Incidental finding of arteria lusoria during transradial coronary catheterization: Significance in interventional cardiology

Arteria lusoria is the most common anomaly of the aortic arch with an incidence of 0.5%–2.5%. It is mostly diagnosed incidentally while performing imaging for evaluation of other unrelated medical conditions. The aberrant right subclavian artery arises beyond the origin of the left subclavian artery from the aortic arch. This results in a complex right‐subclavian‐aortic anatomy which leads to difficulty in transradial coronary angiography. This can lead to prolonged procedure time and increased use of catheters by unaware interventionists. This is even more important if this is encountered in the setting of an acute myocardial infarction. Our review takes into account clinical significance of this uncommon anomaly in the field of interventional cardiology.     

Dysphagia lusoria: a comprehensive review

Dysphagia lusoria is a rare vascular anomaly identified in a small number of patients being evaluated for dysphagia. The purpose of this paper is to present an illustrative case and provide a comprehensive review of the underlying anatomy, diagnosis, and management of dysphagia lusoria based on a review of the medical and surgical literature over the past 20 years.     

Aberrant subclavian artery causing difficulty in transhiatal esophageal dissection

The right subclavian artery normally arises from the brachiocephalic artery. Anomalies in development may lead to peculiar problems during surgery. We report a patient with esophageal carcinoma who had an aberrant right subclavian artery, posing specific difficulties during a transhiatal esophagectomy, requiring conversion of the procedure into a transthoracic approach. The embryologic basis of this anomaly and the clinical significance are discussed.     

迷走右锁骨下动脉合并主动脉夹层1例

迷走右锁骨下动脉（ARSA）是发自降主动脉近端较常见的主动脉弓大血管异常。ARSA在起始部位可出现内膜撕裂而导致主动脉夹层的发生,从而引起血流受限和后期的动脉瘤样变性。笔者报道了1例起源于ARSA的急性A型主动脉夹层。ARSA合并A型主动脉夹层实属罕见,术前经CT血管造影（CTA）得以确诊,CTA对本病进行外科治疗决策非常有价值。临床医师应对迷走右锁骨下动脉合并主动脉夹层引起注意,以做到早期诊断,早期处理。     

Subclavian Steal Phenomenon Associated With Vascular Ring in an Infant Who Had a Prenatally Diagnosed Right Aortic Arch With an Atretic Aberrant Left Subclavian Artery

Vascular ring is a rare congenital anomaly in which the abnormal origin of the aorta or its branches and pulmonary arteries leads to encircling and compression of the trachea and esophagus. A right aortic arch (RAA) with an aberrant left subclavian artery is one of the most common forms of vascular ring. Here, we report a case of a prenatally diagnosed vascular ring resulting from an RAA with an aberrant left subclavian artery. When the infant was 7 months of age, the development of noisy breathing prompted further evaluation with cardiac magnetic resonance imaging that showed an atretic left subclavian artery associated with collateral retrograde flow from the left vertebral artery to the distal portion of the subclavian artery. Our findings indicate that an untreated RAA with an aberrant left subclavian artery may be associated with an increased risk of developing subclavian artery steal syndrome.     

Subclavian artery dissection during diagnostic cardiac catheterization: The role of conservative management

Dissection of the subclavian artery during routine cardiac catheterization while obtaining cannulation to the left internal mammary artery is an unusual complication and to our knowledge has never been reported. Conservative management of this vascular injury can avoid the sequelae of high-risk surgical repairs made difficult by a complex operative exposure. We describe a case in which dissection of the left subclavian artery was treated conservatively with an excellent outcome.     

Selective use of superficial temporal artery cannulation in infants undergoing cardiac surgery

Arterial cannulation is routinely performed in children undergoing cardiac surgery to aid the intraoperative and intensive care management. Most commonly cannulated peripheral site in children is radial artery, and alternatives include posterior tibial, dorsalis pedis, and rarely superficial temporal artery (STA). Two specific situations in cardiac surgery where STA cannulation and monitoring was useful during the surgical procedure are reported. To our knowledge, such selective use of STA pressure monitoring has not been reported in the literature previously. Our experience suggests that STA monitoring can be useful and reliable during repair of coarctation of aorta or administration of anterograde cerebral perfusion in patients having associated aberrant origin of the right subclavian artery.     

