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Weekly Chest CasesArchive of Old Cases

Case No : 580 Date 2008-12-08

  • Courtesy of Jae Choon Pang, MD, Jae Seung Seo, MD, Semin Chong, MD. / Chung-Ang University, Seoul, Korea.
  • Age/Sex 56 / F
  • Chief ComplaintIncidental abnormal finding on chest radiograph / No known past medical history
  • Figure 1

Diagnosis With Brief Discussion

Diagnosis
Right aortic arch with an aberrant left subclavian artery and Kommerell’s diverticulum
Radiologic Findings
Chest PA (Figure 1A) shows right paratracheal bulging shadow with Right side indentation of trachea.
Lateral chest (Figure 1B) shows anterior displacement of trachea with bulging shadow between trachea and descending thoracic aorta.
Chest CT scan (Figure 2A and 2B) shows a right aortic arch and an aberrant left subclavian artery, which arises form the a diverticulum (Kommerell’s diverticulum )at the junction of aortic arch and the descending thoracic aorta. It seems that the aortic arch and the aneurysm cause posterior indentation and anterior displacement of the trachea.
Brief Review
In 1936, Kommerell reported an aberrant right subclavian artery arising from the descending thoracic aorta of left aortic arch and associated with persistence of a remnant of the right dorsal aorta. The latter appeared as a diverticulum from which the aberrant right subclavian artery originated. This is known as the diverticulum of Kommerell. An aberrant right subclavian artery with a leftsided aortic arch is the most common of the anomalies involving the subclavian artery (1).

In adults, a right-sided aortic arch cause symptoms of early atherosclerotic changes of the anomalous vessels, dissection, or aneurysmal dilatation with compression of surrounding structures (i.e, dysphagia, dyspnea, stridor, wheezing, cough, choking spells, recurrent pneumonia, obstructive emphysema, or chest pain)(2).

Aneurysm associated with right-sided arch cause rupture or dissection up to 53%. Because of the relative rarity of the condition and the limited information available, rupture cannot be predicted by size. Aggressive treatment may be suggested for aneurysms of 3 cm or greater in diameter. Kommerell's aneurysms associated with a right-sided aortic arch may be repaired through a right thoracotomy and atriofemoral bypass(2).
References
1. Kommerell B. Verlagerung des Oesophagus durcheine abnorm verlaufende Arteria subclavia dextra (Arteria Lusoria). Fortschr Geb Roentgenstr 1936;54:590-5.
2. C.S. Cina` et al. Kommerell’s diverticulum and right-sided aortic arch. J Vasc Surg 2004;39:131-9
Keywords
Vascular, Mediastinum, Congenital,

No. of Applicants : 86

▶ Correct Answer : 33/86,  38.4%
  • - Shiga University of Medical Science , Japan Norihisa Nitta
  • - Chungnam National University hospital , Korea (South) Kyoung Jin Oh
  • - Osaka University , Japan Osamu Honda
  • - Kasturba Medical College Manipal , India Paresh Desai
  • - ESCORTS HOSPITAL , India meenu solanki
  • - Soonchunhyang university Bucheon hospital , Korea (South) Minhee Lee
  • - Father Muller Medical College , Mangalore , India nabil mahmood
  • - partner, aditya imaging centre , India vivek patel
  • - Assam medical college , India Karunakaran M
  • - McGill University Health Centre , Canada Amr Ajlan
  • - Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
  • - China Medical University,Taiwan,R.O.C. , Taiwan Jun Jun Yeh
  • - Gimpo Woori Hospital , Korea (South) Son Youl Lee
  • - The Armed Forces HamPyeong Hospital , Korea (South) Bae Geun Oh
  • - SPS APOLLO HOSPITALS , India LOVKESH MITTAL
  • - Shinsegye Rad Clinic, Daegu , Korea (South) Gi Beom Kim
  • - Govt. Medical College, Vadodara, india , India Vijay Vaidya
  • - seoul national university hospital , Korea (South) Ijin Joo
  • - National Taiwan University Hospital , Taiwan Chin-Chung Shu
  • - hospital Sao Paulo , Brazil israel missrie
  • - Changi General Hospital , Singapore Angeline Poh
  • - Soonchunhyang university hospital, Bucheon , Korea (South) ALEUM LEE
  • - Vitalife Clinics , Pune , India. , India Rahul Deshmukh
  • - UZ Gent , Belgium Robert Gosselin
  • - Medical College Chest Hospital,Thrissur,Kerala , India Raveendran TK
  • - Hanmaeum Hospital , Korea (South) Kwon Hyoung Kim
  • - IRCCS S.Luca Hosp. , Italy filippo casolo
  • - Trakya Univercity School of Medicine , Turkey Armagan Sarac
  • - radiology department ANNECY , France gilles GENIN
  • - Mallinckrodt Institute of Radiology , United States Naganathan Mani
  • - clinique de SAVOIE , France, Metropolitan gay-depassier philippe
  • - Yonsei University college of medicine Severance Hospital , Korea (South) Hua Sun Kim
  • - Armed Forces Chun-Cheon Hospital , Korea (South) ChaeHun Lim
▶ Semi-Correct Answer : 29/86,  33.7%
  • - Shinchon Severance Hospital , Korea (South) Ho-Joon Lee
  • - kims,narkatpally , India k bhaskar
  • - Ondokuz Mayis University , Turkey Cetin Celenk
  • - Asian Heart Institute, Nirman Hitech & Apollo clinic , India Jeshil Shah
  • - Soonchunhyang university hospital, Bucheon , Korea (South) Hyelin Kim
  • - CHRU Lille , France Benjamin Damarey
  • - MD PG Resident, PIMS,LONI, MAHARASHTRA, INDIA , India Sushant Bhadane
  • - Ruby Hall Clinic , India sudarshan rawat
  • - IRSA La Rochelle France , France Denis Chabassiere
  • - wonju christial hospital , Korea (South) Daekeon Lim
  • - Retd. Prof Thoracic Surgery B.J.MEDIDCAL COLLEGE Punr India , India Bankim Amin
  • - Samsung Medical Center , Korea (South) Dae Kun Oh
  • - Seoul National University Hospital , Korea (South) Kwang Nam Jin
  • - ROHINI Scans (P) Ltd. Ambattur , India UMAPATHI MAHESH
  • - CH de la C�te Basque , France Paul ARDILOUZE
  • - Apollo Gleneagles hosp , India salim parvez
  • - EKH-Berlin , Germany Michael Weber
  • - Saga University , Japan Ryoko Egashira
  • - Mallinckrodt Institute of Radiology , United States Travis Henry
  • - Radiologic clinic , Korea (South) sauree
  • - second hospital xian jiaotong university , China li ming
  • - Homs National Hospital , Syria Rami Abou Zalaf
  • - Univ. of Miami/Jackson Memorial , United States mantosh rattan
  • - Medical college of Xi , China qiu juan zhang
  • - Dongguk University International Hospital , Korea (South) Hee Seok Choi
  • - Hospital Sotiria, Athens, Greece , Greece Vasilios Tzilas
  • - McGill University Health Center , Canada Alexandre Semionov
  • - Soonchunhyang University Cheonan Hospital , Korea (South) Park Sang Hyun
  • - CHRU lille , France manuel toledano
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