Author + information
- Received January 17, 2017
- Revision received February 6, 2017
- Accepted February 9, 2017
- Published online April 12, 2017.
- Nagaraja Moorthy, DMa,∗ (, )
- Rajiv Ananthakrishna, DMa,
- Dattatreya P.V. Rao, DMa,
- Madhav Hegde, MDb and
- Manjunath C. Nanjappa, DMa
- aDepartment of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
- bDepartment of Radiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India
- ↵∗Address for correspondence:
Dr. Nagaraja Moorthy, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, India 560069.
A 67-year-old male, hypertensive nonsmoker was admitted with unstable angina. He gave a history of acute anterior wall myocardial infarction 4 months earlier for which he underwent primary percutaneous coronary intervention (PCI) with stenting of the left anterior coronary artery (LAD). During primary PCI, incidentally isolated right aortic arch (Figure 1A, Online Video 1) was noticed, and there was difficulty in hooking both right and left coronaries. However, the primary PCI with stenting of the culprit vessel LAD was performed via a transradial approach, and the left circumflex coronary artery (LCx) lesion was medically managed. During readmission, in view of the difficulties in the previous intervention due to the right aortic arch, it was decided to perform coronary angiography via a left radial artery approach. Surprisingly, the guidewire was repeatedly entering the descending thoracic aorta, which was situated on the right of the spine. The TIG catheter (Terumo Corporation, Tokyo, Japan) was used to enter the arch and ascending aorta. With the “M”-shaped (Figure 1B, Online Videos 2 and 3) loop of the catheter, it was realized that the left subclavian artery was arising anomalously from the descending thoracic aorta with a retroesophageal course. There was difficulty in hooking both right and left coronaries (Figure 1C, Online Video 4) with the TIG catheter. Coronary angiography showed a patent stent in mid-LAD with progression of the LCx lesion. Using a 6-Fr extra-backup guide catheter with gentle manipulation using the reverse end of a 0.035-inch (190-cm) guidewire, we were successful in engaging the left coronary artery. The culprit lesion in the distal LCx was stented using a 2.5 × 24-mm drug-eluting stent. Later esophagogram using diluted contrast showed a severe indentation on the posterior aspect of the esophagus (Figure 1D, Online Video 5) caused by the retroesophageal course of the anomalous left subclavian artery. A computed tomography aortogram confirmed the right aortic arch (Figure 1E) with an aberrant left subclavian artery arising from the descending thoracic aorta following a retroesophageal course (Figure 1F), resulting in a prominent compression of the esophagus, a finding consistent with left-sided arteria lusoria. The sequential branching pattern of the arch of the aorta were left common carotid artery, right common carotid artery, and right subclavian followed by the anomalous left subclavian artery (Figures 1G and 1H). A virtual computed tomography esophagogram showed significant compression of esophagus caused by the retroesophageal course of the left subclavian artery (Figure 1I). However, the patient never experienced dysphagia in the past despite significant compression of the esophagus. Most patients with an aberrant subclavian artery are asymptomatic, and with increasing use 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, though challenging, are feasible. This is the first description to our knowledge of incidental discovery of right aortic arch with left-sided arteria lusoria in an adult during transradial intervention.
For supplemental videos and their legends, please see the online version of this paper.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received January 17, 2017.
- Revision received February 6, 2017.
- Accepted February 9, 2017.
- 2017 American College of Cardiology Foundation