Diverticula of Kommerell and Aberrant Subclavian Arteries Complicated by Aneurysms

Abstract

This is a retrospective evaluation of the incidence of aberrant subclavian arteries (ASAs) and diverticula of Kommerell, as well as the occurrence and significance of associated aneurysms. Thoracic aortograms obtained during a 12.5-year period were reviewed, seeking the presence of aberrant right and left subclavian arteries (ARSAs/ALSAs), diverticula of Kommerell, and the incidence of associated aortic aneurysms. Several cases were evaluated with computed tomography concomitantly. Results were correlated with a literature review. Twenty-two ASAs were identified. Nineteen were on the right (ARSAs) and three were on the left (ALSAs). A diverticulum of Kommerell (DOK) was also present on the right in seven and on the left in three. Five of these patients had complicating aneurysms. Four of these were associated with ARSAs and their diverticula. Two were atherosclerotic; one was a limited dissection and one of uncertain etiology was ruptured. One additional aneurysm (atherosclerotic) involved an ALSA/DOK. The patient with the ruptured aneurysm died in surgery; three were managed conservatively because of concomitant disease; and one is being followed because of the small size (2.5 cm) of the aneurysm. ARSAs are relatively uncommon and ALSAs are rare. Both ARSA and ALSA are frequently associated with a DOK. Aneurysms rarely involve ASAs (with or without a DOK), but they are associated with a high mortality rate if they are not discovered before rupture. Early diagnosis plus surgical and/or endovascular management can be lifesaving.

Kommerell's diverticulum: A rare aortic arch anomaly

“…The symptoms most commonly present after the age of forty years when the aortic wall becomes atherosclerotic and rigid and include dysphagia (dysphagia lusoria), cough, noisy breathing, chest pain, and lower respiratory tract infection. The complications include rupture of the aneurysm with mediastinal hemorrhage, which could prove fatal, 8 recurrent pneumonias, obstructive emphysema, or aortic dissection. 9 Various congenital cardiac anomalies are seen to be associated with aortic arch anomalies, and these include Tetralogy of Fallot, pulmonary stenosis, tricuspid atresia, and truncus arteriosus.…”

Multidetector computed tomographic angiography of aberrant subclavian arteries

“…11 Early diagnosis and elective surgical management of these aneurysms seems necessary because of the high mortality rate associated with rupture. 9 Generally, an aberrant subclavian artery is an isolated anomaly, but may be associated with other cardiovascular anomalies. An ARSA is associated principally with coarctation of the aorta, patent ductus arteriosus and intracardiac defects.…”

“…1 Kommerell's diverticulum can compress the trachea or oesophagus either directly, by aneurysmal dilatation, or age-related atherosclerotic changes. 9 Rarely, with failure in regression of the right ductus, a loose vascular ring may be formed by the left aortic arch with an ARSA, right pulmonary artery and right ductus arteriosus. A complete vascular ring is formed by the right arch with an ALSA, left pulmonary artery, and left ductus arteriosus.…”

Cardiovascular dysphagia — anatomical and clinical implications

“…It commonly occurs in cases of left aortic arch with ARSA (0.5-2.0%) [39], or RAA with ALSA (0.05-0.1%) [98]. In a cohort of 22 patients with ARSA, Kommerell's diverticulum was present in 37% of the cases [38]. Diverticulum at the origin of the ARSA is a remainder of the primitive right dorsal aorta.…”