J INVASIVE CARDIOL 2017;29(8):E90-E91.
Key words: arteria lusoria, coronary angiography, dysphagia, transradial intervention
A 56-year-old male diabetic was admitted with diagnosis of evolved anterior-wall myocardial infarction (MI) with post-infarct angina. The results of a physical examination were unremarkable. Electrocardiogram showed features of evolved anterior-wall MI and cardiac biomarkers were elevated. Echocardiography showed hypokinesia in the left anterior descending (LAD) territory; left ventricular ejection fraction was 45%. Coronary angiography via right radial artery was planned. During coronary angiography, a 0.035˝ guidewire (Terumo) repeatedly entered the descending thoracic aorta. Contrast injection in the abnormal artery showed right subclavian artery arising from descending thoracic aorta (Figure 1; Video 1). However, with the tip of the Optitorque Tig catheter (Terumo) directed toward the aortic arch, the guidewire could enter the arch and ascending aorta (Figure 2; Video 2). The right coronary artery was cannulated with the Optitorque catheter with difficulty (Figure 3; Video 3), but it was not possible to cannulate the left coronary artery with the same catheter. The Optitorque catheter was exchanged to a 3.5 Extra Backup 6 Fr guide catheter and the left coronary artery was engaged cautiously with the help of the reverse end of a 0.035˝ guidewire taking a E-shaped loop (Figure 4; Videos 4A and 4B). The right coronary artery was normal and the mid LAD showed focal critical stenosis. The LAD was stented with a 2.5 x 18 mm drug-eluting stent. Later, esophagogram with contrast swallow revealed posterior oblique indentation of the proximal esophagus in relation with the catheter in the right subclavian artery (Figure 5; Video 5). Subsequently, computed tomography aortogram confirmed the aberrant right subclavian artery arising from the descending thoracic aorta following a retroesophageal course, resulting in a prominent compression of the esophagus, a finding consistent with arteria lusoria (Figure 6). Most patients with an aberrant subclavian artery are asymptomatic, and with the increasing popularity of transradial access to perform coronary angiography, arteria lusoria may be discovered as an incidental surprise. Transradial coronary angiography and interventions in patients with arteria lusoria, while technically challenging, are feasible without crossover to femoral approach. Interventional cardiologists should be aware of this rare entity when guidewire or catheter repeatedly enter the descending thoracic aorta rather than the ascending aorta during transradial coronary intervention.
From the Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript accepted February 3, 2017.
Address for correspondence: Nagaraja Moorthy, MD, DM, FACC, Assistant Professor, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India 560069. Email: email@example.com