Search

The right vertebral artery (VA) rarely arises from the right common carotid artery (CCA); however, the majority of anomalous right VAs are seen in combination with an aberrant right subclavian artery (SA). Independent (or isolated) right VA of the right CCA origin is extremely rare, with only a few cases reported previously. We herein report an additional case diagnosed incidentally using computed tomography angiography. This patient had a left VA arising from the aortic arch between the origins of the left CCA and left SA. The bilateral VAs took an anterior course and entered the C3 transverse foramina, at an extremely high level.

Introduction The right subclavian artery normally arises as the first vessel from the brachiocephalic trunk. An aberrant right subclavian artery (ARSA) arises directly from the aortic arch and crosses behind the trachea towards the right arm. This variant occurs in approximately 1–2% of the population; however, the frequency increases in individuals with chromosomal abnormalities such as trisomy 21 and 22q11.2 microdeletion. Prenatal identification of ARSA therefore has a role in screening for such conditions. Methods Databases were searched for studies reporting the prenatal ultrasound evaluation of ARSA and its frequency in normal fetuses and in those with chromosomal abnormalities. Results A total of 23 studies were evaluated. Feasibility for the ultrasound evaluation of ARSA was 85–95%. The sonographic detection of ARSA is best in the three-vessel trachea view; however, sagittal and coronal imaging of the aortic arch may be useful. ARSA in isolation was not found to be associated with chromosomal abnormalities. The prevalence of ARSA in chromosomally abnormal fetuses was up to 24-fold higher than in normal fetuses, but the majority of chromosomally abnormal fetuses with ARSA had additional abnormal ultrasound findings, particularly cardiac abnormalities. Conclusions The prenatal detection of ARSA is a clinically useful prenatal marker for chromosomal abnormalities. In isolation, it is unlikely to be associated with pathogenic genetic variants. The ultrasound diagnosis of ARSA should prompt meticulous assessment of associated abnormalities. Invasive diagnostic testing should be offered to patients with non-isolated ARSA or in the presence of non-reassuring screening results or other risk factors.

Los anillos vasculares son anomalías anatómicas que ocurren durante el desarrollo embrionario del arco aórtico, sus ramas y de la arteria pulmonar. Estas estructuras vasculares pueden conducir a grados variables de sintomatología respiratoria y/o digestiva debido a la formación de un anillo completo o parcial que comprime la tráquea y/o el esófago. La arteria subclavia derecha aberrante es la anomalía más común del arco aórtico, con una incidencia reportada entre 0.5 a 2.5%. Generalmente es asintomática, sin embargo, la disfagia es el síntoma más frecuente porque en la mayoría de los casos transcurre detrás del esófago. El diagnóstico puede ser incidental en casos asintomáticos o como resultado del estudio de síntomas digestivos y/o respiratorios persistentes o recurrentes. Los pacientes sintomáticos requieren intervención quirúrgica. Describimos el caso de una paciente de 3 meses de edad con arteria subclavia derecha aberrante. El esofagograma mostró compresión extrínseca del esófago, y la angiotomografía computada confirmó el diagnóstico. La corrección quirúrgica se realizó exitosamente.

Aberrant right subclavian artery (ARSA) is a relatively rare congenital anomaly of the aortic arch. A 74-year-old woman was referred to our Cardiac Surgery Department for chest pain. Angio-CT scan showed an acute aortic dissection and revealed an ARSA routed behind the trachea. We performed supra-coronary ascending aorta and total arch replacement with Frozen Elephant Trunk (FET) technique. The ARSA was then termino-terminal anastomosed to one branch of the Thoraflex arch graft. Postoperative CT-scan indicated a successful reconstruction of the aortic arch, proving the open stent-grafting technique as a useful and effective approach for aortic disease with ARSA.

Background: The current study aims to determine the prevalence of variations of the aortic arch using computed tomography angiography (CTA), as well as morphometries and gender correlations. Materials and methods: A retrospective, transverse, observational and descriptive study of 220 CTA was performed. The branching pattern, most cranial vertebral level of the aortic arch, area of the proximal, middle and distal segments of the arch, area of each branch, and the path of atypical arteries were recorded. Results were analysed and stratified by gender. Results: The typical aortic arch branching pattern was present in 77.7% without statistical significance between genders. The most common variant was a two-branch pattern with a common trunk and a left subclavian (13.6%), followed by a typical branching pattern with an added left vertebral artery (7.3%). T3 was the most frequent cranial level (32.3%), followed by T2–T3 (26.8%), and T3–T4 (23.2%). The mean areas of the aortic arch were 685.5 ± 183.9, 476.1 ± 124.1, and 445.0 ± 145.1 mm2 for the proximal, middle and distal segments, with statistical difference between men and women in the middle and distal segments. Three paths of atypical arteries were identified: bifurcated vertebral artery (0.5%), aberrant right subclavian artery (0.5%), and left subclavian ostium obstruction (0.5%). Conclusions: Mexican population has one of the highest prevalence of variations in the aortic arch branching pattern. The high probability of finding these should be taken into consideration when assessing patients. A standardised classification method would contemplate future un-reported findings, without causing confusion by the different numbers assigned by each author.

