Truncus Bicaroticus With Arteria Lusoria: A Rare Combination of Aortic Root Anatomy Complicating Cardiac Catheterization

Treatment

ARSA and COCA are considered normal anatomic variants and no treatment is indicated if the patient is asymptomatic. If symptoms are present, they often arise from aneurysmal or occlusive complications of the vascular anatomy. In patients with isolated ARSA and mild dysphasia or reflux symptoms, the use of prokinetics and antireflux medications may provide relief. It is important to note the coexistence of ARSA and COCA is more likely to produce esophageal compression compared to ARSA alone due to formation of a more complete vascular ring. Surgical management has been described in severe cases of ARSA involving risk of aneurysm rupture, right upper limb ischemia, or compression of the esophagus or trachea.

Several surgical approaches have been described, including simple ligation and division of ARSA and reimplantation of the RSA into the right CCA or ascending aorta.⁵ A recent review of 180 cases of ARSA diagnosed on CT angiography with concomitant common carotid trunk in half of studied individuals focused on a hybrid open and intravascular procedure. This procedure involved a double transposition or bypass (LSA to left common carotid artery and ARSA to the right CCA) followed by implantation of a thoracic stent graft. Few cases are eligible for these procedures or require them for definitive treatment.²³

Conclusions

Recognition of aortic arch anatomical variants such as our case of ARSA with concomitant COCA may influence clinician decisions in various specialties, such as interventional cardiology, interventional neurology, cardiothoracic surgery, and gastroenterology. While most patients with these conditions are asymptomatic, some may present with dysphagia, dyspnea, and/or stroke symptoms. In our practice, discovery of such anomalies periprocedurally may affect cardiac catheterization access site, catheter selection, and additional imaging. The presence of arteria lusoria can be of critical importance when encountering a patient with myocardial infarction as switching from transradial to transfemoral approach may be required to gain access to the ascending aorta. Overall, transradial coronary angiography and percutaneous coronary intervention is not contraindicated in the setting of ARSA/COCA and can be safely performed by an experienced operator.

It is important for surgical specialists to be aware of the coexistence of anomalies where the discovery of one aberrancy can signal coexistent variant anatomy. If aortic arch anatomy is unclear, it is useful to perform nonselective angiography and/or further imaging with CT angiography. Knowledge of abnormal aortic arch anatomy can decrease fluoroscopy time and contrast load administered, thereby reducing potential periprocedural adverse events.