The Surgical Management of Aortic Root Vessel Anomalies Presenting in Adults

Subclavian steal syndrome in a right aortic arch with aberrant left subclavian artery atresia

Congenital aortic arch anomalies are an uncommon diagnosis resulting from embryologic malformations during the fourth to eighth week of gestation. Asymptomatic variants frequently are overlooked in the perinatal period and diagnosed incidentally during adulthood. Symptomatic variants can present with steal syndrome or dysphagia lusoria. The right aortic arch is a rare anomaly that is usually associated with other congenital anomalies but can occur in isolation. The most common types of right aortic arches are mirror image branching or an aberrant left subclavian artery. Aortic arch anomalies are important to recognize as they may have important implications in management. We present a 74-year-old female with a right aortic arch and aberrant left subclavian artery that was discovered after a fall. An extensive evaluation and work-up revealed symptoms consistent with subclavian steal syndrome that resolved following a carotid-axillary bypass. Subclavian steal secondary to a right aortic arch is extremely rare. This report reviews the current literature of a right aortic arch with an aberrant left subclavian artery presenting as a subclavian steal syndrome.

Incidental finding of an absent left common carotid artery

We describe a case of a young woman evaluated for Raynaud's phenomenon in whom an extremely rare variation, the absence of the left common carotid artery, was incidentally detected as an isolated finding. The detection of vascular anomalies may be important for future endovascular or surgical interventions.

Absent right common carotid artery associated with aberrant right subclavian artery

Rarely, the external and internal carotid arteries arise separately from the brachiocephalic trunk and right subclavian artery (SA) or the aortic arch and reflect the absence of a common carotid artery (CCA). We report a 45-year-old man with absent right CCA associated with aberrant right SA, an extremely rare combination, diagnosed by computed tomography (CT) angiography during follow-up for postoperative aortic dissection. Retrospective careful observation of preoperative postcontrast CT revealed the absent right CCA. Previously reported arch variations associated with absent CCA include cervical aortic arch, double aortic arch, and right aortic arch.

Aberrant left vertebral artery transposition and concomitant carotid-subclavian bypass for treatment of acute intramural hematoma with thoracic endovascular aortic repair

Aberrant left vertebral artery (LVA) origin off the aortic arch is an uncommon anatomic variant. Treatment of the thoracic aortic pathology that necessitates its coverage has not been described. We present a patient with an acute intramural hematoma with a dominant LVA originating from the aortic arch. A LVA-to-carotid artery transposition with shunt placement, carotid-to-subclavian bypass, and thoracic endovascular aortic repair were performed. The patient recovered uneventfully, without any evidence of stroke. This case study shows that aberrant left vertebral anatomy presents a unique and interesting challenge and that vertebral shunt techniques during revascularization can be performed without stroke.

Absent right common carotid artery with stenting of symptomatic internal carotid artery stenosis

Absent common carotid artery with independent origin of internal and external carotid arteries from the subclavian artery is a rare but recognized phenomenon. We describe one such case with an associated symptomatic proximal high-grade stenosis of the right internal carotid artery. The abnormal carotid anatomy was not initially well appreciated, resulting in a failed surgical exploration and subsequent successful endovascular carotid stenting. To our knowledge, this is the first reported case of carotid stent in a right internal carotid artery originating from the subclavian artery.

MDCT in diagnosing acute aortic syndromes: reviewing common and less common CT findings

Nontraumatic acute thoracic aortic syndromes (AAS) describe a spectrum of life-threatening aortic pathologies with significant implications on diagnosis, therapy and management. In this context, multidetector computed tomography (MDCT) is the gold standard due to its intrinsic diagnostic value; its performance approaches 100% sensitivity and specificity, and it is accepted as a first-line modality for suspected acute aortic disease. MDCT allows early recognition and characterisation of acute aortic syndromes as well as the presence of any associated complications - findings that are essential for optimising treatment and improving clinical outcomes. Although classic CT findings have long been known, other unusual signs are continually reported in the medical literature. We reviewed the classic and less common CT findings, correlating them with pathophysiology, timing and management options, to achieve a definite and timely diagnostic and therapeutic definition.

Clinical cerebrovascular anatomy

Stroke is often the result of carotid atheroma, which may cause ischemia via progressive arterial narrowing or lead to superimposed thrombus formation and subsequent atheroembolism to the intracerebral vasculature. Revascularization through carotid endarterectomy or carotid artery stenting with embolic protection devices has produced favorable results in appropriately selected patients. In planning the percutaneous approach, an arch aortogram is first acquired to determine arch type and identify the presence of any anatomic variants which may affect the approach to the procedure and catheter selection. Subsequent imaging of the cerebral vasculature is performed to delineate the collateral circulation that is present, including an evaluation of the Circle of Willis. Although Doppler ultrasound, computed tomography (CT), and magnetic resonance angiography (MRA) may be useful in evaluating the presence of carotid or cerebrovascular disease, digital subtraction angiography is required prior to performance of a percutaneous intervention in order to create a procedural "roadmap". Additionally, the comprehensive management of cerebrovascular disease requires a detailed knowledge of the specific clinical syndromes that result from ischemia in each vascular territory. This methodical review of cerebrovascular anatomy and stroke syndromes will provide the operator with the tools to conduct a thorough neurological assessment prior to revascularization, evaluate any periprocedural complications that may arise, and evaluate the patient with suspected stroke.

Adult polysplenic syndrome accompanied by aberrant right subclavian artery and hemangioma in a cleft spleen: a case report

We present a case of adult polispleny syndrome accompanied by cleft spleen containing a cavernous hemangioma and an aberrant right subclavian artery. Patients with polysplenic syndrome are usually lost in childhood and rarely reach adulthood. The most frequently accompanying vascular abnormality is an interrupted inferior vena cava with azygous-hemiazygous continuation. Arterial vascular anomalies are rather rare, and there are several reports in the medical literature where cases of childhood polyspleny syndrome are accompanied by pulmonary arteriovenous fistulas or a main hepatic artery originating from the superior mesenteric artery. The case presented here seems to be the first report of adult polysplenic syndrome with an aberrant subclavian artery and a splenic cavernous hemangioma. The possible congenital vascular anomalies which eventually could accompany adult polysplenic syndrome cases are clinically important for the approach to the patient and planning of eventual vascular interventions.

Multi-slice tomographic diagnosis of isolated right aortic arch in an elderly patient

Occasional report of asyntomatic right aortic arch in a 90-year-old man with any congenital defect associated.