Mirror-image right aortic arch: a proposed mechanism in symptomatic vascular ring

We describe a rare case of right aortic arch with mirror-image branching and a left ductus arteriosus that form an anomalous vascular ring. The unusual feature of this symptomatic vascular ring is presence of a left (posterior) circumflex descending aorta in lieu of an aortic diverticulum which usually represents the posterior element of the vascular ring associated with right aortic arch and mirror-image branching. This we believe is the seventh reported case of Type 1 right aortic arch and only the third such case with a left circumflex descending aorta. Accurate diagnosis was made by barium esophagogram and angiocardiogram and was confirmed surgically. We propose a new theory as to why some vascular rings formed by the right aortic arch are symptomatic while others are not.