Important Variations of Aortic Branches: Imaging Case Series.

Various anatomical variations are known to occur in branches of the aorta. Some of these variations are common while others are quite uncommon. However, these variations carry significant implications when the patient is diseased and some intervention or surgical procedure is to be done. Most of these variations are usually incidentally detected. This imaging case series illustrates some clinically important variations of aortic branches including branches of the aortic arch and abdominal aorta, with a review of the literature. All cases illustrated here were detected incidentally.

Hypertrophic Osteopathy Concurrent with an Aberrant Right Subclavian Artery in a Dog.

A 13-year-old spayed female cocker spaniel was presented with a 2-month history of swelling in several digits and intermittent hindlimb lameness. Radiographs revealed marked soft-tissue swelling and periosteal new bone formation without cortical bone destruction, characteristic of hypertrophic osteopathy (HO), in the distal parts of all extremities except for the right forelimb. However, no notable findings were detected in thoracic radiographs. An ultrasonography indicated cranial bladder wall thickening, which resolved following antibiotic therapy. Computed tomographic angiography identified a potential underlying cause as an aberrant right subclavian artery (ARSA) originating from the aortic arch, compressing the esophagus and causing mild esophageal cranial dilation to the aberrant vessel. No other intrathoracic or neoplastic lesions were observed. Gastrointestinal symptoms, such as regurgitation, were absent. Although an ARSA was likely the cause of HO, surgical correction was declined by the owner. To the best of our knowledge, this is the first reported case of HO concurrent with ARSA in dogs.

A Computed Tomography Study on the Prevalence of Lusorian Artery Among Hungarian Adults.

Introduction The aberrant right subclavian artery (ARSA), also called as lusorian artery (LA) is a developmental anomaly that exists in conjunction with a right non-recurrent laryngeal nerve (NRLN) in almost all cases. The average prevalence of such a vascular variation is estimated as 1%, although, studies have reported very different population means. Up to date, there is no available data on the frequency of this pattern in the Hungarian population. It can be treated as an indirect marker of a NRLN. Any preoperative information on the course of the inferior laryngeal nerves can help surgeons reduce the risk of an iatrogenic injury during thyroidectomies, especially in an environment where access to intraoperative neuromonitoring is limited. Objectives The primary aims were to determine the prevalence of an ARSA, predict the existence of an NRLN in the Hungarian population, and provide demographic analysis. Methods A retrospective, computed tomography-based study was carried out. Demographic description and statistical analysis were provided where applicable. Detected anomalous vasculatures were visualized with 3D segmentation, and images were interpreted. Results The imaging database review identified three patients with ARSA out of 686 eligible recordings, resulting in a frequency of 0.437% in the study population. All three patients were female and had a retroesophageal LA. Two of them had a Kommerell's diverticulum. One patient had common carotid arteries with a single origin. Conclusions The frequency of an ARSA and a concomitant NRLN among Hungarians fits into the results of recent meta-analyses. Preoperative assessment of this anomaly may reduce vocal cord complication rates of thyroidectomies.

Associated Anomalies and Outcome in Patients with Prenatal Diagnosis of Aortic Arch Anomalies as Aberrant Right Subclavian Artery, Right Aortic Arch and Double Aortic Arch.

