Ann Thorac Surg 2008;85:663. doi:10.1016/j.athoracsur.2007.04.069
© 2008 The Society of Thoracic Surgeons
Images in Cardiothoracic Surgery
Right Aortic Arch With Multiple Ligamentum Arising From Kommerell’s Aortic Diverticulum
Christopher W. Baird, MDa,*,
Larry Watts, MDb
a Levine Children’s Hospital, The Sanger Clinic, Charlotte, North Carolina
b Department of Thoracic and Cardiovascular Surgery, Carolinas Medical Center, Charlotte, North Carolina
* Address correspondence to Dr Baird, Levine Children’s Hospital, The Sanger Clinic, 1001 Blythe Blvd, Suite 300, Charlotte, NC 28201 (Email: cbaird{at}sanger-clinic.com).
A 24-year-old symptomatic woman presented with severe dysphagia. A subsequent upper gastrointestinal series revealed esophageal compression, an upper endoscopy showed inflammation, and a computed tomographic scan (Fig 1) with three-dimensional reconstruction (Fig 2) showed a unique variant of a vascular ring with two ligaments arising from an aortic (Kommerell’s) diverticulum to pulmonary artery (Pulm Art) that compressed the mid-esophagus (Fig 3). Cardiac echocardiography revealed a right aortic arch and normal intracardiac anatomy.
A double lumen endotracheal tube was placed and the patient underwent surgery through a muscle sparring left mini-thoracotomy. The pleura were retracted where the esophagus (Eso) was identified and found to be severely compressed under two ligaments and an aortic (Kommerell’s) diverticulum (KD). The ligaments arose from the diverticulum and attached to the pulmonary artery (L1) and left subclavian artery (LSCA) (L2) (Fig 3). After division of the ligaments, the aorta (Ao) was cross-clamped for 6 minutes while the diverticulum was excised and oversewn. To ensure that the external esophageal compression was completely relieved the aorta was pexied to the spine (Fig 4).
Aortopexy has been historically used for re-suspension of the innominate artery to relieve tracheal compression. Similarly we have found it quite useful to add a posterior aortopexy when repairing vascular rings to further relieve esophageal compression and prevent recurrences. Recovery was uneventful and the patient was doing well without dysphagia at 3-month follow-up.
