S4272 Kommerell Diverticulum: A Unique Etiology of Dysphagia

Introduction: The right subclavian artery typically arises from the aortic arch, however in 0.5%–2% of individuals, an aberrant right subclavian artery originates from the proximal descending aorta, coursing anterior or posterior to the esophagus or trachea. Aneurysmal dilation, seen in approximately 60% of cases, is known as Kommerell diverticulum. Compression of the aerodigestive tract may cause dysphagia (termed dysphagia lusoria), cough, stridor, chest pain, or upper limb ischemia. Case Description/Methods: An 82-year-old man with a medical history of hypertension, hyperlipidemia presented after a fall. A chest X-ray revealed an incidental bilateral paratracheal prominence. Subsequent computed tomography (CT) angiography demonstrated an aberrant right subclavian artery with a retroesophageal course and a 3.6 cm aneurysmal dilation at its origin with mural thrombus - findings consistent with Kommerell diverticulum. Vascular surgery was consulted and due to the size of the aneurysm, surgical repair was recommended. The patient underwent right carotid-to-subclavian bypass, ligation of the aberrant subclavian artery, and placement of thoracic branch endograft to exclude the aneurysm. On post-operative day 1, he experienced dysphagia to liquids, which resolved after a 3-day course of prednisone (10 mg daily). At his 2-week follow-up, computed tomography angiography confirmed successful repair. However, 3-weeks post-operatively, he returned with progressive dysphagia to solids and liquids for 3 days. Repeat CT angiography demonstrated esophageal compression from the repaired Kommerell diverticulum. A short course of methylprednisolone led to resolution of his symptoms. At his 3-month gastroenterology follow-up, he remained asymptomatic. Discussion: CT angiography is the preferred imaging modality for evaluating Kommerell diverticulum. Surgical repair, either open or endovascular, is indicated for symptomatic cases or asymptomatic cases with a diameter greater than 3 cm. As illustrated by this case, dysphagia may present both pre- or post-operatively. In our case, steroids were used empirically to manage presumed post-surgical inflammation with resolution of symptoms.