Aneurysm of an aberrant right subclavian artery: case report and review of the literature

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.

Beyond the Classic Causes of Dysphagia: Bayford-Autenrieth Dysphagia

Dysphagia lusoria (DL) is a rare clinical entity that presents with dysphagia derived from the anatomical obstruction of the esophagus by an aberrant vessel originating from the right subclavian artery. We present the case of a 64-year-old patient with a medical history of chronic, intermittent, mild, and self-limited dysphagia for over 20 years, wherein we formulated the diagnosis of DL. A 64-year-old woman arrived at the emergency department with a 24-hour history of acute progressive dysphagia, leading to intolerance to oral intake and minimal exertion dyspnea. A thorough clinical analysis and exclusion of other more common clinical entities will lead to its diagnosis. Our patient presented with respiratory symptoms, which is rare considering that these clinical presentations are more common in the pediatric population, explained by its tracheal elasticity. The combination of respiratory symptoms in an elderly patient, along with the typical mechanical dysphagia of DL, adds complexity to the diagnostic process, making this case unique.

Aberrant right subclavian artery: case report and literature review

The aberrant right subclavian artery, also known as the arteria lusoria, is the most common aortic arch anomaly, occurring in 0.5 to 1% of the population. There is a higher prevalence in women and it is usually associated with other anatomical variations, such as the non-recurrent laryngeal nerve, present in 86.7% of cases. In the majority of cases, the aberrant right subclavian artery causes no symptoms. We describe this anomaly in an 82-year-old, hypertensive, and asymptomatic patient who had undergone a thoracoabdominal angiography to investigate a chronic DeBakey type III aortic dissection with dilation of the descending aorta. The aberrant right subclavian artery followed a retroesophageal course and was associated with a Kommerell diverticulum. In view of its rarity, we conducted an integrative bibliographic review of literature from the last 6 years indexed on the Medline, UpToDate, Lilacs, Scielo, and Portal Capes databases and discuss the most frequent anatomical changes, symptomatology, and therapeutic management adopted.

Artéria subclávia direita aberrante: relato de caso e revisão de literatura

Resumo A artéria subclávia direita aberrante, também conhecida como artéria lusória, é a anomalia do arco aórtico mais comum, ocorrendo entre 0,5 e 1% da população. Possui prevalência em mulheres e normalmente está associada a outras variações anatômicas, como o nervo laríngeo não recorrente, presente em 86,7% dos casos. Em sua maioria, a artéria subclávia direita aberrante não apresenta sintomas. Descrevemos essa alteração em uma paciente de 82 anos, hipertensa e assintomática, que havia sido submetida a uma angiotomografia toracoabdominal para a avaliação de uma dissecção crônica tipo III (DeBakey) associada à dilatação de aorta descendente. No achado, a artéria subclávia direita aberrante apresentava percurso retroesofágico associado a um divertículo de Kommerell. Devido à raridade, realizamos revisão bibliográfica integrativa das bases de dados MEDLINE, UpToDate, LILACS, SciELO e Portal CAPES dos últimos 6 anos e discutimos as alterações anatômicas mais frequentes, a sintomatologia e as condutas terapêuticas adotadas.

Type A aortic dissection repair with a dissection stent in presence of aberrant subclavian artery

Aberrant right subclavian artery is a rare congenital aortic arch anomaly. We report on a case of type A aortic dissection and aberrant right subclavian artery. The 65-year-old female patient received a replacement of the ascending aorta and arch repair using an uncovered AMDS (Ascyrus Medical Dissection Stent; CryoLife Inc., Kennesaw, GA, USA) with debranching of both common carotid arteries. Postoperative computed tomography scan revealed regular aortic blood flow with the unrestricted carotid artery and aberrant right subclavian artery perfusion.