Improvement of left ventricular diastolic function after alcohol septal ablation for obstructive hypertrophic cardiomyopathy? Yes, of course, but...: reply

We would like to thank Dr Veselka for his interest in our workand appreciate the opportunity to respond to his letter. Ourarticle illustrated that successful alcohol septal     

Aneurysms of an aberrant right subclavian artery: report of two cases

Aneurysm of the aberrant right subclavian artery is rare. We report two patients who underwent successful repair using hypothermic circulatory arrest and retrograde cerebral perfusion. One patient presented with progressive dysphagia to solids and hoarseness of voice due to pressure exerted by the expanding aneurysm, and the second patient, with a dissected subclavian aneurysm, presented with transient ischaemic attacks and a previous cerebral infarct secondary to embolism. Repair in both patients was done through a median sternotomy with femoral arterial and right atrial venous cannulation. Under hypothermic circulatory arrest, the origin of the subclavian aneurysm was divided off the aorta and closed with a Dacron patch from outside the aorta in one patient, and from within the aorta in the other patient. Concomitant revascularisation of the right upper limb was achieved using a 12-mm Hemishield Dacron graft from the ascending aorta to the distal right subclavian artery. The graft to subclavian anastomosis was done under hypothermic circulatory arrest as distal control was not possible. The graft to the aortic anastomosis was done over a side-biting clamp during rewarming. Both patients were successfully treated without major morbidity.     

Successful urgent endovascular surgery for symptomatic subclavian artery aneurysmal compression of the trachea.

The purpose of this study is to report the progress of a patient who entered the hospital with symptomatic tracheal compression from a large right subclavian artery aneurysm that was treated with a self-expanding stent graft. The patient was at increased risk for traditional surgery, thus endovascular isolation of the aneurysm was felt to be reasonable. A flexible self-expanding stent graft was placed via a brachial artery cutdown and common femoral access without complication. The symptoms improved and the patient remained asymptomatic at 2-year follow-up with serial CT scan confirmation of aneurysm regression. This unusual case illustrates that endovascular decompression of an aneurysm may have some benefit in alleviating subacute symptoms of extrinsic encroachment into other vital structures. Technical and clinical success was achieved with the stent graft deployment and this seems to be a reasonable alternative to surgery in such patients.     

Utility of endoscopic ultrasound in the diagnosis of aberrant right subclavian artery

BACKGROUND AND AIMS: Aberrant right subclavian artery (ARSA) is the most common congenital anomaly of the aortic arch occurring in 0.4-2.0% of the general population. Instead of arising from the brachiocephalic artery, the ARSA arises as the last branch from the aortic arch. The aim of this study was to determine the prevalence of ARSA in patients undergoing upper endoscopic ultrasound (EUS) and to describe the EUS characteristics of ARSA. METHODS: A retrospective review was conducted of 7513 upper EUS exams performed from 1 July 2000 to 1 February 2005. RESULTS: In total, 27 (0.36%, 95% CI 0.22-0.50%) of 7513 patients undergoing upper EUS were found to have an ARSA (10 male, 17 female; mean age 58 years, range 23-81 years). Of the 27 patients, 16 had only radial EUS, 10 had radial and linear EUS, and one had only linear EUS. In all 26 patients who underwent radial imaging, a well-defined, anechoic tubular structure was seen originating from the aortic arch and passing between the esophagus and spine. In all 11 patients undergoing linear imaging, the abnormal anatomy was detected and the vascular nature confirmed by Doppler. In one patient, both radial and linear imaging identified unsuspected aneurismal dilatation of the ARSA; a rare condition referred to as Kommerell's diverticulum (KD). None of the other 26 patients had symptoms to suggest an ARSA. Of the 14 patients who had computed tomography (CT) prior to EUS, only four were initially reported to have ARSA. However, later review of the CT scans verified an ARSA in all 14 patients. Of the two patients who underwent a barium swallow, only one had findings suggestive of ARSA. CONCLUSIONS: This report highlights the utility of both radial and linear EUS imaging in identifying previously unsuspected ARSA and associated anomalies. This report also suggests the need for careful review of the CT in patients suspected of having ARSA due to the frequent failure of radiologists to identify, or report, this anomaly when particular focus is not given.     

Pseudopulmonary artery sling in a 22q11 deletion newborn with tetralogy of Fallot and isolated left subclavian artery

We report an interest and mystifying cardiovascular imaging in a 22q11 deletion neonate with rare congenital heart defects, including anomalous origin of the left pulmonary artery arising from the right pulmonary artery and in front of the trachea, called pseudo-pulmonary artery sling, combined with isolated left subclavian artery confirmed by multidetector row computed tomography.     

Emergent stent graft isolation of a knife-related subclavian arterial venous fistula: lessons learned during long-term follow-up.

We present the unusual case of a 42-year-old gentleman who entered the trauma center with a hemothorax and intermittent bright red pulsatile blood from three stab wounds in the ipsilateral supraclavicular fossa. The patient was found on emergent angiography to have a large right subclavian artery to vein fistula that was treated successfully with a Dacron-covered stent. Angiography, 2 years following stent-graft isolation, confirmed a durable result with evidence of hemodynamically insignificant neointimal growth through the pores of the graft material. This case provides insight into the long-term effects of a Dacron-covered stent in patients with traumatic arterial injury. We discussed the advantages and disadvantages of different graft materials based on these angiographic findings.     

The aquarium in the right heart

We presented a case with massive hepatic portovenous gas (HPVG) and gastric emphysema, probably due to increased intraluminal pressure in the stomach after bagging and noninvasive ventilation. There are multiple microbubbles in the inferior vena cava, right atrium and right ventricle. There has been only one case report ever published showing the similar features of the “aquarium sign” in the right heart in a patient with intussusception. We believe our case is a good illustration of this extremely rare entity in echocardiography.     

