Surg Radiol Anat (2009) 31:319–323
DOI 10.1007/s00276-008-0442-2
R EV IE W
Anatomical variations in the branches of the human aortic arch
in 633 angiographies: clinical signiWcance and literature review
Konstantinos I. Natsis · Ioannis A. Tsitouridis ·
Matthaios V. Didagelos · Andis A. Fillipidis ·
Konstantinos G. Vlasis · Prokopios D. Tsikaras
Received: 28 January 2008 / Accepted: 6 November 2008 / Published online: 26 November 2008
© Springer-Verlag 2008
Abstract
Background The variations of vessels arising from the
aortic arch are numerous. The purpose of the present study
is the description of the aortic arch branches’ variations, in
order to oVer useful data to anatomists, radiologists, vascu-
lar, neck and thorax surgeons. In addition, literature has
been reviewed so as to enable a comparison of our results
with those of other studies and an analysis of the variations’
clinical implications is possible.
Materials and methods A total of 633 digital subtraction
angiographies of Caucasian Greek patients were examined.
No computed tomography or magnetic resonance angiog-
raphies were included.
Results Eight types of the aortic arch were found. The
classiWcation from I to VIII was made according to the inci-
dences recorded, with type I being the most and type VIII
K. I. Natsis (&) · P. D. Tsikaras
Department of Anatomy, Medical School,
Aristotle University of Thessaloniki,
P.O. Box 300, 54124 Thessaloniki, Greece
e-mail: natsis@med.auth.gr
I. A. Tsitouridis · A. A. Fillipidis
Radiology Department, The “Papageorgiou” General Hospital,
Ring Road, Nea Efkarpia, 56429 Thessaloniki, Greece
M. V. Didagelos · K. G. Vlasis
Medical School, Aristotle University of Thessaloniki,
Thessaloniki, Greece
M. V. Didagelos
7 Paisiou Monaxou, 54632 Thessaloniki, Greece
K. G. Vlasis
180 Mihalakopoulou, 11527 Athens, Greece
P. D. Tsikaras
33 Kassandrou, 54632 Thessaloniki, Greece
being the least frequent. Type I, brachiocephalic trunk
(BT), left common carotid artery (LCC), left subclavian
artery (LS), 527 (83%); type II, BT with LCC and LS, 96
(15%); type III, BT, LCC, left vertebral artery (LV), LS, 5
(0.79%); type IV, right subclavian artery (RS), carotids in
common, LS, 1 (0.16%); type V, carotids in common-LS,
RS, 1 (0.16%); type VI, carotids and subclavians in com-
mon, 1 (0.16%); type VII, RS, right common carotid artery
(RCC), LCC, LS, 1 (0.16%); type VIII, BT, thyroidea ima,
LCC, LS, 1 (0.16%).
Conclusions Despite the fact that the variations in ques-
tion are usually asymptomatic, they may cause dyspnea,
dysphagia, intermittent claudication, misinterpretation of
radiological examinations and complications during neck
and thorax surgery. Furthermore, these variations may be
accompanied by other congenital abnormalities.
Keywords Aortic arch branches anatomy ·
Anatomical variations · Angiographies · Vascular anatomy
Abbreviations
BT Brachiocephalic trunk
RS Right subclavian artery
RCC Right common carotid artery
LCC Left common carotid artery
LS Left subclavian artery
LV Left vertebral artery
Introduction
The variations of vessels arising from the aortic arch are
numerous. It is characteristic that one to six branches may
be found [4, 20]. The aortic arch described as “normal”
(most common) type, is the one that gives rise to three
123
320
branches: (1) the brachiocephalic trunk (BT), which
branches to the right subclavian (RS) and to the right com-
mon carotid (RCC) arteries, (2) the left common carotid
(LCC) artery and (3) the left subclavian (LS) artery [1, 19].
The purpose of this study has been the determination of
the frequency of the aortic arch branches’ variations, in
order to provide useful data to anatomists, radiologists, vas-
cular, neck and thorax surgeons. Additionally, literature has
been reviewed in order to compare our results with those in
other studies and to analyze the clinical implications of the
variations found.
Materials and methods
A total of 633 digital subtraction angiographies (DSA) of
the aortic arch and its branches performed by the Seldinger
technique, via the femoral artery, were examined. No MR
or CT angiographies were included. These angiographies
belonged to 447 male and 186 female Greek patients and
they were performed during a 5-year period, from 2000 to
2005. The age range was 19–79 years old. A review of the
literature concerning the same topic was carried out. The
results of other authors were summarized and compared
with ours and then the clinical signiWcance of each varia-
tion, as described in literature, was noted. The clinical
aspect of each variation in our patients has not been
reported in the present study.
Results
Eight types of the aortic arch (I–VIII) were observed. The
classiWcation from I to VIII was made according to the inci-
dences recorded with type I being the most and type VIII
being the least frequent. The morphology and frequency of
each one are mentioned below. The arterial branches are
described starting from right (Wrst branch) to left (last branch).
Type I (527 cases: 375 male, 152 female, 83%): the most
common type of the aortic arch, that is, the “normal” aortic
arch as described in literature, giving rise to three branches:
(1) the BT (or innominate artery), which then branches into
the RS and RCC, (2) the LCC and (3) the LS (Fig. 1I).
Type II (96 cases: 67 male, 29 female, 15%): the second
