TAVI in a patient with a double-lumen aortic arch

An 84-year-old male patient with symptomatic severe calcific aortic stenosis was scheduled for elective transcatheter aortic valve implantation (TAVI). The preprocedural echocardiographic examination incidentally revealed, on the suprasternal view, findings indicative of a double-lumen aortic arch (Figure 1A, Figure 1B, Moving image 1, Moving image 2). This is a type of abnormal vascular ring which completely surrounds the trachea and oesophagus and, in the majority of cases, leads to symptoms resulting from compression of these structures12. The subsequent computed tomography confirmed the double-lumen aortic arch arising from the ascending aorta at the level of the sternal angle (Figure 1C, Figure 1D). A dominant left aortic arch (LAA) and a hypoplastic right aortic arch (RAA) encircled the trachea and the oesophagus resulting in a complete vascular ring formation which terminated into the proximal descending aorta (Figure 1E). The left subclavian and carotid artery branched from the LAA, while the right subclavian and carotid artery emerged from the RAA with an absence of the brachiocephalic artery, thus forming the classic “4-vessel sign”1