Objective: To investigate the frequency and types of chromosomal abnormalities in fetuses with the aberrant right subclavian artery (ARSA) and to evaluate its association with other ultrasonographic findings. Materials and Methods: In all, 11,666 fetal anatomic surveys were performed between March 2014 and March 2020. The cases diagnosed as ARSA were examined. Accompanying ultrasound findings and chromosomal abnormalities were collected. Results: ARSA was detected in 140 fetuses (1.2%). The ARSA appeared isolated in 47.1% (66/140) of cases and the remaining 52.9% (74/140) of cases were associated with cardiac or extracardiac malformations and soft markers. Chromosomal abnormalities were detected in 17.8% (25/140) of all cases. Trisomy 21 was the most common chromosomal anomaly with a prevalence of 11.4% (16/140). The corresponding rate was 3% (2/66) and 18.9% (14/74) for isolated and non-isolated ARSA, respectively. DiGeorge syndrome was detected in 3% (n=2) and Turner syndrome was in 3% (n=2) of the isolated group. ARSA was not an isolated finding in any of the 4 fetuses with trisomy 18. Conclusion: Isolated ARSA may be the only antenatal predictor of trisomy 21 or other chromosomal anomalies, including DiGeorge or Turner syndrome. Hence, visualization of the right subclavian artery should be a part of the fetal anatomic survey and genetic analysis should be recommended even in the absence of associated findings., Amaç: Aberran sağ subklavyen arteri (ASSA) olan fetüslerde kromozomal anomalilerin sıklığını ve tiplerini belirlemek ve diğer sonografik bulgularla ilişkisini değerlendirmektir. Gereç ve Yöntemler: Mart 2014 ile Mart 2020 tarihleri arasında toplam 11,666 fetal anatomik inceleme yapıldı. ASSA tanısı konulan olgular incelendi. Eşlik edilen ultrason bulguları ve kromozom anormallikleri toplandı. Bulgular: Yüz kırk fetüste (%1,2) ASSA tespit edildi. ASSA, olguların %47,1’inde (66/140) izole olarak göründü ve olguların geri kalan %52,9’u (74/140) kardiyak anomaliler, ekstrakardiyak malformasyonlar veya minör belirteçler ile ilişkili bulundu. Tüm olguların %17,8’inde (25/140) kromozom anormallikleri tespit edildi. Trizomi 21, %11,4 (16/140) prevalansı ile en sık görülen kromozomal anomaliydi. İzole ve izole olmayan ASSA için karşılık gelen oranlar sırasıyla %3 (2/66) ve %18,9 (14/74) idi. İzole grupta %3 (n=2) DiGeorge sendromu ve %3 (n=2) Turner sedromu da saptandı. ASSA, trizomi 18’i olan 4 olgunun hiçbirinde izole bir bulgu değildi. Sonuç: İzole ASSA, trizomi 21’in veya DiGeorge veya Turner sendromu dahil diğer kromozomal anomalilerin tek antenatal prediktörü olabilir. Bu nedenle, sağ subklavyen arterin görselleştirilmesi fetal anatomik incelemenin bir parçası olmalı ve ilişkili bulguların yokluğunda bile genetik analiz önerilmelidir

Highlights • Blunt thoracic aortic injuries are life threatening and require urgent intervention. • Rare presentation of a blunt thoracic aortic injury in a patient with an aberrant right subclavian artery off the aortic arch distal to the takeoff of the left subclavian artery. • An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR., Introduction Blunt thoracic aortic injuries (BTAIs) are an uncommon traumatic injury that if not treated promptly, can result in death. We present the case of a BTAI with aberrant aortic anatomy. Presentation of case A 60-year-old female was involved in a motor vehicle crash where she suffered significant polytrauma including a BTAI. She was also found to have an aberrant right subclavian artery originating from the aortic arch. Thoracic Endovascular Aortic Repair (TEVAR) with a right common carotid artery to right subclavian artery bypass was accomplished. She required three more vascular surgical interventions, two for persistent type II endoleak and the third for left upper extremity acute limb ischemia. She had a 2-month hospital course for her devastating injuries and was eventually discharged home. A follow-up CT angiogram showed a stable thoracic aortic arch stent. Discussion BTAIs are uncommon in the trauma population. In our patient who had an aberrant right subclavian artery, further procedures were required in the form of a right common carotid artery to right subclavian artery bypass and embolizations to resolve endoleaks. Conclusion Blunt thoracic aortic injuries are life threatening and require urgent intervention. TEVAR is associated with better outcomes. An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR. TEVAR is still an option for repair of blunt thoracic aortic injuries despite anatomic variations as open repair still carries an increased risk of morbidity and mortality.