most common pattern, including two branches of the aortic
arch: (1) a common stem which is divided into the RS,
RCC and LCC and (2) the LS (Fig. 1II).
Type III (5 cases: 2 male, 3 female, 0.79%): Left verte-
bral arising directly from the arch and not from the left sub-
clavian, providing an aortic arch pattern with four branches:
(1) BT, (2) LCC, (3) LV and (4) LS (Fig. 1III).
Type IV (1 case: female, 0.16%): common origin of the
common carotids (arch with three branches): (1) RS, (2)
123
Surg Radiol Anat (2009) 31:319–323
common stem for the RCC and the LCC (bicarotid trunk)
and (3) LS (Fig. 1IV).
Type V (1 case: male, 0.16%): common origin of the
common carotids and aberrant RS (arch with three
branches): (1) common stem for the RCC and the LCC
(bicarotid trunk), (2) LS and (3) RS as the last branch of the
arch (Fig. 1V).
Type VI (1 case: male, 0.16%): common origin of the
common carotids and common origin of the subclavians
(arch with two branches-avian form): (1) common stem for
the RCC and the LCC and (2) common stem for the RS and
the LS (Fig. 1VI).
Type VII (1 case: female, 0.16%): absence of the BT
(arch with four branches): (1) RS, (2) RCC, (3) LCC and
(4) LS (Fig. 1VII).
Type VIII (1 case: male, 0.16%): An additional branch
from the aortic arch—the thyroidea ima artery (arch with
four branches): (1) BT, (2) thyroidea ima artery (3) LCC
and (4) LS (Fig. 1VIII).
Discussion
As our results have showed, in about 17% of the individu-
als examined, the aortic arch’s branches did not follow the
“normal/usual” branching pattern, having variations in their
number and origin. These variations are likely to occur as a
result of diVerent development of certain branchial arch
arteries during the embryonic period of gestation [5].
It is obvious that any combination of number and origin
of the aortic arch branches may occur. In the current study,
we have described the three most frequent patterns (type I–
III), according to literature and our results. All the remain-
ing variations are very rare and in our specimen Wve of
them have been observed (type IV–VIII).
Type I of the aortic arch is described as the “normal”
aortic arch and it is found with an incidence of 64.9–94.3%
according to the literature, higher than any other type
[4, 12, 19, 27, 28]. Our relative incidence of 83% lies
between this wide range.
Type II, the second most common pattern presents an
incidence of 11–27% [4, 19, 27]. Only Nelson and Sparks
[28] have reported this type third in a row, in American–
Japanese men, with an incidence of 1.03%. Nizankowski
et al. [29] have mentioned an even lower frequency of
0.9% in a Polish population. In the current study, it appears
second, as it is the case in most studies, with an incidence
of 15%. This type is also called “bovine aortic arch”,
although it does not absolutely resemble the aortic arch of
the cattle [18]. Although very rare, clinical symptoms
related to this variation have been reported and they have
been mainly attributed to the widening of the superior
mediastinum [13].
Surg Radiol Anat (2009) 31:319–323
Fig. 1 The eight types of the
aortic arch we found in
angiographies (*variation of
origin)
Type III is described third by most authors, with the fre-
quency of 2.5–8% and second by Nelson and Sparks with
the frequency of 3.1% in American–Japanese men [4, 19,
27, 28]. Our incidence of 0.79% classiWed it third in a row,
but it was quite lower than the range of 2.5–8%, approach-
ing more the frequency of 1.3% mentioned by Nizankowski
et al. [29]. We should focus our attention on this variation,
especially as neurovascular interventionalists and neurosur-
geons, since the vertebral artery injury is a well-known
complication of the extended lateral decompression during
anterior cervical spine surgery, which can result in exsan-
guinations and permanent neurological deWcits [21]. More-
over, the vertebral artery may be wrongly considered
occluded or diseased, either by eluding catheterization dur-
ing angiography or by lying outside the region of interest
during non-invasive studies such as CT angiography, MR
angiography or Doppler sonography [9, 11]. However, this
variation cannot be related to any clinical symptoms unless
an aneurysm is formed [2, 15, 28].
321
All the remaining variations are very rare and most of
them have an incidence of less than 1% [4] (Table 1). Our
corresponding percentages are also below 1%.
Type IV, with the bicarotid trunk between the subclavian
arteries, has also been described in the literature [4]. The
bicarotid trunk is the most common cause of tracheobron-
chial compression due to a congenital cardiovascular anom-
aly [8]. However, the common origin of the carotids does
not seem either to aVect brain oxygen supply or to increase
the risk of a neurological injury in infants undergoing
venoarterial extracorporeal membrane oxygenation (ECMO)
[17]. Moreover, an analysis of the associations of this
common carotid stem with various other congenital cardio-
vascular lesions has showed a signiWcant association with
many of them such as the congenital polyvalvular disease,
the trisomy 13, 18, and 21 syndromes, the tetralogy of
Fallot and the clinical Noonan phenotype [34].
In Type V, the RS arises as the last branch of the arch
and it is known as aberrant RS or arteria subclavia dextra
123
322 Surg Radiol Anat (2009) 31:319–323

