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Case Report
Open Access Peer-reviewed

Stanford B Dissection with Right Radial Cardiac Catheterization in a Patient with Arteria Lusoria & Kommeral’s Diverticulum

Yuvraj Chowdhury, Shakil A. Shaikh, Ali Salman, Jonathan D. Marmur, Osagie Igiebor, Moro O. Salifu, Samy I. McFarlane
American Journal of Medical Case Reports. 2020, 8(9), 271-273. DOI: 10.12691/ajmcr-8-9-4
Received April 20, 2020; Revised May 22, 2020; Accepted May 29, 2020

Abstract

An Aberrant Right Subclavian Artery (ARSA) is a rare congenita; anomaly (0.4-1.8%) of the aorta in which the right subclavian artery arises from the aortic arch distal to the origin of the left subclavian artery often coursing behind the esophagus to reach the right arm. It courses behind the esophagus in about 80% of cases, between the esophagus and the trachea in 15%, and anterior to the trachea or mainstem bronchus in 5%. Patient with this anomaly rarely have symptoms (90-95%) but when symptomatic the ARSA give rise to symptoms of dysphagia lusoria, dyspnea and chronic cough. In a vast majority of patients ARSA is clinically silent till right radial angiography is performed. We are reporting a case of dissection of the retroesophageal right subclavian artery traveling into the descending thoracic aorta (Stanford Type B) during right radial cardiac catherization performed on a patient presenting with non-ST elevation myocardial infarction.

1. Introduction

An Aberrant Right Subclavian Artery (ARSA) is a rare developmental anomaly (0.4-1.8%) of the aorta in which the right subclavian artery arises from the aortic arch distal to the origin of the left subclavian artery often coursing behind the esophagus to reach the right arm 1.

While it was fisrt described by Hanuld in 1735; this arterial anomaly in its symptomatic form “dysphagia lusoria” was described by Bayford in 1787 (lusoria= abnormal arterial course) 2, 3.

A German Radiologist, Burkhard Friedrich Kommerell observed that the ARSA often arises from a dilated segment of the descending aorta and described it as remainder of the primitive right dorsal aorta. This vascular anomaly often seen with ARSA but not limited to it was been subsequently named the Lusorian artery or Kommerell’s diverticulum 4.

Since the introduction of diagnostic trans-radial catheterization in 1989 and its use for coronary intervention in 1993, the trans-radial approach has become increasingly popular. However, a review of literature shows that successful right radial cardiac catheterization could be successfully performed in only 60% of cases of ARSA 5. This is because the right trans-radial approach in patients with ARSA makes it difficult to approach the aorta root and requires the catheter to curve back into the ascending aorta.

We are reporting a case of dissection of the retroesophageal right subclavian artery traveling into the descending thoracic aorta (Stanford Type B) during right radial cardiac catherization performed on a patient presenting with non-ST elevation myocardial infarction.

2. Report of the Case

A 58-year-old, otherwise healthy, woman who presented to our emergency department (ED) after feeling that her heart abruptly began pounding at work. She indicated that, while her work as an airline ground staff involved walking large distances every day, she never experienced such symptoms before. These symptoms persisted for 3-4 hours and patient also developed retrosternal chest tightness and lightheadedness. She had been a lifetime nonsmoker, occasionally drank a glass of wine and had never abused any illicit drugs. An electrocardiogram (ECG) performed in the ED demonstrated a narrow complex tachycardia with no discernable P waves, at a rate of 160 beats per minute. An attempt at closed nose blowing (Valsalva Maneuver) in the ER reverted her supraventricular tachycardia (SVT) back to normal sinus rhythm at a rate of 98 beats per minute. This resolved her palpitations but she continued to have mild discomfort in the center of her chest. Her blood pressure was 143/90 mm of Hg, temperature 98.30F and she was saturating 99% breathing 18 breaths per minute of room air. Her cardiovascular examination was noncontributory. She had no jugular venous distention, a regular heart rate with no murmurs or gallop on auscultation, equal air entry in her lungs and no edema in her extremities. Lab analysis revealed a troponin elevation of 1.39 ng/ml (normal <0.015 ng/ml). All other hematological and biochemical tests were within normal limits. Her elevated troponin was attributed to a Type II Myocardial Infarction from the SVT (likely atrioventricular nodal reentrant tachycardia). An electrophysiological (EP) study and a with possible ablation was planned. However, because of persistence of her chest tightness and elevation in her troponin a cardiac catheterization prior to the EP study was performed to rule out coronary artery disease.

