BRANCHING PATTERNS OF THE LEFT - IJIR

Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in

GANESH ELUMALAI et al CLASSIFICATION OF TYPE - I and TYPE - II “BRANCHING PATTERNS OF THE LEFT ARCH AORTA” *Ganesh Elumalai1, Sushma Chodisetty2, Pavan Kumar D3 1

Department of Embryology, College of Medicine, Texila American University, South America Department of Casualty and Emergency medicine, Tribhuvan University, National Medical College, Nepal 3 Senior Resident, Department of General Medicine, Guntur General Hospital, Andhrapradesh, India 2

Abstract: The adult archetype of the Aortic arch and its branches are formed, due to the different growth pattern of the aortic or branchial arch arteries and their associated “migration” and “merging” of their branches. Knowledge about the branching pattern of the aortic arches was utmost significant during supra-aortic angiography, aortic instrumentation, thoracic, head and neck surgeries. The branching pattern of the arch of the aortas shows significant variations but, until today there was no uniform data available for the classification of these branching patterns. The left arch aortas are most common observation than the right arch of the aorta. The purpose of this study to review the branching patterns of the left arch aorta and describe the uniform classification of branching patterns of the left arch aorta. Subsequent to the complete analysis of various (normal and unusual) types of the branching patterns of the left arch aorta, we designed totally three variables to classify it, the variables are 1. (T)-Trunks, 2. (V)-Variations, and 3. (P)-Patterns. The (T)-Trunks variables are denoted by roman numerals I –VI, the (V)-Variation variables (now concerns only for the Type-I and Type-II) are marked as numerical values from 1-22 and, the (P)Patterns variables are distinct as (now concerns only for the Type-I and Type-II) alphabets values a – f. In future, if any new patterns were identified under this Type – II, Doubled trunk left aortic arch configuration, it would be followed next to the Variations-22, Type-II (22b). The further classification under the Trunk-III to VI variables, and its Variations and Patterns would be discussed in future. Keywords: Arch of aorta, Brachiocephalic trunk, Common carotid artery, Subclavian artery, Vertebral artery.

incidence in 74.0% - 89.4% cases in radiological investigations [1,2,3] and 63.5% to 77.3% in cadaveric studies [4,5,6]. The adult archetype of the Aortic arch and its branches are formed, due to the different growth pattern of the aortic or branchial arch arteries and their associated “migration” and “merging” of their branches [7]. The most common variance of the aortic arch was observed as the anomalous aortic arch origin of the left vertebral artery (LVA). The anomalous branching patterns in the aortic arch are due to the deviations or disturbances the normal growth pattern of the aortic or branchial arch arteries during the embryonic period. Knowledge about the branching pattern of the aortic arches was utmost significant during supraaortic angiography, aortic instrumentation, thoracic, head and neck surgeries. The aim of the present study to review the branching patterns of the left arch aorta and describe the uniform classification of branching patterns of the left arch aorta. The universal classifications of the branching patterns of the arch aorta were noticed as Type-A, Type-B, Type-C…etc or Type-I, Type-II, Type-III…. and so on [8 -17]. In this, the Type-I or Type- A patterns of one author did not correspond with the same observations on the other authors. Also, there were no clear uniform pieces of information about, what these A, B, C… or I, II, III… symbols are indicating. The branching pattern of the arch of the aortas shows significant variations but, until today there was no uniform data’s are available for their classifications. The left arch aortas are most common observation than the right arch aorta [18]. The purpose of this study to review the branching patterns of the left arch aorta and describe the uniform classification of branching patterns of the left arch aorta.

2. Materials 1. Introduction Arch of the aorta, was the upward continuation of the Ascending aorta and it was normally branched out into three vessels patterns called, the brachiocephalic trunk (BCT) or innominate artery, the left common carotid artery (LCCA) and the left subclavian artery (LSA),

Imperial Journal of Interdisciplinary Research (IJIR)

The aim of the present study to review the branching patterns of the left arch aorta and describe the uniform classification for the branching patterns of the left arch aorta. The complete literature review surveys were conducted and cumulated all the pieces of information received nearly from the past twentyfive decades of previous workers on the branching Page 161

Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in patterns of the arch of the aorta, derived from the different demographical observations [19 - 228].

3. Methods of Classifications: Subsequent to the complete analysis of various (normal and unusual) types of the branching patterns of the left arch aorta, we designed totally three variables to classify it, the variables are 1. (T)Trunks, 2. (V)-Variations, and 3. (P)-Patterns. The (T)-Trunks variables are denoted by roman numerals I –VI, the (V)-Variation variables (now concerns only for the Type-I and Type-II) are marked as numerical values from 1-22 and, the (P)-Patterns variables are distinct as (now concerns only for the Type-I and Type-II) alphabets values a – f. (Table 1).

arch”. In the true bovine arch, a single great vessel arises from the arch of the aorta, called the brachiocephalic trunk [229, 230]. It gives derivations for the innominate artery, the left common carotid artery, and the left subclavian artery. Further, the innominate artery was branches into the right common carotid artery and the right subclavian artery (Figure-1). Uncommonly the true bovine trunk or Type - I (Singled trunk) left arch, may also exhibit many unusual sub-types variations (Variations-1 to Variations-22) and sub-type patterns (Pattern-a, to Pattern-f) branching configurations follows the Type-II. Table 2: Ganesh Elumalai et al, Classification of “Type – I” Branching patterns of the Left Arch Aorta

Ganesh Elumalai et al, Classification of "Branching patterns of the Left Arch Aorta"

Table 1: Variables and its Symbols used in “Ganesh Elumalai et al, Classification of “Branching patterns of the Left Arch Aorta”

