Successful right transbrachial cerebral angiography in a patient with aberrant right subclavian artery: A technical note

Abstract

Aberrant right subclavian artery (RSCA) is a congenital anomaly in which the RSCA arises as the final branch of the aortic arch, the presence of which makes cerebral angiography (CAG) via the right transbrachial approach (RTBA) difficult to perform. Herein, we present a case of aberrant RSCA in which the right transbrachial CAG was successfully executed and review its technical details in consideration of the anatomy of the aberrant RSCA. A 51-year-old man was admitted to our hospital with an unexplained subcortical hemorrhage in the left parietal lobe. Diagnostic CAG was performed via the RTBA, leading to the diagnosis of aberrant RSCA. Despite some technical difficulty, the Simmons curve was formed at an acute angle between the aberrant RSCA and the aortic arch. Once the Simmons curve is formed, torque control of the catheter can result in the bilateral common carotid artery (CCA) cannulation without switching to a transfemoral approach. Left CCA angiography confirmed an arteriovenous fistula in the distal left anterior cerebral artery. Subsequently, the suspected source of intracerebral bleeding and associated hematoma were surgically resected. Early detection of aberrant RSCA is crucial when using the RTBA. Depending on the procedure of catheterization, the right transbrachial CAG can be performed even in patients with aberrant RSCA; therefore, its continued usage seems worthy of consideration after setting a time limit.

Keywords: Aberrant right subclavian artery; Arteriovenous malformation; Concomitant vascular anomaly; Technical difficulties; Transbrachial cerebral angiography.

Fig. 1

The images above (A, B) are axial CT scans of the head obtained upon admission. (A) CT demonstrating a subcortical hemorrhage (40 mm) in the left parietal lobe. (B) CTA showing no vascular abnormalities identified as the source of bleeding. The images below (C, D) are preoperative DSA. The left ICA angiograms in the anteroposterior (C) and lateral (D) projections reveal a fistula at the distal left anterior cerebral artery (arrowheads), suggesting a source of bleeding.

Fig. 2

3D-CTA of the chest in anteroposterior (A), left lateral (B), and posteroanterior (C) projection confirms the presence of an aberrant RSCA (arrowhead). The aberrant RSCA arises from the descending aorta in the superoposterior direction.

Fig. 3

The radiographic imaging above (A–D) was obtained before accessing the carotid arteries. (A) X-ray image showing that the guidewire was exclusively advanced into the descending aorta. (B) Aortography revealing that the RSCA (arrowhead) is the final branch of the aortic arch. (C) X-ray image showing that the guidewire successfully advanced into the ascending aorta. (D) X-ray image subsequently shows the guidewire and catheter intolerantly herniating into the descending aorta. The radiographic imaging below (E–H) was obtained after selecting carotid arteries. (E) X-ray image showing that the catheter selects the right CCA while forming a Simmons curve. (F) Right CCA angiography showing a common trunk shared by the right CCA (arrowhead) and the right VA (black arrow). (G) Intra-aortic injection just distal to the origin of the right CCA showing, in order, the left CCA (arrowhead), the left VA originating directly from the aortic arch (black arrow), and the left subclavian artery. (H) DSA overlay showing that the right CCA is successfully selected by the catheter (arrowhead).

Fig. 4

Schematic illustration of catheterization to access carotid arteries. The summarized behavior of the Simmons catheter was overlain on the 3D CTA image of the chest in an anteroposterior projection. (A, B) After the catheter was slowly retracted from the ascending aorta, the Simmons curve was formed at an acute angle between the aberrant RSCA and the aortic arch. (C) Once the Simmons curve is formed, torque control of the catheter can result in right CCA cannulation. (D) The catheter is pushed out of the right CCA and dropped into the aortic arch while maintaining the Simmons curve. (E) By torqueing and advancing the catheter, the Simmons curve is guided into the ascending aorta, utilizing the outer wall of the descending aorta as a fulcrum. (F) The left CCA was accessed with a catheter using guidewire-assisted induction.