We aimed to evaluate retrospectively associated anomalies and outcome in prenatal aortic arch anomalies (AAAs). We included ninety patients with aberrant right subclavian artery (ARSA), right aortic arch (RAA) with mirror image branching (RAA-mirror) or aberrant left subclavian artery (RAA-ALSA) and double aortic arch (DAA) between 2011 and 2020. In total, 19/90 (21.1%) had chromosomal anomalies, the highest rate being within the ARSA subgroup (17/46, 37%). All (13/13) of the RAA-mirror subgroup, 10/27 (37.0%) of RAA-ALSA, 13/46 (28.3%) of ARSA and 0/4 within the DAA subgroup had additional intracardiac anomaly. The rate of extracardiac anomalies was 30.7% in RAA-mirror, 28.3% in ARSA, 25.0% in DAA and 22.2% in the RAA-ALSA subgroup. A total of 42/90 (46.7%) had isolated AAAs: three (7.1%) with chromosomal anomalies, all trisomy 21 (3/26, 11.5%) within the ARSA subgroup. Out of 90, 19 (21.1%) were lost to follow-up (FU). Two (2.2%) intrauterine deaths occurred, and six (6.7%) with chromosomal anomalies terminated their pregnancy. In total, 63 (70.0%) were liveborn, 3/63 (4.8%) with severe comorbidity had compassionate care and 3/60 (5.0%) were lost to FU. The survival rate in the intention-to-treat cohort was 53/57 (93%). Forty-one (77.4%) presented with vascular ring/sling, two (4.9%) with RAA-ALSA developed symptoms and one (2.4%) needed an operation. We conclude that intervention due to vascular ring is rarely necessary. NIPT could be useful in isolated ARSA cases without higher a priori risk for trisomy 21 and after exclusion of other anomalies.

Stanford type B aortic dissection in a patient with aberrant right subclavian artery.

An aberrant right subclavian artery is a rare aortic arch anomaly where the right subclavian artery arises from the proximal part of the descending thoracic aorta and distal to origin of left subclavian artery. It usually courses behind the esophagus. Type B aortic dissection along with aberrant right subclavian artery is not common. A middle-aged man presented with complaints of epigastric pain and on evaluation was found to have aberrant right subclavian artery with type B aortic dissection. A total arch replacement with frozen elephant trunk surgery and an extra-anatomic bypass of right subclavian artery were performed. Type B aortic dissection is more often an incidental finding and its association with aberrant right subclavian artery is unusual. Such association should be identified and treated accordingly to avert clinical complications.

Non-recurrent laryngeal nerve injury associated with an aberrant right subclavian artery: a case report.

Background: Injury to the recurrent laryngeal nerve (RLN) is a recognised complication of surgery in the neck. The presence of a non-recurrent laryngeal nerve (NRLN) significantly increases the risks of a nerve injury. Given that NRLNs are strongly associated with vascular abnormalities that can be visualised on preoperative imaging, we describe a case to raise awareness of this association with the aim of reducing the risk of iatrogenic nerve injury. Case Description: A 61-year-old gentleman was referred by his family doctor with a history of radiating left arm pain and paraesthesia consistent with C6 +/- C7 radiculopathy. The patient failed conservative management, and elected to undergo an anterior cervical discectomy and fusion procedure. Preoperative magnetic resonance imaging (MRI) showed an incidental finding of an aberrant right subclavian artery (ARSA) following a retro-oesophageal path. Surgery was performed with a right sided cervical approach without intraoperative complications; however, the patient had marked dysphonia post-operatively. Assessment by otorhinolaryngology (ORL) concluded that this was most likely secondary to a right NRLN palsy. The patient underwent a vocal fold injection laryngoplasty for temporary vocal fold augmentation, and the voice subsequently recovered and remained asymptomatic at 1-year post-procedure. Conclusions: This case demonstrated that identification of vascular anomalies associated with NRLNs on preoperative imaging should prompt a left sided cervical approach to avoid a nerve injury during surgery.

Dysphagia lusoria in a young patient with a concomitant aortic arch anomaly, successfully treated with surgery: a case report.

Dysphagia is a common condition in clinical practice; however, an unusual type of dysphagia due to compression of the esophagus by an abnormal right subclavian artery may be discovered in a rare subset of patients. The prognosis and treatment will depend on the severity of the symptoms and the compromise of surrounding structures. We present the case of an 18-year-old female who presented with gradually progressive dysphagia. At first, it was treated as gastroesophageal reflux disease; nonetheless, the dysphagia became severe, and after a thorough evaluation, an aberrant right subclavian artery that compressed the esophagus was discovered along with a truncus bicaroticus. She was successfully treated with surgery without any complications. On follow-ups, she's doing well.

