Logo American Journal of Case Reports

Call: 1.631.629.4328
Mon-Fri 10 am - 2 pm EST

Contact Us

Logo American Journal of Case Reports Logo American Journal of Case Reports Logo American Journal of Case Reports

26 June 2021: Articles  Argentina

Transradial Approach to Cerebral Aneurysm Occlusion in a Patient with an Aberrant Right Subclavian Artery: A Case Report

Challenging differential diagnosis, Diagnostic / therapeutic accidents, Management of emergency care, Rare disease, Clinical situation which can not be reproduced for ethical reasons

Javier Goland A* , Gustavo F. Doroszuk A

DOI: 10.12659/AJCR.931443

Am J Case Rep 2021; 22:e931443



BACKGROUND: Retroesophageal right subclavian artery, aberrant right subclavian artery, or lusoria artery constitutes an anatomical variation with a very low prevalence in the general population. Its presence in a patient does not add difficulty for cerebral arteries catheterization when a femoral approach is used, but may make the catheterization of cerebral vessels difficult when a right transradial approach is used. Unfortunately, this type of configuration of the artery is discovered after the decision to use the type of approach.

CASE REPORT: A 60-year-old woman with a diagnosed subarachnoid hemorrhage was studied with angiography through a transradial approach. A left carotid bifurcation aneurysm was diagnosed after three-vessel angiography was performed with a Simmons type 2 catheter, making a complete loop between the right subclavian artery, aortic arc, and left carotid artery. The ruptured cerebral aneurysm was completely occluded with 8 coils. The microcatheter used for the procedure emerged from the tip of an intermediate catheter located at the union of the vertical and horizontal segment of the petrous segment of the left carotid artery.

CONCLUSIONS: The presence of an aberrant right subclavian artery during cerebral angiography performed through a right transradial approach renders the treatment of a left carotid cerebral aneurysms more difficult but not impossible. Utilizing an appropriate intermediate catheter allows for stable navigation of the microcatheter and complete treatment of the aneurysm. This is the first report of cerebral aneurysm embolization through a right transradial approach in a patient with an aberrant right subclavian artery.

Keywords: aberrant subclavian artery, intracranial aneurysm, Subarachnoid Hemorrhage, Aorta, Thoracic, Cardiovascular Abnormalities, Middle Aged, Subclavian Artery


A retroesophageal right subclavian artery, or arteria lusoria, is an anatomical variant in which the right subclavian artery arises distal to the left subclavian artery as a fourth branch of the aorta. It courses towards the right arm behind the trachea and esophagus. This anatomic variant has just a 1% prevalence in the general population, but is present in almost 1 in 4 individuals who have 1 or more chromosomal defects [1,2]. It remains clinically silent in the majority of cases, usually only discovered during angiographic procedures.

In a study in which a transradial approach was used during coronary interventions, among the 0.45% of patients with a lusoria arteria, the procedural success rate was just 60%, versus 97.5% in patients without this anatomical variant [3]. To date, there have been no reports published on the treatment of cerebral aneurysms in patients with this aberrancy of the right subclavian artery.

Case Report

A 60-year-old woman presented to our unit with a subarachnoid hemorrhage: Hunt Hess 4, Fisher 4 (Figure 1). The patient was intubated, then a right radial approach was used to occlude the aneurism using a technique described in previous publications [4,5].

A Simmons type 2 catheter (Merit Medical Systems, Utah, USA) was slid over a 260 mm 0.035”glide-wire (Terumo Interventional Systems, Somerset, NJ) at the aortic valve. A 90° angle was observed between the ascending aorta and right subclavian artery (Figure 2). Three-vessel angiography was performed with the Simmons catheter. Left carotid injection was performed with a completely curved Simmons catheter (Figure 3). Over the glide-wire, we ascended an intermediate 072” Navien catheter (Medtronic, Minneapolis, Minnesota, USA) up to the carotid petrous segment. Then, over a 0.014”guide-wire, we advanced a microcatheter into the aneurysm (Figure 4), where we released 8 coils to successfully occlude it (Figures 5, 6).


Usually, an aberrant right subclavian artery is discovered after the decision has been made to use the radial approach for an intervention; consequently, it is important to have a tool on hand that can be used to overcome this aberrancy. In such patients, using the right radial artery approach, instead of the Simmons catheter going straight into the ascending aorta, as usual, it ends up in the descending aorta, where a straight-angle curve to the ascending aorta must be navigated to reach the aortic valve.

This variation in anatomy adds a new curve before catheterization of the supra-aortic vessels (Figure 3). This anatomical variant does not preclude further advancement of a Simmons catheter, since a glide-wire can be employed to facilitate navigation of the curve. Nonetheless, the new curvature increases the difficulty of catheterization and makes holding the micro-catheter inside cerebral vessels more difficult during therapeutic procedures. In this scenario, where the pathology is more distant, a long-sheath system cannot be used, since its rigid component does not reach far enough to help navigate the vessel’s aberrant curvature. Similarly, using classic guide catheters alone is useless, because they are too short to provide the stability needed for the procedure.

