A rare anomalous origin of left subclavian artery from the circle of Willis in combination with right sided aortic arch: A case report
A 10-year-old boy referred to the pediatric cardiology clinic of Chamran Hospital, Isfahan University of Medical Sciences, Isfahan, Iran on 1-May-2012 with a chief complaint of recurrent chest pain from two weeks ago. He had an atypical chest pain in the 4th and 5th left intercostals areas without any radiation which lasted for several minutes. He had no other symptoms though.\nIn physical examination, the pulses of left upper limb and left carotid artery were not detected; however, the other pulses were normal. He had no cyanosis or clubbing in his extremities. In heart auscultation, the S1 and S2 sounds were normal and a grade I-II/VI systolic ejection-type murmur was heard on the left sternal border. The other examinations were normal.\nNo abnormal findings were revealed in electrocardiography.\nThe cardiothoracic ratio was in upper normal range and the pulmonary vascular markings were normal in chest X-ray (CXR). The right sided aortic arch was observed in .\nThe main abnormal findings in echocardiography included mild mitral valve prolapse (MVP) and tricuspid regurgitation (TR) with a pressure gradient of 25 mmHg. Besides, the right sided aortic arch was observed.\nIn CT angiogram, the left carotid artery was significantly narrower than the right one which seemed to be dilated for enough cerebral circulation. Moreover, as a rare anomalous finding, the left subclavian artery aroused from this narrow carotid artery and the left vertebral artery originated from this subclavian artery (.A and .B).\nThereafter, the patient underwent the left heart catheterization. The arterial catheter passed from the femoral artery into descending aorta (DAO), ascending aorta (AAO), and left ventricle (LV), respectively. It entered into the right and left coronary arteries (RCA and LCA) normally.\nSystemic sample was saturated. In addition, it entered into the right subclavian and right carotid arteries, but it could not enter into the left brachiocephalic artery.\nLV, coronary arteries and aortic root injections revealed no pathologic findings. The right sided aortic arch was observed again. Aortic arch injection in the right anterior oblique view showed normal right subclavian and right carotid arteries and also showed with no connection of the left subclavian artery to the aortic arch.\nSelective right carotid artery injection showed opacified left subclavian artery. The left subclavian and left vertebral arteries supplied from the circle of Willis (right vertebral artery). Selective right subclavian artery showed no anomaly (.A, .B, and .C).\nFollowing the whole procedures, the patient was discharged and was advised to refer periodically for clinical follow-up.