Aberrant origin of right vertebral artery from the arch of aorta

We present a rare case of an aberrant right vertebral artery originating from the arch of aorta distal to the origin of the left subclavian artery. The incidence of this particular variant of aberrant origin of the right vertebral artery is extremely uncommon with only seventeen cases reported in literature to date. This case was incidentally detected on a staging positron emission tomography-computerized tomography (PET-CT) scan for lung cancer. We review the incidence, embryological mechanism, and clinical importance of this aberrant course of the right vertebral artery.     

Hydrodynamics of aortic arch vessels during perfusion through the right subclavian artery

BACKGROUND: Performing subclavian artery cannulation in patients with an atherosclerotic ascending aorta or acute aortic dissection is of growing interest. To increase knowledge about pressure and flow distribution in the arch vessels, we investigated the in vitro perfusion characteristics in right subclavian artery cannulation. METHODS: Pressures and flow rates in the arch vessels of an aortic arch model were measured during perfusion through the right subclavian artery with different geometries and varying flow rates. Flow visualization was performed by laser light. RESULTS: In normal subclavian artery geometries, pressure and flow showed a significant increase in only the right common carotid artery (8 mm Hg and 25.5 mL/min, respectively, at 5.5 L/min pump flow). In cases of 50% stenosis at the right subclavian artery origin, a reduction of pressure and flow (6 mm Hg and 22.5 mL/min, respectively, at 5.5 L/min pump flow) in the right carotid artery caused by a suction effect was observed. CONCLUSIONS: Right subclavian artery cannulation provides a valuable alternative for ascending aortic cannulation, enabling nearly balanced arch vessel perfusion. Stenosis at the right subclavian artery origin carries the potential risk of slightly reduced perfusion of the right common carotid artery with questionable clinical relevance.     

Congenital right subclavian artery aneurysm: a case report

Aneurysms of the subclavian artery are unusual. The most common causes are atherosclerosis and trauma. We report one case of an elongated and tortuous right subclavian artery with an aneurysm involving the origin of the right vertebral artery. The patient underwent resection of the lesion with an end-to-end anastomosis of the subclavian artery and implantation of the right vertebral artery into the right common carotid artery. Results were consistent with a rare congenital subclavian aneurysm.     

Palliative right ventricular outflow reconstruction in tetralogy of Fallot with pulmonary atresia and aberrant right subclavian artery; report of a case

A 1-month-old girl weighting 3.1 kg was diagnosed as tetralogy of Fallot (TOF) with pulmonary artery atresia (PA) and aberrant right subclavian artery. Before the operation, pulmonary blood flow from a ducus arteriosus was maintained by lipo prostaglandin E1 (PGE1). The patient underwent palliative right ventricular outflow tract reconstruction (pRVOTR) because the proximal aberrant right subclavian artery was stenotic and the ductus arteriosus and branch of the left pulmonary artery were so close. Postoperative course was uneventful and pulmonary artery showed good growth. The pRVOTR as 1st procedure is a useful method for hypoplastic pulmonary artery to get equal and good growth. Although there are controversies about the size of right ventricular outflow tract (RVOT), 5 or 6 mm diameter of RVOT is recommended for the operative repair of hypoplastic left heart syndrome. We concluded that the pRVOTR should be one of the options as 1st palliative procedure for TOF with PA and diminutive pulmonary artery.     

Translocating the aberrant right subclavian artery in dysphagia lusoria.

A case of dysphagia lusoria with unusual associated symptoms in an adult is presented. The condition was treated by division of the aberrant right subclavian artery at its origin through a median sternotomy and translocating the distal subclavian artery to the aortic arch with an interposition Dacron graft. All the reported techniques of dividing and transposing the aberrant right subclavian artery in dysphagia lusoria are reviewed and discussed.     

Surgical treatment of traumatic aneurysm of descending aorta with abnormal right subclavian artery

Among 11 patients with traumatic aneurysms of the descending thoracic aorta, 2 had developmental anomalies of the branches of the arch of the aorta, in particular, independent origin of the right subclavian artery from the descending thoracic aorta. The anomalous right subclavian artery plays the role of a retaining ligament in trauma, and the forming posttraumatic false aneurysm is localized distal of the ostium of the right subclavian artery. The need for clamping the thoracic aorta and both subclavian arteries for the period of aneurysm reconstruction requires catheterization of the arch of the aorta for arterial pressure control. Surgical correction of aneurysm in anomalous origin of the right subclavian artery has peculiarities of its own in the formation of the proximal anastomosis.     

