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CASE REPORT
Year : 2022 | Volume
: 8
| Issue : 3 | Page : 185-187
Truncus bicarotics with arteria lusoria - A rare incidental finding with clinical implications
Digvijay D Nalawade1, Ajitkumar K Jadhav1, Pratik Satyajit Wadhokar1, Rahul Kadu2
1 Department of Cardiology, Dr D Y Patil Medical College, Hospital and Research Centre, Pune, India
2 Pulse Medicare and Cardiac Centre, Sankalp Hospital, Amaravati, Maharashtra, India
Correspondence Address:
Pratik Satyajit Wadhokar
D-28, Emirates Hills, Somatane Phata, Off Mumbai-Pune Highway, Tal- Maval, District Pune - 410 506, Maharashtra
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jpcs.jpcs_65_22
Arteria lusoria, an aberrant right subclavian artery originating distal to the ostium of carotid arteries, is the most common congenital aortic arch anomaly. It is commonly associated with other congenital anomalies of the heart and great vessels resulting from embryologic malformation of the aortic arch, including truncus bicaroticus, which is a common trunk of bilateral common carotid arteries. The association between arteria lusoria and truncus bicaroticus is about 29%. We reported a rare case of truncus bicaroticus with arteria lusoria in a 40-year-old male patient detected incidentally during coronary angiography through the right radial approach.
Keywords: Arteria lusoria, congenital aortic arch anomaly, Kommerell's diverticulum, truncus bicarotics
The most common aortic arch branching pattern in human consists of three great vessels originating from the arch of aorta, and the first branch is the innominate artery, which branches into the right subclavian artery and the right common carotid artery. The second branch is the left common carotid artery, and the last branch is the left subclavian artery.[1] Variations of aortic arch and its branches are well known in the literature, have potential clinical implications with arterie lusoria, aberrant right subclavian artery, being the most common with reported prevalence of 0.4%-2%.[2]
Case ReportA 40-year-old male presented for angina on exertion and dyspnea on exertion in New York Heart Association (NYHA) class II in the past 6 months, which was increased to NYHA class III in the past 15 days. His past medical history included percutaneous transluminal coronary angioplasty with stenting of the left anterior descending 6 years prior. Coronary angiography was planned and performed through the right radial approach. During right radial coronary angiography, advancement of the guide wire into the ascending aorta was found to be difficult, which raised suspicion of the retroesophageal right subclavian artery. After multiple attempts of wire and catheter manipulation, the wire was positioned in ascending aorta, as shown in [Figure 1]a and [Figure 1]b. As coronary angiography revealed double-vessel disease, we proceeded with the right internal mammary artery (RIMA) and left internal mammary artery (LIMA) angiography. During LIMA angiography catheter tip incidentally engaged a common trunk from where both carotid arteries were originating, which was further confirmed on selective angiography of the common trunk as shown in [Figure 1]c and [Figure 1]d. Then selective angiography of the left subclavian artery was done after engaging the left subclavian artery ostium located distal to the origin of the common trunk of truncus bicaroticus. The left vertebral artery and LIMA originated from the left subclavian artery, as shown in [Figure 2]a. Selective angiography of the right subclavian artery was done; the right vertebral artery and RIMA originated from it, as shown in [Figure 2]b. Computed tomography aortogram further confirmed the angiography findings of truncus bicaroticus and arteria lusoria, as shown in [Figure 2]c. On enquiry, the patient denied any symptoms suggestive of trachea-esophageal compression, which may be associated with these anomalies.
Figure 1: (a and b) Fluoroscopic PA and LAO 60° projection demonstrating the characteristic loop of aberrant right subclavian artery with J tip Terumo wire positioned in ascending aorta. (c and d) Angiographic PA and LAO 60° projection demonstrating complete opacification of common trunk from which both common carotid arteries originates, suggestive of truncus bicaroticus. PA: Antero-posterior, LAO: Left anterior oblique.
Figure 2: (a) Angiographic projection demonstrating complete opacification of left subclavian artery, left vertebral artery and left internal mammary artery. (b) Angiographic projection demonstrating complete opacification of right subclavian artery, right vertebral artery and right internal mammary artery. (c) Computed tomography aortogram showing findings of Truncus Bicaroticus and Arteria Lusoria. Discussion With the increasing use of a transradial approach for coronary intervention, incidental detection of arteria Lusoria will be encountered more frequently.[3] It usually originates from the upper portion of the thoracic aorta or as the left-most branch of the aortic arch.[4] It may be associated with truncus bicaroticus, which is a common trunk of bilateral common carotid arteries.[5] Arteria lusoria and truncus bicaroticus are a rare combination of aortic arch anomalies. Aberrant right subclavian artery arises due to involution of the right fourth vascular arch with the proximal right dorsal aorta and the persistence of the right seventh inter-segmental artery, which remains attached to the dorsal aorta. After the rotation of the dorsal aorta, the right seventh inter-segmental artery becomes the aberrant right subclavian artery. The artery crosses the midline between the esophagus and vertebral column to reach the right side.[6] It may remain asymptomatic or cause symptoms by compressing the esophagus and trachea, resulting in dysphagia or hoarseness of voice. Truncus bicaroticus is considered to be a precursor of symptoms wherein truncus compresses the trachea from the front and aberrant right subclavian artery presses the esophagus from behind. Sometimes, the condition may be complicated by the development of an aneurysm in the aberrant artery, which may produce additional symptoms due to the compression of adjacent organs.[7] Klinkhamer stated that truncus bicaroticus is a precondition for tracheal esophageal compression and the development of clinical symptoms because the truncus bicaroticus holds the trachea from the front and the arteria lusoria compresses the esophagus from behind.[4] Aneurysmal dilatation of the aberrant right subclavian artery (Kommerell's diverticulum) can cause thrombosis with resulting arterial embolization to the right upper extremity.[8] Failure to recognize a truncus bicaroticus may lead to a complication during tracheostomy or thyroidectomy. The presence of aberrant right subclavian artery may influence the location of a systemic to pulmonary artery shunt. This anomaly should be considered in the selection of a site for arterial line placement if the need for transesophageal monitoring is also anticipated during surgery. The aberrant vessel may be compressed along its retroesophageal course by the imaging probe, resulting in inaccurate readings.[4]
In our case, though the anomalous combination was diagnosed incidentally and the patient was asymptomatic yet it has important clinical implications, which should be considered. It is very important to recognize these variants as procedures are being performed, and failure to do so may lead to harm for the patient.
Ethics clearance
Appropriate consent of patient was taken before making the case report. As this is a case report the university guidelines do not require an ethical committee and/or Institutional ethical committee clearance for its scientific publication.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
References
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