Identification of Right-sided Aortic Arch Using TEE and its Impact on Cardiac Surgical Planning
Year: 2025
Type: article
Study design: Case Report
Abstract: To perform a transesophageal echocardiographic (TEE) assessment of the aortic arch, the echocardiographer typically begins by locating the descending thoracic aorta, which appears circular at 0° omniplane view.[1] Gradually withdrawing the probe from this position allows visualization of the distal aortic arch, which is identified by visualizing a change in shape from circular to elliptical. In patients with normally oriented (left-sided arch), slight withdrawal of the TEE probe with a clockwise rotation results in visualization of the aortic arch in the long axis.[1] Color and pulse-wave (PW) Doppler interrogation at this position confirms the right-to-left direction of blood flow (from the ascending aorta to the arch) as shown in Figure 1.Figure 1: Normally oriented left-sided arch. Left image: Two-dimensional echocardiographic image of the aortic arch. Middle image: Application of color Doppler. Right image: Pulse-wave Doppler confirming blood flow from right to left (ascending aorta to the arch) as indicated by the arrowWhile attempting to examine the aortic arch in a 63-year-old female patient undergoing coronary artery bypass grafting, the usual clockwise rotation of the TEE probe did not produce the classic appearance of the arch, as demonstrated in the TEE clip [Video]. The TEE probe was then re-advanced in the esophagus to visualize the descending thoracic aorta. Gradual withdrawal of the probe with a counterclockwise rotation revealed the aortic arch. Color and PW Doppler interrogation demonstrated a left-to-right direction of blood flow, consistent with the diagnosis of a right-sided aortic arch as shown in Figure 2. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_y0957boh"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Figure 2: Right-sided aortic arch. Left image: Two-dimensional echocardiographic image of the right-sided arch. Middle image: Application of color Doppler. Right image: Pulse-wave Doppler confirming blood flow from left to right (ascending aorta to the arch) as indicated by the arrowA right aortic arch is found in approximately 0.1% of the population.[2] Rather than arching to the left, the aortic arch curves to the right of the trachea and is positioned on the right side. This condition may be an incidental finding, as observed in our case, or it can be associated with congenital anomalies such as Tetralogy of Fallot or Tricuspid atresia.[1,3] It may be asymptomatic or present with symptoms resulting from compression of the trachea or esophagus caused by anomalous vessels forming a vascular ring around these structures.[4] There are several anatomical variations based on the branching pattern of the great vessels arising from the right-sided arch. The most common include a right-sided arch with four vessels, resulting in an aberrant left subclavian artery, and a right-sided arch that mirrors a typical left-sided arch, with three great vessels arising from it [Figures 3-5].[1,4]Figure 3: Diagram depicting a left-sided aortic arch with normal branching of its vessels. 1: Brachiocephalic artery, 2: Left common carotid artery, 3: Left subclavian artery. PA: Pulmonary arteryFigure 4: Diagram depicting a right-sided aortic arch with four vessels resulting in an aberrant left subclavian artery. 1: Left common carotid artery, 2: Right common carotid artery, 3: Right subclavian artery, 4: Left subclavian artery. PA: Pulmonary arteryFigure 5: Diagram depicting a right-sided aortic arch with mirror image branching. 1: Left brachiocephalic artery, 2: Right common carotid artery, 3: Right subclavian artery. PA: Pulmonary artery.TEE Clip: TEE clip showing the descending thoracic aorta in short axis. Gradually withdrawing the TEE probe with the usual clockwise rotation did not produce the classic appearance of the arch. In our case, the diagnosis of a right-sided aortic arch did not affect surgical decision-making. However, identifying a right-sided arch and the branching pattern of the great vessels can significantly impact surgical planning in procedures involving the arch, such as type A dissections or aortic aneurysms. This diagnosis may critically affect cannulation strategies and the positioning of the antegrade cerebral perfusion cannula in surgeries requiring circulatory arrest. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Source: Annals of Cardiac Anaesthesia
Institutions: University of Kansas Medical Center, Ministry of Health
Language: English
Subfield: Epidemiology
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4412112886