ABSTRACT: With increasing use of transradial access (TRA) to perform coronary angiography, arterial anomalies of the upper extremity are more frequently encountered. We describe a patient with an aberrant right subclavian artery (RSCA) originating as the last major branch of the aortic arch, which eventually led to failure of the transradial approach. Subsequent arch aortography revealed an associated common carotid trunk. The combination of both anomalies is a rare finding and may be associated with a number of other arterial and/or mediastinal organ anomalies.
J INVASIVE CARDIOL 2011;23(10):E241–E243
Key words: aortic arch anomaly, aberrant right subclavian artery, common carotid trunk, transradial catheterization
TRA has become an increasingly popular arterial access for coronary angiography and interventions because it significantly lowers the risk of access site complications,1-3 allows early patient mobility and has the potential of reducing hospital costs.4 Anatomic variations of the upper extremity arteries are not uncommon, but have not been frequently encountered or described in the catheterization laboratory with the predominance of femoral approach. In the current era, with increasing TRA approach, these anomalies are coming to the forefront. Frequently, these anomalies represent some challenge but rarely lead to significant difficulties with the TRA approach.5 We describe a patient with an aberrant RSCA originating as the last major branch of the aortic arch associated with a common carotid trunk where a rare anatomic anomaly makes the TRA approach technically challenging.
Case Report. A 29-year-old female with a history of cocaine abuse and uncontrolled hypertension, chest discomfort, and mild troponin elevation was scheduled for diagnostic coronary angiography. TRA was preferred due to morbid obesity. Right radial access was obtained without difficulty, but the guidewire could not be advanced into the ascending aorta (Figure 1). A manual contrast injection raised the possibility of an aberrant RSCA (Figure 2). The TRA approach was aborted and access was obtained via the right femoral artery. Ascending and arch aortography revealed the RSCA arising as the last cardinal branch from the aortic arch, distal to the left subclavian artery (Figure 3). In addition, both common carotid arteries originated from a common trunk (Figures 3 and 4). Coronary angiography revealed no obstructive disease and cardiac biomarker elevation was attributed to hypertensive urgency in the setting of cocaine abuse.
Discussion. An aberrant RSCA arising as the last branch of the aortic arch is the most common type of congenital aortic arch anomaly with a reported incidence of 0.2-2%.6,7 This forms an incomplete vascular ring that evolved embryologically due to involution of the right 4th aortic arch and persistence of the 7th intersegmental artery in its attachment to the aorta. The vessel usually takes a retroesophageal course and may result in dysphagia due to compression of the esophagus, a clinical syndrome termed dysphagia lusoria.8-11 The symptoms of dysphagia occur more frequently if the aberrant RSCA develops an aneurysm at the site of aortic attachment.9 This anatomic variance can lead to significant difficulty with or failure of TRA for coronary angiography and intervention.5,12
An aberrant RSCA can be associated with other congenital cardiac anomalies. Septal defects (ventricular, atrial, or atrioventricular canal defects) have been reported in 28% of cases. Conotruncal anomalies such as Tetralogy of Fallot, truncus arteriosus, transposition of the great arteries, and interrupted aortic arch occur in 27%. Left-sided cardiac anomalies such as hypoplastic left-heart syndrome, coarctation of the aorta, and mitral stenosis occur in 14% of these patients.13
The presence of an aberrant RSCA must be identified in children with cyanotic heart disease because it may hinder palliative shunt procedures in many of these anomalies. In addition, there is an association of aberrant RSCA with Down syndrome and knowledge of its presence is essential when evaluating feeding difficulties in these patients.14
An isolated common carotid trunk has been reported in about 13% of the general population and is more frequently seen in patients with esophageal atresia-tracheoesophageal fistula, DiGeorge anomaly, and anomalous origin of the left coronary artery from the pulmonary artery. This is rarely symptomatic but may cause respiratory distress in the pediatric population due to tracheal compression with symptoms ranging from recurrent pulmonary infections to stridor and apneic spells.15
The combination of aberrant RSCA with a common carotid trunk is exceedingly rare with an estimated prevalence of <0.05%.16,17 These patients can be asymptomatic or present with dysphagia or respiratory symptoms due to both anterior and posterior limitation of the tracheoesophageal tract.