S.No

PATTERN

1

Singled trunk pattern (I)

Ganesh Elumalai et al, Classification of “Branching patterns of the Left Arch Aorta” (T)(V) (P) Variables Trunk (s) Variation (s) Patterns (s) (for TYPE I (for TYPE I Symbols I - IV & II) 1 - 22 & II) a - f

TYPE

BRANCHING PATTEREN

True Bovine trunk (T)

4. Classification of “Branching Patterns of The Left Arch Aorta”: The (T)-Trunks variables are denoted by roman numerals, Type-I to Type-IV. In this, the roman numerals are indicating the total number of trunks arises from the arch (left) of the aorta. The Type - I indicated as Singled (one) trunk branch configuration of the left arch aorta, the Type - II for Doubled (two) trunks, the other trunk variables are Type – III resembles the Tripled (three) trunks, the Type - IV shows Quadriad (four) trunks, the Type V exhibits Pentad (five) trunks and the Type - VI distinct as Hexad (six) trunk branching configurations arises from the left arch aorta. Under the Type - II (Doubled (two) trunks) to Type - VI (Hexad (six) trunks) Trunks) variables, the (V)Variations variables were sub-classified as numerical values for the normal and unusual branching configurations from the left arch aorta. In the Type I and Type – II variables, Variations-1 to Variations22 subtypes were further sub-classified into different (P)-Pattern variables, indicated as the alphabets values from the Pattern-a, to Pattern-f.

4.1

Type - I (Singled trunk): (Table-2)

The Type - I, Singled trunk branching configuration also called as a “true bovine aortic


Figure 1: Type - I (Singled trunk) - The “True Bovine trunk” Left Arch Aorta. (Right common carotid (RCCA); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian artery (LSA))

4.2

TYPE - II (Doubled trunk):

The Type - II, Doubled trunk aortic arches shows, the two trunk branching configurations from the arch of the aorta. Under this Type - II, Doubled trunk, the (V) Variation variables were sub-classified into twenty-two numerical values and it is marked from Variations-1 to Variations-22 sub-types of unusual branching configurations from the left arch aorta. The Variations-1 to Variations-22 sub-types variables were further sub-classified into different (P)-Pattern variables and it was indicated as the alphabets values from the Pattern-a to Pattern-f. The Variations-1, Type - II, Doubled trunk indicates the brachiocephalic trunk (RBCT) as the first branch and, accompanied with an unusual trunk. Page 162

Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in Both are originated from the left arch aorta, as Variations-1, Type - II, Doubled trunk configuration. In this, the brachiocephalic trunk has remained as the Right brachiocephalic trunk (RBCT) accompanied with an unusual trunk called the Left brachiocephalic trunk (LBCT) (formed by the fusion of the left common carotid artery (LCCA) and the left subclavian artery (LSA)). The Variations-1 was further classified into four (P)-Pattern variables, indicated as Pattern-a, to Pattern-d (Table-3). This Variations-1, Type - II, Doubled trunk type branching configurations are marked as Type-II(1a), Type-II(1b), Type-II(1c) and Type-II(1d), (Figure-2). Table 3: Ganesh Elumalai et al, Classification of “Variations-1, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta

left vertebral artery (LVA) with the Left brachiocephalic trunk (LBCT)). The Variations-2 was sub-classified into four (P)-Pattern variables, specified as Pattern-a, to Pattern-d (Table-4). This Variations-2, Type - II, Doubled trunk type branching configurations are noticeable as TypeII(2a), Type-II(2b), Type-II(2c) and Type-II(2d), (Figure-3). Table 4: Ganesh Elumalai et al, Classification of “Variations-2, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta

Ganesh Elumalai et al, Classification of "Branching patterns of the Left Arch Aorta" S.No


PATTERN

2 3 4 5

TYPE 1a

Doubled Trunk (II)

1b 1c 1d

BRANCHING PATTEREN RBCT + LBCT RBCT+ Reverse LBCT Reverse RBCT + LBCT Reverse RBCT + Reverse LBCT

Figure 2: Variations-1, Type - II (Doubled trunk) Left Arch Aorta: shows the variants of Type-II(1a), TypeII(1b), Type-II(1c),and Type-II(1d). (Right common carotid (RCCA); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian artery (LSA); RBCT-Right Brachiocephalic Trunk and LBCT-Left Brachiocephalic Trunk)

The Variations-2, Type - II, Doubled trunk displays, the brachiocephalic trunk (RBCT) as a first branch and accompanied with an unusual trunk called Vertebral-LBCT, both are originated from the left arch aorta, as Variations-2, Type - II, Doubled trunk configuration. In this, the brachiocephalic trunk has remained as Right brachiocephalic trunk (RBCT) accompanied with an unusual trunk called the “Vertebral-LBCT” trunk (formed by the fusion of the


PATTERN

6 7 8

9

TYPE 2a

Doubled Trunk (II)

2b 2c

2d

BRANCHING PATTEREN RBCT + Vertebral LBCT RBCT + Reverse Vertebral LBCT Reverse RBCT + Vertebral LBCT Reverse RBCT + Reverse Vertebral LBCT


The Variations-3, Type - II, Doubled trunk presents with an unusual trunk as the first branch and accompanied with the brachiocephalic trunk (RBCT), both are originated from the left arch aorta, as Variations-3, Type - II, Doubled configurations. In this, the unusual trunk called the Left brachiocephalic trunk (LBCT) was formed by the fusion of the left common carotid artery (LCCA) and the left subclavian artery (LSA). The Variations-3, were sub-classified into four (P)-Pattern variables as Pattern-a, to Pattern-d (Table-5). This Variations-3 Type - II, Doubled trunk type, branching Page 163

Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in configurations were obvious into Type-II(3a), TypeII(3b), Type-II(3c) and Type-II(3d), (Figure-4). Table 5: Ganesh Elumalai et al, Classification of “Variations-3, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta


PATTERN

10 11 12 13

TYPE 3a

Doubled Trunk (II)

3b 3c 3d

BRANCHING PATTEREN LBCT + RBCT LBCT + Reverse RBCT Reverse LBCT + RBCT Reverse LBCT + Reverse RBCT


The Variations-4, Type - II, Doubled trunk shows, the left brachiocephalic trunk (LBCT) as a first branch and it was accompanied with an unusual trunk called Vertebral-RBCT, both are originated from the arch of the aorta, as Variations-4 Type - II, Doubled trunk configuration. In this, the unusual trunk called the Vertebral-RBCT was formed by the fusion of the left vertebral artery (LVA) with the Right brachiocephalic trunk (RBCT). The Variations-4 were further classified into four (P)-Pattern variables, mentioned as Pattern-a, to Pattern-d (Table-6). This Variations-4, Type - II, Doubled trunk type, branching configurations are apparent into Type-II(4a), Type-II(4b), Type-II(4c) and Type-II(4d), (Figure-5).


Table 6: Ganesh Elumalai et al, Classification of “Variations-4, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta


PATTERN

14 15 16

17

TYPE 4a

Doubled Trunk (II)

4b 4c

4d

BRANCHING PATTEREN LBCT + Vertebral RBCT LBCT + Reverse Vertebral RBCT Reverse LBCT + Vertebral RBCT Reverse LBCT + Reverse Vertebral RBCT

Figure 5: Variations-4, Type - II (Doubled trunk) Left Arch Aorta: a shows the variants of Type-II(4a), TypeII(4b), Type-II(4c),and Type-II(4d). (Right common carotid (RCCA); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian artery (LSA); RBCT-Right Brachiocephalic Trunk and LBCT-Left Brachiocephalic Trunk)

The Variations-5, Type - II, Doubled trunk exhibits with, the “Truncus Bicaroticus” as a first trunk accompanied with another unusual trunk originated from the left arch aorta, as Variations-5 Type - II, Doubled trunk. The left common carotid artery (LCCA) origin was migrated to the right and merges with the originated trunk of the brachiocephalic trunk (BCT) or innominate artery to form a single common trunk called the “Truncus Bicaroticus”. The unusual trunk presents as either the left subclavian artery (LSA) or the fusion of the left subclavian artery (LSA) with the left vertebral artery (LVA) to forms the “Common vertebro-subclavian trunk (CVST)” or “Common subclavian-vertebral trunk (CSVT)”. The Variations-5 were sub-classified into three (P)-Pattern variables as the Pattern-a, to Pattern-c (Table-7). This Variations-5 Type - II, Doubled trunk, branching configurations are evident Page 164

Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in as Type-II(5a), Type-II(5b) and Type-II(5c), (Figure6). Table 7: Ganesh Elumalai et al, Classification of “Variations-5, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta


PATTERN

18 19 20

TYPE 5a

Doubled Trunk (II)

5b 5c

BRANCHING PATTEREN Truncus Bicaroticus + LSA Truncus Bicaroticus + CVST Truncus Bicaroticus + CSVT

This Variations-6, Type - II, Doubled trunk, branching configurations are marked as Type-II(6a), Type-II(6b) and Type-II(6c), (Figure-7). Table 8: Ganesh Elumalai et al, Classification of “Variations-6, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta

Ganesh Elumalai et al, Classification of "Branching patterns of the Left Arch Aorta" S.No 21 22 23

Figure 6: Variations-5, Type - II (Doubled trunk) Left Arch Aorta: shows the variants of Type-II(5a), TypeII(5b) and Type-II(5c). (Right common carotid (RCCA); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian artery (LSA); RBCT-Right Brachiocephalic Trunk and LBCT-Left Brachiocephalic Trunk)

The Variations-6, Type - II, Doubled trunk displays. the unusual trunk presents as either the left subclavian artery (LSA) or the fusion of left subclavian artery (LSA) with the left vertebral artery (LVA) to forms the Common vertebro-subclavian trunk (CVST) or Common subclavian- vertebral trunk (CSVT) as the first trunk accompanied with an unusual trunk called the “Truncus Bicaroticus”, both are originated from the left arch aorta, as Variations6, Type - II, Doubled trunk. The left common carotid artery (LCCA) origin was migrated to the right and merges with the originated trunk of the brachiocephalic trunk (BCT) or innominate artery to form a single common trunk called the “Truncus Bicaroticus”. The Variations-6 were further classified into three (P)-Pattern variables as the Pattern-a, to Pattern-c (Table-8).


PATTERN

TYPE 6a

Doubled Trunk (II)

6b 6c

BRANCHING PATTEREN LSA + Truncus Bicaroticus CVST + Truncus Bicaroticus CSVT + Truncus Bicaroticus


The Variations-7, Type - II, Doubled trunk demarcates, the "Reverse Truncus Bicaroticus" as the first trunk accompanied with the unusual trunk presents as either the left subclavian artery (LSA) or the fusion of left subclavian artery (LSA) with the left vertebral artery (LVA) to forms the Common vertebro-subclavian trunk (CVST) or Common subclavian- vertebral trunk (CSVT), both are originated from the left arch aorta, as Variations-7, Type - II, Doubled trunk. The left common carotid artery (LCCA) origin was migrated beyond to the right and merges with the originated trunk of the brachiocephalic trunk (BCT) or innominate artery to form a single common trunk called the “Reverse Truncus Bicaroticus”. The Variations-7 were sub-classified into three (P)-Pattern variables as the Pattern-a, to Pattern-c (Table-9). This Variations-7 Type - II, Page 165

Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in Doubled trunk, branching configurations are manifest as Type-II(7a), Type-II(7b) and TypeII(7c), (Figure-8). Table 9: Ganesh Elumalai et al, Classification of “Variations-7, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta


PATTERN

24 25 26

TYPE 7a

Doubled Trunk (II)

7b 7c

BRANCHING PATTEREN ReverseTruncus Bicaroticus + LSA ReverseTruncus Bicaroticus + CVST ReverseTruncus Bicaroticus + CSVT

The Variations-8 were sub-classified into three (P)-Pattern variables as the Pattern-a, to Pattern-c (Table-10). This Variations-8 Type - II, Doubled trunk, branching configurations are evident as Type-II(8a), Type-II(8b) and Type-II(8c), (Figure9). Table 10: Ganesh Elumalai et al, Classification of “Variations-8, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta


PATTERN

TYPE

27 28 29

Doubled Trunk (II)

8a 8b 8c

BRANCHING PATTEREN Stem BCT + LSA Stem BCT + CVST Stem BCT + CSVT



The Variations-8, Type - II, Doubled trunk displays, the “Stem BCT as a first trunk accompanied with another unusual trunk originated from the left arch aorta, as Variations-8,Type - II, Doubled trunk. The left common carotid artery (LCCA) arises from the brachiocephalic trunk (BCT) or innominate artery at an average distance of one centimeter (1cm) to two and a half centimeters (2.5cms) from the Aortic arch, but not sharing the true common origin and formed one common trunk configuration, called as the “Stem BCT. The unusual trunk presents as either the left subclavian artery (LSA) or the fusion of the left subclavian artery (LSA) with the left vertebral artery (LVA) to forms the “Common vertebro-subclavian trunk (CVST)” or “Common subclavian-vertebral trunk (CSVT)”.

The Variations-9, Type - II, Doubled trunk presents with, the unusual trunk presents as either the left subclavian artery (LSA) or the fusion of the left subclavian artery (LSA) with the left vertebral artery (LVA) to forms the “Common vertebro-subclavian trunk (CVST)” or “Common subclavian-vertebral trunk (CSVT)” as the first trunk accompanied with Stem BCT, as the another unusual trunk, both are originated from the left arch aorta, as Variations-9, Type - II, Doubled trunk. The left common carotid artery (LCCA) arises from the brachiocephalic trunk (BCT) or innominate artery at an average distance of one centimeter (1cm) to two and a half centimeters (2.5cms) from the Aortic arch, but not sharing the true common origin and formed one common trunk configuration, called as the “Stem BCT.


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Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in The Variations-9 were sub-classified into three (P)-Pattern variables as the Pattern-a, to Pattern-c (Table-11). This Variations-9 Type - II, Doubled trunk, branching configurations are obvious as Type-II(9a), Type-II(9b) and Type-II(9c), (Figure10). Table 11: Ganesh Elumalai et al, Classification of “Variations-9, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta

observable as Type-II(10a), Type-II(10b) and TypeII(10c), (Figure-11). Table 12: Ganesh Elumalai et al, Classification of “Variations-10, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta



PATTERN

30 31 32

TYPE 9a

Doubled Trunk (II)

9b 9c

BRANCHING PATTEREN LSA + Stem BCT CVST + Stem BCT CSVT + Stem BCT


The Variations-10, Type - II, Doubled trunk reveals, the "Reverse Stem BCT" as the first trunk accompanied with the unusual trunk presents as either the left subclavian artery (LSA) or the fusion of the left subclavian artery (LSA) with the left vertebral artery (LVA) to forms the “Common vertebro-subclavian trunk (CVST)” or “Common subclavian-vertebral trunk (CSVT)”, both are originated from the left arch aorta, as Variations-10, Type - II, Doubled trunk. The Variations-10 were sub-classified into three (P)-Pattern variables as the Pattern-a, to Pattern-c (Table-12). This Variations-10 Type - II, Doubled trunk, branching configurations are


PATTERN

33 34 35

TYPE 10a

Doubled Trunk (II)

10b 10c

BRANCHING PATTEREN Reverse Stem BCT + LSA Reverse Stem BCT + CVST Reverse Stem BCT + CSVT

Figure 11: Variations-10, Type - II (Doubled trunk) Left Arch Aorta: shows the variants of Type-II(10a), TypeII(10b) and Type-II(10c). (Right common carotid (RCCA); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian artery (LSA); RBCTRight Brachiocephalic Trunk and LBCT-Left Brachiocephalic Trunk)

The Variations-11, Type - II, Doubled trunk represents, the Common Carotid trunk (CCT) formed by the fusion of right and left common carotid arteries, as a first branch, accompanied with an unusual common trunk called the Common Subclavian trunk (CST). The Common Subclavian trunk (CST), was formed by the fusion of right and left subclavian arteries as the second trunk, both are originated from the left arch aorta, as Variations-11 Type - II, Doubled trunk configuration. The Variations-11 was sub-classified into four (P)-Pattern variables, indicated as Pattern-a, to Pattern-d (Table-13). The Variations-11, Type - II, Doubled trunk branching configurations are visible as Type-II(11a), Type-II(11b), Type-II(11c) and Type-II(11d), (Figure-12).