Her right radial artery was accessed using the modified Seldinger technique and a 6 French Glidesheath was placed. A J wire was advanced under fluoroscopic guidance to the level of the arch of the aorta. Even with deep inspiration the wire repeatedly selectively entered the descending aorta instead of the ascending aorta [Figure 1A]. Subsequent attempts to direct an angled guidewire into the ascending aorta resulted in the patient experiencing central crushing chest pain and all catheter and wire manipulations were stopped. Subclavian angiography during catheter withdrawal demonstrated dissection of an aberrantly origination right subclavian artery [Figure 1B]. The patients pain resolved. Cardiothoracic surgery’s guidance was obtained and the patient was taken immediately for a CT (computed tomography) scan.

The CT scan demonstrated dissection of the retroesophageal right subclavian artery [Figure 1C]. The dissection extended down the descending aorta and terminated in the iliac arteries with no obvious malperfusion [Figure 1D]. Her Stanford B dissection was managed medically with an esmolol drip. A repeat CT scan in 3 days did not show any progression of the dissection and the patient remained free of chest pain. She was discharged home on oral beta blockers with a plan for a short follow up with cardiothoracic surgery and a repeat CT scan in 4 weeks.

3. Discussion

The aorta develops in the 3rd week of gestation 6. Normally, the right aortic arch regresses caudal to the origin of the 7th intersegmental artery which subsequently gives rise to the right subclavian artery. In about 0.4-1.8% of individuals, the regression occurs between the right common carotid and the 7th intersegmental artery. This causes the right subclavian artery to be connected to the left dorsal aorta via the right dorsal aorta, which in normal development would have otherwise regressed. During the course of its development, the origin of the aberrant right subclavian migrates until it is distal to the origin of the left subclavian artery 1.

The aberrant right subclavian artery (ARSA) courses behind the esophagus in about 80% of cases, between the esophagus and the trachea in 15%, and anterior to the trachea or mainstem bronchus in 5% 7. ARSA is seen more often in women and has a female to male prevalence of 3:1 in the general population 8. When present, ARSA may be associated with other vascular anomalies like Truncus bicaroticus (19.2%), Kommerell's diverticulum (14.9%), aneurysm of the artery itself (12.8%), and a Right sided aortic arch (9.2%). Prevalence of this anomaly is higher (26-34%) in patients with down syndrome and other congenital abnormalities. Patient with this anomaly rarely have symptoms (90-95%) but when symptomatic the ARSA give rise to symptoms of dysphagia lusoria, dyspnea and chronic cough 1, 7. Rarely, the ARSA may lead to Ortner’s syndrome by causing compression of the recurrent laryngeal nerve leading to stridor 9.

A study of 10,260 aortic CTA records of 6,804 patients of Chinese patients reported higher rates of aortic dissection or coarctation in patients with ARSA when compared to the control group (52.6% vs 36.8%, p=0.006; 5.1% vs 0.9%, p=0.007, respectively) 10.

Iatrogenic aortic dissection when occurring in the context of arteria lusoria tend to be typically be Stanford B in variety and extend down the descending aorta given the location of the origin of the artery in the descending aorta distal to the left subclavian artery 11.

It is often difficult to identify ARSA on the postero-anterior projection during conventional angiography. The guidewire repeatedly entering the descending aorta during the right radial approach should alert the operator to the possibility of this vascular anomaly. This should prompt an oblique view of the right subclavian artery angiogram which would then better demonstrate the origin of the ARSA distal to the left subclavian artery 12, 13.

4. Conclusion

In a vast majority of patients ARSA is clinically silent till right radial angiography is performed. This case highlights the importance of considering this rare coronary anomaly when the J wire selectively enters the descending aorta during right radial catheterization. In such a case, catheterization of the ascending aorta may be difficult or even impossible (7.1%) 12. Unsuccessful attempts at navigating the wire into the ascending aorta pose the risk of trauma to the endothelial lining and potential adverse outcomes including aortic dissection 14 and intramural hematoma formation 15. They should prompt the angiographer to obtain a subclavian angiogram with oblique views and if unsuccessful consider accessing the ascending aorta either from the left radial or the femoral approach.

Acknowledgements

This work is supported, in part, by the efforts of Dr. Moro O. Salifu M.D., M.P.H., M.B.A., M.A.C.P., Professor and Chairman of Medicine through NIH Grant number S21MD012474.

