Aberrant Origin of Vertebral Artery and its Clinical Implications

Abstract Aberrant origin of vertebral artery is rare. The anatomical features and clinical significance of this lesion remain to be clarified. A comprehensive collection of the pertinent literature resulted in a cohort of 1286 cases involving 955 patients and 331 cadavers. There were more left than right and more unilateral than bilateral aberrant vertebral arteries. Patients with aberrant origin of vertebral artery were often asymptomatic and in only 5.5% of the patients their symptoms were probably related to the aberrant origin of vertebral artery. The acquired cardiovascular lesions were present in 9.5% of the patients, 20.9% of which were vertebral artery-associated lesions. Eight (0.8%) patients had a vertebral artery dissection. Logistic regression analysis showed significant regressions between bovine trunk and left vertebral artery (P=0.000), between the dual origins of vertebral artery and cerebral infarct/thrombus (P=0.041), between associated alternative congenital vascular variants and cervical/aortic dissection/atherosclerosis (P=0.008). Multiple logistic regression demonstrated that side of the aberrant origin of vertebral artery (left vertebral artery) (P=0.014), arch branch pattern (direct arch origin) (P=0.019), presence of the common trunk (P=0.019), associated acquired vascular disorder (P=0.034) and the patients who warranted management (P=0.000) were significant risk predictors for neurological sequelea. The patients with neurological symptoms and those for neck and chest operations/ interventions should be carefully screened for the possibility of an aberrant origin of vertebral artery. The results from the cadaver metrology study are very helpful in the design of the aortic stent. The arch branch pattern has to be taken into consideration before any maneuver in the local region so as to avoid unexpected events in relation to aberrant vertebral artery.

Subclavian and axillary arterial aneurysms: two case reports / Aneurismas do segmento subclavio-axilar: relato de dois casos

Aneurysms of the subclavian-axillary segment are rare, but when diagnosed they must be treated. This article describes two cases of aneurysms of the upper extremities, one in a subclavian artery and the other in an axillary artery. The first case was a 71-year-old male with a pulsating supraclavicular bulge on the right and muscle weakness in the ipsilateral extremity. Duplex scanning and arteriography confirmed the diagnosis of aneurysm of the right subclavian artery and the patient underwent aneurysmectomy and end-to-end anastomosis. The second case was a 24-year-old female patient, with no history of comorbidities, who presented with a pulsating mass in the right axillary region and paresthesia of the ipsilateral extremity. Duplex scanning and arteriography confirmed an aneurysm in the right axillary artery, which was successfully treated with aneurysmectomy and end-to-end anastomosis. Pathology findings showed that the first case was an atherosclerotic aneurysm and the second was a congenital aneurysm.

Os aneurismas do segmento subclávio-axilar são de ocorrência rara e, uma vez diagnosticados, devem ser tratados. Neste trabalho, relatamos dois casos de aneurismas de membros superiores, sendo um da artéria subclávia e outro da artéria axilar. No primeiro caso, o paciente de 71 anos, sexo masculino, apresentava abaulamento pulsátil supraclavicular direito associado à fraqueza muscular no membro ipsilateral. Foram realizados duplex scan e arteriografia, que confirmaram o diagnóstico de aneurisma da artéria subclávia direita, sendo o paciente submetido à aneurismectomia com anastomose término-terminal. No segundo caso, uma paciente de 24 anos, do sexo feminino, sem antecedentes mórbidos ou comorbidades, apresentava queixa de massa pulsátil na região axilar direita associada à parestesia no membro ipsilateral. O duplex scan e a arteriografia confirmaram o aneurisma da artéria axilar direita, que foi tratado com aneurismectomia e anastomose término-terminal com sucesso. O diagnóstico anátomo-clínico foi de aneurisma aterosclerótico no primeiro caso e, no segundo caso, de aneurisma congênito.

Estenose aórtica supravalvar em adulto com anomalia de vasos da base e insuficiência aórtica / Supravalvular aortic stenosis in adult with anomalies of aortic arch vessels and aortic regurgitation

A estenose aórtica supravalvar é uma rara cardiopatia congênita, bastante incomum em adultos. Apresentamos um caso de estenose aórtica supravalvar em adulto com anomalia de vasos do arco aórtico, já com presença de insuficiência aórtica importante, tratado com êxito por meio de plastia da aorta ascendente e troca valvar aórtica.

