Congenital subclavian steal syndrome with multiple cerebellar infarctions caused by an atypical circumflex retroesophageal right aortic arch with atretic.

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Congenital subclavian steal syndrome with multiple cerebellar infarctions caused by an atypical circumflex retroesophageal right aortic arch with atretic aberrant left subclavian artery Apostolos T. Mamopoulos, MD, Bernd Luther, PhD Journal of Vascular Surgery Volume 60, Issue 3, Pages 776-779 (September 2014) DOI: 10.1016/j.jvs.2013.06.086 Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 1 A, Magnetic resonance tomography scan of the brain with multiple infarctions in both cerebellar hemispheres, more pronounced on the left side. Furthermore, diffuse chronic ischemic alterations with atrophy of the brain stem could be demonstrated. In stark contrast, both brain hemispheres were completely free of any pathological findings. The findings described above, combined with the functional duplex-ultrasound examination, were compatible with a chronic vertebrobasilar ischemia. B and C, Magnetic resonance angiography of the thoracic aorta showing a circumflex right-sided aortic arch (anteroposterior [B] and left lateral view [C]). The first supra-aortic branch was the left common carotid artery (LCA) followed by the right common carotid artery (RCA) and the right subclavian artery (RSA; with a 17-mm aneurysmatic proximal segment). An aberrant left subclavian artery (aLSA), proximally occluded, originated from the proximal descending aorta (*). The aortic arch had a retroesophageal segment (inset) without a pronounced diverticulum of Kommerell. Journal of Vascular Surgery 2014 60, 776-779DOI: (10.1016/j.jvs.2013.06.086) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 2 A, Computed tomography angiography showing a ligamentum arteriosum (LA) between the left pulmonary artery (LPA) and the origin of the aberrant left subclavian artery (aLSA). B, The origin of the aLSA from the descending aorta showed no pronounced diverticulum of Kommerell. C, Anteroposterior computed tomography reconstruction of the proximal aLSA with the ostium of the vertebral artery. The proximal segment of the right subclavian artery (RSA) is also visible. Journal of Vascular Surgery 2014 60, 776-779DOI: (10.1016/j.jvs.2013.06.086) Copyright © 2014 Society for Vascular Surgery Terms and Conditions

Fig 3 Intraoperative images of the subclavian carotid transposition. A, The left common carotid artery (LCA) dissected down to its origin; B, the aberrant left subclavian artery (aLSA) was found deeper and dorsal to the carotid artery; C, the aLSA was rotated ventrally to be anastomosed to the carotid artery; D, the completed anastomosis (Anast). E and F, Postoperative 3-dimensional computed tomography reconstructions showing a functioning anastomosis. RCA, Right carotid artery; RSA, right subclavian artery; *, original origin of the aLSA. G, Right-sided aortic arch (RAA) with aLSA. A ligamentum arteriosum (LA) connects the LSA with the left pulmonary artery (LPA). H, RAA with mirror image of the supra-aortic branches. I, RAA with isolated LSA (iLSA). J, Our case, of a circumflex RAA with an aLSA, atretic at its origin (*). Journal of Vascular Surgery 2014 60, 776-779DOI: (10.1016/j.jvs.2013.06.086) Copyright © 2014 Society for Vascular Surgery Terms and Conditions