CASE 11430 Published on 03.02.2014

Teaching Case

Section

Cardiovascular

Case Type

Clinical Cases

Authors

ERKOÇ Mustafa Fatih ¹
ÖZTOPRAK Bilge ²
ALKAN Sevil ³
SOYLU Sinan ⁴

¹ Numune Hastanesi, Radyoloji Bölümü, 58040 SİVAS/TURKEY
² Cumhuriyet Üniversitesi Radyoloji ABD 58100 SİVAS/TURKEY
³ Numune Hastanesi, Enfeksiyon Hastalıkları Bölümü, 58040 SİVAS/TURKEY
⁴ Numune Hastanesi, Genel Cerrahi Bölümü, 58040 SİVAS/TURKEY

Patient

68 years, female

Categories

Area of Interest Thorax, Thoracic wall ; Imaging Technique CT ;

Procedure Audit and standards, Computer Applications-3D ; Special Focus Congenital ;

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Clinical History

A 68 years old female admitted to our hospital with mild breathlessness for 3 months. She had no significant previous medical history.

Differential Diagnosis List

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Kommerrell’s diverticulum with right aortic arc with aberrant left sided subclavian artery.

other vascular abnormalities

congenital heart disseases

Imaging Findings

Patient underwent thorax MD-CT with contrast injection. CT revealed the presence of right aortic arch. The descending aorta was found on the right side of the vertebral column until it reached to its expected location at the level of T9 vertebra. The first branch was the brachiocephalic trunk that fed the right subclavian artery and the right common carotid artery. It was followed by left common carotid artery. Left subclavian artery was in aberrant retro-esophageal position, and was slightly compressing the esophagus. In the origin of the left subclavian artery there was a mildly aneurysmatic dilatation, the so-called Kommerrell’s diverticulum. There was no lesion in the intra-abdominal organs and the patient did not complain of any symptoms such as dysphagia.

Discussion

The right-sided aortic arch is the result of an abnormal organogenesis of primitive aortic arch and its incidence is approximately 0.1% in all population [1]. In half of the cases the left subclavian artery is also aberrant [2, 3]. These anomalies may be isolated or occur in combination with congenital heart defects [4]. Several classifications have been proposed for these anomalies [5-9], but nowadays it is not important to name the lesion according to any of them, on the basis of surgical treatment. The left subclavian artery is the fourth branch arising from the proximal descending aorta via a remnant of the embryological left dorsal aortic root. Often there is a bulbous origin, the diverticulum of Kommerrell. The earliest description of abnormal subclavian artery belongs to David Bayford in the 17th century [10], however it passed into history with the name of Kommerrell after his article published in 1936 [11]. In some cases by the extrinsic compression of the posterior esophagus or trachea, it may present as dysphagia or dyspnea but generally it is asymptomatic which leads to an incidental diagnosis. In the childhood period it mimics bronchial asthma due to its compression to the trachea [12], but in adolescents, dyspnea is the primary complaint because of the rigidity of the trachea [12]. In symptomatic cases, the treatment is surgery.

References

[1] Drnovsek V, Weber ED, Snow RD (1996) Stenotic origin of an aberrant left subclavian artery from a right-sided aortic arch: a case report. Angiology 47:523-9. (PMID: 8644951)

[2] Minato N, Rikitake K, Murayama J, Ohnishi H, Takarabe K (1999) Surgery of the dissecting aneurysm involving a right aortic arch. J Cardiovasc Surg 40:121-5. (PMID: 10221398)

[3] Shuford WH, Sybers RG, Gordon IJ, Baron MG, Carson GC (1986) Circumflex retroesophageal right aortic arch simulating mediastinal tumor or dissecting aneurysm. AJR 1986 146:491 (PMID: 3484865)

[4] Felson B, Palayew MJ (1963) The two types of right aortic arch. Radiology 81:745. (PMID: 14073842)

[5] Stewart JR, Kincaid OW, Edwards JE (1964) An atlas of vascular rings and related malformation of the aortic arch system. Springfield, Ill: Charles C Thomas; 1964 p 3-17;80-129.

[6] Mahoney EB, Manning JA. (1964) Congenital abnormalities of the aortic arch. Surgery 55:1. (PMID: 14114264)

[7] Haughton VM, Fellows KE, Rosenbaum AE (1975) The cervical aortic arches. Radiology 114:675-81. (PMID: 1118572)

[8] Knight L, Edwards JE (1974) Types and associates cardiac anomalies. Circulation 50:1047-51. (PMID: 4430090)

[9] Fu M, Hung JS, Liao PK, Chang CH (1987) Isolated right-sided patent ductus arteriosus in right-sided aortic arch: report of two cases. Chest 91:623-5 (PMID: 3829757)

[10] Bayford D (1794) An account of a singular case of obstructed deglutition. Memoirs Med Soc London 2:275-86

[11] Kommerell B (1936) Verlagerung des Ösophagus durch eine abnorm verlaufende Arteria subclavia dextra (Arteria lusoria). Fortschr Geb Roentgenstrahlen 54:590-5.

[12] Morel V et all (2002) Two cases of \'asthma\' revealing a diverticulum of Kommerell. Respiration 69(5):456-60 (PMID: 12232456)

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