The supravalvular aortic stenosis is a rare congenital heart defect being very uncommon in adults. We present a case of supravalvular aortic stenosis in adult associated with anomalies of the aortic arch vessels and aortic regurgitation, which was submitted to aortic valve replacement and arterioplasty of the ascending aorta with a good postoperative course.

Arterite actínica de artéria subclávia: relato de caso e revisão de literatura / Actinic arteritis of subclavian artery: case report and literature review

Diversas são as complicações possíveis da radioterapia na adjuvância do tratamento de neoplasias. Lesões actínicas de artéria subclávia em pacientes submetidos a este tipo de tratamento para neoplasia de mama são complicações conhecidas, porém com poucos relatos de casos publicados. No presente relato, descrevemos um caso de oclusão de artéria subclávia direita em paciente submetida à radioterapia para tratamento de neoplasia de mama, tratada com a revascularização convencional, com interposição de enxerto de politetrafluoretileno (PTFE). Na revisão da literatura realizada, foram encontrados doze casos descritos que evidenciaram diferentes opções terapêuticas. Concluímos que a arterite actínica de artéria subclávia é uma doença incomum, entretanto sua hipótese deve ser aventada em todos os pacientes com isquemia de membro superior já submetidos a tratamento de radioterapia.

Several complications may occur as a consequence of adjuvant radiotherapy for cancer. One of these complications is actinic lesions of the subclavian artery in patients undergoing radiotherapy for breast cancer; however, there are few reported cases. In the present case report, we describe a case of right subclavian artery occlusion in a patient undergoing radiotherapy for breast cancer. Occlusion was treated by means of conventional artery bypass with interposition graft with polytetrafluoroethylene (PTFE). Our extensive review of the literature revealed 12 reported cases showing the different treatment options performed. We concluded that actinic arteritis of the subclavian artery is an uncommon condition; however, its presence should be considered in all patients with upper limb ischemia who underwent radiotherapy.

Morphology and incidence of atherosclerotic lesions in subclavian arteries - a human autopsy study

To assess different morphological categories of atherosclerotic lesions and their incidence in relation to age and sex in our population. Prospective descriptive observational study. This study was conducted at Mortuary of King Edward Medical University Lahore and Department of Pathology Allama Iqbal Medical College Lahore and completed in one and a half year from. A total of 30 human autopsies were carried out at random. The age range was between 8 and 85 years. Right and Left subclavian arteries were taken out from dead bodies. They were opened lengthwise. One to four areas of tissue were taken from each artery in all cases. Section were prepared from paraffin blocks. They were stain with Haematoxylin and Eosin stain. Special stains were also performed to differentiate all the components of atherosclerotic lesions. The fibrolipid plaques were seen in l3 cases in the right subclavian artery and I3 cases in left subclavian artery. The complicated lesions were seen in 8 cases in the right subclavian artery and 9 cases in the left subclavian artery. 6 of these 8 cases showed ulceration in the right subclavian artery and 2 showed intimal vascularization and haemorrhage alongwith thrombus formation. In the left subclavian artery the ulceration was seen in 7 cases and intimal vascularization and haemorrhage in 2 cases along with thrombus formation. The calcified lesions were present in 7 cases in the right subclavian artery and 8 cases in the left subclavian artery. The morphological changes in media and elastics were seen in 7 cases in right subclavian artery and 8 cases in left subclavian artery. In this study different atherosclerotic lesions are categorized and their relation to age and sex is appreciated in our population. This study is although is preliminary but gives basic and useful data about the incidence of ischemic changes in upper limbs due to raised atherosclerotic lesions in subclavian arteries

Artere sous-claviere droite aberrante. Considerations anatomo-cliniques

Introduction : L'artere sous-claviere droite aberrante est une variation anatomique rare de l'origine de l'artere sous-claviere droite qui nait au-dessous de l'artere sous-claviere gauche. Souvent latente; elle peut se reveler par une dysphagie dite dysphagia lusoria.Observations : Les auteurs rapportent trois observations d'artere sous-claviere droite aberrante (arteria lusoria) decouvertes chez des enfants de facon fortuite. Deux cas etaient reveles par la tomodensitometrie respectivement lors du bilan d'une coarctation de l'aorte et d'une pleuresie enkystee et un troisieme de decouverte peroperatoire au moment de la cure palliative d'une tetralogie de Fallot. Dans tous les cas; aucun geste n'etait realise sur la variation anatomique qui etait asymptomatique. Avec l'apport de l'angiographie numerisee; l'anomalie vasculaire doit etre systematiquement recherchee lors du bilan des malformations cardiovasculaires et viscerales chez l'enfant afin de prevenir ses complications et les surprises operatoires. L'indication chirurgicale est reservee a la dysphagie rebelle au traitement medical et aux formes compliquees. A l'occasion de ces observations; les auteurs font une revue de la litterature permettant de proceder a une mise au point de cette affection au plan anatomique; diagnostique et therapeutique

Left subclavian artery aneurysm presenting as pseudocoarctation on CT angiogram.

