Andersons pediatric cardiology 1294
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furthermore,areknowntobefrequentinotherwisenormal
individuals.73–76,108–111Inthenormalarrangement,thefirstbranchfromthe
aorticarchisthebrachiocephalicartery,whichisright-sided.Itbranchestogive
risetotherightcommoncarotidandsubclavianarteries(seeFig.48.5,right).
Thispatternisfoundinonlytwo-thirdstofour-fifthsofnormalsubjects,withthe
othersubjectsshowingthemultiplevariants.74,75Inthemostfrequentvariation,
thebrachiocephalictrunkandleftcommoncarotidarterytakeacommonorigin
fromtheaorticarch,withthisarrangementerroneouslydescribedasthebovine
pattern.68,74,75,108Othervariants,suchasdirectoriginoftheleftvertebralartery
fromtheaorticarch,occurinupto5%ofsubjects,withaberrantretroesophageal
originoftherightsubclavianarteryfromthedescendingaorta,foundinaround
1%ofotherwisenormalsubjects.73–76Itisparadoxical,therefore,thatmultiple
investigatorshaveignoredtherarityofthefiftharcharterywhileenthusiastically
seeingevensomeofthecommonvariationsinthebranchingpatternas
persistenceofthisentity.77–104Aswehaveshown,thesubclavianarterieschange
theirpositionsignificantlyastheyeffectivelymovecraniallyfromtheiroriginas
theseventhcervicalintersegmentalarteries.Variationsintheextentofthis
remodelingaremuchmorelikelytoproducethedescribedabnormalpatternsof
branchingthanispersistenceoftheextremelyrarefiftharchartery,ashasbeen
implicatedbymanyauthors.38,105,107Othershaveimplicatedpersistenceofthe
arteryofthefiftharchtoexplainproximaloriginofacarotidartery.106This
againseemsmostunlikely,withremodelingoftheinitiallybilaterallysymmetric
systemofarchesprovidingamuchmorerealisticexplanation.68,70,108–111The
fascinationwithpersistenceofthefiftharchisnowsogreatthatalmostany
variationinthearrangementoftheaorticarchanditsbranchesisnow
interpretedasrepresentingpersistenceofitsenigmaticartery.112
Table48.3
AlltheCasesPublishedintheWorldLiteratureWithAbnormalities
inBranchingoftheBrachiocephalicArteriesontheBasisof
PersistenceoftheArteriesoftheFifthArch
SlNo. Year Author
Case
BovineorPseudobovineArch
1
1978 Maeda
1
2
1982 Anzai
1
3
1990 Yoshii
1
4
1991 Pearl
1
AnatomyoftheProposedFifthArch
Reference
Variantofbovineaorticarchwithcoarctation
Truebovineaorticarchwithcoarctation
Pseudobovinearchwithcoarctationandpatentarterialduct
Truebovineaorticarchwithcoarctationandpatentarterialduct
77
78
79
80
5
1992 DaCosta
1
Truebovineaorticarchwithcoarctationofaorta
6
1998 Morikawa 1
Truebovinearchwithcoarctation
7
1998 Morikawa 2
Pseudobovinearchwithcoarctation
8
1998 Tomita
1
Pseudobovinearchwithcoarctation
9
2000 Zartner
1
Truebovinearchwithcoarctationandpatentarterialduct
10
2001 Atsumi
1
Truebovinearchwithcoarctation
11
2004 Isomatsu
1
Truebovinearchwithcoarctation
12
2006 Iwase
1
Truebovinearchwithcoarctationandpatentarterialduct
13
2006 Ming
1
Pseudobovinearchwithcoarctation
14
2006 Ming
2
Pseudobovinearchwithcoarctation
15
2006 Ming
3
Pseudobovinearchwithcoarctation
16
2006 Ming
4
Pseudobovinearchwithcoarctation
17
2006 Carroll
1
Truebovinearchwithcoarctation
18
2007 Bernheimer 2
Truebovinearchwithcoarctation
19
2007 Zhao
1
Truebovinearchwithcoarctation
20
2007 Zhao
2
Truebovinearchwithcoarctation
21
2007 Zhong
1
Truebovinearchwithcoarctation
22
2007 Zhong
2
Pseudobovinearchwithcoarctation
23
2007 Zhong
3
Truebovinearchwithcoarctation
24
2007 Zhong
4
Truebovinearchwithcoarctation
25
2010 Yu
1
Truebovinearchwithcoarctation
26
2012 Ohashi
1
Coarctationofaorta;detailsofarchvesselsnotavailable
27
2013 Inoue
1
Truebovinearchwithcoarctation
28
2014 Uysal
1
Truebovinearchwithcoarctation
29
2013 Malakan
1
Truebovinearchwithcoarctation
30
