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Isolation of the left subclavian artery in an infant with tetralogy of Fallot, right aortic arch and DiGeorge syndrome. Echocardiographic diagnostic case study

Maciej A. Karolczak
Maciej A. Karolczak
, 
Wojciech Mądry
Wojciech Mądry
 and 
Darren James Grégoire
Darren James Grégoire
   | Apr 30, 2019
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Article Category: case-report
Published Online: Apr 30, 2019
Page range: 66 - 70
Received: Nov 04, 2018
Accepted: Jan 22, 2019
DOI: https://doi.org/10.15557/jou.2019.0010
Keywords
© 2019 Maciej A. Karolczak et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Fig. 1.

Preoperative CT angiography. Ao – ascending aorta, PA – pulmonary trunk, LPA – left pulmonary artery, RAo – right aortic arch, DA – ductus arteriosus, LCCA – left common carotid artery, LVA – left vertebral artery
Preoperative CT angiography. Ao – ascending aorta, PA – pulmonary trunk, LPA – left pulmonary artery, RAo – right aortic arch, DA – ductus arteriosus, LCCA – left common carotid artery, LVA – left vertebral artery

Fig. 2.

Formation of left-sided aortic arch. RaoG – right dorsal aorta, LAoG – left dorsal aorta, LSA – left subclavian artery (the arrow indicates the direction of its migration), LCA – left carotid artery, III and IV – pharyngeal (aortic) arch arteries, DA – ductus arteriosus, AoS – aortic sac, PA – pulmonary trunk (author’s own scheme – M.A.K)
Formation of left-sided aortic arch. RaoG – right dorsal aorta, LAoG – left dorsal aorta, LSA – left subclavian artery (the arrow indicates the direction of its migration), LCA – left carotid artery, III and IV – pharyngeal (aortic) arch arteries, DA – ductus arteriosus, AoS – aortic sac, PA – pulmonary trunk (author’s own scheme – M.A.K)

Fig. 3.

Systole. A round cross-section of the ascending aorta (AoAs) filled with red, and the pulmonary trunk (PA) and the right pulmonary artery (RPA) – blue color. A bulge corresponding to the origin of the left common carotid artery (*) is present in the anterior left contour of the ascending aorta (*)
Systole. A round cross-section of the ascending aorta (AoAs) filled with red, and the pulmonary trunk (PA) and the right pulmonary artery (RPA) – blue color. A bulge corresponding to the origin of the left common carotid artery (*) is present in the anterior left contour of the ascending aorta (*)

Fig. 4.

A slightly higher cross-section, diastole. The ascending aorta (AoAsc) is not filled with color. Despite the diastolic phase, the pulmonary trunk (PA) and its two branches (RPA and LPA) are filled with intensive blue color – with distinct turbulence. A bulge corresponding to the outlet of the ductus arteriosus (*) is seen in the anterior contour of the pulmonary trunk (PA). The left common carotid artery is not visible during this phase. VBC – the brachiocephalic vein
A slightly higher cross-section, diastole. The ascending aorta (AoAsc) is not filled with color. Despite the diastolic phase, the pulmonary trunk (PA) and its two branches (RPA and LPA) are filled with intensive blue color – with distinct turbulence. A bulge corresponding to the outlet of the ductus arteriosus (*) is seen in the anterior contour of the pulmonary trunk (PA). The left common carotid artery is not visible during this phase. VBC – the brachiocephalic vein

Fig. 5.

A further shift of ultrasonic beam upwards, systole. Cross-sections of the ascending aorta (Ao) and the left common carotid artery (LCCA), which runs separately at the same level – both vessels are coded in red – as well as the ductus arteriosus (*) and the pulmonary trunk (PA) – these vessels are filled with blue color, indicative of a flow in the opposite direction
A further shift of ultrasonic beam upwards, systole. Cross-sections of the ascending aorta (Ao) and the left common carotid artery (LCCA), which runs separately at the same level – both vessels are coded in red – as well as the ductus arteriosus (*) and the pulmonary trunk (PA) – these vessels are filled with blue color, indicative of a flow in the opposite direction

Fig. 6.

Even a higher position of the plane of the beam, systole. Cross-sections of the apical portion of the aortic arch (Ao) and the left common carotid artery (LCCA) filled with red color and the ductus arteriosus (*) filled with blue color. A very close proximity of these vessels is noticeable
Even a higher position of the plane of the beam, systole. Cross-sections of the apical portion of the aortic arch (Ao) and the left common carotid artery (LCCA) filled with red color and the ductus arteriosus (*) filled with blue color. A very close proximity of these vessels is noticeable

Fig. 7.

Systole. The ascending aorta (Ao) branching into the left common carotid artery (LCCA) is shown; both vessels are filled with red color and the initial segment of the aortic arch (AAo – blue color)
Systole. The ascending aorta (Ao) branching into the left common carotid artery (LCCA) is shown; both vessels are filled with red color and the initial segment of the aortic arch (AAo – blue color)

Fig. 8.

Systole. Further shift of the ultrasound beam to the left side – two close parallel vessels with opposite directions of flow: the left common carotid artery (LCCA) coded in red and the left subclavian artery with ductus arteriosus coded in blue (LSA + PDA)
Systole. Further shift of the ultrasound beam to the left side – two close parallel vessels with opposite directions of flow: the left common carotid artery (LCCA) coded in red and the left subclavian artery with ductus arteriosus coded in blue (LSA + PDA)

Fig. 9.

During diastole, the left subclavian artery/ductus arteriosus (PDA+LSA) are more intensely filled, whereas the red color coding for blood flow in the left common carotid artery disappears. Poorly filled with blue color brachiocephalic vein (BCV) is most superficially seen
During diastole, the left subclavian artery/ductus arteriosus (PDA+LSA) are more intensely filled, whereas the red color coding for blood flow in the left common carotid artery disappears. Poorly filled with blue color brachiocephalic vein (BCV) is most superficially seen

Fig. 10.

Postoperative assessment. Visible carotid segments of LCCA and LVA. Systole. The direction of the flow in the left vertebral artery is opposite to the flow in the left common carotid artery
Postoperative assessment. Visible carotid segments of LCCA and LVA. Systole. The direction of the flow in the left vertebral artery is opposite to the flow in the left common carotid artery

Fig. 11.

Recorded flow in the left vertebral artery using pulse Doppler. Systolic flow. Closure of the ductus arteriosus undoubtedly reduced cerebral steal with maintained perfusion in the left upper extremity
Recorded flow in the left vertebral artery using pulse Doppler. Systolic flow. Closure of the ductus arteriosus undoubtedly reduced cerebral steal with maintained perfusion in the left upper extremity
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