Case Report Arteria Lusoria: An Anomalous Finding …downloads.hindawi.com/journals/cric/2016/8079856.pdfCase Report Arteria Lusoria: An Anomalous Finding during Right Transradial

Case ReportArteria Lusoria An Anomalous Finding duringRight Transradial Coronary Intervention

David Allen1 Hilary Bews1 Minh Vo1 Malek Kass1

Davinder S Jassal123 and Amir Ravandi12

1Section of Cardiology Department of Internal Medicine Max Rady College of Medicine Rady Faculty of Health SciencesUniversity of Manitoba Winnipeg MB Canada2Department of Radiology Max Rady College of Medicine Rady Faculty of Health Sciences University of ManitobaWinnipeg MB Canada3Institute of Cardiovascular Sciences St Boniface Albrechtsen Research Centre University of Manitoba Winnipeg MB Canada

Correspondence should be addressed to Amir Ravandi aravandisbrcca

Received 17 April 2016 Accepted 7 June 2016

Academic Editor Expedito E Ribeiro

Copyright copy 2016 David Allen et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Arteria Lusoria or aberrant right subclavian artery (ARSA) is present in 06ndash14 of individuals It typically remains clinically silentand is often discovered during angiographic proceduresThe presence of ARSA canmake a right transradial approach for coronaryangiography and angioplasty technically more difficult With the use of catheter support we describe two cases in which a righttransradial approach for catheterization was successful in the setting of ARSA As such the presence of ARSA does not warrantabandoning a transradial approach for coronary angiography and angioplasty

1 Introduction

Arteria Lusoria or aberrant right subclavian artery (ARSA)is the most common congenital arch anomaly in whichthe right subclavian artery originates from the descendingaorta distal to the left subclavian at the ductus arteriosus[1] On its course towards the right arm the aberrant vesseltravels retrotracheal and retroesophageal [1] The prevalenceof ARSA ranges from 06 to 14 [1]The prevalence of ARSArises exponentially to 26ndash34 in individuals with Downsyndrome and other chromosomal defects [1]

ARSA remains clinically silent in the majority of casesIn approximately 5 of individuals ARSA is associated withan aberrant umbilical vein tricuspid atresia or tetralogyof Fallot [1] Rarely ARSA can accompany Kommerellrsquosdiverticulum an aneurysm of the descending aorta at theorigin of the ARSA [2] This can present clinically as dyspha-gia dyspnea or subclavian steal syndrome often requiringsurgical intervention [2]

Despite reports of complications on right radial approachfor angiography we report two cases demonstrating thesuccess and safety of this approach

2 Case 1

A 42-year-old man with a past history of hypertensionand hyperlipidemia presented to hospital with acute onsetof retrosternal chest discomfort He had an elevation ofhis cardiac biomarkers and was diagnosed with non-STelevationmyocardial infarction (NSTEMI) During coronaryangiography right radial access with a 6 Fr Side arm sheathwas obtained The advancement of any catheters into theascending aorta from the radial approach was very diffi-cult due to tortuous angulation at the junction betweenthe ascending aorta and the right innominate artery Withthe help of a 003510158401015840 Glidewire (Terumo InterventionalSystems Somerset NJ) a pigtail was advanced into theascending aorta and an aortic root angiography was per-formedThis confirmed the presence of ARSA (Figure 1) Forcatheter exchanges a 260 cm 003810158401015840 J curved wire (CordisHialeah FL) was used A JL35 diagnostic catheter (CordisHialeah FL) was used for left coronary angiography anda JR40 diagnostic catheter (Cordis Hialeah FL) was usedfor right coronary angiography For the PCI procedure a6 Fr XB 35 guiding catheter (Cordis Hialeah FL) was

Hindawi Publishing CorporationCase Reports in CardiologyVolume 2016 Article ID 8079856 3 pageshttpdxdoiorg10115520168079856

