Right-sided aortic arch with isolation of the left innominate artery and hypoplasia of the left internal carotid artery.

PURPOSE: Here, we report a case of the right-sided aortic arch with isolation of the left innominate artery and hypoplasia of the left internal carotid artery. METHODS: A 42-year-old male patient underwent a whole-body computed tomography angiography (CTA) examination upon the clinical suspicion of vasculitis. RESULTS: CTA revealed a right-sided aortic arch with the isolation of the left innominate artery and hypoplasia of the left internal carotid artery. CONCLUSION: The right-sided aortic arch, with the isolation of the left innominate artery, is a scarce vascular variation that may occur with other cardiovascular anomalies such as ventricular septal defect. It can be asymptomatic or can present with symptoms of subclavian steal syndrome. Although its association with the agenesis of the left internal carotid artery has been reported, its association with the hypoplasia of the left internal carotid artery has not been reported previously to the best of our knowledge.

Morphological, embryological, and clinical implications of the bi-carotid trunk, aberrant right subclavian artery, and bilateral linguofacial trunk.

A female cadaver fixated with 10% formalin solution was dissected during a routine undergraduate anatomy class. It was found that both the right and left carotid arteries arose from a bi-carotid trunk as the first branch of the aortic arch. The bi-carotid trunk was followed by the left subclavian artery. The aberrant right subclavian artery (the last branch) had a retro-oesophageal course. These variations were associated with the linguofacial trunk bilaterally. The group of variant anatomy of vessels encompassing the bi-carotid trunk, aberrant right subclavian artery, and the linguofacial trunk is extremely rare. A similar case has not been reported yet in the literature. The anatomic and morphologic variations of the aortic arch and its branches are important for diagnostic and surgical procedures in the thorax and neck region. Thoracovascular surgeons and interventional radiologists should be aware of these anomalies during head and neck surgery, aortic instrumentation, and four-vessel angiography.

Right vertebral artery arising from the right common carotid artery with an absent brachiocephalic trunk.

The right and left vertebral arteries are the first branches of the ipsilateral subclavian arteries. However, in the presence of anatomical variation due to complex embryogenesis, the vertebral artery can arise directly from the aortic arch or any of its major branches. The atypical origin of the vertebral artery is commonly associated with the left vertebral artery. Anatomical variation in the origin of the right vertebral artery is rare. Most available reports are case reports from international studies. We report on a case of right vertebral artery arising from the ipsilateral common carotid artery with an absent brachiocephalic trunk in a South African patient examined by digital subtraction angiography. Reports on anatomical variations are of diagnostic importance prior to surgical interventions or endovascular treatment of cerebrovascular diseases such as cerebral aneurysms and arteriovenous malformations.

Successfully Kissing Stent of Innominate Artery and Left Common Carotid Artery Subsequent to Blunt Injury, in the Setting of a Bovine Aortic Arch.

Blunt injuries of the great vessels arising from the aortic arch are usually fatal. The innominate artery lesions represent the most common site of injury after the aortic isthmus distal to the left subclavian artery. Injuries are usually located at the origin of the vessel from the aortic arch, especially in patients with bovine aortic arch. Open traditional repair is a successful but invasive treatment, with long hospital stay and different possible complications. Although a bovine aortic arch presents an increased technical challenge, it is possible to achieve a complete and safe repair of the innominate artery injuries through a total endovascular treatment, with important reduction of risks and complications related to operation, compared to traditional open repair. We report the case of a 62-year-old man in our hospital with a posttraumatic pseudoaneurysm of the innominate artery in the setting of a bovine aortic arch, associated with a transection of the descending thoracic aorta. In the urgent setting, the patient was submitted to a kissing stent of innominate artery-left common carotid artery and deployment of thoracic endoprosthesis to exclude the aortic transection, with good final result.

A two-vessel aortic arch: Rare configuration with bilateral brachiocephalic arteries.