Background: The most common aortic arch abnormality is an aberrant right subclavian artery (ARSA). ARSA-esophageal fistula is a rare sequela that can present with a life-threatening upper gastrointestinal (GI) bleed. Case Report: We report the case of an 88-year-old male who presented with signs of upper GI bleeding. Esophagogastroduodenoscopy demonstrated extrinsic compression of the upper third of the esophagus with ulceration. Imaging studies revealed ARSA posterior to the esophagus with pseudoaneurysm formation. These findings confirmed an upper GI bleed secondary to ARSA-esophageal fistula. The patient underwent prompt embolization of the ARSA pseudoaneurysm, followed a few days later by coil embolization of the ARSA pseudoaneurysm. Despite these interventions, the patient continued to have bleeding with anemia. He and his family opted to avoid any further interventions and instead pursued comfort care. The patient was discharged to hospice and died 3 months later. Conclusion: ARSA-esophageal fistula is a rare but potentially lethal cause of upper GI bleeding. Initial signs and symptoms can be subtle, but the presence of a GI bleed requires immediate stabilization. Surgical interventions have been shown to have longer-lasting success, but endovascular repair may be an option for patients who are deemed unfit for surgery but still require prompt stabilization. Regardless of the intervention, mortality rates for ARSA-esophageal fistula are high.

An aberrant right subclavian artery usually arises from the aortic arch just distal to the left subclavian artery and crosses behind the esophagus on its way to the right axillary artery. Several reconstructive techniques of this artery in aortic surgery have been reported but mostly resulted in troublesome procedures. Here, we describe an alternative strategy presenting the occlusion of the aberrant right subclavian artery through the right pleural approach followed via extraanatomical axillary artery bypass. This surgical approach might be a simple and safe option for the aberrant right subclavian artery.

Congenital aortic arch malformations manifest a broad-spectrum of differences and abnormalities that come from disturbed embryogenesis of branchial arches. Current case was a 10 months old baby girl with length of 69 cm (less than –3 SD) and weight of 5.5 kg (less than –3 SD). The patient had history of recurrent lower respiratory tract infections since the time of birth and failure to gain adequate weight since the time of birth. The patient has been having multiple check-ups with registered medical practitioners in the nearby locality and multiple courses of antibiotics with only partial resolution of symptoms. The 2-D echocardiogram showed her to be a case of supracardiac type of “Total Anomalous Pulmonary Venous Return (TAPVR)”. All pulmonary veins making a confluence and draining into the right atrium. Significant turbulence observed at the level of superior vena cava to right atrium junction. A level of obstruction was recorded at the junction of the confluence of pulmonary veins and the vertical vein. There was aberrant right subclavian artery from the aortic arch as its third branch with no obstruction or aneurysm formation, having retrotracheal and esophageal course.

Aim Analyze if the evaluation of aberrant right subclavian artery in the prenatal echography has improved the detection of chromosomal, genetic and/or morphological abnormalities in our population. Methods Descriptive, observational, cross-sectional study of the cases of aberrant right subclavian artery diagnosed in our Prenatal Diagnosis Unit between January of 2011 and December of 2018. Results Two hundred and fifty-seven cases of aberrant right subclavian artery were diagnosed and among them, 179 were considered isolated cases and thus were confirmed after birth. The detection of aberrant right subclavian artery did not improve itself neither the diagnosis of trisomy 21 in the second trimester of pregnancy nor other chromosomal or genetic abnormalities, including the not isolated cases. There were two cases of trisomy 21 diagnosed in the second trimester that presented major sonographic disorders and an inadequate examination during the first trimester. When aberrant right subclavian artery was associated with soft markers of aneuploidy in the second trimester, any case was a trisomy 21. Aberrant right subclavian artery seems to be associated with some minor and major heart defects, especially ventriculoseptal defect and aneurismatic ductus, and in some cases, also with clubfeet. Conclusion When an adequate screening of aneuploidies and a thorough ultrasound have been performed during the first trimester, aberrant right subclavian artery hardly helps to perform other diagnosis in the second trimester.

An aberrant right subclavian artery (ARSA) is one of the famous anatomical abnormalities with a prevalence of 0.16-4.4%. In esophagectomy, anatomical abnormalities of the ARSA could cause complications with some surgical procedures. An 85-year old man was referred to our department for esophageal adenocarcinoma that was at a slightly high position for esophagectomy with the abdominal approach. However, he had a significant past medical history. This risk factor made it difficult to perform thoracoscopic esophagectomy. He underwent mediastinoscopic esophagectomy (ME) with the left cervical and laparoscopic approach. The ARSA presented no difficulties with the ME surgical technique including the dissection of the left recurrent laryngeal nerve lymph node. Although this patient had a respiratory dysfunction and some difficulties in a prone position, ME enabled a safe esophagectomy with lymph node dissection.

