Aberrant right subclavian artery

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Aberrant right subclavian arteries (ARSA), also known as arteria lusoria, are among the commonest aortic arch anomalies.

Epidemiology

The estimated incidence is 0.5-2%¹.

Clinical presentation

They are often asymptomatic, but around 10% of people may complain of tracheo-oesophageal symptoms, almost always as dysphagia, termed dysphagia lusoria^3 2.

Pathology

Course

Instead of being the first branch (with the right common carotid as the brachiocephalic artery), it arises on its own as the fourth branch, distal to the left subclavian artery. It then hooks back to reach the right side with its relationship to the oesophagus variable³:

80% posterior to the oesophagus
15% between oesophagus and trachea
5% anterior to the trachea

Associations

as can be expected from the embryological development of the artery, the right recurrent laryngeal nerve is usually non-recurrent, entering the larynx directly.
aneurysmal dilatation (aberrant subclavian arterial aneurysms) of the proximal portion of an aberrant right subclavian artery can occur, a pouch-like aneurysmal dilatation is called a diverticulum of Kommerell.
if there is a retro-oesophageal course
- it can get compressed between the oesophagus and the vertebra
- the incidence of stenosis/occlusion in this segment is higher
it can be associated with trisomy 21 ⁵⁴, trisomy 18 and other chromosomal defects.

Radiographic features

Plain radiograph

Lateral radiographs of the chest may show obliteration of the retrotracheal space.

Fluoroscopy

An upper GI contrast study will demonstrate displacement of the contrast-filled oesophagus⁵. This displacement by the aberrant vessels produces the so-called bayonet deformity of the aberrant right subclavian artery.

CT/MRI

CT and MRI both demonstrate the aberrant branch arising from the distal left aortic arch and coursing rightwards and can define the relationship between the aberrant artery and the trachea and oesophagus⁵.

Complications

The presence of an aberrant right subclavian artery poses a substantial risk of life-threatening haemorrhage in patients undergoing surgery like oesophagectomy. Moreover, the recurrent laryngeal nerve does not follow the orthodox course, which is important in thyroid and parathyroid surgeries ⁶.