We present a case of type B aortic dissection with a rare aortic arch branching variation whereby two separate brachiocephalic trunks arise from the arch. This case also highlights the potential implications of this variant in the management of thoracic aortic dissections and aneurysms.

Absent left common carotid artery in a right aortic arch: Separate origins of left internal and external carotid arteries from brachiocephalic artery.

We present a case of cyanotic congenital heart disease with left common carotid artery agenesis in the setting of the right aortic arch highlighting the potential implications in management.

The so-called "bovine aortic arch": a possible biomarker for embolic strokes?

PURPOSE: To examine the prevalence of the so-called bovine aortic arch variation (common origin of the brachiocephalic trunk and the left common carotid artery) in embolic stroke patients, compared with a control group. METHODS: Aortic arch branching patterns were retrospectively evaluated in 474 individuals with (n = 152) and without (n = 322) acute embolic stroke of the anterior circulation. Contrast-enhanced CT scans of the chest and neck (arterial contrast phase, 1-2-mm slice thickness) were used to evaluate aortic arch anatomy. The stroke cohort included 152 patients who were treated for embolic strokes of the anterior circulation between 2008 and 2018. A total of 322 randomly selected patients who had received thoracic CT angiographies within the same time frame were included as a control group. RESULTS: With a prevalence of 25.7%, the bovine aortic arch variant was significantly more common among patients suffering from embolic strokes, compared with 17.1% of control patients (p = 0.039, OR = 1.67, 95%CI = 1.05-1.97). Stroke patients were more likely to show the bovine arch subtype B (left common carotid artery originating from the brachiocephalic trunk instead of the aortic arch) (10.5% vs. 5.0%, p = 0.039, OR = 2.25, 95%CI = 1.09-4.63), while subtype A (V-shaped common aortic origin of the brachiocephalic trunk and the left carotid) was similarly common in both groups. There was no significant difference regarding the frequency of other commonly observed variant branching patterns of the aortic arch. CONCLUSION: The bovine aortic arch, particularly the bovine arch subtype B, was significantly more common among embolic stroke patients. This might be due to altered hemodynamic properties within the bovine arch.

Anomaly in the Embryogenesis of the Aorta associated with Subclavian Steal Phenomenon.

Congenital aortic arch anomalies are rare and may be associated with other congenital cardiovascular malformations. The authors report a rare case of anomaly in the aortic arch embryogenesis, presenting with a right aortic arch and an isolated innominate artery, associated with the subclavian steal phenomenon. This condition is discussed considering the Edwards hypothetical double embryonic arch and its clinical aspects.

Incomplete isolation of the left innominate artery from the right aortic arch: a rare case of double-outlet right ventricle with pulmonary stenosis.

Isolation of the left innominate artery from the right aortic arch is a rare anomaly. Herein, we present an even rarer case of incomplete isolation of the proximal left innominate artery with the right aortic arch in a 3-month-old female infant with a double-outlet right ventricle and pulmonary stenosis. Surgical repair at 6 months of age was successful, leading to the restoration of adequate flow in the left arm.

A case of right aortic arch with isolated left innominate artery and global cerebral white matter atrophy.

A right aortic arch with an isolated left innominate artery is a rare form of aortic arch anomaly. We present a case of neonatal diagnosis of this anomaly with concerning findings of global cerebral white matter atrophy at 13 months of age.

A systematic review and meta-analysis of variations in branching patterns of the adult aortic arch.

