Carotid Artery Stenting in Right-sided Aortic Arch: A Case Report

Abstract

The present report describes a patient with pseudo-occlusion of the left internal carotid artery accompanied by aortic anomalies consisting of right-sided aortic arch with aberrant left subclavian artery arising from Kommerell’s diverticulum. Initial attempt of carotid artery stenting via the trans-femoral approach was unsuccessful because of low origin of the left common carotid artery. Therefore, carotid artery stenting (CAS) via the trans-brachial approach was successfully performed with distal balloon protection. Eight months later, the patient presented with restenosis of the left internal carotid artery, and CAS via the trans-brachial approach was performed again. CAS via the trans-brachial approach should be considered when standard femoral access is relatively contraindicated due to aortic anomalies consisting of a right-sided aortic arch.

Right-sided aortic arch with complex anomalies presented with transient ischemic attack

“…Patients with a right aortic arch with a left ligamentum arteriosum are more likely to develop Kommerell’s diverticulum, which is a remnant part of the left fourth aortic arch arising as a left SCA aneurysm. [ 14 ] An ALSA’s proximal segment that is conically dilated at its aortic origin is referred to as a diverticulum. However, it is also referred to as “lusoria root,” “remnant diverticulum,” and “lusoria diverticulum.” Kommerell’s diverticulum can be seen behind the trachea in 5% of cases, between the trachea and esophagus in 15% of cases, and in the retroesophageal region in 80% of cases.…”

“…[ 19 ] The other case was pseudo-occlusion of the left ICA. [ 14 ] We report a case of anterior circulation insufficiency due to symptomatic left CCA and ICA stenosis (30–50%) causing the patient’s symptoms. Furthermore, asymptomatic right CCA stenosis (30%) was traced only on the native brain CT scan as a watershed infarction of the left posterior, frontal, and parieto-occipital cortex but without any neurological deficit.…”

“…They did overcome this difficulty by shifting to the transbrachial route when the catheter passes through only one steep turn at the low origin of the left CCA. [ 14 ] In another case of CAS of the left ICA stenosis in a patient with RAA, the examiner successfully completed the procedure though a transfemoral approach, attributing this success to the preoperative recognition of the aortic arch anatomy. [ 18 ] From their experiences, we believe that the preoperative diagnosis with the knowledge of the anatomical characteristic of RAA can limit the technical difficulties during endovascular procedures.…”

Endovascular Treatment Strategy for Acute Basilar Artery Occlusion with Unexpected Right-Sided Aortic Arch

“…Unexpected anatomical variant of the aortic arch may increase procedural difficulty of neuro-EVT via the femoral artery approach. 8 Even in cases of patients with a normal aorta, the meandering of tortuous vessels tends to delay the femoral artery access procedure by 30 minutes or more, which is also associated with unsuccessful revascularization. 9 Neuro-EVT is often performed via femoral artery approach.…”

Successful Endovascular Thrombectomy for Acute M1 Occlusion in a Patient with Situs Inversus: A Case Report

“…However, if patients have not only mirror-image branching but some other anatomical variations, it may be difficult to advance guiding catheter into target vessels. Ohtani et al 6) reported a carotid artery stenting case for left internal carotid artery stenosis with right aortic arch. In that report, a 4 Fr modified Simmons catheter via trans-femoral approach could not be advanced into left common carotid artery because left common carotid artery was originated from the low part of ascending aorta.…”