Fatal subclavian stent infection remote from implantation.

We report the unusual case of a 66-year-old alcoholic male who presented with acute arm ischemia 4 months following ipsilateral subclavian artery stenting. The patient had a petechial rash and Janeway lesions in the distribution of the affected subclavian artery. He had been treated for an infected dialysis graft 10 days prior to entry into the hospital. Subsequent angiogram confirmed a patent stent with intraluminal filling defects and occlusion of the brachial artery. Thrombectomy yielded material that was consistent with septic emboli and CT scan of the chest was suggestive of a mycotic aneurysm around the stent. The subclavian stent was removed surgically and the aneurysm was repaired. Unfortunately, the patient had multiple comorbidities and died of complications during recovery. This is the first case of a subclavian stent infection following septicemia remote from implantation.     

A Different Kind of Christmas Tree: Anomalous Origin of the Right Coronary Artery from the Pulmonary Artery (ARCAPA)

Anomalous right coronary artery from the pulmonary artery (ARCAPA) is a rare congenital coronary anomaly that has an incidence of 0.002%. We report a case of a previously healthy female who presented to our hospital with pneumonia and was incidentally discovered to have ARCAPA. This was initially diagnosed on echocardiography by the unusual echocardiographic finding of multiple color flow Doppler signals around the right ventricular free wall and apex which were subsequently confirmed by angiography to be due to extensive collateral circulation between the left and right coronary arteries. This represents an unusual echocardiographic manifestation of this very rare condition.     

Balloon angioplasty of postoperative coarctation in the transverse arch in infants: protecting the common carotid artery.

We performed balloon angioplasty in three patients with postoperative coarctation in the transverse arch adjacent to the left common carotid artery. The age at arch reconstruction was 5, 6, and 2 days, while the interval between operation and balloon dilatation was 59 days, 87 days, and 12 months, respectively. Two balloons, one in the stenosis and the other in the left common carotid artery, were introduced over a wire sequentially and inflated simultaneously until the waist of the balloon in the arch disappeared. After balloon dilatation, a significant reduction in the peak-to-peak pressure gradient and an increase in vessel diameters were observed in all patients. Further growth of the transverse arch was documented at follow-up in two patients. No aneurysm has been detected in any patients. We believe that placing a protective balloon in the neck vessel increases safety during balloon dilatation of coarctation in the transverse arch.     

Response to Gauster et al.

SIR, We would like to thank Dr Gauster and his colleagues fortheir interest in our article and their helpful comments regardingthe figure on trophoblast MHC-I. In our article, we aimed     

Endovascular treatment of the subclavian artery: stent implantation with or without predilatation.

The endovascular treatment of subclavian artery (SA) lesions is less invasive than open surgical repair, with a low rate of complications. We report our experience in 89 subclavian obstructive lesions (n = 86) treated with stenting: 76 (85.3%) stenoses and 13 (14.6%) total occlusions. The left side was most frequently involved (83.1%), localized at the prevertebral segment in 91%. Technical success was obtained in 83 (93.3%) cases, 100% in stenotic lesions and 53.8% in total occlusions. There were nine global complications (10.1%): five (5.6%) at site of puncture, two distal embolization (2.2%), and two (2.3%) major events. The long-term follow-up was 3.51 +/- 1.98 years, during which time 13 (16.8%) restenoses and 2 (2.6%) reocclusions were noted. Subgroup analysis of patients with stenting after predilatation versus direct stenting technique showed in-hospital complications only in the first group, with a restenosis rate of 28.5% vs. 4.7%, respectively (P = 0.003). We consider stenting for SA obstructive lesions the first therapeutic option.     

The Heterogeneity of Microsatellite Instability in Multiple Gastric Cancers

To obtain a better understanding of the role of genetic instability in developing gastric cancer, it is of great interest to examine microsatellite alterations in synchronous multiple gastric cancers that are thought may have the same genetic background and the same microenvi-ronment of the stomach. We report our experience with two patients with synchronous multiple gastric cancers: patient 1 showed two carcinomas in the stomach, whereas patient 2 showed two carcinomas and two adenomas in the stomach. We examined the DNAs from the two cases for microsatellite instability and expected that the status of microsatellite instability in each tumor from the same stomach would be the same. However, patient 2 revealed heterogeneity in the microsatellite instability, i.e . an early cancer that showed some apparent alterations, whereas the other advanced cancer and two adenomas did not. On the other hand, neither of the two carcinomas in patient 1 showed microsatellite instability. To our knowledge, there has been no previous report of microsatellite instability in multiple gastric cancers. In this report, we describe a case that revealed such a heterogeneity of the microsatellite instability, in which the carcinogenic process of each tumor may undergo different genetic alterations even under the same genetic conditions and background.