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Heart, Lung and Circulation (2015) xx, 1–5 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2015.04.172

Aberrant Right Subclavian Artery (Arteria Lusoria) Challenging 4-French Homolateral Transradial Coronary Catheterisation in Adulthood Antonio Zingarelli a*, Margherita Castiglione Morelli b, Sara Seitun b, Gian Paolo Bezante c, Manrico Balbi a, Claudio Brunelli c Interventional Cardiology[1_TD$IF], University of Genoa[6_TD$IF], [7_TD$IF]Genoa, [8_TD$IF]Italy [3_TD$IF]Radiology and Interventional Radiology, San Martino University Hospital and Scientific Institute for Cancer Research, Genoa, Italy c Clinic of Cardiovascular Diseases, University of[12_TD$IF] Genoa, Genoa[13_TD$IF], Italy a

b

Received 13 March 2015; received in revised form 31 March 2015; accepted 8 April 2015; online published-ahead-of-print xxx

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 multislice computed tomography. Tips and tricks have been suggested to complete the 4-French procedure avoiding changing the vascular access. Keywords

Anatomical variations  Aberrant right subclavian artery  Arteria lusoria  Coronary catheterisation  Transradial access

Introduction Aberrant right subclavian artery (ARSA) or Arteria Lusoria (from Latin: lusus naturae) is a bizarre congenital aortic arch anomaly, first described by Hunauld in 1735 [1], relatively frequent in autoptical and surgical series (0.5-1.8% of individuals) [2,3], but rarer in angiographic studies (incidence estimated between 0.1-0.4%) [4,5]. It appears to be more associated with chromosomal disorders (trisomy 21 and 18, deletion 22) and may be diagnosed in childhood with some cardiovascular defects (tetralogy of Fallot, pulmonary atresia, aortic coarctation). ARSA derives from anomalous embryologic development of the aortic system with involution and disappearance of the right fourth vascular arch and proximal right dorsal aorta and the persistence of the right seventh intersegmental artery attached to the abnormally persistent distal right

dorsal aorta originating from the proximal descending thoracic aorta [6]. Once such primordial altered vascular arrangement has been completed, instead of being the normal first branch of the left-sided aortic arch (with the right common carotid as the brachiocephalic trunk), ARSA arises on its own as the fourth branch from the posterolateral portion of the distal arch (after the left subclavian artery). In about one-third of cases, it originates from an aortic outpouch as a remnant of the right dorsal aorta, named Diverticulum of Kommerell, that can be detected as a localised slight aneurysm formation [7]. Then, ARSA hooks back in the superior mediastinum, crosses the midline to reach the right supraclavicular space, following a retro-oesophageal course (between vertebral column and oesophagus), less frequently passing between oesophagus and trachea and rarely being anterior to the trachea.

*Corresponding author. Interventional Cardiology, Clinic of Cardiovascular Diseases, University of Genoa, San Martino University Hospital and Scientific Institute for Cancer Research, Largo R. Benzi, 10, 16132 Genoa, Italy. Tel.: +390105552848; fax: +[16_TD$IF]390105556680 Email: [email protected] © 2015 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.

Please cite this article in press as: Zingarelli A, et al. Aberrant Right Subclavian Artery (Arteria Lusoria) Challenging 4-French Homolateral Transradial Coronary Catheterisation in Adulthood. Heart, Lung and Circulation (2015), http://dx.doi.org/ 10.1016/j.hlc.2015.04.172

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It is often asymptomatic, but around 10% of subjects may complain of tracheo-oesophageal symptoms (dysphagia, dyspnoea or chronic cough) due to compressive mechanisms with contiguous organs. We report a case of accidental finding of ARSA diagnosed in an adult man during a 4-French coronary angiography performed by right transradial access and then confirmed by multi-slice computed tomography, in which tips and tricks

have been suggested to complete the 4-French procedure avoiding the changing of vascular access.

Case A 54 year-old man with ventricular pre-excitation, type Wolff-Parkinson-White, came to our hospital for elective coronary angiography in relation to effort angina and

Figure 1 308 Left Anterior Oblique projections. In A, atypical course (black arrowheads) of 4-French Judkins right catheter in right subclavian artery and its unusual curvature (black arrow) passing retrogradely over a standard angiographic wire through distal aortic arch to ascending tract. Clockwise, in B and C, aortic arch angiograms with visualisation of aberrant take-off of right subclavian artery (ARSA) as separated fourth branch arising posteriorly from distal tract of aortic arch (white arrowhead) and then curving on right side (white arrow). In D (cranial view) and e (caudal view), selective injection of right (with Amplatz Right catheter) and left coronary (with Judkins Left catheter) arteries, both free of critical stenosis. Note the catheter angulation while cannulating the left coronary artery (e, white arrow). Abbreviations RCCA: right common carotid artery LCCA: left common carotid artery LSA: left subclavian artery. Please cite this article in press as: Zingarelli A, et al. Aberrant Right Subclavian Artery (Arteria Lusoria) Challenging 4-French Homolateral Transradial Coronary Catheterisation in Adulthood. Heart, Lung and Circulation (2015), http://dx.doi.org/ 10.1016/j.hlc.2015.04.172

