Anomalous Origin of the Right Vertebral Artery: Incidence and Significance

Vertebral arteria lusoria-Hyrtl's original description (1859), case illustration, and literature analysis

PURPOSE

A translation of the initial observation of vertebral arteria lusoria reported by Hyrtl in 1859 is followed by a review of all cases published until May 2023 to identify the anatomical and clinical features characterizing the typical form of this rare variant.

METHODS

PubMed, Google Scholar, and Google queries were performed with "vertebral arteria lusoria", "retroesophageal vertebral artery", and "aberrant vertebral artery" as keywords (in English, German, and French). A feature was considered typical when present in at least 75% of analyzed cases. A case of incidentally discovered vertebral arteria lusoria illustrates the typical form of the variant.

RESULTS

The analysis of 56 publications yielded 66 observations of right-sided vertebral arteria lusoria published between 1859 and May 2023. A small caliber, a retro-esophageal location, and passage through the foramen transversarium of C7 were typical. There was no evidence of association with clinical symptoms or other cardiovascular anomalies.

CONCLUSION

A typical vertebral arteria lusoria is an incidentally discovered nondominant aberrant right VA originating from the proximal descending aorta and following a retro-esophageal course to enter the C7 foramen transversarium, without associated aortic arch branching anomalies or congenital cardiovascular pathologies.

Embryology of the vertebral artery and variants of the adult

The vertebral arteries represent in the adult the main blood supply of the posterior cranial fossa, even if they appear relatively late during the embryological life. We reviewed all the most important steps of the vertebral artery's embryological development and the most common variants that can occur in the adult. The aim of this review is to summarize the main events of the development of this artery and to give an embryological explication for the most common variants of this artery.

Case report: Right vertebral and carotid artery anomalies with an aberrant right subclavian artery in two patients

Abnormal origins of the vertebral artery with supra-aortic vessel variants are exceedingly uncommon. Herein, we present two cases of the vertebral artery originating from the right common carotid artery associated with the right subclavian artery arising separately as the initial branch of the aortic arch, followed by the right common carotid artery. We reviewed the embryology of the anomalous origins of the vertebral and subclavian arteries. These variants can significantly affect surgical planning and cause severe clinical symptoms.

Aortic arch anomalies, embryology and their relevance in neuro-interventional surgery and stroke: A review

BACKGROUND

Congenital aortic arch anomalies are commonly encountered during neurointerventional procedures. While some anomalies are identified at an early age, many are incidentally discovered later in adulthood during endovascular evaluations or interventions. Proper understanding of the normal arch anatomy and its variants is pivotal to safely navigate normal aortic arch branches and to negotiate the catheter through anomalies during neurointerventional procedures. This is particularly relevant in the increasingly "transradial first" culture of neurointerventional surgery. Moreover, some of these anomalies have a peculiar predilection for complications including aneurysm formation, dissection, and rupture during the procedure. Therefore, an understanding of these anomalies, their underlying embryological basis and associations, and pattern of circulation will help endovascular neurosurgeons and interventional radiologists navigate with confidence and consider relevant pathologic associations that may inform risk of cerebrovascular disease.

METHODS

Here, we present a brief review of the basic embryology of the common anomalies of the aortic arch along with their neurological significances and discuss, through illustrative cases, the association of aortic arch anomalies with cerebral vascular pathology.

CONCLUSIONS

Understanding the aortic arch anomalies and its embryological basis is essential to safely navigate the cerebral vascular system during neurointerventional surgeries.

Esophageal cancer with right vertebral artery variation observed during thoracoscopic esophagectomy: a case report

Background

Variation of the vertebral artery bifurcation is rare. This branching abnormality can cause unexpected vertebral artery damage and bleeding during thoracoscopic esophagectomy. There are few reports of abnormal branching of the vertebral artery associated with neurosurgery but none related to esophagectomy. We report the case together with the results of the evaluation of vertebral artery bifurcation and length in 50 patients with esophageal cancer in our hospital.

Case presentation

Thoracoscopic esophagectomy was performed on a 70-year-old patient with esophageal cancer. During lymph node dissection around the right reccurent laryngeal nerve, an unusual blood vessel was found running along the right subclavian artery. We determined this blood vessel to be the right vertebral artery branching far more centrally than usual. Because this anatomical abnormality was clarified, we could then recognize that the right reccurent laryngeal nerve coursed around the right vertebral artery and the right subclavian artery and thus was running in a larger arch than usual.

Conclusion

Long right vertebral artery may appear in the surgical field of the thoracoscopic esophagectomy. Knowledge of such anatomical variation is important to prevent iatrogenic injury of the right vertebral artery and the right reccurent laryngeal nerve.

Anomalous origin of right vertebral artery from right common carotid artery

Anomalous origin of vertebral arteries is a rare vascular anomaly and mostly discovered as incidental findings during computed tomography angiogram , magnetic resonance angiography or digital subtracted angiogram of the aortic arch and cerebral vessels. Herein, we present an extremely rare case of a 31-year-old female who presented with headache after emotional trauma. A conventional cerebral angiogram showed anomalous origin of the right vertebral artery. This finding was incidentally discovered, and it is of utmost importance for future head and neck endovascular interventions to avoid inadvertent arterial injury.

Incidental Finding of a Duplicated Vertebral Artery Followed by a Spinal Dural Arteriovenous Fistula on Spinal Angiography

Duplicated origin of the vertebral artery (VA) is an extremely rare normal anatomic variant. While most often considered non-pathological, duplicated origin carries an increased risk of dissection. An association with vascular pathologies such as aneurysms, arteriovenous malformations, and AV fistulas has been suggested. The objective is to describe this unusual anatomic variant with is concomitant vascular pathology and review current literature. The authors report a case of incidentally-discovered duplicated origin of the left VA in patients with a spinal dural arteriovenous fistula (dAVF). A 61-year-old man with a history significant for sarcoidosis presented with progressive lower extremity weakness and paresthesias. MRI of the thoracic spine demonstrated significant confluent edema and patchy contrast enhancement in the caudal spinal cord and conus medullaris which did not appear related to the patient's neurosarcoidosis. A diagnostic spinal angiogram incidentally demonstrated that the left V1 segment had a duplicated origin, one branch arising from the aortic arch and the other branch arising from the left subclavian artery, with union at the C5 transverse foramen. This finding represented an incidental anomaly discovery was noted to be incidental and was not believed to be related to the patients underlying pathology. Subsequently, a dAVF was discovered, originating from the right T7 spinal artery. Location of this vascular malformation directly correlated with the patient’s symptoms. The patient then underwent embolization of the spinal dAVF and recovered uneventfully. Duplicated origin of the VA is an extremely rare but well-described variant, most commonly involving the left VA. To our knowledge, this is the only reported spinal dAVF associated with duplicated origin of the left VA. An association with other pathological entities has been suggested, and thus this case adds to a growing body of cases characterizing these relationships.

The right vertebral artery arising from the right common carotid artery: report of a rare case

Anomalous origins of the vertebral arteries are uncommon and generally associated with other abnormalities of the supra-aortic vessels. We present an extremely rare case where the right vertebral artery is arising from the right common carotid artery, with an absent brachiocephalic trunk, and the right common carotid artery as the first branch of the aortic arch followed by right subclavian artery, without any other abnormalities of the supra-aortic vessels. This vessel variation can affect endovascular procedures, surgical interventions and cause some unexpected clinical symptoms.