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Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in


Table – 14: Ganesh Elumalai et al, Classification of “Variations-12, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta

Ganesh Elumalai et al, Classification of "Branching patterns of the Left Arch Aorta" Ganesh Elumalai et al, Classification of "Branching patterns of the Left Arch Aorta" S.No

PATTERN

36 37 38 39

TYPE 11a

Doubled Trunk (II)

11b 11c 11d

BRANCHING PATTEREN CCT + CST CCT + Reversed CST Reversed CCT + CST Reversed CCT + Reversed CST

Figure 12: Variations-11, Type - II (Doubled trunk) Left Arch Aorta: a shows the variants of Type-II(11a), TypeII(11b), Type-II(11c),and Type-II(11d). (Right common carotid (RCCA); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian artery (LSA); CCT-Common Carotid Trunk and CST-Common Subclavian Trunk)

The Variations-12, Type - II, Doubled trunk characterized as, the Common Subclavian trunk (CST), formed by the fusion of right and left subclavian arteries, as the first branch accompanied with another unusual common trunk called the Common Carotid trunk (CCT). The Common Carotid trunk (CCT) was formed by the fusion of right and left common carotid arteries, it presents as the second trunk, both are originated from the left arch aorta, as Variations12, Type - II, Doubled trunk configuration. The Variations-12 were further classified into four (P)-Pattern variables, indicated as Pattern-a, to Pattern-d (Tale-14). The Variations-12, Type - II, Doubled trunk branching configurations are in evidence as Type-II(12a), Type-II(12b), Type-II(12c) and Type-II(12d), (Figure-13).


S.No

PATTERN

40 41 42 43

TYPE 12a

Doubled Trunk (II)

12b 12c 12d

BRANCHING PATTEREN CST + CCT CST + Reversed CCT Reversed CST + CCT Reversed CST + Reversed CCT

Figure 13: Variations-12, Type - II (Doubled trunk) Left Arch Aorta: a shows the variants of Type-II(12a), TypeII(12b), Type-II(12c),and Type-II(12d). (Right common carotid (RCCA); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian artery (LSA); CCT-Common Carotid Trunk and CST-Common Subclavian Trunk)

The Variations-13 to 22, stands for the unusual Type - II, Doubled trunk left aortic arch configurations. In these Variations, one or two more frequent aortic arch branches are arises from the sources other than the (left) arch of the aorta. The Variations-13, Type - II, Doubled trunk portrays, the presence of Right brachiocephalic trunk (RBCT) trunk as the first branch accompanied with other unusual second trunk, both are originated from the left arch aorta, as Variations-13, Type - II, Doubled trunk configuration. The Variations-13, was sub-classified into four (P)-Pattern variables, indicated as Pattern-a, to Pattern-d (Tale-15). The Variations-13, Type - II, Doubled trunk branching configurations are able to seen as Type-II(13a), Type-II(13b), Type-II(13c) and Type-II(13d), (Figure-14).

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Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in Table 15: Ganesh Elumalai et al, Classification of “Variations-13, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta


PATTERN

44 45

TYPE

13a Doubled Trunk (II)

13b

46

13c

47

13d

BRANCHING PATTEREN RBCT + LCCA ( LSA arises from the DTA) RBCT + LSA (LCCA arises from the DTA) RBCT + CVST (LCCA arises from the DTA) RBCT + CSVT (LCCA arises from the DTA)

Figure 15: Variations-14, Type - II (Doubled trunk) Left Arch Aorta: a shows the variants of Type-II(14a), TypeII(14b), Type-II(14c), Type-II(14d), Type-II(14e) and Type-II(14f). (Right common carotid (RCCA); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian artery (LSA); CCT-Common Carotid Trunk) Table 16: Ganesh Elumalai et al, Classification of “Variations-14, Type –II Doubled Trunk” Branching patterns of the Left Arch Aorta Ganesh Elumalai et.al, Classification of "Branching patterns of the Left Arch Aorta"

S.No

Figure 14: Variations-13, Type - II (Doubled trunk) Left Arch Aorta: a shows the variants of Type-II(13a), TypeII(13b), Type-II(13c),and Type-II(13d). (Right common carotid (RCCA); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian artery (LSA); CVST-Common Vertebro-Subclavian Trunk and CSVTCommon Subclavian- Vertebral Trunk)

The Variations-14, Type - II, Doubled trunk depicts, the presence of Right subclavian artery (RSA) as a first trunk with other unusual second trunk, both are originated from the left arch aorta, as Variations-14, Type - II, Doubled trunk configuration. The Variations-14, was sub-classified into six (P)-Pattern variables, indicated as Pattern-a, to Pattern-f (Tale-16). The Variations-14, Type - II, Doubled trunk branching configurations are discoverable as TypeII(14a), Type-II(14b), Type-II(14c), Type-II(14d), Type-II(14e) and Type-II(14f) (Figure-15).

PATTERN

TYPE

48

14a

49

14b

50

14c Doubled Trunk (II)

51

14d

52

14e

53

14f

BRANCHING PATTEREN RSA + RCCA (LCCA and LSA are arises from the DTA) RSA + LCCA (RCCA arises from Ascending aorta or DTA and LSA are arises from the DTA) RSA + LBCT (RCCA arises from Ascending aorta or DTA) RSA + LSA (RCCA and LCCA arises from the Ascending aorta or DTA) RSA + CCT (LSA arises from the DTA) RSA + Reverse CCT (LSA arises from the DTA)

The Variations-15, Type - II, Doubled trunk represents, the presence of Right subclavian artery (RSA) as a first trunk with other unusual second trunk, both are originated from the left arch aorta, as


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Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in Variations-15, Type - II, Doubled trunk configuration. The Variations-15, was sub-classified into four (P)-Pattern variables, indicated as Pattern-a, to Pattern-d (Tale-17). The Variations-15, Type - II, Doubled trunk branching configurations are perceivable as TypeII(15a), Type-II(15b), Type-II(15c) and TypeII(15d), (Figure-16). Table 17: Ganesh Elumalai et al, Classification of “Variations-15, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta Ganesh Elumalai et al, Classification of "Branching patterns of the Left Arch Aorta"

