Skip to main content
NCBI home page
Journal of Vascular Surgery Cases, Innovations and Techniques logoLink to Journal of Vascular Surgery Cases, Innovations and Techniques
. 2020 Feb 12;6(1):46–49. doi: 10.1016/j.jvscit.2019.10.006

Absence of right common carotid artery in a patient with common origin of the innominate artery and left common carotid artery

Giovanna Golin Guarinello a,∗, Francisco Eduardo Coral a,b,c, Carlos Alberto Engelhorn b,c, Sarah Folly Machado b, Amanda Prokopenko b, Sergio Xavier Salles-Cunha c
PMCID: PMC7016352  PMID: 32072086

Abstract

A 50-year-old woman was referred to the noninvasive vascular laboratory for carotid artery evaluation because of a bruit in the neck. Color Doppler ultrasound examination demonstrated absence of the right common carotid artery and parallel internal and external carotid arteries originating at the brachiocephalic trunk. Computed tomography angiography further described anomalous anatomy, demonstrating a common origin of the innominate artery and left common carotid artery. Knowledge of such unusual anatomy may become valuable in future evaluation or treatment of this patient.

Keywords: Carotid artery, Common origins of the innominate artery and left common carotid artery, Bovine arch, Cerebrovascular disease

Absence of a common carotid artery is a rare finding during initial physical examination or even basic screening or diagnostic ultrasound examinations with approximately 35 reported cases.1,2 Besides the low frequency of such anatomic variation, most patients are asymptomatic. The combination of absence of the common carotid artery with an abnormal aortic arch anatomy is an even rarer condition to be detected in a vascular clinic or ultrasound vascular laboratory, with a single case reporting the same variation although on the left side.3, 4, 5, 6, 7 A case of an asymptomatic 50-year-old woman having carotid artery screening is reported herein because of the extreme rarity of the event: right common carotid artery absence together with a common origin of the innominate artery and left common carotid artery. The patient has agreed to have images and case details published.

Case report

A 50-year-old woman without signs or symptoms of cerebrovascular disease was directed to the noninvasive vascular laboratory because her primary physician found a bruit on the right side of her neck.

Color flow duplex ultrasound

Color Doppler ultrasound was initiated following standard carotid procedures. An Acuson Antares ultrasound system (Siemens Healthcare, Issaquah, Wash) and a linear (7-10 MHz) transducer were used. Three vessels were detected in parallel (Fig 1): the right jugular vein (in blue) and two arteries, each one identified according to flow characteristics—the medially located external carotid artery with oscillatory flow and low end-diastolic velocities (Fig 2, A) compared with the low-resistance flow of the laterally placed internal carotid artery (Fig 2, B). A right common carotid artery bifurcation and a right bulb were not detected with the linear transducer as is usually expected. In addition, a convex transducer did not reveal a low bifurcation of the right common carotid artery. The unusual finding was the detection of independent origins for the right internal and external carotid arteries at the brachiocephalic trunk. Color flow duplex ultrasound did not reveal significant disease. The main finding was therefore the variant anatomy.

Fig 1.

Fig 1

Open in a new tab

Absence of the right common carotid artery. Carótida externa direita, Right external carotid artery; carótida interna direita, right internal carotid artery; subclávia direita, right subclavian artery; TBC, innominate artery.

Fig 2.

Fig 2

Open in a new tab

A, Right external carotid artery flow. B, Right internal carotid artery flow.

Computed tomography angiography (CTA)

To provide additional information about anatomic variants, particularly of the aortic arch, that could interfere with future diagnostic and even therapeutic conditions of the patient, CTA was contemplated because color duplex ultrasound is limited to study of the central vessels of the aortic arch. CTA with a 128-slice scanner (Siemens Healthcare, Erlangen, Germany) confirmed the anomalous origin of the internal and external carotid arteries on the right (Fig 3). In addition, another unusual finding was documented: the origin of the left common carotid artery from the proximal brachiocephalic trunk, pointing to a common origin of the innominate artery and left common carotid artery (Fig 4). Fig 5 demonstrates both anatomic variations.

Fig 3.

Fig 3

Open in a new tab

Computed tomography angiography (CTA) reconstruction: anomalous origin of the internal and external carotid arteries on the right.

Fig 4.

Fig 4

Open in a new tab

Computed tomography angiography (CTA) reconstruction: common origin of the innominate artery and left common carotid artery.

Fig 5.

Fig 5

Open in a new tab

Absence of right common carotid artery and common origin of the innominate artery and left common carotid artery.

Discussion

Absence of a common carotid artery was described by Malacarne in 1784.5,8,9 Prevalence of such a finding is similar on the right or left and higher in women.2,10, 11, 12 In general, such anatomic variations do not cause symptoms and have been detected during imaging examinations.10

Color Doppler ultrasound can suggest the lack of a common carotid artery bifurcation.13,14 A complete diagnostic ultrasound examination, however, requires an additional protocol and the use of a convex/cardiac transducer to study the aortic arch and the subclavian arteries. A more complete evaluation is usually performed with CTA or magnetic resonance angiography.10,15 Images with multiple rotations and translations exemplify anatomic variations and provide reliable information in cases requiring catheterization and endovascular procedures.

Although the term is a widely used misnomer, “bovine arch” occurs when the left common carotid artery has a common origin with the innominate artery. It is the second most common variant of aortic arch branching and has a prevalence close to 14%.16,17 Goyal and Sinha5 described a case of absent left common carotid artery and a bovine arch origin of the left external carotid artery. The case reported herein is another variation combining the bovine arch and absence of the right common carotid artery.