Conclusion. As the TRA approach to coronary angiography and percutaneous interventions continues to gain acceptance, clinicians must be aware of the possible anomalies of the aortic arch and its major branches. Although rare, some of these anomalies (such as the aberrant RSCA) may make this approach technically challenging.
- Agostoni P, Biondi-Zoccai GG, de Benedictis ML, et al. Radial versus femoral approach for percutaneous coronary diagnostic and interventional procedures; Systematic overview and meta-analysis of randomized trials. J Am Coll Cardiol. 2004;44(2):349-356.
- Hildick-Smith DJ, Lowe MD, Walsh JT, et al. Coronary angiography from the radial artery--experience, complications and limitations. Int J Cardiol. 1998;64(3):231-239.
- Sciahbasi A, Pristipino C, Ambrosio G, et al. Arterial access-site-related outcomes of patients undergoing invasive coronary procedures for acute coronary syndromes (from the ComPaRison of Early Invasive and Conservative Treatment in Patients With Non-ST-ElevatiOn Acute Coronary Syndromes [PRESTO-ACS] Vascular Substudy). Am J Cardiol. 2009;103(6):796-800.
- Cooper CJ, El-Shiekh RA, Cohen DJ, et al. Effect of transradial access on quality of life and cost of cardiac catheterization: A randomized comparison. Am Heart J. 1999;138(3 Pt 1):430-436.
- Valsecchi O, Vassileva A, Musumeci G, et al. Failure of transradial approach during coronary interventions: Anatomic considerations. Catheter Cardiovasc Interv. 2006;67(6):870-878.\
- Freed K, Low VH. The aberrant subclavian artery. AJR Am J Roentgenol. 1997;168(2):481-484.
- Proto AV, Cuthbert NW, Raider L. Aberrant right subclavian artery: Further observations. AJR Am J Roentgenol. 1987;148(2):253-257.
- Chahwan S, Miller MT, Kim KA, Mantell M, Kirksey L. Aberrant right subclavian artery associated with a common origin of carotid arteries. Ann Vasc Surg. 2006;20(6):809-812.
- Brown DL, Chapman WC, Edwards WH, Coltharp WH, Stoney WS. Dysphagia lusoria: Aberrant right subclavian artery with a Kommerell's diverticulum. Am Surg. 1993;59(9):582-586.
- Natsis KI, Tsitouridis IA, Didagelos MV, Fillipidis AA, Vlasis KG, Tsikaras PD. Anatomical variations in the branches of the human aortic arch in 633 angiographies: Clinical significance and literature review. Surg Radiol Anat. 2009;31(5):319-323.
- Levitt B, Richter JE. Dysphagia lusoria: A comprehensive review. Dis Esophagus. 2007;20(6):455-460.
- Abhaichand RK, Louvard Y, Gobeil JF, Loubeyre C, Lefevre T, Morice MC. The problem of arteria lusoria in right transradial coronary angiography and angioplasty. Catheter Cardiovasc Interv. 2001;54(2):196-201.
- Myers PO, Fasel JH, Kalangos A, Gailloud P. Arteria lusoria: Developmental anatomy, clinical, radiological and surgical aspects. Ann Cardiol Angeiol (Paris).59(3):147-154.
- Roofthooft MT, van Meer H, Rietman WG, Ebels T, Berger RM. Down syndrome and aberrant right subclavian artery. Eur J Pediatr. 2008;167(9):1033-1036.
- Wells TR, Landing BH, Shankle WR. Syndromal associations of common origin of the carotid arteries. Pediatr Pathol. 1993;13(2):203-212.
- Jan SL, Hwang B, Fu YC, Chi CS. A rare vascular ring caused by an aberrant right subclavian artery concomitant with the common carotid trunk: A report of two cases. Int J Cardiovasc Imaging. 2006;22(2):253-256.
- Tsai IC, Tzeng WS, Lee T, et al. Vertebral and carotid artery anomalies in patients with aberrant right subclavian arteries. Pediatr Radiol. 2007;37(10):1007-1012.
From the Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, Lexington, Kentucky.
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 submitted January 26, 2011, provisional acceptance given February 24, 2011, final version accepted March 28, 2011.
Address for correspondence: Khaled M. Ziada, MD, FACC, FSCAI, Division of Cardiovascular Medicine, Gill Heart Institute, University of Kentucky, 900 S. Limestone Street, 326 Charles T. Wethington Bldg., Lexington, KY, 40536-0200. Email: email@example.com