Left Transradial Access Using a Radial-Specific Neurointerventional Guiding Sheath for Coil Embolization of Anterior Circulation Aneurysm Associated With the Aberrant Right Subclavian Artery: Technical Note and Literature Review

BACKGROUND

Aberrant right subclavian artery (ARSA) is a rare condition, but the most common anomaly of the aortic arch. Although neurointerventions via transradial access (TRA) are becoming increasingly popular worldwide, transradial carotid cannulation has been extremely challenging in patients with an ARSA. Herein, we present a case of ARSA-associated anterior communicating artery (ACoA) aneurysm that was successfully treated with a radial-specific 6F Simmons guiding sheath via left TRA. We also review the relevant literature.

METHODS

A 68-year-old-woman who was diagnosed as having an ARSA-associated ACoA aneurysm underwent simple coiling via left TRA. After the 6F Simmons guiding sheath was engaged into the right common carotid artery using the pull-back-technique, transradial quadraxial system (6F Simmons guiding sheath/6F intermediate catheter/3.2F intermediate catheter/coil-delivery microcatheter) was implemented.

RESULTS

Simple coiling of the aneurysm was successfully achieved without catheter kinking or system instability. The postprocedural course was uneventful. A follow-up magnetic resonance angiography showed no evidence of recanalization 1 years 9 months after the procedure.

CONCLUSIONS

Transradial anterior circulation intervention has been rarely used for patients with an ARSA due to unfavorable catheter trajectory. Left TRA using the 6F Simmons guiding sheath is a useful treatment option to address anterior circulation interventions for patients with an ARSA. Preoperative diagnosis of ARSA is necessary for the application of our method.

The triad of non-recurrent laryngeal nerve; three associated predicting variants in the era of nerve monitoring: A case report

INTRODUCTION AND IMPORTANCE

The prediction and early identification of non-recurrent laryngeal nerve (RLN) may minimize risk of injury. It could be associated with other coincident variants that predict non-RLN, leading to its proper identification.

CASE PRESENTATION

A patient with multinodular goiter underwent total thyroidectomy under intraoperative neuromonitoring (IONM) guidance. Preoperative thoracic computerized tomography (CT) scan/angiography revealed aberrant right subclavian artery (ARSA). During thyroid surgery, the vagus nerve (VN) was identified in the neurovascular bundle. An anatomic variation of the VN was observed, as it was medially placed in relation to the common carotid artery (CCA). Pre-dissection electrophysiological stimulus of the VN (V1) was negative. Thus, a right non-RLN was identified with careful surgical dissection. The branching point of the non-RLN on the VN was identified, and non-RLN was fully exposed until the laryngeal entry. IONM revealed that V1 signal was negative if derived distal to the non-RLN separation, and positive if derived proximal to the non-RLN separation.

CLINICAL DISCUSSION

ARSA detected by preoperative CT scan is associated with non-RLN. The medial course of the VN in relation to the CCA was found as a coincident anatomic variant with the non-RLN. Absence of pre-dissection V1 signal by IONM was an electrophysiological variant associated with the non-RLN.

CONCLUSION

ARSA is a reliable variant for predicting the non-RLN. VN medial to the CCA and absence of electrophysiological V1 signal could precisely predict the non-RLN. Therefore, the coincidence of three anatomical and electrophysiological variants with non-RLN could lead to the prediction of non-RLN.

Arteria lusoria with patent foramen ovale: clinical and embryological significance with literature review

A 73-year-old female donated cadaver had an unusual origin of the right subclavian artery (RSA), which is usually known as 'Arteria lusoria' (AL) or "Aberrant Right Subclavian Artery" (ARSA). This artery originated as the fourth and most extreme left branch from the arch of the aorta (AOA), distal to the origin of the left subclavian artery (LSA), and traversed obliquely upwards, towards the right side posterior to the oesophagus, heading for the thoracic inlet. The brachiocephalic trunk (BCT) was absent. The right common carotid (RCCA), left common carotid (LCCA), LSA and ARSA were four branches that originated from the aortic arch and ran from right to left. The course and distribution of these branches were normal. On opening the right atrium, a patent foramen ovale (PFO) was observed in the upper part of the interatrial septum. As far as we know, this is the first cadaveric case report of arteria lusoria with the presence of an atrial septal defect in the form of a PFO. Early diagnosis of aortic arch abnormalities using diagnostic interventions is beneficial for identifying risk factors after invasive procedures.

