Hybrid endovascular treatment of aneurysm degeneration in a rare right-aortic arch anomaly with Kommerell diverticulum

A, Barium swallow shows enlargement of the superior mediastinum at the jugular level and a right-sided indentation of the esophagus (black arrow). B, Preoperative MIP reconstruction of magnetic resonance angiography (MRA) shows an anterior (A) view of the right-sided aortic arch, with the right and left carotid arteries (RCA and LCA) originating as first branches at the same level, followed by the right subclavian artery (RSA) and the Kommerell diverticulum (KD). S, Superior; I, inferior; R, right; L, left. C, Preoperative MIP reconstruction of MRA showing a left (L) lateral view. The aberrant left subclavian artery (LSA) originates from the KD, connected to the pulmonary artery through the ligamentum arteriosum (LA). A, Anterior; P, posterior. D, Preoperative MIP reconstruction of MRA shows a right (R) lateral view. The LA is connected to the left pulmonary artery (LPA). E, A CT scan cross-section at the level of the KD shows a large aortic aneurysm and an acute-angulated arch. ATA, ascending thoracic aorta.

Final angiography after deployment of endografts shows the complete aneurysm exclusion and the aortic bypass to both carotid and subclavian arteries.

Follow-up CT scan control 18 months after the procedure shows (A) a frontal view of the right-sided arch with the origin of the bypass and the proximal endograft and (B) a posterolateral view of the correct endograft apposition with the complete aneurysm exclusion in the acute-angulated arch.