compared with the previous technique with division of the left arch alone.     

Three-dimensional magnetic resonance imaging of Kommerell diverticulum in a child with recurrent dysphagia

We report a case of a 3-year-old girl with a history of recurrent dysphagia and feeding difficulties. After chest x-ray and esophagogram examination, magnetic resonance imaging revealed the presence of a right-sided aortic arch with an aberrant retroesophageal left subclavian artery arising from a Kommerell diverticulum.     

A double aortic arch mimicking a right aortic arch with an aberrant subclavian artery

A 4-month-old boy was referred for persistent respiratory symptoms despite having undergone division of the ligamentum arteriosus for the diagnosis of a right aortic arch with an aberrant left subclavian artery. A computed tomography scan demonstrated symmetric arch vessels around the trachea at the thoracic inlet, with the left common carotid artery being tethered posteriorly, more suggestive of a double aortic arch with an atretic left arch between the left common carotid and subclavian arteries. This diagnosis was confirmed intraoperatively, and division of the atretic portion released the bronchial obstruction. This case highlights the importance of careful evaluation of the vascular anatomy.     

Repair of Kommerell's diverticulum with aberrant left subclavian artery in an elderly patient with right aortic arch and dysphagia lusoria

A 60-year-old femalepresented with progressive dysphagia and was found to have a right-sided aortic arch with external posterior compression of the upper esophagus due to severe compression from a Kommerell's diverticulum with an aberrant left subclavian artery. This patient underwent division of the diverticulum with an aorto-subclavian graft implantation under femoro-femoral bypass and recovered uneventfully. A review of the literature and discussion of the surgical management is presented.     

Hybrid Repair of a Kommerell's Diverticulum Aneurysm

Abstract   Aneurysms of the right aortic arch with an aberrant left subclavian artery are rare. We report the case of a 77-year-old woman with a Kommerell's diverticulum aneurysm, who underwent a successful hybrid repair, combining surgical off-pump bypass of the aortic arch vessels followed by endovascular aneurysm repair. (J Card Surg 2010;25:67-69)     

Surgical treatment of persistent esophageal compression by an unusual form of right aortic arch

A 32-year-old woman with dysphagia due to an unusual form of right aortic arch and anomalous left subclavian artery had successful repair after two previous failures. The definitive repair was accomplished by resection of the retroesophageal portion of the right aortic arch. The continuity of the aorta was established with a prosthetic graft. The operation was performed through a median sternotomy with cardiopulmonary bypass and circulatory arrest.     

Simultaneous surgery for left lung cancer and the aneurysm of an aberrant left subclavian artery in a patient with right aortic arch

A 69-year-old man with right aortic arch was diagnosed as having left lung cancer (cT2aN1M0, cStage IIA) and an aneurysm of an aberrant left subclavian artery. The aneurysm measured 36 mm in diameter and was located 1 cm peripheral from the origin in the area known as "Kommerell's diverticulu Left carotid artery-to-left subclavian artery bypass graft was placed through a left supraclavicular incision prior to thoracotomy. This bypass graft effectively prevented neurological and ischemic complications of the brain and left upper extremity while we safely and successfully performed resection of the aneurysm along with radical surgery for left lung cancer through left thoracotomy. There have been only 10 case reports, including the present case, that have described surgical resection of lung cancer in a patient with right aortic arch. In addition, this is the 1st report to describe simultaneous surgery for both left lung cancer and an aneurysm of an aberrant left subclavian artery in a patient with right aortic arch.