Endovascular repair of type A aortic intramural hematoma accompanied by aberrant right subclavian artery and Kommerell's diverticulum: a case report

Background

The lesions of aberrant right subclavian artery, Kommerell’s diverticulum and type A aortic intramural hematoma are rare, and we usually treat them with open surgery. In some cases patients have increased risk to undergo surgery, the experiences of endovascular or medical treatment are limited.

Case presentation

Here we reported a case of a 53-year-old man with these three entities present with chest and back ache and attempted a novel approach, thoracic endovascular aortic repair, in the absence of surgical treatment. The patient lived over 5 years and this case provides initial experience and lesson about the endovascular and medical management of the uncommon and dangerous disease- type A aortic intramural hematoma with aortic congenital malformation.

Conclusion

Thoracic endovascular aortic repair with medical treatment may be a potential alternative approach for type A aortic intramural hematoma.

Midterm Outcomes of Endovascular Repair for Stanford Type B Aortic Dissection with Aberrant Right Subclavian Artery

PURPOSE

To evaluate the early and midterm outcomes of endovascular repair of Stanford type B aortic dissection (TBAD) with an aberrant right subclavian artery (ARSA).

MATERIALS AND METHODS

From November 2012 to July 2018, 15 patients (13 male, 2 female) who had TBAD with ARSA underwent total endovascular repair, including thoracic endovascular aortic repair (TEVAR), left subclavian artery (LSA) chimney technique, LSA fenestration technique, and double chimney technique (LSA chimney and ARSA periscope). The mean age was 55 years. Kommerell diverticulum (KD) occurred in 2 patients, which were covered by means of oversized aortic stents. All patients had preoperative imaging examinations for assessing cerebral blood flow and the dominant vertebral arteries.

RESULTS

All procedures were completed successfully. There was no in-hospital mortality. The mean procedural time was 98 ± 40 minutes (range 50-190). The mean preoperative diameters of the maximum descending aorta, false lumen, and true lumen in the descending aorta versus postoperative were 37 ± 10 mm (range 28-67), 18 ± 9 mm (range 9-41), and 19 ± 6 mm (range 10-35) versus 34 ± 9 mm (range 25-64), 5 ± 8 mm (range 0-28), and 28 ± 5 mm (range 19-37), respectively. Right upper extremity weakness was observed in 2 patients, which recovered gradually during follow-up. Immediate type Ia endoleak was detected in 1 patient. The mean follow-up time was 33 ± 20 months. During follow-up, no ARSA steal syndrome, spinal cord ischemia, or strokes were not observed.

CONCLUSIONS

Endovascular treatment for TBAD with ARSA was feasible and safe with a satisfactory midterm follow-up outcome.

Prevalence and Anatomy of Aberrant Right Subclavian Artery Evaluated by Computed Tomographic Angiography at a Single Institution in Korea

Objective

Aberrant right subclavian artery (ARSA) is a rare anatomical variant of the origin of the right subclavian artery. ARSA is defined as the right subclavian artery originating as the final branch of the aortic arch. The purpose of this study is to determine the prevalence and the anatomy of ARSA evaluated with computed tomography (CT) angiography.

Methods

CT angiography was performed in 3460 patients between March 1, 2014 and November 30, 2015 and the results were analyzed. The origin of the ARSA, course of the vessel, possible inadvertent ARSA puncture site during subclavian vein catheterization, Kommerell diverticula, and associated vascular anomalies were evaluated. We used the literature to review the clinical importance of ARSA.

Results

Seventeen in 3460 patients had ARSA. All ARSAs in 17 patients originated from the posterior aspect of the aortic arch and traveled along a retroesophageal course to the right thoracic outlet. All 17 ARSAs were located in the anterior portion from first to fourth thoracic vertebral bodies and were located near the right subclavian vein at the medial third of the clavicle. Only one of 17 patients presented with dysphagia.

Conclusion

It is important to be aware ARSA before surgical approaches to upper thoracic vertebrae in order to avoid complications and effect proper treatment. In patients with a known ARSA, a right transradial approach for aortography or cerebral angiography should be changed to a left radial artery or transfemoral approach.

