Isolated left subclavian artery arising from the main pulmonary artery

A 2-week-old male with antenatal diagnosis of ‘pink’ Tetralogy of Fallot was referred to our unit. The transthoracic echocardiography showed a large malalignment ventricular septal defect with overriding aorta, and mild pulmonary valve stenosis in absence of significant sub-valvar right ventricle outflow tract obstruction. A right aortic arch with a non-bifurcating first branch was demonstrated. On the high parasternal short axis view, a vessel originating from the main pulmonary trunk was detected, going leftward and then superiorly. The flow direction within the anomalous structure was towards the pulmonary circulation, representing an additional pulmonary blood flow supply (A; Supplementary data online, Video S1Supplementary data online, Video S1). This was suspected to be the left duct connected to the left subclavian artery (red arrow). A cardiac computed tomography was performed (B; front view on the left, back view on the right), and the abnormal origin of the left subclavian artery (yellow arrow), connected to the main pulmonary artery through a patent left arterial duct, was confirmed. This rare vascular abnormality can be explained using the hypothetical double arch system. (C). According to this system, the arches regressed (dotted lines) between the left common carotid artery and the left subclavian artery, and at the left dorsal aortic arch, distal to the patent left ductus arteriosus. If left untreated, potential closure of the left duct could lead to isolation of the left subclavian artery that typically results in perfusion to the arm through the vertebral artery. The left subclavian artery then can be reimplanted to the aortic arch during surgical correction or left untouched. Our patient underwent a successfully complete repair, with VSD closure, infundibular patch and reimplantation of the left subclavian artery to the left common carotid.

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