A 36-year-old, hypertensive gentleman with aneurysm of left subclavian artery revealed CT picture suggestive of left subclavian aneurysm with psuedocoarctation of aorta. Cardiac catheterization showed no gradient across the psuedocoarct segment.

Penetrating neck trauma and the aberrant subclavian artery

Vascular injuries from penetrating trauma to the base of the neck are accompanied by significant morbidity and potential mortality. These injuries require several diagnostic adjuncts in order to facilitate early diagnosis and appropriate treatment. Herein reported is the case of a patient who sustained penetrating injury to the thoracic inlet but had a fortuitous anomaly that prevented vascular injury and its attendant complications.

Espessamento médio-intimal na origem da artéria subclávia direita como marcador precoce de risco cardiovascular / Intima-media thickness in the origin of right subclavian artery as an early marker of cardiovascular risk

OBJETIVO: O espessamento médio-intimal (EMI) na artéria carótida comum é considerado fator de risco cardiovascular e marcador de doença arterial coronariana precoce. O objetivo deste trabalho foi investigar a existência de correlação entre o EMI nas artérias carótidas e na origem da artéria subclávia direita, e avaliar o EMI na artéria subclávia como um marcador mais precoce para avaliação de risco cardiovascular. MÉTODOS: Cento e seis pacientes consecutivos, 52 homens e 54 mulheres, com média de idade de 51 anos, foram submetidos à avaliação das artérias carótidas e subclávia direita pela ultra-sonografia vascular com Doppler colorido. Para avaliar a associação entre EMI das artérias carótidas e subclávia direita calcularam-se o coeficiente de correlação de Pearson e o intervalo de 95 por cento de confiança para esse coeficiente. A qualidade da medida do EMI da artéria subclávia direita para diagnóstico de espessamento precoce, considerando-se o espessamento da carótida como padrão de referência (> 0,8 mm), foi descrita por valores de sensibilidade, especificidade, valor preditivo positivo, valor preditivo negativo e acurácia. Pontos de corte para o EMI da artéria subclávia foram sugeridos pela Curva ROC. Valores de p < 0,05 foram considerados estatisticamente significantes. RESULTADOS: Na associação entre 41 artérias carótidas sem EMI, 30 (73 por cento) artérias subclávias direitas apresentavam EMI > 0,8 mm. O valor médio de EMI obtido na artéria carótida foi de 0,87 mm (DP = 0,23) e na artéria subclávia direita foi de 1,17 mm (DP = 0,46), com coeficiente de correlação de 0,31 (95 por cento IC: 0,12 ; 0,47). A avaliação pela curva ROC demonstrou um valor de corte de 0,7 mm para EMI da artéria subclávia direita, tendo como padrão de referência o valor de corte de EMI da artéria carótida de 0,8 mm (sensibilidade 91 por cento, especificidade 27 por cento, VPP 66 por cento, VPN 65 por cento e acurácia 66 por cento). CONCLUSÃO: Existe boa correlação entre o EMI...