References

[1]  Chaoui, R., A. Rake, and K.S. Heling, Aortic arch with four vessels: aberrant right subclavian artery. Ultrasound Obstet Gynecol, 2008. 31(1): p. 115-7.
In article      View Article  PubMed
 
[2]  Bayford, D., An account of a singular case of obstructed deglutition. Mem Med Soc Lond, 1794: p. 275-286.
In article      
 
[3]  Saito, T., et al., Three cases of retroesophageal right subclavian artery. J Nippon Med Sch, 2005. 72(6): p. 375-82.
In article      View Article  PubMed
 
[4]  van Son, J.A.M. and I.E. Konstantinov, Burckhard F. Kommerell and Kommerell's diverticulum. Texas Heart Institute journal, 2002. 29(2): p. 109-112.
In article      
 
[5]  Valsecchi, O., et al., Failure of transradial approach during coronary interventions: anatomic considerations. Catheter Cardiovasc Interv, 2006. 67(6): p. 870-8.
In article      View Article  PubMed
 
[6]  Schleich, J.M., Images in cardiology. Development of the human heart: days 15-21. Heart, 2002. 87(5): p. 487.
In article      View Article  PubMed
 
[7]  Kau, T., et al., Aortic development and anomalies. Seminars in interventional radiology, 2007. 24(2): p. 141-152.
In article      View Article  PubMed
 
[8]  Molz, G. and B. Burri, Aberrant subclavian artery (Arteria lusoria): Sex differences in the prevalence of various forms of the malformation. Virchows Archiv A, 1978. 380(4): p. 303-315.
In article      View Article  PubMed
 
[9]  Bickle, I.C., B.E. Kelly, and D.S. Brooker, Ortner's syndrome: a radiological diagnosis. The Ulster medical journal, 2002. 71(1): p. 55-56.
In article      
 
[10]  Ding, H., et al., PREVALENCE AND COMPLICATIONS OF ABERRANT RIGHT SUBCLAVIAN ARTERY IN CHINESE POPULATION. Journal of the American College of Cardiology, 2018. 71(11 Supplement): p. A568.
In article      View Article
 
[11]  Chung, S.H. and D.S. Kum, Complication of transradial coronary catheterization in aberrant insertion of the right subclavian artery. Korean J Med, 2011. 80(Suppl 2): p. S157.
In article      
 
[12]  Abhaichand, R.K., et al., The problem of arteria lusoria in right transradial coronary angiography and angioplasty. Catheter Cardiovasc Interv, 2001. 54(2): p. 196-201.
In article      View Article  PubMed
 
[13]  Huang, I.L., et al., Dissection of Arteria Lusoria by Transradial Coronary Catheterization: A Rare Complication Evaluated by Multidetector CT. Journal of the Chinese Medical Association, 2009. 72(7): p. 379-381.
In article      View Article
 
[14]  Musuraca G, A.P., Albiero R, Boldi E, Terraneo C, Pancheri F, Dissection of Arteria Lusoria during Transradial PCI: A Rare Complication revealed and followed by Multidetector CT. J Cardiol Ther 2013. 1: p. 34-36.
In article      View Article
 
[15]  Kassimis, G., et al., Aberrant Right Subclavian Artery Hematoma Following Radial Catheterization. JACC: Cardiovascular Interventions, 2013. 6(6): p. 636.
In article      View Article  PubMed
 

Published with license by Science and Education Publishing, Copyright © 2020 Yuvraj Chowdhury, Shakil A. Shaikh, Ali Salman, Jonathan D. Marmur, Osagie Igiebor, Moro O. Salifu and Samy I. McFarlane

Creative CommonsThis work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

Cite this article:

