Kommerell diverticulum in right aortic arch with aberrant left subclavian artery: Routine resection or selective management?

Right aortic arch with aberrant left subclavian artery (RAA-ALSA) is one of the most common complete vascular rings encountered in pediatric cardiovascular practice. The associated Kommerell diverticulum (KD), a remnant of the primitive fourth dorsal aortic arch from which the aberrant subclavian artery arises, forms part of the posterior ring and may contribute importantly to persistent airway and esophageal compression. Historically, repair consisted of division of the ligamentum arteriosum. Recognition that posterior compression can persist after ligamentum division has led many surgeons to add diverticulum resection and transfer or reimplantation of the aberrant subclavian artery. The optimal strategy remains controversial. Advocates of routine KD resection cite persistent compression after simple ring division, the low morbidity of resection in experienced centers, and abnormal diverticular histopathology that may imply future aneurysmal risk. Opponents emphasize that most children do well after less extensive repair that persistent symptoms frequently reflect associated airway disease rather than residual vascular compression, and that evidence proving superiority of universal resection is lacking. This review summarizes the embryology, anatomy, pathophysiology, and surgical management of KD in RAA-ALSA; critically examines evidence for routine and selective resection; and proposes a practical anatomy-driven approach.