When Arteria lusoria meets Truncus bicaroticus: one of the rarest combinations of aortic arch anomalies

The Arteria lusoria or aberrant right subclavian artery (ARSA) constitutes one of the rarest malformations of the aortic arch, it can be associated with other congenital anomalies of the heart and large vessels, in particular the bi-carotid trunk or common origin of the carotid arteries (COCA) which is the presence of a single branch from the aorta giving off both right and left common carotid arteries. We report the case of a patient followed for severe mitral stenosis, and hospitalized for an ischemic cerebral vascular accident, a chest CT scan was performed in front of her clinical and biological degradation, which allowed the fortuitous discovery of an Arteria lusoria (aberrant retro-esophagealartery) associated with a Truncus bicaroticus.

[Arteria lusoria causing dyspnea: about a case]

Arteria lusoria or retroesophageal right subclavian artery is the most common aortic arch malformation, accounting for 0.5-2.5% of cases. It can be detected in patients with symptoms including airway and/or esophageal compression such as dyspnea or dysphagia or even recurrent respiratory infections; but it is mostly asymptomatic, as reported by several authors. We here report the case of a 44-year-old female patient treated in our emergency room due to respiratory distress syndrome associated with arteria lusoria. This is a rare cause of dyspnea which should be suspected in patients with dyspnea not responding to medical treatment. Asymptomatic patients undergo medical treatment associated with simple surveillance. Surgery is necessary when it becomes symptomatic or when it is associated with Kommerell diverticulum (KD).

Arteria lusoria dissection with mediastinal hematoma as a complication of a transradial coronary catheterization: Case report and literature review

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Aberrant right subclavian artery (ARSA), or arteria lusoria is the most common embrologic anomaly of the aortic arch.

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The ARSA arises after the origin of the left subclavian artery and then reaches the posterior mediastinum.

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The presence of ARSA is generally asymptomatic, but may cause complications, during some endovascular procedures.

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Prompt diagnosis and treatment is required to avoid more dreadful complications.

Introduction

Aberrant right subclavian artery (ARSA), or arteria lusoria is the most common embrologic anomaly of the aortic arch. It is generally asymptomatic and incidentally diagnosed during a radiological exam or procedure.

Presentation of case

Here, we report a case of ARSA incidentally diagnosed and injured (dissection with mediastinal hematoma) during a right transradial coronary angiography in a 83 years old female patient. The patient underwent prompt hybrid procedure with the isolation of the right humeral artery from where we positioned a GORE® VIABAHN® 9 × 100 mm endoprosthesis. The procedure was successful with optimal results at early and long term follow up.

Discussion

Sometimes, a dissection of the ARSA may occur, especially for excessive manipulation during endovascular procedures, and when such complication happens it should be promptly treated as it can be life-threatening.

Conclusion

If transradial catheterization during coronary angiography becomes particularly difficult, requires longer time, or the guide wire enters in the descending aorta, particularly attention should be paid, as dreadful complications such as dissection or lesion may happen and prompt treatment is required.

Dyspnea in Patient with Arteria Lusoria: A Case Report

INTRODUCTION

Arteria lusoria is an aberrant right subclavian artery. In symptomatic cases, patients report dysphagia and only in few cases dyspnea, due to external compression of the trachea and esophagus. Symptoms occur in advanced age and diagnosis is made with chest HRCT, when other causes of dysphagia have been excluded.

CASE REPORT

An 83-year-old woman presented with dyspnea and mechanical dysphagia for solids. Therefore, she did a chest high-resolution computed tomography (HRCT) that showed areas of consolidation of the lung parenchyma, pleural effusion and presence of arteria lusoria, with a retroesophageal course. After 18 days, dysphagia and dyspnea worsened. The new chest HRCT revealed bilateral atelectasis of the lower lung lobes and severe compression of esophagus and trachea along the course of the arteria lusoria.

CONCLUSION

Considering its dangerousness, this vascular anomaly should be considered in advanced aged patients with dysphagia and dyspnea, once other causes have been excluded.

Coronary Angiography in Patients with Arteria Lusoria via Right Radial Access: A Case Series and Literature Review

Transradial is becoming the access of choice for coronary angiography (CAG). Arteria lusoria (AL) poses a challenge for right transradial access because it can cause difficulty in accessing the ascending aorta. Of 18,686 patients who underwent CAG in Geisinger Medical Center from 2012 to 2018, 6 had a diagnosis of AL. Four underwent attempted right radial access, in 3 cases before AL was identified. All were successful, and one patient had successful right transradial percutaneous coronary intervention. CAG and PCI can be successfully performed using right radial access in patients with AL.

Coexistence an aberrant right subclavian artery with other congenital anomalies: case report and review of the literature

Aberrant right subclavian artery is the most common aortic arch anomaly that frequently occurs in coexistence with other congenital cardiovascular anomalies. A 32-year-old male patient was hospitalized with ventricular septal defect, chronic heart failure NYHA class III, pulmonary arterial hypertension. Contrast-enhanced multislice computed tomography revealed membranous ventricular septal defect, persistent left superior vena cava, bicuspid aortic valve and aberrant right subclavian artery. Aberrant right subclavian artery was clinically silent and discovered accidentally. The patient underwent heart-lung transplantation due to pronounced, irreversible pulmonary hypertension. This article reports a rare coexistence of aberrant right subclavian artery with other congenital anomalies of the heart and great vessels in living men.