Aberrant Right Subclavian Artery: Demographics, Morphological Features and Follow up CT Scans Dynamics.

Introduction: Aberrant right subclavian artery (ARSA) is the most common of the aortic arch anomalies, occurring in .5% to 1% of the population. There is no standardized follow up protocol, especially in the asymptomatic cases. The purpose of the present study was to evaluate the natural history of ARSA and the role of serial CT scans. Methods: This is a single-center retrospective study of patients with ARSA depicted on chest computed tomography (CT) scans between February 2013 and July 2022. Data were collected from their medical records. Measurements of the aorta at different segments including the aortic diameter at the orifice of ARSA, and ARSA at ostium followed by 1 cm intervals were collected, as well as for follow-up CT scans. Results: 65 patients were diagnosed with ARSA, 70.8% of whom were women. The average age for the cohort was 58.569 ± 16.99 years. The median follow up time was 4 years (range 0-10 years), KM estimated survival after ARSA diagnosis at 1 and 5 years as 97% and 93%, respectively. Nineteen patients had a second CT scan and were included in the morphological CT dynamic analysis, on average of 29 ± 27 months apart (range 7-108). The mean ARSA diameter at origin was larger in the second scan 16.91 ± 4.31 mm compared to the initial scan 16.31 ± 4.96 mm, (P = .04).The mean aortic arch diameter in the first and second CT were 28.54 ± 4.24 and 29.64 ± 5.14 (P = .10), respectively. All other measurements did not disclose any significant enlargement over time. Conclusions: Our cohort demonstrate a benign natural history of ARSA with slow growth rates. However, due to our small sample size we can't draw a clinically sound recommendation on the need for imaging follow up, and further larger cohort with longer follow up interval are required.

Complex Hybrid Repair of an Aberrant Right Subclavian Artery With Rapidly Developing Kommerell's Diverticulum.

Introduction: An aberrant right subclavian artery (ARSA) is an aortic anomaly that, in some cases, can be complicated with Kommerell's diverticulum (KD) at the origin of the ARSA. Progression and rupture of KD are associated with high mortality. Timely intervention is therefore required; however, there are no clinical guidelines for the most suitable intervention. Report: A 50 year old, previously healthy, male patient developed dysphagia. He was diagnosed with an aberrant right subclavian artery and KD. The KD increased in size from 4 - 7 cm within 2 months. He underwent single stage hybrid aortic repair involving an aortic valve replacement, total aortic arch debranchment, two thoracic endovascular aortic repair stents, and subclavian plugs. He developed a stroke during the post-operative period; however, all neurological symptoms had disappeared at 6 months and computed tomography showed no endoleaks and all supraortic vessels were open. Discussion: Literature on KD is limited; therefore, there is no consensus on KD treatment. Increasing awareness of rapidly developing KD will add to current knowledge of the disease. One stage cardiac and non-cardiac surgery was successfully performed with no long term complications.

Thoracic endovascular aortic repair for type B aortic dissection with aberrant right subclavian artery: a single-center retrospective study.

Objective: To evaluate the outcomes of thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) with aberrant right subclavian artery (ARSA). Methods: A retrospective analysis was conducted on patients with TBAD and ARSA who underwent TEVAR between the period of January 2017 and December 2022. Patient demographics, computed tomography angiography (CTA) measurements, surgical procedures, and postoperative outcomes were reviewed. Results: A total of 9 patients (6 males and 3 females) were included in the study. 4 ARSA were reconstructed, 3 by periscope technique and 1 by in vitro fenestration technique. 3 left subclavian arteries (LSA) were reconstructed, 1 by the chimney technique and 2 by the single-branched stent technique. 2 patients underwent reconstruction of both ARSA and LSA. The overall technical success rate was 100%, with no occurrences of stroke, paraplegia, or mortality within 30 days. 1 patient experienced immediate type Ia endoleak, which resolved after 3 months. 1 patient developed weakness in the right upper limb, while 1 patient presented mild subclavian steal syndrome (SSS); both cases showed recovery during follow-up. The average follow-up duration was 35.6 ± 11.1 months, during which no reinterventions, deaths, or strokes were observed. Conclusion: Our limited experience involving 9 patients demonstrates that early and mid-term outcomes of TEVAR for the treatment of TBAD with ARSA are satisfactory.