Dysphagia Lusoria is a condition when aberrant right subclavian artery (ARSA) causes esophageal compression. We report 2 cases of Dysphagia Lusoria treated by hybrid endovascular technique which included subclavian to carotid transposition and embolization of origin of ARSA. By using this technique, we avoided the need for thoracotomy. Both patients had complete symptom relief without any surgery related complication.

Highlights • Aberrant right subclavian artery (ARSA) is a rare cause of dysphagia. • Surgical intervention is the mainstem of therapy. • Endoscopic dilation is a suitable treatment alternative in non-surgical candidates., Introduction The aberrant right subclavian artery (ARSA) is a rare cause of dysphagia. Surgical intervention has remained the mainstem of therapy, accompanied with certain morbidities and mortalities. Although rarely reported in literature, endoscopic dilation may be considered a suitable treatment alternative in patients who are not a surgical candidate or do not consent for surgery. We report a case suffering from dysphagia and diagnosed with ARSA treated by endoscopic dilation. Presentation of case A 52-year-old male presented to our clinic in 2015 with dysphagia. Chest Computed Tomography scan confirmed the diagnosis of ARSA. He first underwent esophagogastroduodenoscopy (EGD) with staged dilation of the stricture, making him free of his symptoms for an approximate 2.5 years. Upon recurrence of symptoms in 2018, he underwent repeat endoscopic dilation, which again completely resolved the symptom with an excellent peri-operative and post-operative course. Conclusion Endoscopic dilation of the esophageal stricture in patients with ARSA is a safe alternative to surgery in patients who are unable or unwilling to undergo surgery. It provides relief for a relatively long time and can be safely repeated multiple times upon recurrence.

Arterioenteric or arteriotracheal fistula is a known complication of an aberrant right subclavian artery (ARSA) and is often associated with prolonged nasogastric or endotracheal intubation or oesophageal stenting. Fistula formation from the ARSA can present unexpectedly with rapid exsanguination with massive haemoptysis or haematemesis, and unless promptly recognised and treated is rapidly fatal. We present a novel endovascular method for treating a fistula between the oesophagus, trachea and an ARSA in an unstable patient following oesophageal stent removal, utilising a covered iliac limb stent, eliminating the need for an open surgical approach.

Background Aberrant right subclavian artery (ARSA) with associated Kommerell diverticulum (KD) is a rare congenital aortic disease. KD patients have a high risk of rupture, dissection, and compression of adjacent structures. Although several treatment options have been proposed (traditional surgery, hybrid operation, and endovascular intervention), a consensus regarding optimal surgical management has not yet been established. Case presentation A case of successful hybrid repair of distal aortic arch dissection aneurysm by dissecting KD and ARSA with debranching of right and left common carotid arteries, left subclavian artery, and stent grafting was presented. Conclusions The hybrid operation is suitable for elderly patients or those with high risks. Along with intervention, the hybrid operation needs to be developed as a minimally invasive method.

Background: Coarctation of the aorta (CoA) can either present alone as an isolated condition or in association with other aortic arch or cardiac anomalies. One percent of patients with CoA have concomitant an aberrant right subclavian artery (ARSA). Purpose: We report the case of a 35-year-old woman with uncontrolled hypertension who was found to have CoA and ARSA. Results: The patient was treated successfully using a hybrid procedure comprising ARSA ligation and subclavian to carotid transposition, followed by thoracic endovascular aortic repair. Conclusions: Patients with CoA should be carefully studied, considering the possible coexistence of other congenital aortic arch defects, such as ARSA. Hybrid repair is a safe and effective approach for this condition.

Diverticulum of Kommerell is a congenital anomaly in the development of the primitive embryonic aortic vasculature resulting in either an aberrant left subclavian artery (ALSA) from a right-sided aortic arch (RSAA) or an aberrant right subclavian artery (ARSA) from a left-sided aortic arch (LSAA). Kommerell’s diverticulum (KD), is extremely rare in the general population having prevalence of 0.7–2.0 %. KD with true aneurysmal dilatation like any vascular lesion of the thoracic aorta weakens the vasculature and increases the risk of aortic rupture. Timely surgical intervention is of paramount importance in most of these cases. Variable clinical presentations in patients with KD are either a result of compression of some mediastinal organs or strangulation by the vascular ring from the aberrant subclavian artery (ASA). We report a case of a 39 years old Chinese female with a rare co-existence of a huge KD with a microaneurysm, an aberrant right subclavian artery (ARSA), and ventricular septal defect (VSD). She underwent a successful operation and all her pre-surgical symptoms disappeared.

