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Right aortic arch with left subclavian artery arising from Kommerell's diverticulum
European Journal of Radiology Extra 60 (2006) 109–111
Right aortic arch with left subclavian artery arising from Kommerell’s diverticulum Ersin Ozturk ∗ , Bulent Karaman, Guner Sonmez, Huseyin Onur Sildiroglu, Hakan Mutlu, Murat Velioglu GATA Haydarpasa Teaching Hospital, Department of Radiology, Uskudar, Istanbul, Turkey Received 24 July 2006; received in revised form 14 September 2006; accepted 15 September 2006
Abstract We report CT and MR angiographic findings of a patient having right-sided aortic arch with retroesophageal left subclavian artery arising from Kommerell’s diverticulum. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Right aortic arch; Kommerell’s diverticulum; Aberrant left subclavian artery; Magnetic resonance angiography; Computed tomography
1. Introduction Numerous possible anomalies of aortic arch may occur depending upon the site of involution of the embryonic aortic arches. They result from the abnormal or incomplete regression of one of the six embryonic branchial arches. Arch anomalies that produce a vascular ring can produce symptomatic obstruction of the trachea and esophagus [1]. Thoracic aortography, computed tomography (CT), or magnetic resonance (MR) imaging are used to diagnose such aortic arch anomalies. In this report, we present MR angiographic findings of a man having right-sided aortic arch with retroesophageal left subclavian artery arising from Kommerell’s diverticulum.
right aortic arch with an aberrant left subclavian artery arising from the diverticulum of Kommerell, and both trachea and esophagus were compressed by this vascular ring (Fig. 1A and B). MR angiography was performed to assess the vascular anatomy. At MR angiography the left common carotid artery (LCCA) was shown to arise from the ascending aorta as a first branch followed by the right common carotid artery (RCCA), then the right subclavian artery (RSA) and finally the left subclavian artery (LSA) as the last branch. We demonstrated that this last branch was arising from Kommerell’s diverticulum and continuous at retroesophageal space (Fig. 2A–C). We offered echocardiography but that was normal. We suggested a further angiographic examination to detect probable accompanying cardiac anomalies but this was not accepted by the patient.
2. Case report 3. Discussion A 52-year-old man was referred to our hospital with a 1-year history of disphagia. A PA chest radiograph revealed widening of the upper mediastinum and the right-sided aortic arch. A CT of the thorax was performed. CT scans showed the ∗ Corresponding author. Tel.: +90 212 2797578 (R)/5422879 (O); fax: +90 212 5422808. E-mail address: [email protected] (E. Ozturk).
1571-4675/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2006.09.009
In our case, the first radiologic abnormality was widening of upper mediastinum and the right-sided aortic arch. To exclude different diagnosois for mediastinal widening and to demonstrate the associated vascular abnormalities we performed non-invasive diagnostic procedures as CT and MR angiography. At our examination we decided that our case has right-sided aortic arch with retroesophageal left subclavian
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E. Ozturk et al. / European Journal of Radiology Extra 60 (2006) 109–111
Fig. 1. (A and B) Contrast-enhanced CT scans showing retroesophageal left subclavian artery arising from Kommerell’s diverticulum (arrows).
