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Left subclavian artery aneurysm and arteria lusoria with Kommerell’s diverticulum

I read with interest the case study of Nair and colleagues regarding surgical repair of a left subclavian artery aneurysm and an aberrant right subclavian artery with a small Kommerell’s diverticulum in an asymptomatic young patient, which were both incidentally diagnosed on a preoperative clinical work-up for inguinal hernioplasty. Aneurysms of the subclavian arteries are extremely rare. Aberrant right subclavian artery, known as arteria lusoria, is the most common congenital abnormality of the aortic arch, and its aneurysmal dilatation is also very rare. The combination of these 2 aneurysms in the same patient has not been reported until now, to my best knowledge. No reference is cited by the authors to support their claim that the combination of these 2 rare clinical conditions has a reported incidence of 0.13% to 1%. In my opinion, the patient of Nair and colleagues did not have a combination of these 2 rare clinical entities. Regarding the diagnosis, the authors state: ‘‘computed tomography confirmed the diagnosis of a large aneurysm at the origin of the left subclavian artery, and anomalous origin of the aberrant right subclavian artery with a small Kommerell’s diverticulum’’. This diagnosis, beside the provided Figure 1 and their own intraoperative observation, contradict their title, abstract, and introduction regarding the combination of these 2 rare clinical entities. Kommerell’s diverticulum is a normal broadening of the proximal origin of the aberrant right subclavian artery from the aortic arch, and is most frequently present in patients with a right aortic arch and an aberrant left subclavian artery. The 60% of patients who have an aberrant right subclavian artery also have a Kommerell’s diverticulum, and most patients with Kommerell’s diverticulum are asymptomatic. However, the term Kommerell’s diverticulum is not a synonym of aneurysm. Davidian and colleagues have addressed the confusion in the literature regarding this subject and terminology. Also, ‘‘aberrant right subclavian artery aneurysm’’ and ‘‘aberrant right subclavian artery with a small Kommerell’s diverticulum’’ are different clinical entities, which require different management. In my opinion, asymptomatic and nonaneurysmatic aberrant right subclavian artery with a small Kommerell’s diverticulum usually does not require surgical repair. The primary indication for surgical repair of Kommerell’s diverticulum is a diameter >50mm and the presence of clinical symptoms, according to Ota and colleagues. While Nair and colleagues emphasized the concept that ‘‘surgical intervention is indicated for all patients with a symptomatic aberrant right subclavian artery’’, I think they offered an unnecessary, extensive, and aggressive surgical repair to their asymptomatic patient. The left subclavian artery aneurysm in their patient, even asymptomatic, was the only indication for surgical repair, because of the risk of rupture. The treatment of the left subclavian artery aneurysm with endovascular stent graft placement, with or without conventional surgery, would also have been an effective alternative, minimally invasive, and much less aggressive option for their asymptomatic patient. The authors offered their patient, in my opinion, a demanding surgical repair: they performed 2 surgical incisions, right supraclavicular and left posterolateral thoracotomy, used 3 tube grafts for vascular anastomosis and aortic reconstruction, and even instituted cardiopulmonary bypass with aortic crossclamping. An aortic crossclamp distal to the left subclavian artery and above the aberrant right subclavian artery in a patient with small right vertebral artery, especially without adjunctive protective measurements, is not without clinical hazards such as brainstem infarct, paraplegia, and renal failure.