The objective of the present study was to determine the frequency of malformations and chromosomal abnormalities in a population of fetuses with an aberrant right subclavian artery (ARSA). This is a 6-year retrospective study of fetuses with a prenatal diagnosis of ARSA conducted during the period between September 2013 and June 2019 at a fetal medicine unit. Data were collected from ultrasound, fetal echocardiograms, genetic studies, and neonatal records. An ARSA was diagnosed in 22 fetuses. An ARSA was an isolated finding in 18 out of 22 cases (82%). Associated abnormal sonographic findings were found in 4 cases. All cases underwent invasive testing. In 1 of the cases, a chromosomal abnormality was detected (mos 45,X [13]/46,X,e(X) (p22.1q22.1)). No cases of congenital heart disease were found in any of these fetuses. There were two cases in which the postnatal evaluation revealed a malformation: one case of hypospadias and 1 case of cleft palate. The presence of an isolated ARSA is benign and is not associated with chromosomal abnormalities. The finding of ARSA, however, warrants a detailed fetal ultrasound in order to exclude major fetal abnormalities and other soft markers. O objetivo do presente estudo foi determinar a frequência de malformaçães e anomalias cromossômicas em uma população de fetos com artéria subclávia direita aberrante (ARSA). MéTODOS: Este é um estudo retrospectivo de 6 anos de fetos com diagnóstico pré-natal de ARSA realizado durante o período de setembro de 2013 a junho de 2019 em uma unidade de medicina fetal. Os dados foram coletados de ultrassom, ecocardiograma fetal, estudos genéticos e registros neonatais. Um ARSA foi diagnosticado em 22 fetos. Um ARSA foi um achado isolado em 18 dos 22 casos (82%). Achados ultrassonográficos anormais associados foram encontrados em 4 casos. Todos os casos foram submetidos a testes invasivos. Em um dos casos, foi detectada uma anormalidade cromossômica (mos 45, X [13] / 46, X, e (X) (p22.1q22.1)). Nenhum caso de doença cardíaca congênita foi encontrado em qualquer um desses fetos. Houve dois casos em que a avaliação pós-natal revelou a malformação: um caso de hipospádia e 1 caso de fenda palatina. CONCLUSãO: A presença de ARSA isolado é benigna e não está associada a anormalidades cromossômicas. O achado de ARSA, no entanto, justifica uma ultrassonografia fetal detalhada para excluir anormalidades fetais importantes e outros marcadores leves.

Arteria lusoria is a rare cause of dysphagia in which dysphagia due to esophageal compression. The upper GI endoscopy does not bring significant element that can orient the diagnosis. The injected thoracic CT scan remains the key examination for the diagnosis of dysphagia lusoria and to characterize the defective artery., Arteria lusoria is a rare cause of dysphagia, in which dysphagia due to esophageal compression. The upper GI endoscopy does not bring significant element that can orient the diagnosis. The injected thoracic CT scan remains the key examination for the diagnosis of dysphagia lusoria and to characterize the defective artery.

An aberrant right subclavian artery (ARSA) is a rare arterial anomaly. Although a few cases of total endovascular repair for the ARSA aneurysm have been previously reported, anatomical limitations and the possibility of endoleaks remained. In this case, we created 4 holes on the stent graft for each cervical branch, with reference to the preoperative computed tomography findings. This approach might enable us to repair all types of thoracic aortic aneurysms with ARSA with each anatomical feature.

We report an emergent complex hybrid repair of a type A intramural hematoma with a tear of the aortic arch at the site of Kommerell's diverticulum and an aberrant right subclavian artery. We identified a type IA endoleak intraoperatively, which was managed immediately with proximal extension. Performing this operation in the hybrid operating room facilitated optimal surgical management.

Se presenta una paciente femenina de 54 años con hallazgo incidental de arteria subclavia derecha aberrante, también conocida en la literatura como arteria lusoria. Se puede considerar a la arteria lusoria como la anomalía embriológica del arco aórtico más común; descrita desde 1735 por Hunauld. La incidencia se estima entre 0.5-2% en la población general.1 La anatomía se describe como 4 arterias originandose del cayado aórtico: arteria carótida común derecha, carótida común izquierda, subclavia izquierda y subclavia derecha (la cual cruza la línea media en su recorrido). La prevalencia de esta anomalía varía según la región geográfica, en Estados Unidos se reporta una prevalencia de 0.5%.1 La falta de protocolos estandarizados de tratamiento hacen que el mismo sea basado en criterio médico, la sintomatología del paciente y su capacidad para ser sometido a procedimientos invasivos. La paciente descrita no presentaba sintomatología por lo que no recibió tratamiento.

Background An anomalous origin of the right vertebral artery (VA) from the right internal carotid artery (ICA) occurs only rarely. Case Description A 70-year-old man underwent carotid artery stenting for right internal carotid artery stenosis. In this patient, the right VA arose from the right ICA associated with an aberrant right subclavian artery. Conclusion Embryologically, failure of involution of 1 of the first 6 intersegmental arteries causes various abnormal origins of the VA. The embryonic development of this anomaly is also reviewed.

Aberrant right subclavian artery (ARSA) with associated Kommerell diverticulum (KD) is a rare congenital aortic arch anomaly. Patients with KD have a high risk of rupture, dissection, compression of adjacent structures, as well as distal embolization symptoms. Several treatment options have been proposed (surgical, hybrid, endovascular), however, a consensus regarding optimal surgical management has not been established yet. We present a successful single-stage hybrid repair of distal aortic arch dissection aneurysm with dissecting KD and ARSA with debranching of innominate and left common carotid artery, bilateral carotid-subclavian bypass, and stent grafting.