-<p><strong>Aberrant right subclavian arteries</strong> <strong>(ARSA)</strong>, also known as <strong>arteria lusoria</strong>, are among the commonest <a href="/articles/variant-anatomy-of-the-aortic-arch">aortic arch anomalies</a>. </p><h4>Epidemiology</h4><p>The estimated incidence is 0.5-2%.</p><h4>Clinical presentation</h4><p>They are often asymptomatic, but around 10% of people may complain of tracheo-oesophageal symptoms, almost always as dysphagia, termed <a href="/articles/dysphagia-lusoria">dysphagia lusoria</a><sup> 3</sup>.</p><h4>Pathology</h4><h5>Course</h5><p>Instead of being the first branch (with the <a href="/articles/common-carotid-artery-2">right common carotid</a> as the <a href="/articles/brachiocephalic-trunk">brachiocephalic artery</a>), it arises on its own as the fourth branch, distal to the <a href="/articles/subclavian-artery">left subclavian artery</a>. It then hooks back to reach the right side with its relationship to the <a href="/articles/oesophagus">oesophagus</a> variable:</p><ul>
+<p><strong>Aberrant right subclavian arteries</strong> <strong>(ARSA)</strong>, also known as <strong>arteria lusoria</strong>, are among the commonest <a href="/articles/variant-anatomy-of-the-aortic-arch">aortic arch anomalies</a>. </p><h4>Epidemiology</h4><p>The estimated incidence is 0.5-2% <sup>1</sup>.</p><h4>Clinical presentation</h4><p>They are often asymptomatic, but around 10% of people may complain of tracheo-oesophageal symptoms, almost always as dysphagia, termed <a href="/articles/dysphagia-lusoria">dysphagia lusoria</a><sup> 2</sup>.</p><h4>Pathology</h4><h5>Course</h5><p>Instead of being the first branch (with the <a href="/articles/common-carotid-artery-2">right common carotid</a> as the <a href="/articles/brachiocephalic-trunk">brachiocephalic artery</a>), it arises on its own as the fourth branch, distal to the <a href="/articles/subclavian-artery">left subclavian artery</a>. It then hooks back to reach the right side with its relationship to the <a href="/articles/oesophagus">oesophagus</a> variable <sup>3</sup>:</p><ul>
-<li>aneurysmal dilatation (<a href="/articles/aberrant-subclavian-arterial-aneurysms">aberrant subclavian arterial aneurysms</a>) of the proximal portion of an aberrant right subclavian artery can occur, a pouch-like aneurysmal dilatation is called a <a href="/articles/kommerell-diverticulum">diverticulum of Kommerell</a>
~~-</li>~~
+<li>aneurysmal dilatation (<a href="/articles/aberrant-subclavian-arterial-aneurysms">aberrant subclavian arterial aneurysms</a>) of the proximal portion of an aberrant right subclavian artery can occur, a pouch-like aneurysmal dilatation is called a <a href="/articles/kommerell-diverticulum">diverticulum of Kommerell</a>.</li>
~~-<li>it can be associated with <a href="/articles/down-syndrome">trisomy 21</a> <sup>5</sup>, <a href="/articles/edwards-syndrome-1">trisomy 18</a> and other chromosomal defects.</li>~~
-</ul><h4>Radiographic features</h4><h5>Plain radiograph</h5><p>Lateral radiographs of the chest may show obliteration of the <a href="/articles/retrotracheal-space">retrotracheal space</a>.</p><h5>Fluoroscopy</h5><p>An upper GI contrast study will demonstrate displacement of the contrast-filled oesophagus. This displacement by the aberrant vessels produces the so-called <a href="/articles/bayonet-deformity-aberrant-right-subclavian-artery">bayonet deformity</a><a href="/articles/bayonet-deformity-of-aberrant-right-subclavian-artery"> of the aberrant right subclavian artery</a>.</p><h5>CT/MRI</h5><p>CT and MRI both demonstrate the aberrant branch arising from the distal left aortic arch and coursing rightwards and can define the relationship between the aberrant artery and the trachea and oesophagus.</p><h4>Complications</h4><p>The presence of an aberrant right subclavian artery poses a substantial risk of life-threatening haemorrhage in patients undergoing surgery like <a href="/articles/oesophagectomy">oesophagectomy</a>. Moreover, the recurrent laryngeal nerve does not follow the orthodox course, which is important in thyroid and parathyroid surgeries <sup>6</sup>.</p>
+<li>it can be associated with <a href="/articles/down-syndrome">trisomy 21</a> <sup>4</sup>, <a href="/articles/edwards-syndrome-1">trisomy 18</a> and other chromosomal defects.</li>
+</ul><h4>Radiographic features</h4><h5>Plain radiograph</h5><p>Lateral radiographs of the chest may show obliteration of the <a href="/articles/retrotracheal-space">retrotracheal space</a>.</p><h5>Fluoroscopy</h5><p>An upper GI contrast study will demonstrate displacement of the contrast-filled oesophagus <sup>5</sup>. This displacement by the aberrant vessels produces the so-called <a href="/articles/bayonet-deformity-aberrant-right-subclavian-artery">bayonet deformity</a><a href="/articles/bayonet-deformity-of-aberrant-right-subclavian-artery"> of the aberrant right subclavian artery</a>.</p><h5>CT/MRI</h5><p>CT and MRI both demonstrate the aberrant branch arising from the distal left aortic arch and coursing rightwards and can define the relationship between the aberrant artery and the trachea and oesophagus <sup>5</sup>.</p><h4>Complications</h4><p>The presence of an aberrant right subclavian artery poses a substantial risk of life-threatening haemorrhage in patients undergoing surgery like <a href="/articles/oesophagectomy">oesophagectomy</a>. Moreover, the recurrent laryngeal nerve does not follow the orthodox course, which is important in thyroid and parathyroid surgeries <sup>6</sup>.</p>

References changed:

1. Brauner E, Lapidot M, Kremer R, Best L, Kluger Y. Aberrant Right Subclavian Artery- Suggested Mechanism for Esophageal Foreign Body Impaction: Case Report. World J Emerg Surg. 2011;6(1):12. <a href="https://doi.org/10.1186/1749-7922-6-12">doi:10.1186/1749-7922-6-12</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/21477337">Pubmed</a>
2. Ka-Tak W, Lam W, Yu S. MDCT of an Aberrant Right Subclavian Artery and of Bilateral Vertebral Arteries with Anomalous Origins. AJR Am J Roentgenol. 2007;188(3):W274-5. <a href="https://doi.org/10.2214/AJR.05.0694">doi:10.2214/AJR.05.0694</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/17312035">Pubmed</a>
3. González-Sánchez M, Pardal-Refoyo J, Martín-Sánchez A. The Aberrant Right Subclavian Artery and Dysphagia Lusoria. Acta Otorrinolaringol Esp. 2013;64(3):244-5. <a href="https://doi.org/10.1016/j.otorri.2011.11.005">doi:10.1016/j.otorri.2011.11.005</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/22261645">Pubmed</a>
4. Beloosesky R, Shrim A, Steinberg M, Khatib N, Bronshtein M. Isolated Aberrant Right Subclavian Artery at 14-16 Weeks of Gestation and Down Syndrome. J Clin Ultrasound. 2018;46(1):62-3. <a href="https://doi.org/10.1002/jcu.22543">doi:10.1002/jcu.22543</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/29080315">Pubmed</a>
5. Freed K & Low V. The Aberrant Subclavian Artery. AJR Am J Roentgenol. 1997;168(2):481-4. <a href="https://doi.org/10.2214/ajr.168.2.9016231">doi:10.2214/ajr.168.2.9016231</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/9016231">Pubmed</a>
6. Mahmodlou R, Sepehrvand N, Hatami S. Aberrant Right Subclavian Artery: A Life-Threatening Anomaly That Should Be Considered During Esophagectomy. J Surg Tech Case Rep. 2014;6(2):61-3. <a href="https://doi.org/10.4103/2006-8808.147262">doi:10.4103/2006-8808.147262</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/25598945">Pubmed</a>
3. Borenstein M, Minekawa R, Zidere V et-al. Aberrant right subclavian artery at 16 to 23 + 6 weeks of gestation: a marker for chromosomal abnormality. Ultrasound Obstet Gynecol. 2010;36 (5): 548-52. <a href="http://dx.doi.org/10.1002/uog.7683">doi:10.1002/uog.7683</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/20503237">Pubmed citation</a><span class="auto"></span>
5. Donnelly LF, Fleck RJ, Pacharn P, Ziegler MA, Fricke BL, Cotton RT. Aberrant subclavian arteries: cross-sectional imaging findings in infants and children referred for evaluation of extrinsic airway compression. (2002) AJR. American journal of roentgenology. 178 (5): 1269-74. <a href="https://doi.org/10.2214/ajr.178.5.1781269">doi:10.2214/ajr.178.5.1781269</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/11959744">Pubmed</a> <span class="ref_v4"></span>
6. Mahmodlou R, Sepehrvand N, Hatami S. Aberrant Right Subclavian Artery: A Life-threatening Anomaly that should be considered during Esophagectomy. (2014) Journal of surgical technique and case report. 6 (2): 61-3. <a href="https://doi.org/10.4103/2006-8808.147262">doi:10.4103/2006-8808.147262</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/25598945">Pubmed</a> <span class="ref_v4"></span>
1. Weissleder R, Wittenberg J, Harisinghani MM et-al. Primer of Diagnostic Imaging, Expert Consult- Online and Print. Mosby. (2011) ISBN:0323065384. <a href="http://books.google.com/books?vid=ISBN0323065384">Read it at Google Books</a> - <a href="http://www.amazon.com/gp/product/0323065384?ie=UTF8&tag=radiopaediaor-20&linkCode=as2&camp=1789&creative=9325&creativeASIN=0323065384">Find it at Amazon</a><div class="ref_v2"></div>
2. Ka-tak W, Lam WW, Yu SC. MDCT of an aberrant right subclavian artery and of bilateral vertebral arteries with anomalous origins. AJR Am J Roentgenol. 2007;188 (3): W274-5. <a href="http://dx.doi.org/10.2214/AJR.05.0694">doi:10.2214/AJR.05.0694</a> - <a href="http://www.ncbi.nlm.nih.gov/pubmed/17312035">Pubmed citation</a><div class="ref_v2"></div>
4. Beloosesky R, Shrim A, Steinberg M, Khatib N, Bronshtein M. Isolated aberrant right subclavian artery at 14-16 weeks of gestation and Down syndrome. J Clin Ultrasound. 2018;46 (1):62-63 <a href="doi: 10.1002/jcu.22543">doi: 10.1002/jcu.22543</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/29080315">Pubmed citation</a><span class="auto"></span>

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