Case Reports

Aberrant Right Subclavian Artery Associated

with a Common Origin of Carotid Arteries
Santiago Chahwan, MD,1 Matthew Todd Miller, MD,2 Kiup Alex Kim, MD,1
Mark Mantell, MD,1 and Lee Kirksey, MD,1 Philadelphia, Pennsylvania, and Toledo, Ohio

We present a patient with a rare anomaly of the aortic arch. Angiography revealed an aberrant
right subclavian artery (aRSA) originating from the middle of the aortic arch. Angiography also
demonstrated an anomalous origin of the left common carotid artery sharing a common trunk
with the innominate artery and a large right vertebral artery arising from the right common carotid
artery. Although this particular combination of anomalies has been reported in cadaver cases, to
our knowledge this is the first premortem angiographic description of a patient in which an aRSA
originates from the middle of the arch between the anomalous bovine arch trunk and the left
subclavian trunk.

An aberrant right subclavian artery (aRSA) is a
common anomaly of the aortic arch. Since the first
description by Hunald in 1735,1 aRSA has been
reported in association with other different ana-
tomical anomalies of the aortic arch. As a clinical
entity, aRSA usually has no symptomatology and
no pathological significance. Our review of the re-
ported anomalies associated with aRSAs in a
Medline search of the English-language literature
from 1960 to present included a common origin of
the bilateral common carotid arteries, a replaced
right or left vertebral artery, a nonrecurrent right
inferior laryngeal nerve, coarctation of the aorta, a
right-sided thoracic duct, and a right-sided aortic
arch.2,3 It is important to recognize these anomalies
in advance of any surgical intervention in order to
plan the correct operative approach, for either an
open or an endovascular route. Different anomalies
1
Division of Vascular Surgery, Department of Surgery, Graduate
Hospital, Philadelphia, PA, USA.
2
Jobst Vascular Center, Toledo, OH, USA.
Correspondence to: Santiago Chahwan, MD, Division of Vascular
Surgery, Department of Surgery, Graduate Hospital, Suite 805-Pepper
Pavilion, 1800 Lombard Street, Philadelphia, PA, 19146, USA, E-mail:
gschahwan@hotmail.com
Ann Vasc Surg 2006; 20: 809–812
DOI: 10.1007/s10016-006-9074-3
Ó Annals of Vascular Surgery Inc.
Published online: May 31, 2006
of the aortic arch and the embryological develop-
ment are briefly discussed.
CASE REPORT
A 75-year-old man with a past medical history of
hypertension, diabetes, and peripheral vascular disease
presented with vague transient ischemic attack symp-
toms (left-sided paresthesias). The carotid duplex dem-
onstrated by velocity a >50% right common carotid
stenosis as well as an internal carotid artery stenosis.
The vertebral arteries had antegrade flow bilaterally.
The patient underwent a diagnostic arteriogram with
selective catheterization of the aortic arch and visuali-
zation of the extracerebral and intracerebral vessels. The
arteriogram revealed a left-sided aortic arch with the
branches from right to left as follows: a common trunk
for the right and left common carotid arteries (bovine
arch) with a right vertebral artery originating from the
right common carotid artery, an aberrant takeoff of the
right subclavian vessel, and a common trunk of the left
subclavian and left vertebral artery (Fig. 1c). The prox-
imal right common carotid artery was tortuous at its
origin. However, the right common carotid artery and
the bifurcation were patent with no obvious occlusive
disease. Tortuosity within the internal carotid artery was
observed just below the level of the petrous portion of
the temporal bone and was without stenosis. No other
defects were identified (Figs. 2 and 3). No intervention
was performed, and the patient was managed with an
antiplatelet regimen.

