Kommerell diverticulum

Kommerell diverticulum (also known as Kommerell's diverticulum) is a rare congenital vascular anomaly of the aortic arch in which there is a bulging outpouching (diverticulum) at the origin of an aberrant subclavian artery arising from the aortic arch or descending aorta. It is classified under congenital malformations of the great arteries (ICD-10: Q25.4). The diverticulum represents a remnant of the embryonic fourth aortic arch and is most commonly associated with an aberrant right subclavian artery (arteria lusoria) arising from a left aortic arch, or less frequently with an aberrant left subclavian artery from a right aortic arch. The anomaly primarily affects the cardiovascular system but can secondarily impact the respiratory and digestive systems through compression of adjacent mediastinal structures. Many individuals with Kommerell diverticulum remain asymptomatic throughout life, with the condition discovered incidentally on imaging studies. When symptoms occur, they are typically caused by compression of the esophagus (dysphagia lusoria — difficulty swallowing) or trachea (dyspnea, chronic cough, stridor, or recurrent respiratory infections). In some cases, the diverticulum may enlarge over time, and there is a recognized risk of aneurysmal dilation, dissection, or rupture, which can be life-threatening. Symptoms may present at any age, from infancy through adulthood, depending on the size of the diverticulum and degree of vascular ring formation. Management depends on the severity of symptoms and the size of the diverticulum. Asymptomatic patients with small diverticula may be monitored with periodic imaging surveillance. Surgical intervention is recommended for symptomatic patients or when the diverticulum is large (generally greater than 3 cm) due to the risk of rupture. Surgical options include open repair with division of the aberrant vessel and reimplantation, or increasingly, hybrid and endovascular approaches including thoracic endovascular aortic repair (TEVAR). Early diagnosis and appropriate management are important to prevent potentially fatal complications.

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