S.No

PATTERN

54

55

56

57

TYPE

15a

Doubled Trunk (II)

15b

15c

15d

BRANCHING PATTEREN RSA + VertebralLBCT (RCCA arises from Ascending aorta or DTA) RSA + Reversed Vertebral-LBCT (RCCA arises from Ascending aorta or DTA) RSA + CVST (RCCA arises from Ascending aorta or DTA and LSA are arises from the DTA) RSA + CSVT (RCCA arises from Ascending aorta or DTA and LSA are arises from the DTA)

Figure 16: Variations-15, Type - II (Doubled trunk) Left Arch Aorta: a shows the variants of Type-II(15a), TypeII(15b), Type-II(15c),and Type-II(15d). (Left Brachiocephalic Trunk (LBCT); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian


artery (LSA); CVST-Common Vertebro-Subclavian Trunk and CSVT-Common Subclavian- Vertebral Trunk)

The Variations-16, Type - II, Doubled trunk describes, the presence of Right common carotid artery (RCCA) alone or in the form of Common Carotid Trunk (CCT) as a first trunk, accompanied with another unusual second trunk, and both are originated from the left arch aorta, as Variations-16, Type - II, Doubled trunk configuration. The Variations-16, was sub-classified into five (P)Pattern variables, indicated as Pattern-a, to Pattern-e (Tale-18). The Variations-16, Type - II, Doubled trunk branching configurations are identified as Type-II(16a), Type-II(16b), Type-II(16c), TypeII(16d) and Type-II(16e), (Figure-17). Table 18: Ganesh Elumalai et al, Classification of “Variations-16, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta


PATTERN

58

59

TYPE

16a

Doubled Trunk (II)

16b

60

16c

61

16d

62

16e

BRANCHING PATTEREN RCCA + LBCT (RSA arises from the Ascending aorta or DTA) RCCA + LCCA (RSA and LSA arises from the Ascending aorta or DTA) RCCA + LSA (RSA and LCCA are arises from Ascending aorta or DTA) CCT + LSA (LCCA arises from the DTA) RCCA + RSA (LCCA and LSA are arises from the DTA)

Figure 17: Variations-16, Type - II (Doubled trunk) Left Arch Aorta: a shows the variants of Type-II(16a), TypeII(16b), Type-II(16c), Type-II(16d) and Type-II(16e). (Right common carotid (RCCA); Right subclavian artery Page 170

Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in (RSA); Left common carotid (LCCA); Left subclavian artery (LSA); CCT-Common Carotid Trunk)

The Variations-17, Type - II, Doubled trunk illustrates, the presence of Right common carotid artery (RCCA) as a first trunk with other unusual second trunk in the combination of Left Vertebral artery (LSA), both are originated from the left arch aorta, as Variations-17, Type - II, Doubled trunk configuration. The Variations-17, was further classified into four (P)-Pattern variables, indicated as Pattern-a, to Pattern-d (Tale-19). The Variations-17, Type - II, Doubled trunk branching configurations are recognized as Type-II(17a), Type-II(17b), TypeII(17c) and Type-II(17d), (Figure-18). Table19: Ganesh Elumalai et al, Classification of “Variations-17, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta

II(17b), Type-II(17c),and Type-II(17d). (Left Brachiocephalic Trunk (LBCT); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian artery (LSA); CVST-Common Vertebro-Subclavian Trunk and CSVT-Common Subclavian- Vertebral Trunk

The Variations-18, Type - II, Doubled trunk given a picture, the Common Carotid Trunk (CCT) as a first trunk with an unusual second trunk may present with the combination of the Left Vertebral artery (LSA), both are originated from the left arch aorta, as Variations-18, Type - II, Doubled trunk configuration. The Variations-18, was sub-classified into four (P)-Pattern variables, indicated as Pattern-a, to Pattern-d (Tale-20). This Variations-18, Type - II, Doubled trunk branching configurations are noticed as Type-II(18a), Type-II(18b), Type-II(18c) and Type-II(18d), (Figure-19). Table – 20: Ganesh Elumalai et al, Classification of “Variations-18, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta


PATTERN

63

17a

64

65

66

TYPE

17b

Doubled Trunk (II)

17c

17d

BRANCHING PATTEREN RCCA + VertebralLBCT (RSA arises from the Ascending aorta or DTA) RCCA + Reversed Vertebral-LBCT (RSA arises from the Ascending aorta or DTA) RCCA + CVST (LCCA arises from the Ascending aorta and the RSA originated form DTA) RCCA + CSVT (LCCA arises from the Ascending aorta and the RSA originated form DTA)


PATTERN

TYPE

67

18a

68

18b

69

70

Doubled Trunk (II)

18c

18d

BRANCHING PATTEREN CCT + LSA (RSA arises from the Ascending aorta or DTA) CCT + RSA (LSA arises from the DTA) CCT + CVST (RSA arises from the Ascending aorta or DTA) CCT + CSVT (RSA arises from the Ascending aorta or DTA)

Figure 18: Variations-17, Type - II (Doubled trunk) Left Arch Aorta: a shows the variants of Type-II(17a), Type-


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Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in Figure 19: Variations-18, Type - II (Doubled trunk) Left Arch Aorta: a shows the variants of Type-II(18a), TypeII(18b), Type-II(18c),and Type-II(18d). (Common carotid Trunk (CCT); Right Common Carotid artery (RCCA); Left common carotid (LCCA); Right subclavian artery (RSA); Left subclavian artery (LSA); CVST-Common Vertebro-Subclavian Trunk and CSVT-Common Subclavian- Vertebral Trunk)

configuration. The Variations-20, was sub-classified into six (P)-Pattern variables, indicated as Pattern-a, to Pattern-f (Tale-22). This Variations-20, Type - II, Doubled trunk branching configurations are subclassified as Type-II(20a), Type-II(20b), TypeII(20c), Type-II(20d), Type-II(20e) and Type-II(20f), (Figure-21).