Aberrant right subclavian artery: a novel approach and an overview of operative techniques.

An aberrant right subclavian artery (ARSA) is a rare variation of normal anatomy occurring in 0.5% to 1.8% of the population. No current guidelines are available regarding ARSA management, and surgical intervention should be evaluated carefully. Moreover, symptomatic patients with a dominant left arch and aberrant ARSA require a surgical approach from the right side of the chest for ligation and division of the aberrant artery at its origin on the aorta. The ARSA can then be reimplanted onto the right common carotid artery via a supraclavicular incision. The extensive mobilization in the chest allows for easy reimplantation in the supraclavicular region and eliminates reliance on the collateral circulation. Postoperative monitoring is reliable and easy with radial pulse examinations.

Incomplete vascular ring of the aortic arch presenting with dysphagia in an adult: case report.

Anomalies of the arterial branches of the arch of the aorta are rare, with the aberrant right subclavian artery being the most common of this anomaly. Majority of the anomalies are asymptomatic and often discovered as incidental findings. In the great majority of the symptomatic cases, the presentation may be either with breathlessness or dysphagia or both. This is in addition to the nature of the intrinsic arterial disease of the aberrant vessel, especially in adult patients; and unless borne in mind, the diagnosis is often missed leading to delays and wrong treatment. In this report we present a case of dysphagia in an adult male Nigerian initially diagnosed as œsophageal stricture from herbal potion ingestion but review of his imaging investigations gave a final diagnosis of dysphagia lusoria from an aberrant right subclavian artery. The difficulty in making a diagnosis and the need for a multidisciplinary review of the imaging investigations are highlighted. The patient was successfully treated by a combined trans-thoracic and cervical approach with division and re-implantation of the aberrant vessel unto the right common carotid artery. He has remained symptom-free for 2 years after surgery. Although the great majority of these anomalies are often asymptomatic, it is important they are borne in mind both in imaging investigations as well as in procedures involving structures in the upper visceral mediastinum. Various surgical approaches have been documented in the management of symptomatic ones; it is however recommended that options that ensure revascularization of the affected limb be selected.

Medial-type persistent trigeminal artery and ipsilateral posterior communicating artery supplying bilateral posterior cerebral arteries combined with an aberrant right subclavian artery and bicarotid trunk.

PURPOSE: To describe a case of a medial-type persistent trigeminal artery (PTA) associated with multiple arterial variations. METHODS: A 34-year-old woman with multiple sclerosis underwent cranial magnetic resonance (MR) angiography from the aortic arch to the neck region and intracranial region for the evaluation of an unruptured cerebral aneurysm that was previously detected on MR imaging. The MR machine was a 3-T scanner. RESULTS: There was an aberrant right subclavian artery and bicarotid trunk, medial-type left PTA and ipsilateral posterior communicating artery (PCoA) supplying bilateral posterior cerebral arteries (PCAs). The unruptured aneurysm was located at the paraclinoid segment of the left internal carotid artery and was treated successfully by coil embolization via a transfemoral approach. CONCLUSION: Only 10% of PTAs are classified as the medial type. The association with extremely large ipsilateral PCoA, which supplies the bilateral PCAs, has not been previously reported. Aberrant right subclavian arteries are common and are frequently associated with a bicarotid trunk. Before catheterization of the cerebral arteries, the aortic arch and its branches must be evaluated by MR angiography or computed tomography angiography to prevent catheterization failure via the right transradial approach.