Implications of anomalous right subclavian artery in the repair of neonatal aortic coarctation

Spinal cord perfusion is predominantly from the anterior spinal artery, which arises from the vertebral arteries by way of the subclavian arteries. Anomalous origin of the right subclavian artery and coarctation of the aorta is considered to be an increased risk factor for spinal cord damage, possibly because of the minimal collateral circulation during aortic clamping. The aim of this study is to review 5 consecutive cases of neonatal aortic coarctation with ARSA. METHODS: Five neonates (0.8 to 4.6 kg) underwent operation between July 1999 and December 2000 with resection of the coarctation and end-to-end anastomosis. Both subclavian arteries (n = 5) and left carotid artery (n = 4) were clamped, leaving the right carotid artery as the sole provider of perfusion for the spinal cord. RESULTS: Despite clamping of both subclavian arteries, right radial artery pressure was measurable in 4 of the 5 cases. Aortic cross-clamp times varied from 12 to 26 minutes at a core temperature of 34 degrees to 35 degrees C. There was no operative mortality. None of the neonates developed any major neurologic sequelae. CONCLUSIONS: When clamping the two subclavian arteries during coarctation repair, the spinal artery is left with collateral blood flow that can theoretically originate from the carotid arteries through the circle of Willis and retrogradely down the vertebral arteries. The presence of such collateral circulation was documented as recordable blood pressure in the right radial artery during surgical repair.     

A case of right aortic arch with the stenotic left subclavian artery at its origin complaining of left nuchal pain

A 25 year-old male was transfered to our department with a complaint of left nuchal pain. Angiography revealed a right aortic arch with the stenotic left subclavian artery at its origin and poor left vertebral artery. The anomaly was classified an intermediate type of Stewart type (2) and (3). It was very rare and we have found only 3 same cases in literature. The complaint disappeared after the ascending aorto-left subclavian artery bypass.     

Anomalous right subclavian artery with ascending aortic aneurysm: a case report

We report a rare case of the ascending aortic aneurysm with an anomalous origin of the right subclavian artery. The right subclavian artery branched from the aorta as the fourth major vessel and ran behind the esophagus. Moreover, the left and right coronary arteries arose ectopically from the posterior and the left aortic sinus, respectively.     

Giant pseudoaneurysm of right subclavian artery presenting with severe respiratory distress

Subclavian artery pseudoaneurysms are rare; and cases involving subclavian artery pseudoaneurysms presenting with compression on trachea leading to breathing difficulty are exceptional. We present a case report of huge subclavian artery pseudoaneurysm presenting with hoarseness of voice, respiratory distress, and aphonia. Patient was operated through median sternotomy, with the incision extended over the swelling. Aortic looping was done before opening the aneurysm. Rent in the right subclavian artery was identified and repaired. Because of the absence of a distal pulsation beyond the repaired site, we placed a reversed saphenous vein graft from the ascending aorta (end-to-side) to the right subclavian artery distal to repaired site (end-to-side). Good pulsation was achieved in the right brachial, right radial, and right ulnar arteries. Patient was extubated after 6 hours in stable condition.     

Combined open and endovascular repair of a true right subclavian artery aneurysm without proximal neck

A 52-year-old man, without a medical history, presented with an incidentally detected large, intrathoracic aneurysm of the right subclavian artery. The aneurysm was characterized by the absence of a proximal neck and extended distally close to the origin of the right vertebral artery. We successfully excluded this aneurysm with a combined endovascular and minimally invasive open repair, thereby avoiding a sternotomy or lateral thoracotomy: a stent-graft was placed from the proximal brachiocephalic trunk to the common carotid artery, completely covering the origin of the right subclavian artery. The right subclavian artery was oversewn just distally to the aneurysm and revascularization of the right arm was assured by a carotido-subclavian bypass. Clinical follow-up was uneventful and radiological follow-up by CT-scan showed discrete, but progressive shrinkage of the completely excluded aneurysm.     

A median sternotomy approach for symptomatic right subclavian artery in the adult]

A case of 33-year-old woman with aberrant right subclavian artery was reported. She was admitted to the hospital complaining of progressive dysphagia of six months' duration. The esophagogram revealed an oblique tubular defect in the superior thoracic esophagus. Aortograms confirmed the presence of an anomalous right subclavian artery arising as a fourth branch of the aortic arch, passing behind the esophagus in its course to the right arm. Operation was performed on Sept. 4, 1990. Through a median sternotomy, the ascending aorta and the two carotids were dissected free. With gentle forward retraction of the ascending aorta to the left, the origin of the aberrant right subclavian artery could easily be exposed. The right subclavian artery was then divided and its origin from the distal aortic arch oversewn. The vessel was removed from the retroesophageal position and blood flow reestablished to the right arm by an end-to-side anastomosis to the right carotid artery, using a temporary shunt tube. These procedures were accomplished without difficulty. Postoperatively, the patient made an uneventful recovery and was discharged 16 days after the procedure. A postoperative esophagogram confirmed the removal of the esophageal compression. The blood pressure was equal in the two upper extremities. In follow-up study, her symptoms had completely disappeared.     

A case of traumatic aneurysm of innominate artery with occlusion of right subclavian artery

A 42-year-old woman with history of chest blunt trauma from an automobile accident 250 days earlier had suffered easy fatigability of the right upper extremity. She had difference of blood pressure between upper extremities, 94/60 mmHg in the right and 126/70 mmHg in the left. Chest CT showed dilation of the innominate artery which compressed the trachea. Aortography showed an aneurysm of the innominate artery and occlusion of the right subclavian artery at its origin. The aneurysm of the innominate artery was resected and replaced with a 6 mm Dacron graft with aid of the external shunt. The right subclavian artery was also reconstructed with same graft. The aneurysm of the innominate artery should be suspected as a rare complication in blunt trauma of the chest.     