OBJECTIVE: The aortic arch (AA) is the main conduit of the left side of the heart, providing a blood supply to the head, neck, and upper limbs. As it travels through the thorax, the pattern in which it gives off the branches to supply these structures can vary. Variations of these branching patterns have been studied; however, a study providing a comprehensive incidence of these variations has not yet been conducted. The objective of this study was to perform a meta-analysis of all the studies that report prevalence data on AA variants and to provide incidence data on the most common variants. METHODS: A systematic search of online databases including PubMed, Embase, Scopus, ScienceDirect, Web of Science, SciELO, BIOSIS, and CNKI was performed for literature describing incidence of AA variations in adults. Studies including prevalence data on adult patients or cadavers were collected and their data analyzed. RESULTS: A total of 51 articles were included (N = 23,882 arches). Seven of the most common variants were analyzed. The most common variants found included the classic branching pattern, defined as a brachiocephalic trunk, a left common carotid, and a left subclavian artery (80.9%); the bovine arch variant (13.6%); and the left vertebral artery variant (2.8%). Compared by geographic data, bovine arch variants were noted to have a prevalence as high as 26.8% in African populations. CONCLUSIONS: Although patients who have an AA variant are often asymptomatic, they compose a significant portion of the population of patients and pose a greater risk of hemorrhage and ischemia during surgery in the thorax. Because of the possibility of encountering such variants, it is prudent for surgeons to consider potential variations in planning procedures, especially of an endovascular nature, in the thorax.

Prenatal Ultrasonic Diagnosis and Prognostic Analysis of Isolated Left Subclavian Artery (ILSCA) and Left Brachiocephalic Trunk (ILBCT) Malformation.

The purpose of the study was to explore the prognosis, as well as antenatal ultrasonic features of isolated left subclavian artery (ILSCA) and isolated left brachiocephalic trunk (ILBCT) malformations, in order to improve prognosis and provide guidance for prenatal diagnosis. The origin and routing of cephalic and cervical vessels were observed in patients diagnosed with right aortic arch or right arterial duct arch in our hospital from March 2015 to March 2017, and the spectrum features related to ILSCA and ILBCT were analyzed. Fetuses diagnosed as ILSCA, or, and ILBCT were followed up for 3 months after birth. At the same time, a literature review was carried out for ILBCT and ILSCA in Pubmed. In our study, two cases with ILSCA and ILBCT were both diagnosed prenatally. They are not accompanied by other congenital malformations or chromosome abnormalities. No abnormality was found during postnatal follow-up except that left radial pulsation was weakened and blood pressure of the left upper limb decreased in baby with ILSCA. In baby with ILBCT, in addition to these abnormal changes, the left common carotid artery pulse disappearance too. In pubmed, three of 12 ILSCA or ILBCT did not have other congenital malformation or chromosome abnormalities. They were not diagnosed until the age of 3, 10, and 47 because of school exams or atypical symptoms, such as headaches, chest pain. Symptom of ILBCT or ILSCA without other abnormality is silent, and therefore they cannot be diagnosed timely after birth prenatal diagnosis is necessary for they can be treated in time.

A systematic classification of the vertebral artery variable origin: clinical and surgical implications.

Several congenital anomalies regarding the right (RVA) and left (LVA) vertebral artery have been described. The current paper aims to perform a systematic literature review of the variable vertebral artery (VA) origin from the aortic arch (AOA) and its branches. The incidence of these variants and the ensuing AOA branching pattern are highlighted. Atypical origin cases were found more commonly unilaterally, while LVA presented the majority of the aberrancies. The LVA emersion from the AOA (3.6%) and the RVA from the right common carotid artery (RCCA) (0.14%) were the commonest origin variations. Aberrant RVA origin as last branch of the AOA is very rare. Eighteen cases (0.12%) with an aberrant right subclavian artery (ARSCA) were found. Among them, the RVA originated from the RCCA and right subclavian artery in 94.4 and 5.6%, respectively. Sporadic cases had an AOA origin bilaterally; RVA and LVA had a double origin in 0.027 and 0.11%, respectively. A dual origin was detected in 0.0069%, bilaterally. The atypical VA origin may coexist with: (i) an ARSCA, (ii) a common origin of brachiocephalic artery and left common carotid artery (the misnomer bovine arch) and (iii) a bicarotid trunk. The aberrant VA origin favors hemodynamic alterations, predisposing to cerebrovascular disorders and intracranial aneurysm formation. Detailed information of VA variants is crucial for both endovascular interventionists and diagnostic radiologists involved in the treatment of patients with cerebrovascular disease. Such information may prove useful to minimize the risk of VA injury in several procedures.