Such anatomic variations are not necessarily related to indications for treatment of carotid or other arterial disorders of the aortic arch. However, anatomic variations must be considered in the planning of endovascular procedures. Even some operations could be surprisingly affected by such variant anatomy. Noninvasive vascular laboratories, especially those specialized in definitive diagnosis and preoperative mapping beyond basic screening, should have additional protocols, awareness, and specific training to deal with such unusual cases.

Conclusions

Variant anatomy of the extracranial carotid arteries, in particular absence of the common carotid artery, especially if it is associated with aortic arch alterations, is rarely observed. Physical examination and color Doppler ultrasound require additional protocols and training to suspect and to detect such findings. CTA and magnetic resonance angiography are requested as needed to complete the examination of arch and carotid anatomic variations.

Footnotes

Author conflict of interest: none.

The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest.

References

  • 1.Kobayashi D., Natarajan G., Joshi A., Aggarwal S. Congenital absence of bilateral common carotid arteries. Ann Thorac Surg. 2013;95:719. doi: 10.1016/j.athoracsur.2012.06.052. [DOI] [PubMed] [Google Scholar]
  • 2.Braun R., Velayudhan V., Loona J. Absent left common carotid artery in a trauma patient. J Vasc Interv Radiol. 2017;28:230. doi: 10.1016/j.jvir.2016.08.020. [DOI] [PubMed] [Google Scholar]
  • 3.Ulger F.E., Ulger A., Colak M. Absence of the right common carotid artery: Doppler ultrasonographic and MR angiographic findings. Vascular. 2014;22:364–367. doi: 10.1177/1708538113516316. [DOI] [PubMed] [Google Scholar]
  • 4.Quinones G., Srinivasan A. Absence of the right common carotid artery: a rare case without separate origins of the internal and external carotid arteries. Clin Imaging. 2017;43:184–187. doi: 10.1016/j.clinimag.2017.03.009. [DOI] [PubMed] [Google Scholar]
  • 5.Goyal S., Sinha A.K. A rare case of absent left common carotid artery with bovine origin of the left external carotid artery. BMJ Case Rep. 2016;2016 doi: 10.1136/bcr-2016-012540. bcr2016012540. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Purkayastha S., Gupta A.K., Varma D.R., Bodhey N.K., Vattoth S. Absence of the left common carotid artery with cervical origin of the right subclavian artery. AJNR Am J Neuroradiol. 2006;27:708–711. [PMC free article] [PubMed] [Google Scholar]
  • 7.Maybody M., Uszynski M., Morton E., Vitek J.J. Absence of the common carotid artery: a rare vascular anomaly. AJNR Am J Neuroradiol. 2003;24:711–713. [PMC free article] [PubMed] [Google Scholar]
  • 8.Robert L.K., Gerald B. Absence of both common carotid arteries. AJR Am J Roentgenol. 1978;130:981–982. doi: 10.2214/ajr.130.5.981. [DOI] [PubMed] [Google Scholar]
  • 9.Cerase A., Rubenni E., Tassi R., Stromillo M.L., Venturi C. Absence of the right common carotid artery. Surg Radiol Anat. 2009;31:815–817. doi: 10.1007/s00276-009-0522-y. [DOI] [PubMed] [Google Scholar]
  • 10.Wood E.A., Malgor R.D., Labropoulos N. Diagnosing common carotid artery agenesis using duplex ultrasound. Vasc Endovascular Surg. 2011;45:727–732. doi: 10.1177/1538574411418013. [DOI] [PubMed] [Google Scholar]
  • 11.Dahn M.S., Kaurich J.D., Brown F.R. Independent origins of the internal and external carotid arteries. A case report. Angiology. 1999;50:755–760. doi: 10.1177/000331979905000909. [DOI] [PubMed] [Google Scholar]
  • 12.Bryan R.N., Drewyer R.G., Gee W. Separate origins of the left internal and external carotid arteries from the aorta. AJR Am J Roentgenol. 1978;130:362–365. doi: 10.2214/ajr.130.2.362. [DOI] [PubMed] [Google Scholar]
  • 13.Yim S.J., Ryu J.H., Baik J.S., Kim J.Y., Park J.H., Han S.W. Common carotid artery agenesis: duplex ultrasonographic findings. J Clin Neurol. 2009;5:149–150. doi: 10.3988/jcn.2009.5.3.149. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 14.Woodruff W.W., Strunsky V.P., Brown N.J. Separate origins of the left internal and external carotid arteries directly from the aortic arch: duplex sonographic findings. J Ultrasound Med. 1995;14:867–869. doi: 10.7863/jum.1995.14.11.867. [DOI] [PubMed] [Google Scholar]
  • 15.Cakirer S., Karaarslan E., Kayabali M., Rozanes I. Separate origins of the left internal and external carotid arteries from the aortic arch: MR angiographic findings. AJNR Am J Neuroradiol. 2002;23:1600–1602. [PMC free article] [PubMed] [Google Scholar]
  • 16.Popieluszko P., Henry B.M., Sanna B., Hsieh W.C., Saganiak K., Pekala P.A. A systematic review and meta-analysis of variations in branching patterns of the adult aortic arch. J Vasc Surg. 2018;68:298–306.e10. doi: 10.1016/j.jvs.2017.06.097. [DOI] [PubMed] [Google Scholar]
  • 17.Layton K.F., Kallmes D.F., Cloft H.J., Lindell E.P., Cox V.S. Bovine aortic arch variant in humans: clarification of a common misnomer. AJNR Am J Neuroradiol. 2006;27:1541–1542. [PMC free article] [PubMed] [Google Scholar]

Articles from Journal of Vascular Surgery Cases and Innovative Techniques are provided here courtesy of Elsevier

RESOURCES