Percutaneous stenting for symptomatic stenosis of aberrant right subclavian artery

Aberrant origin of the right subclavian artery is the most common abnormality of the aortic arch vessels and occurs in approximately 0.5% to 1% of the population. Symptoms can result from compression of the esophagus by the aberrant vessel, aneurysm formation, or atherosclerotic occlusion. Occlusive symptoms are typically relieved by surgical revascularization (i.e., transposition or carotid-subclavian bypass) through a cervical approach. An alternative approach to the management of stenosis of normal subclavian arteries is percutaneous angioplasty and stenting, an approach not previously used for occlusive disease of an aberrant right subclavian artery. We describe a case of focal stenosis of an aberrant right subclavian artery causing dizziness and arm claudication in a patient who underwent successful percutaneous angioplasty and stenting. (J Vasc Surg 1998;27:756-8.)     

Anomalous origin of the right coronary artery from the pulmonary artery combined with aortic valve stenosis

We report the case of a 41-year-old patient presenting with anomalous of origin of the right coronary artery from the pulmonary artery (ARCAPA) and severe aortic valve stenosis. Surgical correction was performed by partial (T-shaped) sternotomy. After replacing the bicuspid aortic valve, the right coronary artery ostium was directly reimplanted into the aortic root. The main pulmonary artery was reconstructed using an autologous pericardial patch. Postoperative recovery was uneventful. Four cases involving an association of the bicuspid aortic valve and ARCAPA have been reported in the literature. This potential relationship should be considered whenever diagnosing a bicuspid aortic valve.     

Hypoplastic left heart syndrome with anomalous origin of the right coronary artery

Hypoplastic left heart syndrome in association with an anomalous origin of a coronary artery from the pulmonary artery is a very rare congenital malformation. In the few reported cases, the left coronary artery or the circumflex artery arises from the right pulmonary artery. We describe a newborn who presented with hypoplastic left heart syndrome, and at the time of operation had an anomalous origin of the right coronary artery from the right pulmonary artery that was detected. The patient underwent a successful modified Norwood procedure with direct reimplantation of the right coronary artery to the neo-aorta.     

Interrupted left aortic arch and isolated right subclavian artery from the right pulmonary artery

We report a 10-day-old newborn, weighing 2.9 kg with an interrupted left aortic arch type B, a large subarterial ventricular septal defect and a right ductus connecting the right pulmonary artery to an isolated right subclavian artery. The patient underwent successful total surgical repair and the isolated right subclavian artery was ligated. He was discharged from hospital without complication and maintains excellent perfusion to the right arm via collaterals.     

Surgical treatment of anomalous origin of the left coronary artery in infancy

Two cases of anomalous origin of the left coronary artery (LCA) from the pulmonary artery (PA) are reported in which early surgical correction was achieved by an end-to-end anastomosis of the left subclavian artery (LSA) to the LCA, with cardiopulmonary bypass and deep hypothermia. The clinical improvement was rapid and the left ventricular function recovered almost completely. We recommend this type of surgical correction, early in life, for infants in severe cardiac failure and anomalous origin of the LCA.     

High incidence of arterial dissection associated with left vertebral artery of aortic origin

The incidences of arterial dissection of the vertebral artery (VA) of aortic origin and VA of subclavian artery origin were determined. The origins of the left and right VAs were confirmed by angiography in 860 and 717 patients, respectively. Left VA of aortic origin was found in 21 patients (6 females and 15 males) but no right VA of aortic origin was found. Left VA of left subclavian artery origin was found in 837 patients and right VA of right subclavian artery origin in 717 patients. Arterial dissection of the VA occurred in 17 patients (6 females and 11 males), four patients with left VA of aortic origin, seven with left VA of left subclavian artery origin, four with right VA of right subclavian artery origin, and two with bilateral VAs of subclavian artery origin. Left VA of aortic origin (4 of 21 patients) was associated with a significantly higher incidence of VA dissection than left VA of left subclavian artery origin and right VA of right subclavian artery origin (p < 0.001). Left VA of aortic origin is associated with a predilection for VA dissection in comparison to VA of subclavian artery origin.     

Anomalous vertebral artery origins: the first and second reports of two variants

We present two cases of aberrant origins of vertebral arteries. Case 1 is of a patient undergoing evaluation of an infrarenal aortic aneurysm stent graft. Computed tomography (CT) angiogram revealed an aberrant right vertebral artery that subsequently joined a second right vertebral artery that had the typical origin off the right subclavian artery. This represents an unusual anatomic variation not previously reported in the literature. Case 2 is of a patient being evaluated for thoracic aorta injury. CT angiogram of the chest revealed a five-vessel aortic arch with aberrant origin of the bilateral vertebral arteries distal to the left subclavian artery.