Left common carotid artery agenesis with bovine origin of the left internal carotid artery.

The absence of the left common carotid artery, with separate origins of the external carotid and internal carotid arteries from the aortic arc is a well-described but extremely rare congenital anomaly. We present a unique case of agenesis of left common carotid artery depicted at MR angiography where the left internal carotid artery had a bovine origin (from the brachiocephalic trunk) and the left external carotid artery arose from the aortic arc. In addition, it is important to diagnose this anatomical variant especially prior to interventional procedures, as it could hinder the catheterization of these arteries.

Deletion of yes-associated protein (YAP) specifically in cardiac and vascular smooth muscle cells reveals a crucial role for YAP in mouse cardiovascular development.

RATIONALE: Our previous study has shown that yes-associated protein (YAP) plays a crucial role in the phenotypic modulation of vascular smooth muscle cells (SMCs) in response to arterial injury. However, the role of YAP in vascular SMC development is unknown. OBJECTIVE: The goal of this study was to investigate the functional role of YAP in cardiovascular development in mice and determine the mechanisms underlying YAP's actions. METHODS AND RESULTS: YAP was deleted in cardiomyocytes and vascular SMCs by crossing YAP flox mice with SM22α-Cre transgenic mice. Cardiac/SMC-specific deletion of YAP directed by SM22α-Cre resulted in perinatal lethality in mice because of profound cardiac defects including hypoplastic myocardium, membranous ventricular septal defect, and double outlet right ventricle. The cardiac/SMC-specific YAP knockout mice also displayed severe vascular abnormalities including hypoplastic arterial wall, short/absent brachiocephalic artery, and retroesophageal right subclavian artery. Deletion of YAP in mouse vascular SMCs induced expression of a subset of cell cycle arrest genes including G-protein-coupled receptor 132 (Gpr132). Silencing Gpr132 promoted SMC proliferation, whereas overexpression of Gpr132 attenuated SMC growth by arresting cell cycle in G0/G1 phase, suggesting that ablation of YAP-induced impairment of SMC proliferation was mediated, at least in part, by induction of Gpr132 expression. Mechanistically, YAP recruited the epigenetic repressor histone deacetylase-4 to suppress Gpr132 gene expression via a muscle CAT element in the Gpr132 gene. CONCLUSIONS: YAP plays a critical role in cardiac/SMC proliferation during cardiovascular development by epigenetically regulating expression of a set of cell cycle suppressors.

Working through challenges of subclavian, innominate, and aortic arch regions during transradial approach.

OBJECTIVES: The aim of this review is to discuss different methods of working through subclavian, innominate, and aortic arch anatomical challenges to increase the success rate of transradial approach (TRA). BACKGROUND: Anatomical challenges in the subclavian, innominate, and aortic arch regions are important reasons for failure of TRA. There is limited modern literature describing methods to overcome these challenges and reduce TRA failure. METHODS: A number of primary subclavian, innominate, and aortic arch anatomical challenges are identified and management techniques to overcome them are discussed. RESULTS: Subclavian, innominate, and aortic arch anatomical challenges can be divided into five subsets, including (1) tortuosity, (2) loop, (3) stenosis, (4) congenital aberrancy, and (5) combined challenges. In depth discussion with supportive examples for the identification and management of these challenges are provided. CONCLUSIONS: Despite lower rates of bleeding and vascular complications as compared to transfemoral approach, the adoption of TRA has been relatively slow in part due to frustration from operator failure during the learning curve. Anatomical challenges of subclavian, innominate, and aortic arch regions play an important role in TRA procedural failure. Using a simple, conceptual, framework to classify the anatomical or functional problem and then applying a logical approach to these challenges can facilitate management and augment operator success rates for TRA.

Hybrid repair of penetrating aortic ulcer associated with right aortic arch and aberrant left innominate artery arising from aneurysmal Kommerell's diverticulum with simultaneous repair of bilateral common iliac artery aneurysms.

