eComment. Right cervical aortic arch and aberrant left subclavian artery.

the reconstructed RAA was detected by echocardiography at 2 and 8 months after surgery and successfully treated by balloon angioplasty. After 18 months, the patient was asymptomatic, and her growth percentile improved from the 20th to 35th percentile. LV function normalized. Facial haemangiomas progressively decreased and disappeared (Fig. 2). DISCUSSION DAA is an anomaly caused by failure of regression, or regression at an abnormal site, of the fourth aortic arch [3]. DAA can be associated with segmental atresia of one of the arches classified into 4 subtypes according to the location of the atretic segment: types A and B are relatively common, but types C and D are rare [4]. We reported a case of DAA with hypoplastic RAA and LAA type C atresia. Our patient presented with congestive heart failure because of severe systemic obstruction, whereas the most commonly reported clinical presentation of DAA is caused by airway compression [1, 5]. Our surgical strategy was to reconstruct the aortic segment with an augmentation patch because the hypoplastic segment of the RAA was long and tortuous and direct anastomosis between the ascending and descending aorta was advised against; in addition, the marked cervical position of the RAA clearly contraindicated thora-cotomy. Notably, surgical dissection to identify the remnant of LAA was interrupted to avoid any damage to the left laryngeal recurrent nerve, the phrenic nerve and the LSA. The decision not to excise LAA was also supported by the fact that the patient was not symptomatic for stridor or feeding disorder and the cervical position of the RAA made the area between the RAA and LAA sufficiently wide. In our case, the potential development of collateral circulation was limited by hypoplastic RCCA and LSA and the origin of RSA being distal to the obstruction. Hence, the LCCA was the only patent supraortic vessel that could supply the collateral circulation towards the RSA. Thus, distal aortic perfusion was guaranteed retro-gradely from the intracranial vertebrospinal arterial system and through multiple extracranial superficial collateral branches. Therefore, we postulated that the multiple haemangiomas localized exclusively on the right side of the head could be the expression of such a collateral pathway. Indeed, these vascular anomalies progressively disappeared after improvement in the RAA obstruction. With such complex DAA presentations, echocardiography might reveal the underlying cause of cardiac dysfunction but cardiac catheterization, angiography and CT scan provide a precise anatomical and physiological evaluation, allowing the establishment of …