809
810 Case reports
Fig. 2. Aortogram showing arch vessel anomalies.
DISCUSSION
Aortic arch anomalies are common congenital
aberrations, which typically do not manifest any
overt clinical symptoms. They are usually found
Annals of Vascular Surgery
Fig. 1. (A) Normal aortic
arch. (B) Bovine arch. (C)
Our variant.
incidentally during aortograms, workup for medi-
astinal trauma, or autopsy. Among all the variants,
the most frequent anomaly is the common origin of
left carotid and innominate artery, also known as a
bovine arch (BA) (Fig. 1b), which is prevalent in
approximately 22% of the population and accounts
for 73% of all arch vessel anomalies. An aRSA as
the most distal branch of the aortic arch is rare,
representing approximately 1% of all arch vessel
anomalies. Eighty percent of aRSAs travel behind
the esophagus, 15% travel between the esophagus
and trachea, and 5% travel anterior to the trachea
or mainstem bronchus.4 Usually, an aberrant aRSA
has no clinical or pathological significance unless it
becomes symptomatic; the most common associ-
ated symptom is dysphagia associated with com-
pression of the esophagus between the trachea and
the artery, termed dysphagia lusoria. This term was
coined by Bayford in 1794 for a patient with dys-
phagic symptoms and an autopsy finding of a ret-
roesophageal aRSA, with the Latin term lusus
naturae meaning ‘‘freak of nature’’ or ‘‘conspicuous
congenital deformity.’’5 Other reported symptoms
include dyspnea and coughing, chest pain, and
esophageal fistulization.6 Venous compression has
been reported as an unusual cause of superior vena
cava syndrome. KommerellÕs diverticulum is an
aneurysmal degeneration of the proximal portion
of an aRSA. This occurs rarely but can be both life-
and limb-threatening due to the risk of rupture
and/or embolization. Independent origin of all
vessels without innominate artery has also been
reported, albeit in a low percentage of individuals.
Vol. 20, No. 6, 2006
Fig. 3. Arteriogram of the right carotid (light contrast).
Our report represents an extremely rare combi-
nation of anomalies of the aortic arch: first, the
right subclavian artery originates directly from the
middle of the aortic arch; second, the left and right
common carotid arteries share a common origin;
and third, the right vertebral artery originates from
the right common carotid artery. We have come
across case reports of an aRSA associated with a BA
in the literature; however, the unique feature of
our patient is that his aRSA originates from the
middle of the arch, between the common trunk of
the carotid arteries and the left subclavian trunk.
Epstein and Debord7 reported an aRSA originating
distal to the origin of the left subclavian, with a
common origin of the right and left common car-
otid arteries, and successfully treated the patientÕs
3-year history of progressive dysphagia via a right
supraclavicular neck incision, transection, and
transposition of the distal right subclavian artery
with reimplantation into the right common carotid
artery. Gluncic and Marusic8 reported cadaveric
discovery of a BA anomaly and an aRSA, retro-
esophageal and retrotracheal, originating as the
most distal branch of the aortic arch. Poultsides
et al.9 reported a rare cadaver discovery of a prox-
imal common trunk giving origin to both carotid
arteries and a distal common trunk giving origin to
Case reports 811
both subclavian arteries. Their review of medical
records did not reveal any previous symptoms in
this patient. Shaw et al.10 presented three cases of
carotid stenosis in the setting of a BA successfully
treated with stents, but we did not encounter any
arteriographically significant stenosis in our pa-
tient. DÕAyala et al.11 presented a successful
angioplasty and stenting of the innominate artery
stenosis in a BA.
Aortic arch anomalies have an embryological
basis for their formation. An aRSA is thought to
arise from the interruption of the embryonic right
arch proximal to the seventh cervical interseg-
mental artery. The BA is thought to arise from the
persistence of the third pair of embryological cer-
vical aortic arches during the seventh week of
gestation.12 The high prevalence of these anomalies
makes them important whenever endovascular or
open repair of the arch vessels is considered.
With regard to the etiology of our patientÕs
symptoms, we do not feel that the anatomic variant
itself caused his symptomatology. We are not
aware of any studies that show increased embolic
events in variant arteries that do not have athero-
sclerotic disease. However, there are reports docu-
menting that tortuosity of the cerebral vessels can
lead to cerebral hyperperfusion and/or embolic
events.13 The finding of stenosis by duplex ultra-
sound velocity criteria, which was not confirmed
by arteriography, may be due to the tortuosity of
the vessels. Since beginning antiplatelet therapy,
the patient has remained asymptomatic.
CONCLUSIONS
Our finding is pertinent because of implications on
surgical strategy. A malpositioned subclavian may
be associated with a nonrecurrent right inferior
laryngeal nerve, which may be important in neck
surgeries because of the risk of damage to it. Also,
an unsuspected aRSA is at risk for accidental injury
during any form of invasive procedure, such
as thoracoscopic esophagectomy.14 A thorough
knowledge of these common anatomic variants is
necessary for practitioners treating the aortic arch
vessels. When identified prior to intervention,
adjustment may be made for open vascular expo-
sure or percutaneous access site and approach
strategy.
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