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Right Aortic Arch in Patient With Mediastinal Adenopathy FREE TO VIEW

Abdul Hamid Alraiyes, MD; Khalid Alokla, MD; Fayez Kheir, MD; Jaime Palomino, MD
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Tulane University, New Orleans, LA

Chest. 2013;144(4_MeetingAbstracts):19A. doi:10.1378/chest.1703787
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SESSION TITLE: Bronchology Case Report Posters I

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: A right-sided aortic arch (RAA) is a rare anomaly of the cardiovascular system. We report a case of (RAA) in a patient with mediastinal lymphadenopathy finally diagnosed as sarcoidosis. Endobronchial ultrasound with real-time guided transbronchial needle aspiration (EBUS-TBNA) played a significant role in obtaining a sufficient tissue sample to make the diagnosis.

CASE PRESENTATION: A 27-year-old man presented history of progressive dry cough with mild shortness of breath, low grade fevers and night sweats. He was well built, never-smoker, and working as a police officer. Physical examination of the chest revealed increase of bronchial sounds on both lung fields, heart exam was unremarkable for any extra heart sounds or murmurs and the rest of the exam was normal. Radiographic examination of the chest showed right paratracheal mass displacing the trachea to the left. CT scan of the chest revealed a right-sided aortic arch with mediastinal and hilar adenopathy. Based on the radiographic findings the patient underwent EBUS-TBNA. The bronchoscopy showed diffused cobblestone of the airway. The EBUS identified the aortic arch on the right side of the tracheal wall, out-layering the superior vena cava vein. Multiple ultrasound guided TBNA were obtained from the lymphnodes stations which revealed multiple non-caseating granulomas. The final diagnosis was sarcoidosis.

DISCUSSION: Right aortic arch is a rare cardiovascular anomaly caused by interruption in the development of the third and fourth branchial arch in embryologic life. Patients with this cardiovascular anomaly are usually asymptomatic, however in some cases, cyanotic congenital heart disease like tetralogy of Fallot has been reported with RAA, these patients are usually diagnosed in fetal life or early childhood. On plain chest X-ray, RAA is recognized as the aorta descends on the right of the air-filled trachea. CT chest angiography can make the diagnosis as the left or right sidedness of the aortic arch refers to the position of the aortic arch relative to the trachea . RAA ultrasound findings described in literature are mainly in fetal life. We present a case of RAA with mediastinal lymph adenopathy with the EBUS findings of the RAA. EBUS-TBNA was performed with no complications, which emphasize the importance of using EBUS in such cases with cardiovascular anomalies to minimize the rate of catastrophic outcomes.

CONCLUSIONS: EBUS-TBNA can be helpful in some cases of cardiovascular anomalies that mandate mediastinal lymph nodes transbronchial needle aspiration due to its role in easy identification of vascular vs. nonvascular structures.

Reference #1: Knight L and Edwards JE. Right aortic arch. Types and associated cardiac anomalies. Circulation. 1974;50(5):1047-1051

Reference #2: Ha GJ, Sung MJ, Lee YS et al. A case of right sided aortic arch combined with atrial septal defect. Journal of cardiovascular ultrasound. 2011;19(1):32-34

DISCLOSURE: The following authors have nothing to disclose: Abdul Hamid Alraiyes, Khalid Alokla, Fayez Kheir, Jaime Palomino

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