1. Bovine Arch – A Marker for Thoracic Aortic Aneurysm Remo Moomiaie, MD a, Matthew Hornick, BA a, Hamid Mojibian, MD b, Esther S. Lee, BA b, Maryann Tranquilli, RN a, John A. Rizzo, PhD c, and John A. Elefteriades, MD a Section of Cardiac Surgery a and Department of Radiology b, Yale University School of Medicine, New Haven, CT; Departments of Preventive Medicine & Economics c, Stony Brook School of Medicine, Stony Brook, NY.

2. 1. Lippert H, Pabst R. Arterial Variations in Man: Classification and Frequency. München: J.F. Bergmann Verlag, 1985. 2. Layton KF, Kallmes DF, Cloft HJ, Lindell EP, Cox VS. Bovine aortic arch variant in humans: clarification of a common misnomer. AJNR Am J Neuroradiol 2006;27:1541- 1542. “Bovine arch” refers to group of congenital variants of human aortic arch vessels in which there is aberrant origin of the left common carotid artery. Two anatomic configurations*: Common origin of innominate artery and left common carotid artery (most common) 1 Left common carotid artery originates from innominate artery at distance from aorta (less common) 1 * Note that bovine arch is a misnomer – the cow’s aorta does not resemble either of these configurations. 2

3. Study Aims Bovine arch traditionally viewed as “normal,” clinically insignificant variant Clinicians have noted in general terms that bovine arch is common in patients with thoracic aortic aneurysm (TAA) This study aims to better define association between bovine arch and aortic disease, including TAA development and complications

4. Patient Population Aneurysm Group: 175 patients with known TAA and thoracic CT or MRI scan on record, randomly selected from Yale Center for Thoracic Aortic Disease database Control Group: 240 patients without TAA, randomly selected from all patients who underwent thoracic CT scan at Yale-New Haven Hospital between May 2006 and May 2008

5. Methods Thoracic scans of TAA group and control group retrospectively reviewed for presence of bovine arch, and imaging reports screened for citation of bovine arch by radiologist TAA patients’ charts retrospectively reviewed for serial TAA diameter, presence of bicuspid aortic valve, and clinical outcomes (dissection, rupture, repair) TAA growth rate = (final diameter – initial diameter)/ duration between scans

6. Results: Bovine Arch and TAA ANEURYSM GROUPBA+BA-% BA+P value (vs. comparison) All TAA (n=174)3613820.7<0.0001 (vs. No TAA) Ascending TAA177119.30.19 (vs. Desc) Descending TAA133129.50.20 (vs. Root) Arch TAA060 Root TAA63016.70.80 (vs. Asc) CONTROL GROUP No TAA (n=240) BA+ 16 BA- 224 %BA+ 6.7 P value (vs. comparison) <0.0001 (vs. All TAA) Incidence of bovine arch significantly greater in patients with TAA than in patients without TAA Bovine arch not significantly associated with aneurysms at any particular location Imaging reports (radiologists) cited bovine arch in only 6 of 36 bovine arch patients Table 1. Incidence of Bovine Arch (BA) by TAA Location and Compared to Non-TAA Control Group

7. Results: Bovine Arch and TAA Incidence of Bovine Arch (BA) by TAA Location and Compared to Non-TAA Control Group Bovine arch significantly more common in patients with TAA than in patients without TAA

8. Results: TAA Growth Rate and Bovine Arch PopulationAll patients*BA- (n)BA+ (n) p value (BA- vs. BA+) Overall TAA0.10 0.16 (46) 0.42 (23) 0.014 Chronic dissection0.310.27 (12)0.57 (9)0.046 No dissection0.050.11 (35)0.33 (14)0.14 Root/Ascending/Arch0.090.11 (27)0.28 (15)0.15 Descending0.120.20 (20)0.68 (8)0.026 3. Coady MA, Rizzo JA, Elefteriades JA. Developing surgical intervention criteria for thoracic aortic aneurysms. Cardiol Clin 1999;17:827-839. Table 2. TAA Growth Rate in Patients With and Without Bovine Arch (cm/yr) - comparison data from Coady et al. 3 * TAAs grow significantly faster in patients with bovine arch than in patients without bovine arch Faster expansion rate in setting of bovine arch statistically significant in descending and chronically dissected aneurysms

9. Results (continued) BA+ (n=36) BA- (n=138) p value (BA- vs. BA+) Type A3190.57 Type B11220.057 Total14410.32 % Dissected38.929.7 Table 3. Dissection in TAA, by BA groupings Higher overall dissection rate in bovine arch patients, but not statistically significant Nearly significant association between bovine arch and type B dissection rate Other results: No significant association between bovine arch and bicuspid aortic valve No significant difference in mean age at TAA discovery or mean age of TAA repair between bovine arch and non-bovine arch groups

10. Conclusions 1) Bovine aortic arch is significantly more common in patients with TAA than in the general population. 2) Radiology reports often overlook bovine arch. 3) Aortas in bovine arch patients grow faster than general TAAs. 4) Bovine arch patients tend to dissect, especially in the descending aorta.

11. Conclusions (continued) 5) These observations argue strongly that bovine arch should not be considered a normal variant of aortic arch anatomy.

12. Recommendations 1) We encourage radiologists to consistently report bovine arch anatomy on thoracic scans, for purposes of serial follow-up to monitor for TAA development. 2) Since “bovine arch” is a misnomer, we propose the name “common origin aortic arch” to describe this group of anatomic variants.