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suspected inducible myocardial ischaemia after an ergometer test. Right radial artery puncture was performed with a 21-gauge open needle and cannulated by 4-French (F) 11-centimetres introducer (Avanti+ Sheath, Cordis Corp, Fremont, CA, USA) without any complication. After catheterisation of the right arm with a 0.035’’ standard guidewire, a redundant anomalous course of the 4F Judkins right catheter (Quick Care Infiniti, Cordis Corp, Fremont, CA, USA) reaching the aortic arch was radioscopically evident besides a high degree angulation between the aortic arch and right subclavian artery take-off (Figure 1a) that prevented engagement of the right coronary artery.

The vascular anomaly was better highlighted after aortography with evidence of a fourth epiaortic vessel originating from the posterolateral wall of the distal tract of the aortic arch suggestive for of ARSA (Figure 1b, 1c). As it was tough to push the catheter toward the ascending aorta for selective injection of the coronary ostia, a stiff extralong guidewire (0.035’’ - 260 cm Emerald Amplatz Superstiff, Cordis Corp, Fremont, CA, USA) was then employed to reinforce and strengthen the 4-French thin catheter and facilitate its manipulation. This simple[17_TD$IF] although crucial technique allowed a successful selective coronary injection, particularly advantageous in the case of torsion of a small diameter catheter for a right

Figure 2 MSCT 3D volume-rendering reconstructions (A, anterior and B, posterior view) and conventional imaging according to sagittal and axial planes (C and D) at level of ARSA course in superior mediastinum. In A and B, note the anomalous posterior take-off from distal aortic arch (white arrowhead); in C (sagittal plane) and D (axial plane) the abnormal retro-oesophageal course (broad white arrow) and its close anatomical contiguity with the oesophagus (thin white arrow). Abbreviations: T: trachea. Please cite this article in press as: Zingarelli A, et al. Aberrant Right Subclavian Artery (Arteria Lusoria) Challenging 4-French Homolateral Transradial Coronary Catheterisation in Adulthood. Heart, Lung and Circulation (2015), http://dx.doi.org/ 10.1016/j.hlc.2015.04.172

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coronary artery cannulation, without the need for changing to larger diameter catheters (Figure 1d, 1e). Later, a multi-slice computed tomography (MSCT) with a second-generation 128-slice dual source scanner (Somatom Definition Flash, Siemens Healthcare, Erlangen, Germany) detailed its anomalous course with retro-oesophageal localisation (Figure 2).

Discussion This case describes a retro-oesophageal ARSA diagnosed in an adult man during 4-French right transradial coronary angiography and confirmed by MSCT angioscan. Over the past decade, the traditional transfemoral approach for coronary catheterisation has been progressively replaced worldwide in favour of transradial access, preferred nowadays by many operators as first-choice arterial approach. The growing adoption of this vascular route improves the comfort of the patient and the early mobilisation after the procedure, simplifying staff assistance as well as reducing vascular and bleeding complications and, consequently, hospital stay and costs. Due to the potential small calibre of the radial artery in certain[18_TD$IF] subsets of adult patients[19_TD$IF] (women, elders and subjects with small body surface) and to accelerate post-procedural mechanical haemostasis and reduce the risk of radial occlusion, a reasonable option may be ‘‘slender’’ radial catheterisation by a small catheter calibre (4F or even 3F sizes) for diagnostic coronary procedures and employing 5F or 6[4_TD$IF]F[5_TD$IF] catheters, preferably sheathless[20_TD$IF] (equivalent to 3F and 4F sheath calibers, respectively), in case of subsequent coronary interventions [8]. Besides, anatomical arterial anomalies of the radial course and brachiocephalic system may hinder catheterisation while aortic arch variants often force operators to abandon the radial approach [4,9]. Among these complex vascular variants, ARSA is considered an angiographic finding that often hampers and sometimes complicates cardiac catheterisation performed by a homolateral transradial approach [10,11]. This case of ARSA emphasises how challenging it is to reach the aortic root and coronary ostia with a 4-French catheter due to its elongated and abnormal course into the mediastinum and unfavourable angulation between the distal aortic arch and ARSA take-off. In such circumstances, while performing fluoroscopic catheterisation from the right transradial access, it is crucial to suspect this aortic arch anomaly whenever the catheter (over a standard angiographic guidewire) tends to advance spontaneously in the descending aorta or deforms abnormally when attempts are carried out to reach the aortic arch. For completing the 4-French procedure successfully without abandoning the access, the first useful manoeuvre is a slow withdrawal of the catheter and standard guidewire together when they go down to the descending aorta, and then to try to cross retrogradely the aortic arch after