artery arising from Kommerell’s diverticulum. Major artery anomalies of the thorax have been previously classified into five main groups as: (1) double aortic arch (2) right aortic arch with a left ligamentum arteriosum or persistent ductus arteriosus, (3) aberrant subclavian artery, (4) aberrant left pulmonary artery and (5) abnormalities placed innominate artery [1]. Any of these anomalies may present with tracheal and/or esophageal compression. Thus, symptoms and signs include stridor, respiratory infections and dyspagia [2]. A right-sided arch does not necessarily cause symptoms, but arch anomalies that produce a vascular ring can produce symptomatic obstruction of the trachea and esophagus [1]. Dysphagia was caused by diverticulum of Kommerell in our patient. Aberrant LSA with right aortic arch is the most common type of the right-sided aortic arch. This was the result of interruption of the left fourth aortic arch between the LCCA
and LSA. From the right aortic arch, LCCA arises as a first branch, followed by RCCA, RSA, LSA and LSA courses posterior to esophagus to reach the left arm. Posterior esophageal compression may occur and be responsible for dysphagia. The descending aorta may lie on each side of the spine (more commonly right sided). The remnant of the left dorsal aortic root may appear as a diverticulum (Kommerell) at the origin of the LSA [3]. In our case, the branching of thoracic aorta is similar to right-sided aortic arch with aberrant LSA (LCCA, RCCA, RSA and LSA, respectively). However, our aortic arch was high positioned and our LSA was arising from Kommerell’s diverticulum. There was a case also reported in literature as symptomatic stenotic origin of LSA [4]. MR angiographic findings of right-sided aortic arch with retroesophageal left subclavian artery arising from Kommerell’s diverticulum is scarcely reported. We emphasize that
Fig. 2. (A–C) Contrast-enhanced MRA images of the thorax; coronal slice from the raw data (A) and maximal intensity projection (MIP) images (B and C) demonstrating right aortic arch with aberrant left subclavian artery arising from the diverticulum of Kommerell as the last branch (arrows). Branching abnormality of the aortic arch can also be seen.
E. Ozturk et al. / European Journal of Radiology Extra 60 (2006) 109–111
these anomalies should be kept in mind by vascular surgeons and interventionists. References [1] Lincoln JC, Deverall PB, Stark J, Aberdeen E, Waterston DJ. Vascular anomalies compressing the esophagus and tracea. Thorax 1969;24:295–306.
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[2] Yap J, Haywrad PA, Lincoln C. Right aortic arch aberrant subclavian arteries: a cause of esophageal compression. Ann Thorac Surg 1999;68:2331–2. [3] Cina CS, Arena GO, Bruin G, Clase CM. Kommerll’s diverticulum and aneurysmal right-sided aortic arch: a case report and review of the literature. J Vasc Surg 2000;32:1208–14. [4] Drowsek V, Weber ED, Snow RD. Stenotic origin of an aberrant left subclavian artery from a right sided aortic arch: a case report. Angiology 1996;47:523–9.
Right aortic arch with left subclavian artery arising from Kommerell’s diverticulum Ersin Ozturk ∗ , Bulent Karaman, Guner Sonmez, Huseyin Onur Sildiroglu, Hakan Mutlu, Murat Velioglu GATA Haydarpasa Teaching Hospital, Department of Radiology, Uskudar, Istanbul, Turkey Received 24 July 2006; received in revised form 14 September 2006; accepted 15 September 2006
Abstract We report CT and MR angiographic findings of a patient having right-sided aortic arch with retroesophageal left subclavian artery arising from Kommerell’s diverticulum. © 2006 Elsevier Ireland Ltd. All rights reserved. Keywords: Right aortic arch; Kommerell’s diverticulum; Aberrant left subclavian artery; Magnetic resonance angiography; Computed tomography
1. Introduction Numerous possible anomalies of aortic arch may occur depending upon the site of involution of the embryonic aortic arches. They result from the abnormal or incomplete regression of one of the six embryonic branchial arches. Arch anomalies that produce a vascular ring can produce symptomatic obstruction of the trachea and esophagus [1]. Thoracic aortography, computed tomography (CT), or magnetic resonance (MR) imaging are used to diagnose such aortic arch anomalies. In this report, we present MR angiographic findings of a man having right-sided aortic arch with retroesophageal left subclavian artery arising from Kommerell’s diverticulum.
right aortic arch with an aberrant left subclavian artery arising from the diverticulum of Kommerell, and both trachea and esophagus were compressed by this vascular ring (Fig. 1A and B). MR angiography was performed to assess the vascular anatomy. At MR angiography the left common carotid artery (LCCA) was shown to arise from the ascending aorta as a first branch followed by the right common carotid artery (RCCA), then the right subclavian artery (RSA) and finally the left subclavian artery (LSA) as the last branch. We demonstrated that this last branch was arising from Kommerell’s diverticulum and continuous at retroesophageal space (Fig. 2A–C). We offered echocardiography but that was normal. We suggested a further angiographic examination to detect probable accompanying cardiac anomalies but this was not accepted by the patient.