2 Case Reports in Cardiology

Figure 1 Angiographic images from Case 1 (A) aortogram of the ascending transverse and descending aorta demonstrating the ARSA(B) anterior-posterior projection demonstrating the characteristic loop of ARSA with the guidewire in the descending aorta (C) left anterioroblique cranial projection with Judkins left catheter engaging the left main demonstrating an 80 mid LAD coronary artery lesion (D) thecharacteristic loop of ARSA (E) ballooning of the LAD lesion (F) final result ARSA aberrant right subclavian artery LAD left anteriordescending RCCA right common carotid artery LCCA left common carotid LSA left subclavian artery

used to allow adequate support during the LAD interven-tion

3 Case 2

A 51-year-old woman presented for angiography followinga NSTEMI A right radial approach with a 6 Fr Sheathwas selected Multiple guidewires consistently engaged thedescending aorta A Judkins right 40 catheter (CordisHialeah FL) was placed at the right subclavian arteryostium With gentle clockwise motion and simultaneousadvancement of the 003810158401015840 guidewire the ascending aortawas successfully engaged (Figure 2) As with Case 1 catheterexchanges were done with a 260 cm 003810158401015840 J curved wire(Cordis Hialeah FL) Angioplasty was performed usinga 6 Fr XB 40 guiding catheter (Cordis Hialeah FL) Asubsequent computed tomography of the chest confirmed thediagnosis of ARSA

4 Discussion

In the vast majority of patients as in the two cases illus-trated ARSA is clinically silent until right radial coronaryangiography is entertained With the increasing use of atransradial approach for coronary angiography as a resultof the lower risk of access site related complications ARSA

will be encountered more frequently [3] ARSA can beconfirmed by aortography and should be suspected whencatheterization of the ascending aorta proves difficult andthe catheter favors entry into the descending aorta Due tothe increased anatomical complexity ARSA may increasenumber of catheters used and prolong angiography timeespecially if previously unrecognized [3]

Previous studies have described low procedural successrates of 610 during catheterization in the setting of ARSAdue to increased technical demand [4] We have demon-strated with the two current cases that catheter support androtation can facilitate successful nontraumatic entry intothe ascending aorta [3] In addition a transradial approachin the setting of ARSA appears safe with no significantdifference in dissection rate between anatomically normaland variant subclavian arteries [4] As in all cases in whichcomplex percutaneous coronary intervention is requiredspecific attention should be placed on appropriate guidesupport In the absence of this consideration towards gainingaccess from another approach would be warranted

5 Conclusion

While right radial angiography and angioplasty are techni-cally more demanding in the setting of ARSA it does notnecessitate abandoning the right radial approach [5]

Case Reports in Cardiology 3

Figure 2 Angiographic images fromCase 2 (A) lateral projection showing characteristic loop of ARSA (B) left anterior oblique view of rightcoronary artery showing a 90 proximal lesion (C) with subsequent stenting (D) right anterior oblique caudal view of left coronaries witha 70 circumflex 90 OM1 and 70 OM3 (E) final result (F) A 3D volume rendered imaged from a contrast-enhanced CT angiographicdataset demonstrating vessels arising from the arch in the following order RCCA LCCA LSA and ARSA ARSA aberrant right subclavianartery OM obtusemarginal RCCA right common carotid artery LCCA left common carotid LSA left subclavian artery AscAo ascendingaorta Desc Ao descending aorta

Ethical Approval

The authors have conformed to institutional ethical guide-lines

Consent

Consent was obtained from patients included in the casereport

Competing Interests

The authors report no financial relationships or conflict ofinterests regarding the content herein

References

[1] C Scala U Leone Roberti Maggiore M Candiani et al ldquoAber-rant right subclavian artery in fetuses with Down syndrome asystematic review and meta-analysisrdquo Ultrasound in Obstetricsand Gynecology vol 46 no 3 pp 266ndash276 2015

