(1068) An Unexpected Turn: Right Aortic Arch and Endovascular Therapy

Introduction: Right aortic arch is an uncommon anatomical anomaly seen in approximately 0.05% of the general population. Besides its association with congenital heart disease and obstructive symptoms of the upper aerodigestive tract, it is usually a benign condition. However, data about the indirect complications of such an anomaly in cases where cannulation of the involved vessels is required are lacking.

Description: We present the case of an 82-year-old female with a past medical history of essential hypertension, hyperlipidemia, and multiple myeloma (in remission) who presented to our hospital with acute right-sided hemiparesis, left-sided gaze preference, and aphasia. The patient was outside the window for thrombolysis, as the last known normal was 13 hours before presentation. CT head was unremarkable; CTA head revealed an acute left middle cerebral artery (MCA) occlusion. CT cerebral perfusion showed more than 70% penumbra in the left MCA territory. The patient was taken for emergent endovascular thrombectomy. A right radial approach was adopted initially. However, a right aortic arch with mirror branching was unexpectedly discovered on aortic angiography. After multiple failed attempts to cannulate the left innominate artery, a left radial approach had to be taken. Subsequently, a successful thrombectomy was performed.
The patient subsequently made a near-complete neurological recovery, with mild aphasia being her only residual symptom. She was discharged to an inpatient rehab facility for continued therapy.

Discussion: Advancements in endovascular therapy for acute ischemic strokes have improved outcomes over the years. However, anatomic variability in the vascular system poses a significant challenge to routine procedures, requiring rapid adaptation to ensure optimal outcomes in time-sensitive conditions such as ischemic strokes. We aim to raise awareness about right aortic arch variants and provide our experience navigating the anomaly successfully.