The presence of an asymptomatic aberrant right subclavian artery: A potential risk factor in esophageal surgery?

Bleeding of an aberrant right subclavian artery following transthoracic en bloc esophagectomy and intrathoracic gastric reconstruction is a rare but severe complication in esophageal surgery. Preoperative diagnosis can be achieved by computed tomography or magnetic resonance angiography (MRA). Various treatment options are available; thus, the treatment can be challenging and should be adjusted to the severity of the symptoms. Bleeding of an aberrant right subclavian artery can result from perioperative vascular injury or various postoperative complications. We report about a case of a patient with esophageal cancer and an asymptomatic, simultaneously existing aberrant right subclavian artery. The patient underwent a successful conventional Ivor-Lewis esophageal resection without any life-threatening bleeding. Early detection and intraoperative identification was of major importance for successful surgery.

The Non-Recurrent Laryngeal Nerve: a meta-analysis and clinical considerations

Background

The Non-Recurrent Laryngeal Nerve (NRLN) is a rare embryologically-derived variant of the Recurrent Laryngeal Nerve (RLN). The presence of an NRLN significantly increases the risk of iatrogenic injury and operative complications. Our aim was to provide a comprehensive meta-analysis of the overall prevalence of the NRLN, its origin, and its association with an aberrant subclavian artery.

Methods

Through March 2016, a database search was performed of PubMed, CNKI, ScienceDirect, EMBASE, BIOSIS, SciELO, and Web of Science. The references in the included articles were also extensively searched. At least two reviewers judged eligibility and assessed and extracted articles. MetaXL was used for analysis, with all pooled prevalence rates calculated using a random effects model. Heterogeneity among the included studies was assessed using the Chi² test and the I² statistic.

Results

Fifty-three studies (33,571 right RLNs) reported data on the prevalence of a right NRLN. The pooled prevalence estimate was 0.7% (95% CI [0.6–0.9]). The NRLN was found to originate from the vagus nerve at or above the laryngotracheal junction in 58.3% and below it in 41.7%. A right NRLN was associated with an aberrant subclavian artery in 86.7% of cases.

Conclusion

The NRLN is a rare yet very clinically relevant structure for surgeons and is associated with increased risk of iatrogenic injury, most often leading to temporary or permanent vocal cord paralysis. A thorough understanding of the prevalence, origin, and associated pathologies is vital for preventing injuries and complications.

Aberrant right subclavian artery (arteria lusoria) challenging 4-French homolateral transradial coronary catheterisation in adulthood

We report a case of an accidental finding of an aberrant right subclavian artery diagnosed in an adult man during a 4-French coronary angiography performed by right transradial access, then confirmed by multi-slice computed tomography. Tips and tricks have been suggested to complete the 4-French procedure avoiding changing the vascular access.

Beware of arteria lusoria during lymph node dissection of the right paratracheal fossa for lung cancer surgery

An asymptomatic elderly woman presented with a solitary right upper lobe mass revealed to be non-small cell lung cancer following routine surveillance post mastectomy. Upon review of CT with contrast in preparation for rigid bronchoscopy and right upper lobectomy, we noticed that the patient had a rare case of arteria lusoria. This is the presence of an aberrant right subclavian artery extending from the left side of the aortic arch, crossing posteriorly across the midline to supply the upper limb. We suggest that with a documented 100% diagnostic sensitivity on 64 multislice computed tomography, the presence of arteria lusoria within the posterior paratracheal fossa may cause life-threatening complications in the unaware during systematic lymph node dissection for non-small cell lung cancer (NSCLC).

Retrospective study of 11,479 fetopathological examinations]

OBJECTIVE

The aberrant right subclavian artery is a malformation of the aortic arch present at less than 2 % of the individuals in the general population. This incidence is higher in trisomy 21, making it possible use the aberrant right subclavian artery as a prenatal marker of trisomy 21.

MATERIAL AND METHODS

This work, which relates to a series of 11,479 consecutive fetal autopsies aims to measure the force of association between the aberrant right subclavian artery and trisomy 21, to confront our results with the sonographic series previously published and to contribute to assess the place that can have this sign in the echographic screening and the fetopathologic diagnosis of trisomy 21.

RESULTS

The isolated presence of an aberrant right subclavian artery does not represent an argument sufficient for the indication of a karyotype. But the detection of this anomaly must make pay a special attention in search of other associated signs.

CONCLUSION

On the results of this study, the aberrant right subclavian artery has to be considered as a part of the spectrum not only of trisomy 21, but also of many other congenital syndromes.