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Author: Vanessa Gray, MS IV
Texas A&M HSC College of Medicine/Scott and White Hospital,
Introduction: Chest pain is a common chief
complaint with nearly six million visits to emergency departments
each year. There are numerous causes of chest pain, with many
having potentially deadly consequences. A duct of Kommerell
aneurysm, a rare complication of an aberrant right subclavian
artery (ARSA), is one that can be potentially fatal if not
diagnosed promptly and accurately; however, with its non-specific
symptoms of dysphagia, cough and less commonly chest pain, making
the diagnosis of this congenital anomaly is both challenging and
Case Presentation: A 57-year-old man presented
with a 30-45 minute history of tearing chest pain that radiated to
his left jaw, neck, and interscapular region. He had no other
associated symptoms, and no prior history of this type of chest
pain. Physician examination revealed significantly higher systolic
blood pressures in his lower extremities when compared to his upper
extremities and chest tenderness that was reproducible with
palpation. Initial blood work was unremarkable with negative
cardiac markers, an ECG showing ventricular paced rhythm, and a
chest X-ray demonstrated mediastinal widening. A CT scan confirmed
an intimal flap in the descending aorta, an intramural hematoma,
and an anomaly posterior to the esophagus that joined with the
aortic arch. Consequently, the patient was diagnosed with an
aberrant right subclavian artery, a duct of Kommerell aneurysm, and
a Type B aortic dissection. He underwent emergent surgery to repair
the ARSA by reanastomosis to the brachiocephalic artery, and
placement of a Dacron graft to correct his dissection.
Discussion: In 1936, Dr. Kommerell was one of
the first physicians to clinically diagnose an aberrant right
subclavian artery and duct of Kommerell aneurysm, hence his
namesake, in a patient who presented with dysphagia. The ARSA was
later found to originate from the incomplete embryonic development
of the right, fourth aortic arch. The incidence of an ARSA is
around 1% of the total population, while occurrence of a duct of
Kommerell aneurysm is only 0.5% of the total population. Common
complications of an ARSA are atherosclerosis, aneurysms,
dissections, and vascular stenosis. Interestingly, our patient did
not present with cough or dysphagia, symptoms commonly seen with an
ARSA and duct of Kommerell aneurysm secondary to compression of the
posterior esophagus. Thus, this case exemplifies that while it is
exceedingly rare to find an aberrant right subclavian artery, a
duct of Kommerell aneurysm and a Type B dissection occurring
simultaneously, it is important to use a systematic approach and
have a broad differential diagnosis when working up a patient with
chest pain in order to prevent potentially fatal complications.
January Issue of IMpact