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eComment: A tribute to Burckhard F. Kommerell – a German radiologist

Plastic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover 30625, Germany

Asymptomatic pseudo-aneurysm of the aortic arch in a patient with aberrant right subclavian artery. A complication of Kommerell's diverticulum?

We appreciate the recent report by Dr. Panagiotou and coworkers describing the case of a 56-year-old male with a pseudo-aneurysm of a left aortic arch adjacent to a Kommerrell's diverticulum at the orifice of the left subclavian artery [1].

We would like to credit Professor Dr. Burckhard F. Kommerell (1901–1990) for his description of an aortic diverticulum associated with an aberrant right subclavian artery [2]. As chief of the section of radiology at the Charite University Clinic in Berlin since 1934, he published the first report in 1936 with the following description:

‘Thus far an aberrant course of the right subclavian artery has not been reported in a living patient. In these circumstances it seems appropriate to publish an observation that I have made while performing a radiologic examination of the stomach. A 65-year-old man was examined because of a presumed diagnosis of stomach cancer. The sagittal view of a barium swallow examination demonstrated a delay in the passage of contrast medium at the level of the aortic knob. The aortic knob was left-sided and did not show any abnormality except for a small calcium deposit in its wall. Repositioning of the patient in a more oblique direction demonstrated that the esophagus was pushed forward at the level of the aortic knob. To the left and behind the esophagus there was a mass, that, because of its pulsatile character, was interpreted as being a vessel. At this location the esophagus was compressed [...]. The trachea and the other thoracic organs were all normal, as were the clinical findings. This radiologic finding can only be interpreted as being an aberrant origin of the right subclavian artery. However, the pulsating mass behind the esophagus does not consist of the right subclavian artery itself, because the calibre of this vessel is much smaller. Much more likely this mass consists of an aortic diverticulum, from which the right subclavian artery originates.’

Kommerell described a patient who had a left aortic arch and an aberrant right subclavian artery. In this vascular anomaly, the right subclavian artery arises as the last branch of the aortic arch and courses from the proximal descending aorta to the right arm, passing behind the esophagus. This anomaly of the 4th aortic arch results from regression of the right aortic arch between the right carotid and right subclavian arteries. Kommerrell pointed out that a diverticulum at the origin of the aberrant right subclavian artery is a remainder of the primitive right dorsal aorta.

We encountered a 55-year-old male suffering acute thoracic pain, vertigo and hypertension with a rupture of a Kommerrell's diverticle in a right aortic arch in aortic dissection Stanford type B [3]. This patient underwent emergency distal aortic arch replacement and subsequent bilateral subclavian artery bypass grafting in a single procedure.

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1. Panagiotou M, Filias V, Prokaris C, Koletsis E. Asymptomatic pseudoaneurysm of the aortic arch in a patient with aberrant right subclavian artery. A complication of Kommerrell's diverticulum? Interact Cardiovasc Thorac Surg 2008;7:730–732.[Abstract/Free Full Text]
2. Kommerrell B. Verlagerung des Ösophagus durch eine abnorm verlaufende Arteria subclavia dextra (Arteria lusoria). Fortschr Geb Roentgenstrahlen 1936;54:590–595.
3. Knobloch K, Lichtenberg A, Lotz J, Haverich A. Rupture of a Kommerrell's diverticle in a right aortic arch in aortic dissection Stanford type B. Eur J Cardiothorac Surg 2005;27:347.[Free Full Text]

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