Purpose of review To address the incidental versus pathogenic nature of dysphagia lusoria and to provide a review of the cause, clinical presentation, diagnosis, and treatment of this condition with respect to recent literature. Recent findings Case reports comprise the majority of recent literature concerning dysphagia lusoria. Many patients with an aberrant right subclavian artery (ARSA) have additional coexisting vascular anomalies. While most individuals present around age 50, some present as children and neonates. Of note, this population may present with dysphagia as opposed to respiratory findings alone, as previously described. In the diagnostic workup, most patients receive a battery of radiologic tests, which may not be necessary. Significantly, dietary modifications and medical management alone may resolve symptoms. Nonetheless, a wide range of operative techniques are available for the treatment of dysphagia lusoria. Summary Clinicians should have a higher suspicion for dysphagia lusoria in patients with known vascular, heart, or chromosomal anomalies. Diagnosis should begin with a barium esophagram followed by a computed tomography angiogram or magnetic resonance angiogram. Avoid unnecessary studies. In many cases, an ARSA may be an incidental finding with comorbid gastroesophageal reflux disease or another medical condition responsible for the symptoms. Medical versus surgical management should be considered on a case-by-case basis.

p.p1 {margin: 0.0px 0.0px 2.9px 0.0px; text-align: justify; font: 9.0px 'Helvetica Neue Light'} Sag aberrant subclavian arter (ARSA), nadir gorulen ve genellikle asemptomatik seyreden konjenital bir anomalidir (populasyonun %0.5-1.8’i). Bu calismada supraklavikular insizyon ile basarili bir sekilde tedavi edilen uc kiz hastanin sunulmasi amaclandi. Ameliyat sirasinda ortanca yas 15’di (aralik: 10-18 yas). Ameliyat sirasinda ve sonrasinda komplikasyon izlenmedi. Bilateral ulnar ve radyal pulsasyonlari ameliyat sonrasi normaldi. Ameliyat sonrasinda beslenme ile ilgili problem gozlenmedi. Supraklavikuler insizyon ile ARSA’ nin uc yan anastomozu, disfaji lusoriasi olan cocuklar icin uygulanabilir ve minimal invaziv bir yontem olarak dusunulmelidir.

Aortic atresia with interrupted aortic arch (IAA) is an exceptional condition. In absence of associated lesion, the flow to the brain and the retrograde flow to the coronary arteries can only come from vessels on the descending aorta. This flow needs to be large enough to supply the brain and the myocardium. The only IAA type compatible with survival is type C where the flow from descending aorta could be insured by the left carotid and the left vertebral artery, branch of the left subclavian artery. Only one such a case was described in the literature. All the other surviving cases had an associated lesion including: a double aortic arch, an aorto-pulmonary window (AP window), an aberrant right subclavian artery or a bilateral patent ductus arteriosus (PDA). We report a case of aortic atresia with IAA type B associated with a double aortic arch that underwent a successful bi-ventricular one-stage neonatal Norwood-Rastelli repair and is doing well after 18 months.

Objectives We present a case in which a 44-year-old female smoker with a complex medical and surgical history presented with acute upper limb ischemia. Methods The patient was diagnosed with thoracic outlet syndrome causing symptomatic thrombosis of an aberrant right subclavian artery associated with diverticulum of Kommerell. The patient had history of extensive surgeries and radiation in the right chest with fibrotic changes, so surgical dissection in the area was associated with significant risk of nerve injury. Therefore, revascularization of the arm was performed via carotid to brachial artery bypass with reversed saphenous vein and the thoracic outlet was decompressed with segmental clavicular resection. Results Patient has been symptom free for 3 years with patent bypass. Conclusions This case demonstrates a unique presentation of distal thrombosis of a symptomatic aberrant right subclavian artery related to thoracic outlet syndrome. The combined claviculectomy–vein bypass is a safe and efficacious surgical approach that provides durable relief.

Aberrant right subclavian is a rare anomaly presenting in 0.3–3.0% of the population. Kommerell’s diverticulum is an aneurysm associated with this phenomen; data relating to its incidence is sparse. Currently there are no well-established guidelines for the treatment of Kommerell’s diverticulum, limitation being the rare occurrence of disease and heterogenous population with disease presentation. This case report illustrates a novel approach to the repair of a symptomatic Kommerrel’s diverticulum with severe coronary disease. Management should be tailored on a case by case basis to the individual patient.