Intracranial support catheters have both adequate flexibility to conform to such curves and enough length to reach the carotid artery’s petrous segment and provide stability to the microcatheter. We believe these 2 characteristics are the basis for the therapeutic success we achieved in our patient. The key moment in our procedure was negotiating the intracranial support catheter with the glide-wire at the first loop between the right subclavian and left carotid artery. This step required a very distal wire position as the intracranial support catheter was advanced. Once the tip of the catheter reached the carotid artery’s petrous segment, however, the remainder of the procedure was relatively straight-forward.

This is the first report of cerebral aneurysm embolization in a patient with an aberrant right subclavian artery. Based on our experience, we believe that using an intermediate catheter is key to approaching the carotid vessel and, once there, holding the microcatheter inside the aneurysm so it can be treated.


The discovery of an aberrant right subclavian artery during cerebral angiography performed through a right transradial approach renders the treatment of cerebral aneurysms more difficult. Utilizing an intracranial support catheter can facilitate the embolization of cerebral aneurysms in patients with this anatomical variant.


1.. Polednak AP: Clin Anat, 2017; 30(8); 1024-28

2.. Scala C, Leone Roberti Maggiore U, Candiani M: Ultrasound Obstet Gynecol, 2015; 46(3); 266-76

3.. Valsecchi O, Vassileva A, Musumeci G: Catheter Cardiovasc Interv, 2006; 67(6); 870-78

4.. Goland J, Doroszuk G: Surg Neurol Int, 2019; 10; 87

5.. Goland J, Doroszuk GF, Garbugino SL, Ypa MP: Surg Neurol Int, 2017; 8; 73


19 May 2022 : Case report  Serbia

Bilateral Emphysematous Pyelonephritis Associated with COVID Pneumonia: A Case Report

Am J Case Rep In Press; DOI: 10.12659/AJCR.936370  

17 May 2022 : Case report  USA

High-Frequency Oscillatory Ventilation for Refractory Hypoxemia in Severe COVID-19 Pneumonia: A Small Case ...

Am J Case Rep In Press; DOI: 10.12659/AJCR.936651  

13 May 2022 : Case report  Japan

A case of exacerbation of haloperidol-induced rhabdomyolysis following the onset of COVID-19

Am J Case Rep In Press; DOI: 10.12659/AJCR.936589  

13 May 2022 : Case report  USA

Acute Disseminated Encephalomyelitis After SARS-CoV-2 Vaccination

Am J Case Rep In Press; DOI: 10.12659/AJCR.936574  

In Press

20 May 2022 : Case report  Canada

Diagnostic Puzzle of Acute Ischemic Stroke Mimics – Seizure Versus Post-Stroke Recrudescence: A Case Report

Am J Case Rep In Press; DOI: 10.12659/AJCR.936826  

19 May 2022 : Case report  Saudi Arabia

Extremes of Anemia: The Lowest Hemoglobin Values Probably Ever Reported in the Pediatric Literature Attribu...

Am J Case Rep In Press; DOI: 10.12659/AJCR.936252  

19 May 2022 : Case report  Brazil

Acute Hepatitis with Positive Autoantibodies: A Case of Natalizumab-Induced Early-Onset Liver Injury

Am J Case Rep In Press; DOI: 10.12659/AJCR.936318  

19 May 2022 : Case report  Japan

Successful Percutaneous Fogarty Thrombectomy for Subacute Lower Limb Ischemia Due to Resistant Thrombus in ...

Am J Case Rep In Press; DOI: 10.12659/AJCR.936377  

Most Viewed Current Articles

31 Dec 1969 : Case report  USA

Penile Necrosis Associated with Local Intravenous Injection of Cocaine

DOI :10.12659/AJCR.935250

Am J Case Rep 2022; 23:e935250

31 Dec 1969 : Case report  Oman

Myocarditis, Pulmonary Hemorrhage, and Extensive Myositis with Rhabdomyolysis 12 Days After First Dose of P...

DOI :10.12659/AJCR.934399

Am J Case Rep 2022; 23:e934399

31 Dec 1969 : Case report  Brazil

Lipedema Can Be Treated Non-Surgically: A Report of 5 Cases

DOI :10.12659/AJCR.934406

Am J Case Rep 2021; 22:e934406

31 Dec 1969 : Case report  USA

A Rare Case of Coronavirus Disease 2019 Vaccine-Associated Cerebral Venous Sinus Thrombosis Treated with Me...

DOI :10.12659/AJCR.935355

Am J Case Rep 2022; 23:e935355

Your Privacy

We use cookies to ensure the functionality of our website, to personalize content and advertising, to provide social media features, and to analyze our traffic. If you allow us to do so, we also inform our social media, advertising and analysis partners about your use of our website, You can decise for yourself which categories you you want to deny or allow. Please note that based on your settings not all functionalities of the site are available. View our privacy policy.

American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923