lusoria (ASDL). Regardless of the morphology of the

(present study) (%)

633 angiographies
remaining aortic arch branches, ASDL is generally found in
1.4% with a wide range from 0.13% to the high percentage
Natsis et al.
of 25% of people [4]. The speciWc type we found, with the

Greek
bicarotid trunk, is attributed to the incidence of 0.7% by

0.79
0.16
0.16
0.16
0.16
0.16
83
15
Liechty et al. [19]. The importance of the bicarotid trunk
has been previously described. As far as the aberrant RS is
et al.[27] (%)

62 cadavers
concerned, it originates from the left-half of the body and in

India
Nayak

its course to the right arm it usually (85%) crosses the mid-
91.4
4.8
1.6

1.6
–

–
–
–
line behind the esophagus, thus called retroesophageal RS

Japanese men
[3, 10, 25]. Furthermore, it may run between the trachea
et al. [29] (%) et al. [12] (%) Sparks [28] (%)

American–
193 cadavers
and the esophagus or in front of the trachea [6]. Although
Nelson and

these variations are often asymptomatic, they have been

1.03

incriminated as causing a condition called “dysphagia luso-

94.3

3.1
–
–
–
–
–

Portuguese ria”. This situation is characterized by diYculty in swallow-

ing and pain in some cases, due to the pressure applied by
33 cadavers

the artery onto the wall of the esophagus [3, 10, 25]. In this
Nizankowski Grande

case, surgical management is necessary [26]. When the

82
–
–
–
–
–
–
–

aberrant RS comes in touch with the trachea, it may cause

453 cadavers

dyspnea, whereas when it is found in front of the trachea, it

may cause complications during tracheostomy [6]. Finally
Polish

the aberrant RS may be accompanied by variations in the

0.9
1.3

0.4

course of the recurrent laryngeal nerve. In such cases the

–

–
–
–

cadavers

right laryngeal nerve cannot form a loop around the RS and

[19] (%)
Liechty

it is called “non-recurrent” laryngeal nerve [23].

1000
64.9
27.1
2.5

0.7

Type VI, belongs to the avian form, with two branches

–

–
–
–

arising from the aortic arch like in birds [22]. However it is

American
Comments: 500 cadavers 516 cadavers 80 cadavers 79 cadavers 157 cadavers 59 cadavers

very rare [4, 7, 30] and its clinical importance is related to

black

that of the bicarotid trunk or to that of the ASDL when the

51.7
41.4

1.7

1.7
–
–

–
–

right subclavian emerging from the common subclavian

Anson [24] (%)
McDonald and

stem follows an abnormal route to the neck, like the one

American

described in type V.
white

Type VII, is also very rare [4, 19] and it seems to bear no
1.46
66.9
25.5

1.3
–
–
–
–

clinical importance.
Type VIII, the thyroidea ima artery, regardless of its ori-
Table 1 Incidence of the types of aortic arch branches’ variations
Williams et al. [35] (%)

