Hybrid Repair of an Aberrant Left Subclavian Artery Arising from a Right-sided Aortic Arch with Kommerell’s Diverticulum

Congenital anomalies of the aortic arch are rare, aberrant left subclavian artery (ALSA) arising from right-sided aortic arch with Kommerell’s diverticulum is one such case. Fewer than 50 cases have been documented, with various anomalies and its management. We present a case successfully treated with a hybrid repair that features both diagnostic and therapeutic considerations. We report the case of a 38-year-old woman with the history of exertional dyspnea. She was initially treated for bronchitis after pulmonary function tests. The symptoms persisted after the treatment, which prompted the need for further evaluation. Computed tomography angiography revealed ALSA originating from the right-sided aortic arch with Kommerell’s diverticulum, leading to compression of the trachea and esophagus. The treatment was planned as a hybrid repair. The first stage involved left common carotid artery-to-left subclavian artery bypass, with ligation of the proximal subclavian artery, followed by thoracic endovascular aortic repair (TEVAR). During the procedure, retrieval of the device’s nose cone was complicated by sharp arch angulation and interaction with the graft fabric. The procedure was successfully managed with a snaring through brachial access. The recovery from the procedure was uneventful and without symptoms. At 3 months follow-up, the patient was asymptomatic with complete resolution. ALSA arising from right-sided aortic arch with Kommerell’s diverticulum is a rare case. We performed a hybrid repair with bypass and TEVAR as an effective procedure even in complex anatomy, with uneventful recovery, supporting the safety.