2. Case report 3. Discussion A 52-year-old man was referred to our hospital with a 1-year history of disphagia. A PA chest radiograph revealed widening of the upper mediastinum and the right-sided aortic arch. A CT of the thorax was performed. CT scans showed the ∗ Corresponding author. Tel.: +90 212 2797578 (R)/5422879 (O); fax: +90 212 5422808. E-mail address: [email protected] (E. Ozturk).
1571-4675/$ – see front matter © 2006 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ejrex.2006.09.009
In our case, the first radiologic abnormality was widening of upper mediastinum and the right-sided aortic arch. To exclude different diagnosois for mediastinal widening and to demonstrate the associated vascular abnormalities we performed non-invasive diagnostic procedures as CT and MR angiography. At our examination we decided that our case has right-sided aortic arch with retroesophageal left subclavian
110
E. Ozturk et al. / European Journal of Radiology Extra 60 (2006) 109–111
Fig. 1. (A and B) Contrast-enhanced CT scans showing retroesophageal left subclavian artery arising from Kommerell’s diverticulum (arrows).
artery arising from Kommerell’s diverticulum. Major artery anomalies of the thorax have been previously classified into five main groups as: (1) double aortic arch (2) right aortic arch with a left ligamentum arteriosum or persistent ductus arteriosus, (3) aberrant subclavian artery, (4) aberrant left pulmonary artery and (5) abnormalities placed innominate artery [1]. Any of these anomalies may present with tracheal and/or esophageal compression. Thus, symptoms and signs include stridor, respiratory infections and dyspagia [2]. A right-sided arch does not necessarily cause symptoms, but arch anomalies that produce a vascular ring can produce symptomatic obstruction of the trachea and esophagus [1]. Dysphagia was caused by diverticulum of Kommerell in our patient. Aberrant LSA with right aortic arch is the most common type of the right-sided aortic arch. This was the result of interruption of the left fourth aortic arch between the LCCA
and LSA. From the right aortic arch, LCCA arises as a first branch, followed by RCCA, RSA, LSA and LSA courses posterior to esophagus to reach the left arm. Posterior esophageal compression may occur and be responsible for dysphagia. The descending aorta may lie on each side of the spine (more commonly right sided). The remnant of the left dorsal aortic root may appear as a diverticulum (Kommerell) at the origin of the LSA [3]. In our case, the branching of thoracic aorta is similar to right-sided aortic arch with aberrant LSA (LCCA, RCCA, RSA and LSA, respectively). However, our aortic arch was high positioned and our LSA was arising from Kommerell’s diverticulum. There was a case also reported in literature as symptomatic stenotic origin of LSA [4]. MR angiographic findings of right-sided aortic arch with retroesophageal left subclavian artery arising from Kommerell’s diverticulum is scarcely reported. We emphasize that
Fig. 2. (A–C) Contrast-enhanced MRA images of the thorax; coronal slice from the raw data (A) and maximal intensity projection (MIP) images (B and C) demonstrating right aortic arch with aberrant left subclavian artery arising from the diverticulum of Kommerell as the last branch (arrows). Branching abnormality of the aortic arch can also be seen.
E. Ozturk et al. / European Journal of Radiology Extra 60 (2006) 109–111
these anomalies should be kept in mind by vascular surgeons and interventionists. References [1] Lincoln JC, Deverall PB, Stark J, Aberdeen E, Waterston DJ. Vascular anomalies compressing the esophagus and tracea. Thorax 1969;24:295–306.
111
[2] Yap J, Haywrad PA, Lincoln C. Right aortic arch aberrant subclavian arteries: a cause of esophageal compression. Ann Thorac Surg 1999;68:2331–2. [3] Cina CS, Arena GO, Bruin G, Clase CM. Kommerll’s diverticulum and aneurysmal right-sided aortic arch: a case report and review of the literature. J Vasc Surg 2000;32:1208–14. [4] Drowsek V, Weber ED, Snow RD. Stenotic origin of an aberrant left subclavian artery from a right sided aortic arch: a case report. Angiology 1996;47:523–9.