Normal Style
Yuvraj Chowdhury, Shakil A. Shaikh, Ali Salman, Jonathan D. Marmur, Osagie Igiebor, Moro O. Salifu, Samy I. McFarlane. Stanford B Dissection with Right Radial Cardiac Catheterization in a Patient with Arteria Lusoria & Kommeral’s Diverticulum. American Journal of Medical Case Reports. Vol. 8, No. 9, 2020, pp 271-273. http://pubs.sciepub.com/ajmcr/8/9/4
MLA Style
Chowdhury, Yuvraj, et al. "Stanford B Dissection with Right Radial Cardiac Catheterization in a Patient with Arteria Lusoria & Kommeral’s Diverticulum." American Journal of Medical Case Reports 8.9 (2020): 271-273.
APA Style
Chowdhury, Y. , Shaikh, S. A. , Salman, A. , Marmur, J. D. , Igiebor, O. , Salifu, M. O. , & McFarlane, S. I. (2020). Stanford B Dissection with Right Radial Cardiac Catheterization in a Patient with Arteria Lusoria & Kommeral’s Diverticulum. American Journal of Medical Case Reports, 8(9), 271-273.
Chicago Style
Chowdhury, Yuvraj, Shakil A. Shaikh, Ali Salman, Jonathan D. Marmur, Osagie Igiebor, Moro O. Salifu, and Samy I. McFarlane. "Stanford B Dissection with Right Radial Cardiac Catheterization in a Patient with Arteria Lusoria & Kommeral’s Diverticulum." American Journal of Medical Case Reports 8, no. 9 (2020): 271-273.
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  • Figure 1. Clockwise from top left: A. JR catheter in the aberrant right subclavian artery. B. Dissection of the aberrantly originating right subclavian artery. C. Dissection extending down the descending aorta. D. Dissection of the retroesophageal right subclavian artery
[1]  Chaoui, R., A. Rake, and K.S. Heling, Aortic arch with four vessels: aberrant right subclavian artery. Ultrasound Obstet Gynecol, 2008. 31(1): p. 115-7.
In article      View Article  PubMed
 
[2]  Bayford, D., An account of a singular case of obstructed deglutition. Mem Med Soc Lond, 1794: p. 275-286.
In article      
 
[3]  Saito, T., et al., Three cases of retroesophageal right subclavian artery. J Nippon Med Sch, 2005. 72(6): p. 375-82.
In article      View Article  PubMed
 
[4]  van Son, J.A.M. and I.E. Konstantinov, Burckhard F. Kommerell and Kommerell's diverticulum. Texas Heart Institute journal, 2002. 29(2): p. 109-112.
In article      
 
[5]  Valsecchi, O., et al., Failure of transradial approach during coronary interventions: anatomic considerations. Catheter Cardiovasc Interv, 2006. 67(6): p. 870-8.
In article      View Article  PubMed
 
[6]  Schleich, J.M., Images in cardiology. Development of the human heart: days 15-21. Heart, 2002. 87(5): p. 487.
In article      View Article  PubMed
 
[7]  Kau, T., et al., Aortic development and anomalies. Seminars in interventional radiology, 2007. 24(2): p. 141-152.
In article      View Article  PubMed
 
[8]  Molz, G. and B. Burri, Aberrant subclavian artery (Arteria lusoria): Sex differences in the prevalence of various forms of the malformation. Virchows Archiv A, 1978. 380(4): p. 303-315.
In article      View Article  PubMed
 
[9]  Bickle, I.C., B.E. Kelly, and D.S. Brooker, Ortner's syndrome: a radiological diagnosis. The Ulster medical journal, 2002. 71(1): p. 55-56.
In article      
 
[10]  Ding, H., et al., PREVALENCE AND COMPLICATIONS OF ABERRANT RIGHT SUBCLAVIAN ARTERY IN CHINESE POPULATION. Journal of the American College of Cardiology, 2018. 71(11 Supplement): p. A568.
In article      View Article
 
[11]  Chung, S.H. and D.S. Kum, Complication of transradial coronary catheterization in aberrant insertion of the right subclavian artery. Korean J Med, 2011. 80(Suppl 2): p. S157.
In article      
 
[12]  Abhaichand, R.K., et al., The problem of arteria lusoria in right transradial coronary angiography and angioplasty. Catheter Cardiovasc Interv, 2001. 54(2): p. 196-201.
In article      View Article  PubMed
 
[13]  Huang, I.L., et al., Dissection of Arteria Lusoria by Transradial Coronary Catheterization: A Rare Complication Evaluated by Multidetector CT. Journal of the Chinese Medical Association, 2009. 72(7): p. 379-381.
In article      View Article
 
[14]  Musuraca G, A.P., Albiero R, Boldi E, Terraneo C, Pancheri F, Dissection of Arteria Lusoria during Transradial PCI: A Rare Complication revealed and followed by Multidetector CT. J Cardiol Ther 2013. 1: p. 34-36.
In article      View Article
 
[15]  Kassimis, G., et al., Aberrant Right Subclavian Artery Hematoma Following Radial Catheterization. JACC: Cardiovascular Interventions, 2013. 6(6): p. 636.
In article      View Article  PubMed