[2] S Demirkol S Balta U Bozlar S Sari M Unlu and Z ArslanldquoKommerell diverticulum associated with aberrant left sub-clavian artery and right-sided aortic archrdquo European HeartJournal Cardiovascular Imaging vol 14 no 8 p 764 2013

[3] R K Abhaichand Y Louvard J-F Gobeil C Loubeyre TLefevre and M-C Morice ldquoThe problem of arteria lusoria

in right transradial coronary angiography and angioplastyrdquoCatheterization and Cardiovascular Interventions vol 54 no 2pp 196ndash201 2001

[4] O Valsecchi A Vassileva G Musumeci et al ldquoFailure of trans-radial approach during coronary interventions anatomic con-siderationsrdquo Catheterization and Cardiovascular Interventionsvol 67 no 6 pp 870ndash878 2006

[5] G Kassimis N Sabharwal N Patel and A Banning ldquoAberrantright subclavian artery hematoma following radial catheteriza-tionrdquo JACC Cardiovascular Interventions vol 6 no 6 pp 636ndash637 2013

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2 Case Reports in Cardiology

Figure 1 Angiographic images from Case 1 (A) aortogram of the ascending transverse and descending aorta demonstrating the ARSA(B) anterior-posterior projection demonstrating the characteristic loop of ARSA with the guidewire in the descending aorta (C) left anterioroblique cranial projection with Judkins left catheter engaging the left main demonstrating an 80 mid LAD coronary artery lesion (D) thecharacteristic loop of ARSA (E) ballooning of the LAD lesion (F) final result ARSA aberrant right subclavian artery LAD left anteriordescending RCCA right common carotid artery LCCA left common carotid LSA left subclavian artery

used to allow adequate support during the LAD interven-tion

3 Case 2

A 51-year-old woman presented for angiography followinga NSTEMI A right radial approach with a 6 Fr Sheathwas selected Multiple guidewires consistently engaged thedescending aorta A Judkins right 40 catheter (CordisHialeah FL) was placed at the right subclavian arteryostium With gentle clockwise motion and simultaneousadvancement of the 003810158401015840 guidewire the ascending aortawas successfully engaged (Figure 2) As with Case 1 catheterexchanges were done with a 260 cm 003810158401015840 J curved wire(Cordis Hialeah FL) Angioplasty was performed usinga 6 Fr XB 40 guiding catheter (Cordis Hialeah FL) Asubsequent computed tomography of the chest confirmed thediagnosis of ARSA

4 Discussion

In the vast majority of patients as in the two cases illus-trated ARSA is clinically silent until right radial coronaryangiography is entertained With the increasing use of atransradial approach for coronary angiography as a resultof the lower risk of access site related complications ARSA

will be encountered more frequently [3] ARSA can beconfirmed by aortography and should be suspected whencatheterization of the ascending aorta proves difficult andthe catheter favors entry into the descending aorta Due tothe increased anatomical complexity ARSA may increasenumber of catheters used and prolong angiography timeespecially if previously unrecognized [3]

Previous studies have described low procedural successrates of 610 during catheterization in the setting of ARSAdue to increased technical demand [4] We have demon-strated with the two current cases that catheter support androtation can facilitate successful nontraumatic entry intothe ascending aorta [3] In addition a transradial approachin the setting of ARSA appears safe with no significantdifference in dissection rate between anatomically normaland variant subclavian arteries [4] As in all cases in whichcomplex percutaneous coronary intervention is requiredspecific attention should be placed on appropriate guidesupport In the absence of this consideration towards gainingaccess from another approach would be warranted

5 Conclusion

While right radial angiography and angioplasty are techni-cally more demanding in the setting of ARSA it does notnecessitate abandoning the right radial approach [5]



Ethical Approval


Consent


Competing Interests


References












of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


















Ethical Approval


Consent


Competing Interests


References












of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















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Case Report Arteria Lusoria: An Anomalous Finding …downloads.hindawi.com/journals/cric/2016/8079856.pdfCase Report Arteria Lusoria: An Anomalous Finding during Right Transradial