Introduction: Aberrant right subclavian artery (ARSA, a. lusoria) is one of the most common congenital arch anomalies. The prevalence of ARSA ranges from 1 to 2%. ARSA originates from aortic arch as most distal branch and has it’s own aberrant pathway in mediastinum, most commonly retroesophageal. (1)

Case report: 67-years old male patient with history of arterial hypertension and type II diabetes mellitus was admitted to our hospital for elective coronary angiography. During previous hospital stay coronary angiography using left radial access with implantation of two stents was done due to acute myocardial infarction. Patient was scheduled for another intervention on bifurcation lesion LAD/D1 (Medina 1,1,1). During procedure right radial access with 6Fr guiding catheter was used. The advancement of any cathethers into the ascending aorta was difficult, so we performed angiography of aortic root which revelead ARSA. The procedure was continued with some specific manipulation of guide wires and cathethers. After reaching a bifurcation lesion, stents were implanted using ‘’culotte’’ stenting technique (Figure 1). Postprocedural CT angiography was done to confirm ARSA. Exam showed absence of truncus brachiocephalicus, with common carotid ostium, regular position of left subclavian artery and anomalous ostium of right subclavian artery as most distal branch on aortic root which passes behind the oesophagus (Figure 2).

Discussion: Congenital arch anomaly are mostly diagnosed sporadically during routine radiological scaning. The reason for that is probably the fact that patients are almost always asymptomatic. If there is some difficulties during coronary angiography and guide wires enter directly to the descending aorta when right radial access is used, ARSA should be considered. Interventions in patients with ARSA is complicated and often requires multiple wires and cathethers changes. Only two cases (1) of interventional treatment through ARSA was described in the literature.

Conclusion: The existence of ARSA makes coronary angiography more difficult and demanding procedure, but could be done without switching to another vascular acsses.