Purpose: Aberrant right subclavian artery (ARSA) associated with Kommerell’s diverticulum (KD) is a common congenital arch anomaly. It can be complicated by type B aortic dissection (TBAD) or aneurysmal formation at its ostium. Recently, hybrid repair with thoracic endovascular aortic repair (TEVAR) has appeared to be more favorable. Due to the normal anatomic proximity of the ARSA to the left subclavian artery (LSA) orifice in KD, coverage of the bilateral subclavian arteries (SCAs) to obtain an adequate proximal landing zone (PLZ) is usually required, and double cervicotomy for SCA revascularization potentially increases the risk of complications. Technique: This technique was demonstrated on a 50-year-old man presenting with progressive aneurysmal formation of KD with ARSA after chronic TBAD. A 3-step technique, namely left cervical debranching with a left common carotid artery to LSA bypass graft, TEVAR, and an LSA-to-ARSA endovascular debranching with a self-expanding covered stent by a through-and-through wire from the right brachial artery to the bypass graft, was performed in a 1-stage repair to cover the primary tear of TBAD and preserve the bilateral SCAs. The postoperative course was uneventful. Conclusion: This technique can prevent complications from double cervicotomy and achieve an adequate PLZ with preservation of the bilateral SCAs for TEVAR.

Abnormal right subclavian artery (ARSA) is the most common anomaly of the aortic arch with a rate of 0.5-1.4%. Normally, three vessels arises from the aortic arch, while four vessels arise in ARSA. ARSA leaves the distal of the aortic arch and passes behind the esophagus and trachea. It is also called the abnormal retroesophageal right subclavian artery. It is generally an asymptomatic benign finding, but it can cause esophageal compression causing dysphagia. In this article, an isolated ARSA and trisomy 21 case referred to our clinic in the second trimester of pregnancy and detected ultrasonographically is presented.

Koolen de Vries syndrome is a rare genetic disorder with an estimated prevalence 1:16000 in the general population but it is considered to be an underdiagnosed syndrome. We report a 17q21.31 microdeletion which was diagnosed prenatally in a fetus with aberrant right subclavian artery (ARSA). Koolen de Vries syndrome is a rare chromosomal abnormality and according to the literature this is the first case in which the detection of ARSA led to this syndrome.

La arteria subclavia derecha aberrante (ARSA) es la anomalía del arco aórtico más común. La probabilidad de hallar un ARSA durante un estudio ecográfico es de alrededor de 1%. En aquellos fetos con ARSA, la probabilidad de tener otros hallazgos cardiacos y/o extracardiacos o una anomalía cromosómica es elevada. La prevalencia de la relación del ARSA con el síndrome de Down es de aproximadamente 20%, por lo que este marcador puede contribuir al asesoramiento del síndrome de Down en el segundo trimestre y probablemente en el primer trimestre. La recomendación ante el hallazgo de ARSA es realizar un estudio detallado de la anatomía fetal en busca de otros marcadores de aneuploidías y realizar ecocardiografía fetal. La realización de estudios invasivos quedará limitado a aquellas situaciones en donde además del ARSA se encuentren otros marcadores u otras condiciones que aumenten el riesgo de síndrome de Down. Sin embargo, ante el hallazgo de ARSA aislado, el incremento en el riesgo es igual a cero, pudiendo considerarse una variante de la normalidad.

IntroductionThis study aims to evaluate the predictive value of color Doppler ultrasound for the diagnosis of aberrant right subclavian artery (ARSA) with a co-occurring non-recurrent right laryngeal nerve (NRLN).Material and methodsIn the present study, 58 patients with ARSA (ARSA group) and 1,280 patients without ARSA (controls) were diagnosed by ultrasonography. In addition, 32 patients with ARSA (ARSA operation group) and controls underwent thyroidectomy with surgical exploration with or without NRLN. Then, the incidence of NRLN was analyzed. The right common carotid artery (RCCA) and right subclavian artery (RSA) trends were observed by ultrasound, and classified into two types: RCCA and RSA originating from the innominate artery (IA) (type I), and IA could not be detected (type II).ResultsA total of 32 cases of NRLN were found in the ARSA operation group, but no case was found in controls, and the difference was statistically significant (p = 0.0006). The difference in the constituent ratio of type I and type II was statistically significant between the ARSA group and controls (p = 0.0002). That is, the IA could not be detected in the ARSA group, which was accompanied by the RCCA that originated from the aortic arch, while the IA was detected in most patients in the control group at the level of the sternoclavicular joints.ConclusionsAberrant right subclavian artery can be rapidly detected by ultra­sonography. Aberrant right subclavian artery occurs when the RCCA originates from the aortic arch during detection. Patients with ARSA sometimes have co-occurring NRLN. Hence, vigilance in protecting the NRLN is needed during an operation.