We present the first case of a hybrid endovascular approach to a penetrating aortic ulcer on the left descending aorta with a right aortic arch and aberrant left innominate artery arising from an aneurysmal Kommerell's diverticulum. The patient also had bilateral common iliac artery aneurysms. The three-step procedure consisted of a carotid-carotid bypass, followed by endovascular exclusion of the ulcer and the aneurysmal Kommerell's diverticulum, and then completion by covering the iliac aneurysms. The patient had no complications at 18 months after surgery. In such rare configurations, endovascular repair is a safe therapeutic option.

Thyroidea Ima Artery in Cadavers of a Medical College in Nepal: A Descriptive Cross-sectional Study.

INTRODUCTION: Thyroidea ima artery is a variant arterial branch of arch of aorta supplying the thyroid gland. Understanding the anatomic variances and correctly identifying the thyroidea ima artery is crucial to preventing serious complications both before and after neck surgery. The aim of this study was to find out the prevalence of thyroidea ima artery in cadavers of a medical college in Nepal. METHODS: A descriptive cross-sectional study was carried out at the department of anatomy in Janaki Medical College, Dhanusha, Nepal from 27 December 2022 to 30 June 2023 after ethical clearence from the same institution. Origin of thyroidea ima artery was observed, recorded and photographed. Convenience sampling method was used. Data was analyzed using Microsoft Excel. RESULTS: Out of 35 cadavers, thyroidea ima artery was present in 2 (5.71%), arising from brachiocephalic trunk just proximal to its bifurcation and there was absence of inferior thyroid artery. CONCLUSIONS: Findings from our study showed that thyroidea ima artery originated from brachiocephalic trunk with absence of inferior thyroid artery.

Variation in the Branches of Arch of Aorta in Patients Undergoing Contrast Enhanced Multidetector Computed Tomography in a Tertiary Centre, Nepal.

INTRODUCTION: Variations in the branching pattern of the Arch of Aorta (AoA) are common in patients undergoing contrast-enhanced Multidetector Computed Tomography, the identification of which is crucial in managing patients undergoing cardiovascular/neck surgeries and interventions. METHODS: This prospective cross-sectional study involved 513 patients who were sent to the Department of Radiology for evaluation of various pathologies of chest and neck between August 2018 and July 2019. After approval from the Institutional Review Committee {Reference No: 11(6-11) E2/075/076}, contrast-enhanced computed tomography images were evaluated with variations in branches of the left-sided arch of the aorta and symptoms associated. RESULTS: Variations in branches of the arch of aorta were seen in 69 (13.45%; 95% CI: 10.60%-16.71%) of cases, left common carotid artery and brachiocephalic trunk having common origin or common trunk was 51(9.94%). The mean age was 52.4±20 years (Range 3 months to 92 years) with male to female ratio of 1.3:1. CONCLUSIONS: Contrast-enhanced computed tomography is the modality of choice for the detection of the variations in branches of AoA, recognition of which is crucial in vascular intervention and surgical procedures to reduce the postoperative morbidity and mortality of the patients.

Brachiocephalic artery anomaly at the neck: importance during minimally invasive video-assisted parathyroidectomy.

A 76-year-old woman was referred to our hospital for evaluation of a parathyroid adenoma, detected on sonography. It had been located posteroinferiorly to the right thyroid lobe. Parathyroid scintigraphy confirmed the right inferior parathyroid adenoma. During physical examination of the neck, a pulsatile mass in the anterior inferior right was determined, and because of suspicion for a vascular anomaly, a computed tomography angiography was performed. The computed tomography showed that the right brachiocephalic artery ascended vertically to the level of the inferior border of right thyroid lobe and dividing into the right common carotid artery and subclavian artery at this level. Right subclavian artery after its origin brought about a curve by means of turning first posteromedially and then anterolaterally. Parathyroid adenoma remained between the right thyroid lobe, right common carotid artery, and right brachiocephalic artery. Minimally invasive video-assisted parathyroidectomy was performed and no complication appeared.