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

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. 1. Introduction Right aortic arch with Kommerell’s diverticulum (KD) is a very rare situation. Most patients with KD are asymptomatic; however the most serious issue in the course of aneurysm is its marked propensity towards rupture and dissection [1, 2]. As per earlier reports, all the patients who presented with rupture has died [1]. Therefore the surgical treatment of KD is indicated, before KD will rupture. However it is difficult to image and make a strategy of operation. So, we report the operating procedure and the evaluation method of KD using several views of 3D-CT imaging. 2. Case Presentation A 57-year-old man had abnormal X-ray findings during routine medical checkup and an enhanced computed tomography (CT) showed right aortic arch, Kommerell diverticulum (KD), and aberrant left subclavian artery (ALSA). The maximum diameter of KD was 38？mm, and the aneurysm of aorta was 63？mm (Figure 1). CT revealed a 50% stenosis of the orifice of ALSA. Cerebral magnetic resonance imaging angiography showed hypoplasty of left vertebral artery. Operation was indicated because the diameter was critical, despite the fact that the patient had no symptoms due to KD. 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). After consideration of using 3D-CT imaging with the ribs (Figure 2), it was decided to go for a posterolateral thoracotomy approach through a fourth inters costal incision. Figure 2: 3D-CT imaging, scrolling