Typical branching pattern of the left-sided aortic arch consists of the brachiocephalic trunk (BCT), the left common carotid artery (LCCA) and the left subclavian artery (LSA). Variant patterns have been associated with a broad spectrum of pathologies. The meticulous knowledge of potential aortic arch variants is of utmost importance to radiologists, interventional cardiologists, vascular and thoracic surgeons. The current systematic review collects all aortic arch branching patterns and their frequency as published by various cadaveric studies, calculates prevalence taking into account the gender and the different people background, as well. All extracted variant patterns are classified into types and subtypes according to the number of emerging (major and minor) branches (1, 2, 3, 4 and 5) and to the prevalence they appear. In cases of similar prevalence, total cases were taken into consideration; otherwise the variants were classified under the title “other rare variants”. A systematic online search of PubMed and Google books databases was performed only in cadaveric studies. Twenty studies with typical (78% prevalence) and variable (22%) branching patterns were included. Types 3b, 2b, 4b, 1b and 5b had a prevalence of 81%, of 13%, of 5%, 0% and of 0%, respectively. Common variants were the brachiocephalico-carotid trunk (BCCT, 49% prevalence), the aberrant left vertebral artery (LVA, 41%) and the aberrant right subclavian artery (ARSA, 8%). LVA of aortic origin was detected in 32%, the bicarotid trunk (biCT) in 5% and the bi-BCT trunk in 3%. Thyroidea ima artery, a minor branch emerging from the aortic arch was found in 2%. Coexisted variants were detected in 4% (ARSA with a distinct RCCA and LCCA origin), in 3% (BCCT with a LVA of aortic origin), in 2% (ARSA with a biCT and a vertebrosubclavian trunk). No significant gender or ethnic differences exist among the 5 branching types. The proposed classification scheme aims to become a valuable and easy to use tool in the hands of all physicians involved in diagnosis and treatment of aortic arch pathology. It could be also useful in anatomical education, as well.

Background Diagnostic cerebral angiography (DSA) and neurointerventions have traditionally been performed via transfemoral access (TFA). The perception of a steep learning curve associated with transradial access (TRA) has limited adoption in neurointervention. This study compares the learning curves of transradial vs. transfemoral DSA in a cohort of neurointerventional fellows. Methods The first 150 consecutive radial and femoral DSA were identified for each fellow from a prospective neurointerventional registry from July 2017 to March 2020. Total fluoroscopy time and number of intracranial arteries injected were recorded. Mean fluoroscopy time per intracranial artery injected (termed angiographic efficiency) was calculated and was used as a surrogate measure of technical proficiency. Mean angiographic efficiencies were compared across partitions of 25 consecutive DSAs (e.g. 1–25, 26–50, 51–75, etc.). Results There were 607 radial DSA and 635 femoral DSA identified among 5 fellows. The overall angiographic efficiencies were not significantly different based on access site (radial mean 3.2 min, femoral mean 3.7 min, p>0.05). For 3 fellows without prior endovascular experience, technical proficiency was obtained between 25–50 femoral DSA procedures. Among these same fellows, one fellow achieved technical proficiency after 25–50 radial DSA procedures, while the other 2 fellows had flattened learning curves. There were 2 fellows that had no significant learning curve for either access type, but both had extensive experience with endovascular procedures prior to starting fellowship. Two patients (2/1342 = 0.1%) experienced transient neurologic symptoms post-procedure. Among 635 femoral DSA, there were 22 (3.5%) minor adverse events (14 small groin hematomas not requiring transfusion, 1 pseudoaneurysm, 7 non-flow-limiting dissections). Among 607 radial DSA, there were 3 (0.5%) minor adverse events (2 small forearm hematomas, 1 intraluminal wire removed with radial cut-down), which was significantly less than femoral DSA minor adverse events (p=0.0001). Radial to femoral conversion rate was 1.2% (7/607, 2 radial spasm, 2 unsuccessful radial artery access, 3 aberrant right subclavian artery). Femoral to radial conversion rate was 0.3% (2/635). From March 2019 to February 2020, the proportion of DSA performed via transradial access increased from 36% to 78% at our institution. Conclusion This study demonstrates the learning curves for both TRA and TFA diagnostic cerebral angiograms. Proficiency improves significantly with either type of access, typically requiring between 25–50 procedures. TRA DSA have significantly less access site complications than TFA DSA. Disclosures M. Tso: None. G. Rajah: None. R. Dossani: None. M. Meyer: None. M. McPheeters: None. K. Vakharia: None. M. Waqas: None. K. Snyder: None. E. Levy: None. A. Siddiqui: None. J. Davies: None.

We hereby present a rare variant course of left brachiocephalic vein coexisting with an aberrant right subclavian artery in a patient with a ventricular septal defect with pulmonary atresia. This case highlights the importance of CT angiography in diagnosing associated aortic arch and systemic venous anomalies in complex congenital heart diseases.

[Extract] An otherwise well 42-year-old male presented to the emergencydepartment by ambulance with an impalement injury to the rightside of the neck by a 5-cm diameter and 27-cm length tree branchfollowing a motor bike accident. Physical examination on arrivalrevealed a Glasgow Coma Scale of 15, peripheral capillary oxygensaturation 96% on room air, blood pressure 110/70 mmHg andheart rate of 110 sinus rhythm. Besides an evident anhidrosis on theright side of his face, there were no obvious signs of neurovascularcompromise.