asking the patient to take a prolonged and deep breath. This simple trick may increase the chances of procedural success for the potential reduction of aortic arch convexity and unfavourable ARSA-aortic arch angulation. Alternatives include more curved and supportive 4-French catheters (internal mammary catheter, Amplatz left or Simmons) that may point better at the aortic arch and allow successful probing, preferable to continue with a safer 0.035’’ hydrophilic wire (like Terumo ones), because its slipperiness can avoid inadvertent scrape or dissection of the aortic wall. Once the 4-French catheter reaches the ascending tract, the hydrophilic guidewire must be replaced again with more supportive ones (like 0.035 J-tip superstiff and extra-long for safe catheter exchange). This strategy might mitigate acute subclavian-aortic angulation avoiding potential kinking or even, at worst, severe catheter knotting. In addition, as in our described case, it allows the thin 4-French catheter to be pushed more easily over the wire and favours better catheter manipulation for engagement with the coronary ostia. Finally, when the abovementioned manoeuvers fail for pronounced angulation between ARSA-aortic arch and before switching to alternate access, it is acceptable to try again after exchanging the 4-French catheter (over the extralong stiff guidewire) with a larger diameter catheter ([21_TD$IF]5 or 6French), also suitable to perform a subsequent interventional procedure. In such circumstances, guide catheters with enhanced back-up support are also required for completing angioplasty successfully without abandoning the right transradial access.

Ethical Approval The authors declare that patient gave his informed consent prior to his inclusion in the study.

Acknowledgement We thank Mr. Vincenzo Montaruli, radiology technician, for his support in image processing.

References [1] Hunauld F. Examen de quelques parties d’un singe. Hist Acad Roy Sci 1735;2:516–23. [2] Molz G, Burri B. Aberrant subclavian artery (arteria lusoria): sex differences in the prevalence of the various forms of the malformations. Evaluation of 1378 observations. Virchows Arch A 1978;380:303–15. [3] Richardson JV, Doty DB, Rossi NP, Ehrenhaft JL. Operation for aortic arch anomalies. Ann Thorac Surg 1981;31:426–32. [4] Valsecchi O, Vassileva A, Musumeci G, Rossini R, Tespili M, Guagliumi G, et al. Failure of transradial approach during coronary interventions: anatomic considerations. Catheter Cardiovasc Interv 2006;67:870–8. [5] Nie B, Zhou Y, Li G, Shi D, Wang J. Clinical study of arterial anatomic variations for transradial coronary procedure in Chinese population. Chin Med J 2009;122:2097–102.

Please cite this article in press as: Zingarelli A, et al. Aberrant Right Subclavian Artery (Arteria Lusoria) Challenging 4-French Homolateral Transradial Coronary Catheterisation in Adulthood. Heart, Lung and Circulation (2015), http://dx.doi.org/ 10.1016/j.hlc.2015.04.172

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[6] Edwards JE. Congenital malformations of the heart and great vessels. Section H. Malformations of the thoracic aorta. In: Gould SE, editor. Pathology of the heart. Springfield: Charles C. Thomas; 1960. p. 391–462. [7] Fischer RG, Whigham CJ, Trinh C. Diverticula of Kommerell and aberrant subclavian arteries complicated by aneurysms. Cardiovasc Intervent Radiol 2005;28:553–60. [8] Kiemeneij F, Yoshimachi F, Matsukage T, Amoroso G, Fraser D, Claessen BE, et al. Focus on maximal miniaturisation of transradial coronary access materials and techniques by the Slender Club Japan and Europe: an overview and classification. EuroIntervention 2015;10: 1178–86.

[9] Burzotta F, Brancati MF, Trani C, Tommasino A, Porto I, Niccoli G, et al. Impact of radial-to-aorta vascular anatomical variants on risk of failure in trans-radial coronary procedures. Catheter Cardiovasc Interv 2012;80: 298–303. [10] Patel T, Shah S, Pancholy S, Deora S, Prajapati K, Coppola J, et al. Working through challenges of subclavian, innominate, and aortic arch regions during transradial approach. Catheter Cardiovasc Interv 2014;84: 224–35. [11] Huang I, Hwang H, Li S, Chen CKH, Liu C, Wu M. Dissection of arteria lusoria by transradial coronary catheterization: a rare complication evaluated by multidector CT. J Chin Med Assoc 2009;72:379–81.

Please cite this article in press as: Zingarelli A, et al. Aberrant Right Subclavian Artery (Arteria Lusoria) Challenging 4-French Homolateral Transradial Coronary Catheterisation in Adulthood. Heart, Lung and Circulation (2015), http://dx.doi.org/ 10.1016/j.hlc.2015.04.172

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 perf...
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