2015 Tang
1
Truebovinearchwithcoarctation
31
2016 Valderrama 1
Truebovinearchwithcoarctation
32
2017 Binsalamah 1
Pseudobovinearchwithcoarctation
33
2017 Cetrano
1
Truebovinearchwithcoarctation
34
2015 Chiappa
1
Pseudobovinearchwith
35
2015 Tittel
1
Truebovinearchwithcoarctation
36
2016 Kim
1
Truebovinearchwithcoarctation
37
2016 Hotoda
1
Truebovinearchwithcoarctation
38
2016 Hotoda
2
Pseudobovinearchwithcoarctation
SubclavianorCarotidArteryArisingastheFirstBranch
1
1991 Moes
1
Leftsubclavianarteryasfirstbranchinrightaorticarch
2
1991 Moes
2
Leftsubclavianarteryasfirstbranchinrightaorticarch
3
1991 Moes
3
Leftsubclavianarteryasfirstbranchinrightaorticarch
4
1991 Moes
4
Rightsubclavianarteryasfirstbranchinleftaorticarch
5
2003 Lee
1
Leftsubclavianarteryasfirstbranchinrightaorticarch
6
2006 Lee
3
Leftcommoncarotidarteryasfirstbranch
7
2006 Lee
4
Leftcommoncarotidarteryasfirstbranchinrightarch
81
82
82
83
84
85
86
87
88
88
88
88
89
41
90
90
91
91
91
91
92
93
94
95
96
97
98
99
100
101
102
103
104
104
105
105
105
105
38
106
106
Thecaseswithasinglebrachiocephalictrunkcontainingbilateralcarotidandsubclavianarteries
areerroneouslylabeled“truebovinearch.”Thecaseswithtwoarchvesselswiththeleftcommon
carotidarteryarisingeitherfromthebrachiocephalicarteryorasacommontrunkfromtheaorta
withthesubclavianarteryarisingseparatelyarelabeledas“pseudobovinearch,”astheyare
differentfromthe“bovinearch”buteventhislabelisincorrect.
Conclusions
Thearteriesofthefifthpharyngealarches,iftheydoexist,areexceedinglyrare
entities.Inourextensivestudyoflargenumbersofdevelopingmouseembryos,
wehaveyettoseebilaterallysymmetricchannelsthatparalleltheformationof
thearteriesofthefirstthroughthefourthandthesixthpharyngealarches.
Collateralchannelsextendingbetweenthedistalinsertionsofthefourthand
sixtharcharteries,incontrast,arefoundinuptohalfofalldevelopingmice.3
Althoughsuchchannelshavebeendescribedas“fiftharcharteries”byother
investigators,4,5theydonotoriginatefromtheaorticsac,nordotheyrunin
parallelwiththeotherbilateralchannels(seeFig.48.4).Suchcollateralchannels
arealsotobefoundindevelopinghumanembryos,although,aswehaveshown,
achannelhasbeenfoundinadevelopinghumanembryothatisappreciably
moreinkeepingofwhatmightbeafiftharchartery(seeFig.48.6).Itremainsto
beestablished,nonetheless,whethersucharareentitycouldpersistwiththe
frequencyimpliedbypublishedinterpretationsmadebyclinicalinvestigators,
whoforthemostparthavetakenlittleheedofthenewfindingsregarding
developmentofthepharyngealarchesandtheircontainedarteries(seeTables
48.1to48.3).
Takingallthesefeaturesintoconsiderationandhavingexaminedthefindings
asdescribedintheliterature,weremaindubiousregardingthemajorityofthe
claims.Theimagesprovidedinreportedcasesofdouble-barreledaorta,for
example,rarelyrevealanoriginforthesecondchannelthatisproximaltothe
take-offofthebrachiocephalicartery,althoughtheyoftenoriginateoppositeto
thebrachiocephalicartery.Itisjustaslikelyifnotmoreso,therefore,thatthe
secondchannelsrepresentpersistenceofthedorsalcollateralcommunications
presentinhalfofallmiceduringtheirnormaldevelopment.Withregardto
systemic-to-pulmonarychannels,persistenceofthearteryofthefiftharchdoes,
indeed,providesareasonableexplanationforsomecaseswithinsertionatthe
confluenceofthepulmonaryarteries.Manyofthereportedcases,incontrast,are
equallywellexplainedonthebasisofpersistenceandabnormalremodelingof
thearterialductorelsepersistenceofthecollateralchannels.Inthecaseofthe
variationsinpatternsofbranchingofthearteriesarisingfromtheaorticarch,we
prefertointerpretthefindingsintermsofexcessiveremodelingofthehornsof
theaorticsacratherthanaspersistenceofafiftharchartery.Weacknowledge