The Variations-19, Type - II, Doubled trunk depicts, the presence of Left brachiocephalic trunk (LBCT) trunk as a first trunk with an unusual second trunk, both are originated from the left arch aorta, as Variations-19, Type - II, Doubled trunk configuration. The Variations-19, were sub-divided into two (P)-Pattern variables, indicated as Pattern-a, and Pattern-b (Tale-21). This Variations-19, Type II, Doubled trunk branching configurations are subclassified as Type-II(19a) and Type-II(19b), (Figure20).

Table 22: Ganesh Elumalai et al, Classification of “Variations-20, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta.



PATTERN

71

TYPE


72

19b

BRANCHING PATTEREN LBCT + RCCA (RSA arises from the Ascending aorta or DTA) LBCT + RSA (RCCA arises from the Ascending aorta or DTA)


PATTERN

TYPE

73

20a

74

20b

75

20c

76

20d

Doubled Trunk (II) 77

20e

78

20f

BRANCHING PATTEREN LCCA + LSA (RSA and RCCA arises from the Ascending aorta or DTA) LCCA + RSA (RCCA arises from the Ascending aorta and LSA arises from the DTA) LCCA + RCCA (RSA and LSA arises from the Ascending aorta or DTA) LCCA + RBCT (LSA arises from the DTA) LCCA + CVST (RCCA and RSA arises from the Ascending aorta or DTA) LCCA + CVST (RCCA and RSA arises from the Ascending aorta or DTA)

Figure 20: Variations-19, Type - II (Doubled trunk) Left Arch Aorta: a shows the variants of Type-II(19a) and Type-II(19b). (Left Brachiocephalic Trunk (LBCT); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian artery (LSA) ; Right common carotid (RCCA))

The Variations-20, Type - II, Doubled trunk describes, the presence of Left common carotid artery (LCCA) as a first trunk with another unusual second trunk in the combination of Left Vertebral artery (LSA), both are originated from the left arch aorta, as Variations-20, Type - II, Doubled trunk


Figure 21: Variations-20, Type - II (Doubled trunk) Left Arch Aorta: a shows the variants of Type-II(20a), TypeII(20b), Type-II(20c), Type-II(20d), Type-II(20e) and Page 172

Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in Type-II(20f). (Right common carotid (RCCA); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian artery (LSA); Right Brachiocephalic Trunk (RBCT); CVST-Common Vertebro-Subclavian Trunk and CSVT-Common Subclavian- Vertebral Trunk)

The Variations-21, Type - II, Doubled trunk shows, the presence of Left subclavian artery (LSA) as a first trunk with another unusual second trunk, both are originated from the left arch aorta, as Variations21, Type - II, Doubled trunk configuration. The Variations-21, were further classified into five (P)Pattern variables, indicated as Pattern-a, to Pattern-e (Tale-22). This Variations-21, Type - II, Doubled trunk branching configurations are marked as TypeII(21a), Type-II(21b), Type-II(21c) and TypeII(21d), (Figure-22). Table 22: Ganesh Elumalai et al, Classification of “Variations-21, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta


PATTERN

TYPE

79

21a

80

21b

81

21c

82

83

Doubled Trunk (II)

21d

21e

BRANCHING PATTEREN LSA + RSA (RCCA and LCCA arises from the Ascending aorta or DTA) LSA + RCCA (RSA and LCCA arises from the Ascending aorta or DTA) LSA + LCCA (RSA and RCCA arises from the Ascending aorta or DTA) LSA + CCT (RSA arises from the Ascending aorta or DTA) LSA + Reverse CCT (RSA arises from the Ascending aorta or DTA)

Figure 22: Variations-21, Type - II (Doubled trunk) Left Arch Aorta: a shows the variants of Type-II(21a), TypeII(21b), Type-II(21c), Type-II(21d) and Type-II(21e). (Right common carotid (RCCA); Right subclavian artery (RSA); Left common carotid (LCCA); Left subclavian artery (LSA); Right Brachiocephalic Trunk (RBCT); CCT-Common Carotid Trunk)

The Variations-22, Type - II, Doubled trunk describes, the presence of Common subclavian trunk (CST) trunk as a first trunk with other unusual second trunk, both are originated from the left arch aorta, as Variations-22, Type - II, Doubled trunk configuration. The Variations-22, was sub-classified into two (P)-Pattern variables, indicated as Pattern-a, to Pattern-b (Tale-24). This Variations-22, Type - II, Doubled trunk branching configurations are evidenced as Type-II(22a) and Type-II(22b), (Figure-23). Table 24: Ganesh Elumalai et.al, Classification of “Variations-22, Type –I I Doubled Trunk” Branching patterns of the Left Arch Aorta

Ganesh Elumalai et.al, Classification of "Branching patterns of the Left Arch Aorta" S.No

PATTERN

84

TYPE


85

22b

BRANCHING PATTEREN CST + RCCA (LCCA arises from the Ascending aorta or DTA) CST + LCCA (RCCA arises from the Ascending aorta or DTA)

