Rare Anomaly of the Aortic Arch Combined With Coarctation of the Aorta

tion of the aorta are to be found in the literature.3 � This paper describes such anomalies as they were found in two of our surgical cases, which showed unusual features not hitherto described in the literature available to us. These anomalies, although rare, are of practical importance with a view to differential diagnosis. The etiology of coarctation is still obscure. The two cases presented in this paper should be taken into account in any attempt to explain the condition on the basis of embryological considerations. The descriptions so far given in the literature stated that the right subclavian artery or the right aortic arch occurred distal to the coarctation.1’ 2� 8 We were unable to find a single report on a right subclavian artery or a double arch proximal to the coarctation. And it was precisely this condition which we found in the two patients to be described. Edwards4 recently described a case of Taussig-Bing complex with coarctation, in which the right subclavian artery arose proximal to the coarctation. In the first of our two cases the right subclavian artery arose from the aorta above the coarctation; in the second case the double aortic arch was localized above the coarctation. In both cases the coarctation was found opposite the insertion of the ligamentum arteriosum. Ca8e 1 :* ** M. V., female, aged 19. The onset of symptoms, in 1946, was characterized by pain in the chest, loss of weight and fatigability, which continued until a severe hemoptysis occurred in 1948. Investigation at the time failed to reveal any tuberculous process but a mediastinal tumor was demonstrable by X-rays. The patient was referred to us at the St. Antonius Ziekenhuis, Utrecht. The patient gave no impression of being very ill. The blood pressure determined in the arms was 150/90. Heart: slight systolic murmur. Pirquet tuberculin test: negative. Hematology normal. Fluoroscopy showed a tumor dorsal to the left main bronchus, The esophagus was displaced to the right. Tomography of the hilar region showed marked stenosis of the left main bronchus caused by the tumor. The presence of severe stenosis was confirmed by bronchography. Bronchoscopic examination showed that the bronchial wall was normal and that the stenotic part was still patent, Angiocardiography: apparently satisfactory filling of the tumor with contrast medium suggested a probable aneurysm or a highly vascular neoplasm. Another severe hemoptysis occurred during the patient’s stay in the hospital, this time causing what was considered vital danger. The blood pressure of 150/90 did not strike us as hypertension, and the possibility of coarctation was consequently not considered. An operation was performed in spite of an uncertain diagnosis. The thorax was opened (March 3, 1949; surgeon: A. G. B.), and numerous adhesions were separated without difficulty. The first striking feature was found in the fact that a right subclavian artery arose distal to the left subelavian artery. The right radial pulse was suppressed when this vessel was clamped. The artery extended