Saccular Kommerell aneurysm, a potential pitfall on MDCT imaging - A review of imaging features and potential mimics

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Kommerell aneurysm is an outpouching from a kommerell diverticulum.

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Mimics include saccular aneurysm of the thoracic aorta, ductus diverticulum and dilated Kommerell diverticulum.

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Kommerell aneurysm has the tendency to rupture, therefore, accurate diagnosis is critical.

Saccular Kommerell aneurysm represents a potential pitfall on Multidetector CT (MDCT) imaging, mimicking conditions such as saccular aneurysm of the thoracic aorta, ductus diverticulum and dilated Kommerell diverticulum. Accurate diagnosis of this condition is critical in the management of this potentially fatal condition. This paper reviews the MDCT imaging features of Kommerell aneurysms and its mimics and demonstrates how to make an accurate diagnosis through a series of four cases. MDCT features of Kommerell aneurysms, either saccular or fusiform types arising from a Kommerell diverticulum with atherosclerotic plaque and mural thrombus are discussed.

Abnormalities Associated with Aberrant Right Subclavian Arteries

An aberrant right subclavian artery (ARSA) is an anomaly with a reported incidence of 0.5% to 2%. Usually the aberrant artery follows a retroesophageal course; rarely it takes a course anterior to the esophagus or the trachea. Most patients with an ARSA remain asymptomatic; however, progressive dysphagia develops occasionally. The choice of approach depends on the presence or absence of aneurysmal disease, the urgency of the operation, and the surgeon's experience. A case is reported of a 33-year-old white male patient who had a 3-year history of progressive dysphagia to the point that he was only able to swallow liquids. A barium swallow demonstrated a posterior extrinsic compression of the esophagus. Angiography was performed, which demonstrated an ARSA with a common origin of the right and left common carotid arteries. Surgical correction was performed via a right supraclavicular neck incision. The proximal aberrant artery was mobilized behind the esophagus. The distal, right subclavian artery was exposed, transected, and transposed with reimplantation into the right common carotid artery. An aberrant right thoracic duct was encountered and ligated. The English language literature from 1960 to present was reviewed via a Medline search. Reported anomalies associated with ARSAs include a nonrecurrent right inferior laryngeal nerve, a common origin of the common carotid arteries, a replaced right or left vertebral artery, coarctation of the aorta, a right-sided thoracic duct, and a right-sided aortic arch. It is important to be aware of these associated anomalies and how they impact the operative approach involved in the correction of dysphagia lusoria.

Hand muscle atrophy and digital ischemia as an unusual presentation of an occluded aberrant right subclavian artery: Endovascular or open approach?

INTRODUCTION

An aberrant right subclavian artery (ARSA) or lusorian artery is one of the most common variations of the aortic arch. Although usually without symptoms, some ARSA's occasionally become symptomatic.

PRESENTATION OF CASE

A 51-year old woman presented with a painful right middle finger. Clinical examination showed thenar muscle hypotrophy and blue discoloration of the distal phalanx suggestive of embolization. Magnetic resonance angiography revealed a non-aneurysmal proximally occluded ARSA. A venous common carotid artery to subclavian artery bypass was combined with ARSA ligation proximal to the right vertebral artery.

DISCUSSION

Occlusive symptomatic ARSA disease without aneurysmal dilatation is uncommon. Treatment may include bypass grafting by open surgery or angioplasty with stenting.

CONCLUSION

Treatment for occlusive non-aneurysmal ARSA must be tailored to the individual. Whether an endovascular or surgical approach is preferred depends on localization of the lesion in relation to the esophagus and on the general condition of the patient.