Figure 23: Variations-22, Type - II (Doubled trunk) Left Arch Aorta: a shows the variants of Type-II(22a) and Type-II(22b(). (Common Subclavian Trunk (CST); Right subclavian artery (RSA); Left subclavian artery (LSA) ; Right common carotid (RCCA); Left common carotid (LCCA))

5. Discussion: Arch of the aorta, is the upward continuation of the Ascending aorta and it is normally branching into three vessels patterns called, the brachiocephalic trunk (BCT) or innominate artery, the left common carotid artery (LCCA) and the left subclavian artery (LSA), incidence in 74.0%


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Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in - 89.4% cases in radiological investigations [1,2,3] and 63.5% to 77.3% in cadaveric studies [4,5,6]. The adult archetype of the Aortic arch and its branches are formed, due to the different growth pattern of the aortic or branchial arch arteries and their associated “migration” and “merging” of their branches [7]. The most common variance of the aortic arch was observed as the anomalous aortic arch origin of the left vertebral artery (LVA). The anomalous branching patterns in the aortic arch are due to the deviations or disturbances the normal growth pattern of the aortic or branchial arch arteries during the embryonic period. Knowledge about the branching pattern of the aortic arches was utmost significant during supra-aortic angiography, aortic instrumentation, thoracic, head and neck surgeries. The aim of the present study to review the branching patterns of the left arch aorta and describe the uniform classification of branching patterns of the left arch aorta. If we observed the past five years of the previous works on classification of branching pattern of arch of aorta with the previous references. The majority of the previous workers Ogeng’o, JA et al, and Ajit Kumar et al, [231, 232], are classified the BCT, LCCA and LSA configuration as Type-I pattern. Which is controversy to the Adachi et. al., and Durai Pandian K et al classifications, they classified this BCT, LCCA and LSA pattern as TypeA [233, 234]. According to the Ogeng’o, JA et al and Ajit Kumar et al, Type-I, left arch aorta shows the pattern of Right brachiocephalic trunk, Left common carotid and Left subclavian artery [231, 232], which was the controversy to the Rekha, P et al, Type I pattern, their Type-I pattern shows, the left vertebral artery (LVA) as a branch of the aortic arch between the origins of left common carotid artery and left subclavian artery [235]. The Ogeng’o, JA et al, and Rekha, P et al, describes the TYPE-II as CT (BCT & LCC) and LSA[235]. But, the Ajit Kumar et al, observed the Type-II pattern with an aberrant origin of the left vertebral artery (LVA), which showed a typical vessel arrangement (the BCT, LCCA, LSCA) with the LVA origin between the LCCA and LSA. The left vertebral artery was also arising from the arch of the aorta in addition to the other normal branches [232]. Recently, Vucurevic G et al, observed the aortic arch branching pattern over the 1265 specimens, they describe the Type-II patterns as a double brachiocephalic trunk pattern [8]. The universal classification the branching patterns of the arch aorta were noticed as Type-A, Type-B, Type-C…etc or Type-I, Type-II, TypeIII…. and so on [8 -17]. In this, the Type-I or Typepatterns of one author did not correspond with the various other authors observations of the same TypeI or Type-A patterns. There were no clear uniform


pieces of information about, what this A, B, C…, or I, II, III…, symbols are indicating. The branching patterns of the arch of the aortas are shows significant variations but, until today there was no uniform data are available for the classification of these branching patterns. The left arch aortas are most common observation then the right arch of the aorta [18]. The purpose of this study to review the branching patterns of the left arch aorta and describe the uniform classification of branching patterns of the left arch aorta. The aim of the present study to review the branching patterns of the left arch aorta and describe the uniform classification for the branching patterns of the left arch aorta. The complete literature review surveys were conducted with the pieces of information received nearly from the past twentyfive decades of previous workers on the branching patterns of the arch of the aorta, derived from the different demographical observations [19 - 228].

6. Conclusion: Subsequent to the complete analysis of various (normal and unusual) types of the branching patterns of the left arch aorta, we designed totally three variables to classify it, the variables are 1. (T)Trunks, 2. (V)-Variations, and 3. (P)-Patterns. The (T)-Trunks variables are denoted by roman numerals I –VI, the (V)-Variation variables (only for the TypeI and Type-II) are marked as numerical values from 1-22 and, the (P)-Patterns variables are distinct as alphabets values a – f (Table -1). The (T)-Trunks variables are denoted by roman numerals, Type-I to Type-IV. In this (T)Trunk variables, the roman numerals indicate the total number of trunks arises from the arch (left) of the aorta. The Type - I indicate the Singled (one) trunk branch configuration of the left arch aorta, the other trunk variables are Type - II for Doubled (two) trunks, the Type – III resembles the Tripled (three) trunks, the Type - IV shows Quadriad (four) trunks, the Type - V exhibits Pentad (five) trunks and the Type - VI distinct as Hexad (six) trunks configuration arises from the left arch aorta. Under the Type - II (Doubled (two) trunks) to Type - VI (Hexad (six) trunks) Trunks) variables, the (V)Variations variables (only for the Type-I and TypeII) were sub-classified as numerical values and marked from Variations-1 to Variations-22 types of unusual branching configurations from the left arch aorta. The variables, Variations-1 to Variations-22 subtypes were further sub-classified into different (P)-Pattern variables and it was indicated as the alphabets values as Pattern-a, to Pattern-f. In future, if any new patterns were identified under this Type – II, Doubled trunk left aortic arch configuration, it would be followed next to the Variations-22, Type-II

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Imperial Journal of Interdisciplinary Research (IJIR) Vol-2, Issue-9, 2016 ISSN: 2454-1362, http://www.onlinejournal.in (22b). The further classification under the Trunk-II to VI and its Variations and patterns would be discussed in future.

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