Transradial Approach to Cerebral Aneurysm Occlusion in a Patient with an Aberrant Right Subclavian Artery: A Case Report

Abstract

BACKGROUND Retroesophageal right subclavian artery, aberrant right subclavian artery, or lusoria artery constitutes an anatomical variation with a very low prevalence in the general population. Its presence in a patient does not add difficulty for cerebral arteries catheterization when a femoral approach is used, but may make the catheterization of cerebral vessels difficult when a right transradial approach is used. Unfortunately, this type of configuration of the artery is discovered after the decision to use the type of approach. CASE REPORT A 60-year-old woman with a diagnosed subarachnoid hemorrhage was studied with angiography through a transradial approach. A left carotid bifurcation aneurysm was diagnosed after three-vessel angiography was performed with a Simmons type 2 catheter, making a complete loop between the right subclavian artery, aortic arc, and left carotid artery. The ruptured cerebral aneurysm was completely occluded with 8 coils. The microcatheter used for the procedure emerged from the tip of an intermediate catheter located at the union of the vertical and horizontal segment of the petrous segment of the left carotid artery. CONCLUSIONS The presence of an aberrant right subclavian artery during cerebral angiography performed through a right transradial approach renders the treatment of a left carotid cerebral aneurysms more difficult but not impossible. Utilizing an appropriate intermediate catheter allows for stable navigation of the microcatheter and complete treatment of the aneurysm. This is the first report of cerebral aneurysm embolization through a right transradial approach in a patient with an aberrant right subclavian artery.

Figure 1.

Computed tomography (CT) shows a subarachnoid hemorrhage and left temporal hematoma.

Figure 2.

Later aortogram. Dotted lines mark a 90° angle between the right subclavian artery and aortic arc. Arrowheads indicate subclavian artery direction and black arrows show aortic arc direction.

Figure 3.

A complete curved Simmons catheter is located in the left carotid artery during angiography. White arrow shows distal tip of Simmons catheter in common left carotid artery.

Figure 4.

Oblique anteroposterior angiography shows the microcatheter inside the aneurysm (white arrow) and the first coil entering it (black arrow).

Figure 5.

Oblique anteroposterior angiography shows the aneurysm occluded. Black arrow indicates the tip of the intracranial support catheter within the carotid artery’s petrous segment.

Figure 6.

Final anteroposterior angiography shows the trajectory of the intracranial support catheter (arrowheads) and the aneurysm occluded (arrow).