Surgical repair of severe dysphagia lusoria.

This case report describes a case of severe dysphagia lusoria secondary to an aberrant right subclavian artery causing compression of the esophagus. Our 62-year-old female patient presented with severe dysphagia and underwent right carotid-subclavian bypass with uncovered thoracic endovascular aortic repair and coil embolization of the aberrant right subclavian artery. This case is unique in that an uncovered dissection stent graft was used to avoid occluding the anatomic left subclavian artery and, therefore, avoid a left carotid-subclavian bypass. This case highlights a unique anatomic variant, its surgical repair, and the long-term improvement in the patient's quality of life.

Fenestrated Physician-Modified Endovascular Grafts for Aberrant Right Subclavian Artery and/or Kommerell's diverticulum.

OBJECTIVE: The aim of this case series is to report feasibility, efficiency, and safety of fenestrated physician-modified endografts (PMEGs) in aortic arch pathologies with aberrant right subclavian artery (ARSA) and/or Kommerell's diverticulum (KD). METHODS: All consecutive patients with ARSA and/or KD who underwent hybrid aortic arch repair combined with homemade fenestrated stent-graft from 2018 to 2022 were reviewed. RESULTS: Six patients with ARSA and/or KD underwent hybrid surgery for aortic repair, 4 of whom were men, with a mean age of 49 years. Furthermore, 2 of them were symptomatic with dysphagia, 1 was taken in emergency, 1 had a bovine arch and a KD, and 2 had right descending thoracic aortas. The mean operation time was 138 (111-216) minutes. In addition, 83% of the homemade grafts were double fenestrated. All the proximal landings were in zone 0; the mean proximal aortic diameter was 29 (23-34) mm. The range of diameters for the endografts were 24 to 38 mm. There was a 100% technical success, with 0% 30 days mortality, no stroke, and no endoleak. During the follow-up, no aortic-related death or secondary intervention was required and all supra-aortic vessels remain patent. CONCLUSION: Hybrid aortic arch repair, with fenestrated PMEGs for ARSA and/or KD, is associated with acceptable early and midterm major morbidity and mortality. CLINICAL IMPACT: This retrospective case series analyzed outcomes in 6 patients with an aberrant right subclavian artery and/or Kommerell's diverticulum treated with fenestrated PMEGs during an average 16 month follow-up. The case series suggests that the use of these fenestrated PMEGs for the management of patients with an aberrant right subclavian artery is a safe, effective and durable method in the medium-term.

Hybrid repair of aberrant right subclavian artery using open and endovascular techniques.

An aberrant right subclavian artery, the most common anatomic variant of the aortic arch, occurs in 0.5% of the population. Symptoms generally result from compression of the esophagus and/or trachea as the aberrant vessel passes posteriorly in the mediastinum. Treatment includes revascularization of the right subclavian artery from the right common carotid artery using a cervical approach combined with occlusion of the origin of the aberrant vessel from the thoracic aorta. We describe a hybrid treatment approach for a symptomatic aberrant right subclavian artery using cervical revascularization and branched thoracic stent graft coverage of the origin of the aberrant vessel.

In-vivo imaging of a rare constellation of arterial variants: Aberrant subclavian artery, bicarotid trunk, and ectopic vertebral arteries.

We report in-vivo imaging of a constellation of arterial variants found incidentally on CT-angiography in a 23-year-old woman presenting with an ischaemic stroke. This extremely rare combination includes a common origin of both common carotid arteries, an abnormal origin of the right vertebral artery (VA) from the right common carotid artery and of the left VA from the aortic arch, associated with an aberrant right subclavian artery. This constellation, previously described in a female cadaver, has not been reported in-vivo. Awareness of this configuration is crucial for radiological diagnosis and when performing angiography and endovascular or surgical procedures in thorax, head and neck, to avoid complications.