A healthy 23-year-old woman was referred to our cardiology clinic for evaluation of a murmur and an increasingly pulsatile neck mass (Video), first noted 2 years before presentation. Physical examination revealed a prominent pulsation in the right side of the neck and an early diastolic murmur, grade 2/6, in the aortic position. Her blood pressure was 134/78 mm Hg in the right arm and 122/72 mm Hg in the left arm. No radial–radial or radial–femoral delay was appreciated. Transthoracic echocardiography revealed a bicuspid aortic valve with mild aortic regurgitation. Computed tomographic angiography (reconstructed image) revealed a cervical aortic arch with the left common carotid artery arising from the ascending portion (arrow 1) and the left subclavian artery arising from the descending aorta (arrow 2). Embryologically, this anomaly has been considered to result either from regression of the fourth aortic arch (with persistence of the third) or from the failure of normal caudal descent of the aortic arch system. The patient underwent reconstruction of the cervical arch, with adjustment to an intrathoracic position. She was doing well at follow-up 18 months after surgery.