Arteria lusoria: developmental anatomy, clinical, radiological and surgical aspects

The left aortic arch with an aberrant right subclavian artery, or arteria lusoria, is the most common aortic arch anomaly, occuring in 0.5-2.5% of individuals. Four vessels arise sequentially from the aortic arch: the right common carotid artery, the left common carotid artery, the left subclavian artery and the aberrant right subclavian artery, which crosses upwards and to the right in the posterior mediastinum. It results from a disruption in the complex remodelling of the paired branchial arches, typically of the right dorsal aorta distal to the sixth cervical intersegmental artery. The diagnosis and differentiation of arch anomalies is based on findings at chest radiography in association with those at esophagography. It is usually asymptomatic. When symptomatic, it produces dysphagia lusoria or dyspnea and chronic coughing. Treatment is indicated for symptomatic relief of dysphagia lusoria and for prevention of complications due to aneurysmal dilatation.

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.

[A 16-year-old patient with dysphagia]

A 16-year-old man with an 8-year history of progressive dysphagia was referred to hospital. There was no specific finding in his family history. Physical examination was unremarkable. Complete blood count, serum electrolytes, and liver and kidney function tests were normal. Barium swallow revealed an extrinsic impression of the upper esophagus posteriorly. Magnetic resonance angiography demonstrated an aberrant origin of the right subclavian artery, leaving the aorta below the left subclavian artery. The artery had a retroesophageal course, causing the esophageal narrowing. Due to the persistence and worsening of the patient's symptoms, resection and reconstructive bypass surgery were recommended. Surgical correction was performed through a combined right supraclavicular incision and left posterolateral thoracotomy. After application of a vascular clamp, the aberrant right subclavian artery was ligated almost at its origin, and an end-to-side anastomosis was made with the right common carotid artery. At the end of the operative procedure, good pulses were palpated in the right radial artery. Postoperatively, the patient tolerated a regular diet without symptoms of dysphagia and was discharged on postoperative day 7.

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.

"Grape cluster" aneurysm of the right subclavian artery: an unusual manifestation of fibromuscular dysplasia

Aneurysmal lesions affecting the intrathoracic portion of the subclavian artery are rare. We present a patient who had a right hemispheric stroke and transient ischemic attacks caused by a complex right subclavian artery aneurysm with unusual morphological features. Successful surgical repair of this lesion is described along with pathological studies demonstrating fibromuscular dysplasia. The occurrence of such lesions and their management is reviewed.

Right subclavian artery aneurysms of fibrodysplastic origin: two case reports and review of literature

Right subclavian aneurysms involving the intrathoracic portion of the artery are rare and those of fibrodysplastic origin are mentioned in literature only as sporadic cases. In this article, we present two cases of this uncommon pathologic condition and discuss problems concerning diagnostic tools and technical choices. The two patients underwent a successful vascular graft substitution; an echo-Doppler scan revealed that they had no disease 1 and 2 years after the operation.

Arterio-esophageal communication from a ruptured aberrant right subclavian artery aneurysm. CT diagnosis

We report the computed tomography (CT) findings of an arterio-esophageal communication from an aberrant right subclavian artery aneurysm which had eroded into the esophagus. Pathologic correlation is provided. To our knowledge, this is the first CT demonstration of an aberrant right subclavian aneurysm causing a communication to the esophagus reported in the literature. Previously, one CT case of a left aberrant subclavian artery aneurysm that had ruptured into the esophagus, had been described. The characteristic location of the aberrant vessel with aneurysmal dilation and the presence of abnormal air identified within the wall of the aneurysm on CT, helped establish the diagnosis antemortem.

Diverse presentation of aberrant origin of the right subclavian artery: two case reports

Aberrant origin of the right subclavian artery occurs in up to 1% of the population and can result in a wide range of symptoms. In this report, two cases of this anomaly are presented. In the first case, a patient developed fatal group A streptococcal aortitis. In the second case, the patient complained of chronic cough and intermittent dyspnea. The embryologic genesis of this abnormality is discussed and the current literature is summarized. Although relatively uncommon, it is important to consider this vascular anomaly in the differential diagnosis of patients with dysphagia, dyspnea, chest pain, fever, or mediastinal widening evidenced on chest roentgenography.