OBJECTIVE: Common carotid artery intima-media thickness (IMT) is considered a factor of cardiovascular risk and an early marker of coronary artery disease. This study aimed to investigate the existence of a correlation between IMT in the carotid arteries and at the origin of the right subclavian artery, as well as to evaluate IMT in the subclavian artery as an earlier marker of cardiovascular risk. METHODS: One hundred and six consecutive patients, 52 males and 54 females, average age 51 years, underwent color Doppler ultrasonography to evaluate carotid and right subclavian arteries. The relationship between carotid IMT and right subclavian IMT was assessed using the Pearson's correlation coefficient analysis and a 95 percent confidence interval. Reliability of right subclavian artery IMT measurement for the diagnosis of early thickening (considering a > 0.8 mm carotid thickness as reference) was described as to sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Cut-off values for the right subclavian IMT were indicated by the ROC curve, and p values < 0.05 were considered statistically significant. RESULTS: Out of the 41 patients whose carotid arteries were IMT-free, 30 (73 percent) had right subclavian artery IMT values > 0.8 mm. The mean IMT value for the carotid artery was 0.87 mm (SD = 0.23) and for the subclavian artery, 1.17 mm (SD = 0.46), with a 0.31 correlation coefficient (95 percent CI: 0.12; 0.47). The ROC curve analysis indicated a cut-off value of 0.7 mm for the right subclavian artery IMT, using as reference a 0.8 mm cut-off value for the carotid artery (91 percent sensitivity, 27 percent specificity, 66 percent PPV, 65 percent NPV, and 66 percent accuracy). CONCLUSION: Our study showed that carotid artery IMT correlates well with right subclavian artery IMT. With a 0.7 mm cut-off value, it is possible to detect IMT in the right subclavian artery earlier than in the carotid arteries. The IMT at the...

Subclavian steal syndrome as the presenting feature of hypervascular thyroid nodule.

Subclavian steal syndrome (SSS) is a clinical entity characterized by brachial and basilar insufficiency as a result of critical proximal subclavian artery stenosis or occlusion. We report a patient of giant hypervascular thyroid nodule presenting with features of SSS. The left hand ischemia and symptoms of vertebro-basilar artery in our patient were probably related to stealing of blood by the hypervascular thyroid nodule from the subclavian artery. The patient was relieved of the symptoms upon percutaneous subclavian stent placement.

Cerebral embolism Distal subclavian disease as a rare etiology

Subclavian artery occlusive disease is usually secondary to persistent compression caused by thoracic outlet syndrome [TOS] and rarely due to focal atherosclerosis. Emboli from diseased vessel can flow retrograde to the vertebral or carotid arteries to produce ischemic infarct with or without neurological deficit. We are reporting two cases of distal subclavian artery disease presenting with cerebral embolization, an unusual manifestation. Such surgically correctable lesions producing cerebral emboli and stroke needs consideration while evaluating patients with unusual presentation to prevent further occurrence of stroke

Intrathoracic Aneurysm of the Right Subclavian Artery Presenting with Hoarseness: A Case Report

Intrathoracic segment of the subclavian artery is an unusual location for peripheral arterial aneurysms. They are normally caused by atherosclerosis, medial degeneration, trauma, and infection. We report a case of a patient with right subclavian artery aneurysm presenting with hoarseness. Chest radiograph demonstrated a superior mediastinal mass. Laryngoscopy showed a fixed right vocal cord. By chest computed tomography, magnetic resonance imaging, and angiography, preoperative diagnosis was established as a saccular aneurysm with afferent loop and efferent loop. Patient underwent complete resection of the aneurysm followed by endto-end anastomosis via median sternotomy. Postoperative pathology was consistent with an atherosclerotic aneurysm filled with thrombus. After surgical operation, hoarseness is still continued.

Subclavian artery thrombosis--management with thrombolysis and angioplasty.

A case of acute thrombotic occlusion is presented in a chronically stenosed subclavian artery with subclavian steal phenomenon noted on colour Doppler study and angiography. Because of economic constraints, thrombolysis with angioplasty was done instead of stenting. The patient is on follow-up for the past one year showing considerable improvement. The present case report confirms the efficacy of angioplasty as a suitable option in patients, who cannot afford to have a stent.

Pseudo-takayasu dans la maladie de behcet

Behcet's disease is a chronic multi-system vasculitis that is frequent in Lebanon. The great arteries involvement is rare. We report here an unusual case of subclavian artery occlusion [pseudoakayasu] with a literature review

By Pass carotido-axilar: tratamiento percutáneo de estenosis distal / Carotid to axillary artery by pass percutaneous treatment of distal stenosis

Se analiza el caso de una paciente de sexo femenino, que presentaba una lesión estenosante a nivel de la anastomosis distal de un by pass carotido-axilar. Consultó por claudicación de miembro superior izquierdo, mareos y dos episodios de pérdida de conocimiento. Se constata una estenosis significativa en la anastomosis distal de un by pass carotido-axilar realizado dieciocho meses antes. Se realizó una angioplastía percutánea con stenting, recuperando la paciente su clase funcional y estado neurológico. Se destaca el rol de la angioplastía con uso de stent para el tratamiento de la enfermedad estenosante de un procedimiento quirúrgico realizado previamente