Abstract
A 45-year-old man was referred for cerebral angiography for the work-up of a recent cerebellar transient ischemic attack and suspected right vertebral artery occlusion on noninvasive imaging. Arch aortography revealed a completely aberrant left-sided aortic arch, with the following branches arising from proximal to distal: aberrant left brachiocephalic trunk (LBCT) dividing into the left common carotid artery (LCCA) and the left subclavian artery (LSCA), right common carotid artery (RCCA), and aberrant right subclavian artery (RSCA). The right vertebral artery was found to be occluded at its origin from the RSCA (arrow). The left vertebral artery (LVA) arose normally as a branch of the LSCA. Anatomic variations of the aortic arch are common, the classic branching pattern being seen in only 65% to 83% of aortic arches in large cadaveric, angiographic, and computed tomography series. Such variations are thought to result from the differential development of embryonic branchial arch arteries. The most frequent variants are the common origin of the right brachiocephalic trunk and LCCA (15%-27%), direct origin of the LVA from the aortic arch (0.8%-6%), and aberrant RSCA arising distal to the left subclavian artery (0.5%-1.2%). Several other rare variants ( 1%) have also been reported, none resembling the one described in this article.
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