gin, is found in the percentage of 4–10% in people accord-

black

ing to Bergman et al. [4]. Thomson [31] reports a quite

45.6
51

–
–
–
–
–
–

lower incidence of 0.4%. It may arise from the aortic arch,

the brachiocephalic trunk, the common carotid, the internal
white

thoracic, the pericardiacophrenik, the subclavian, the thyro-

73.8

2.5

1.3

cervical trunk, the inferior thyroid or the transverse scapu-

20

–
–
–

lar artery. It usually, but not always, arises from the right
side [4, 32]. Its clinical importance lies in the fact that it
Japanese

may be injured during surgical procedures in neck, like the

[1] (%)
Adachi

83.3
10.9
4.3

0.2

thyroid resectomy or laryngeal transplantation, when its

–

–
–
–

presence is not revealed preoperatively [33]. Moreover, a

search for an ima artery during a parathyroid arteriography
English
Thomson
[31] (%)

may detect some cases of missed adenomas or hyperplastic

82.4
10.2
5.4

0.8

0.4

glands [16]. Our incidence of 0.16% includes a thyroidea

–

–
–

ima artery that arose from the aortic arch. However, it was a
unique case, so our percentage is much lower than the one
of 4–10% but closer to the one found by Thomson [31] in
Type

VIII
VII
VI
IV
III

V
II

English population.
I

123
Surg Radiol Anat (2009) 31:319–323
A possible cause for the diVerences in incidence among
the various investigators, as it is showed in Table 1, could
be the diVerent race of the specimen examined. This
hypothesis is encouraged by the studies of Williams et al.
(1932), Keith (1895) and McDonald et al. (1940), where in
black people type II has a higher incidence than in Cauca-
sians and the study of Toni et al. (2003), where a higher fre-
quency of IMA in Asians than in Caucasians has been
reported [14, 24, 33, 35].
References
1. Adachi B (1928) Das arteriensystem der Japaner, vol 1. Kenkyu-
sha, Kyoto, pp 29–41
2. Albayram S, Gailloud P, Wasserman B (2002) Bilateral arch ori-
gin of the vertebral arteries. AJNR 23:455–458
3. Backer CL, Ilbawi MN, Idriss FS, DeLeon SY (1989) Vascular
anomalies causing tracheoesophageal compression. Review of
experience in children. J Thorac Cardiovasc Surg 97:725–731
4. Bergman RA, AWW AK, Miyauchi R (1985–2002) Illustrated ency-
clopedia of human anatomic variation (online). http://www.
vh.org/Providers/Textbooks/AnatomicVariants/Cardiovascular/
Text/Arteries/Aorta.html, pp 1–35
5. Barry A (1951) The aortic arch derivatives in the human adult.
Anat Rec 111:221–238
6. Chadha NK, Chiti-Batelli S (2004) Tracheostomy reveals a
rare aberrant right subclavian artery; a case report. BMC Ear
Nose Throat Disord 4: 1. http://www.biomedcentral.com/1472–
6815/4/1
7. Demetriades D (2005) An unusual anatomical aortic arch varia-
tion. J Trauma 58:654
8. Ehren H, Wells TR, Landing BH (1985) Association of common
origin of the carotid arteries with anomalous origin of the left cor-
onary artery from the pulmonary artery. Pediatr Pathol 4:59–66
9. Eisenberg R, Vines F, Taylor S (1986) BiWd origin of the left ver-
tebral artery. Radiology 159:429–430
10. Fazan VPS, Ribeiro RA, Ribeiro JAS, Filho OAR (2000) Right
retroesophageal subclavian artery. Acta Cir Bras 18:54–56
11. Goray BV, Joshi RA, Garg A, Merchanta S, Yadava B, Mah-
eshwariaet M (2005) Aortic arch variation: a unique case with
anomalous origin of both vertebral arteries as additional branches
of the aortic arch distal to left subclavian artery. AJNR 26:93–95
12. Grande NR, Costa SA, Pereira AS, Aguas AP (1995) Variations in
the anatomical organization of the human aortic arch. A study in a
Portuguese population. Bull Assoc Anat (Nancy) 79:19–22
13. Karkoulias KP, Efremidis GK, Tsiamita MS, Trakada GP, Pro-
dromakis EN, Nousi ED, Spiropoulos KB (2003) Abnormal origin
of the left common carotid artery by innominate artery: a case of
enlargement mediastinum. Monaldi Arch Chest Dis 59:222–223
14. Keith A (1895) The modes of origin of the carotid and subclavian
arteries from the arch of the aorta in some of the higher primates.
J Anat Physiol 29:453–458
15. Komiyama M, Morikawa T, Nakajima H, Nishikawa M, Yasui T
(2001) High incidence of arterial dissection associated with left
vertebral artery of aortic origin. Neurol Med Chir (Tokyo) 41:8–12
323
16. Krudy GA, Doppman LJ, Brennan FM (1980) The signiWcance of
the thyroidea lma artery in arteriographic localization of parathy-
roid adenomas. Radiology 136:51–55
17. Lamers LJ, Rowland DG, Seguinn JH, Rosenberg E, Reber K
(2004) The eVect of common origin of the carotid arteries in neu-
rologic outcome after neonatal ECMO. J Pediatr Surg 39:532–536
18. Layton KF, Kallmes DF, Cloft HJ, Lindell EP, Cox VS (2006)
Bovine aortic arch variant in humans: clariWcation of a common
misnomer. AJNR 27:1541–1542
19. Liechty JD, Shields TW, Anson BJ (1957) Variations pertaining to
the aortic arches and their branches. Q Bull Northwest Univ Med
Sch 31:136–143
20. Lippert H, Pabst R (1985) Arterial variations in man. ClassiWca-
tion and frequency. JF Bergmann Verlag, Munich, pp 3–9
21. Lu J, Ebraheim NA (1999) The vertebral artery: surgical anatomy.
Orthopedics 22:1081–1085
22. Mackay YJ (1888) The development of the branchial arterial arch-
es in birds, with special reference to the origin of the subclavians
and carotids. Philos Trans R Soc Lond 179:111–139
23. Maranillo E, Vazquez T, Quer M, Niedenführ MR, Leon X, Viejo
F, Parkin I, Sanudo JR (2008) Potential structures that could be
confused with a nonrecurrent inferior laryngeal nerve: an anatomic
study. Laryngoscope 118:56–60
24. McDonald JJ, Anson BJ (1940) Variations in the origin of arteries
derived from the aortic arch, in American whites and negroes. Am
J Phys Anthropol 27:91–107
25. Meher R, Sabherwal A, Singh I, Raj A (2004) Dysphagia due a to
rare cause. Indian J Surg 66:300
26. Mok CK, Cheung KL, Kong SM, Ong GB (1979) Translocating
the abberant rightsubclavian artery in dysphagia lusoria. Br J Surg
66:113–116
27. Nayak RS, Pai MM, Prabhu LV, D’Costa S, Shetty P (2006) Ana-
tomical organization of aortic arch variations in the India: embry-
ological basis and review. J Vasc Bras 5:95–100
28. Nelson ML, Sparks CD (2001) Unusual aortic arch variations: dis-
tal origin of common carotid arteries. Clin Anat 14:62–65
29. Nizankowski C, Rajchel Z, Ziolkowksi M (1975) Abnormal origin
of arteries from the aortic arch in man. Folia Morphol (Warsz)
34:109–116
30. Poultsides AG, Lolis DE, Vasquez J, Drezner AD, Venieratos D
(2004) Common origins of carotid and subclavian arterial systems:
report of a rare aortic arch variant. Ann Vasc Surg 18:597–600
31. Thomson A (1893) Third annual report of the Committee of Col-
lective Investigation of the Anatomical Society of Great Britain
and Ireland for the year 1891–1892. J Anat Physiol 27:183–194
32. Tohno S, Tohno Y, Matsumoto H, Fujimoto S, Fujimoto T, Futam-
ura N, Furuta K (1989) A case of the thyroidea ima artery arising
from the aortic arch. Kaibogaku Zasshi 64:490–494
33. Toni R, Della Casa C, Mosca S, Malaguti A, Castorina S, Roti E
(2003) Anthropological variations in the anatomy of the human
thyroid arteries. Thyroid 13:183–192
34. Wells TR, Landing BH, Shankle WR (1993) Syndromal associa-
tions of common origin of the carotid arteries. Pediatr Pathol
13:203–212
35. Williams GD, AV HM, Schmeckebier M, Edmonds HM, Graul EG
(1932) Variations in the arrangement of the branches arising from
the aortic arch in american whites and negroes. Anat Rec 54:247–
251
123
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