Andersons pediatric cardiology 1295
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thatourinterpretationsarejustasspeculativeasthosemadebytheinvestigators
whooptforpersistenceofthearteriesofthefiftharch.Ourinterpretations,
nonetheless,aresupportedbyourrecentobservationsindevelopingmouseand
humanembryos.Wehavesummarizedthereasonsunderscoringour
interpretationsinBox48.1.Onthesebases,wesuggestthatasuitabledefinition
fortheenigmaticfiftharcharteryisachannelthatisconfinedtothe
extrapericardialspace,whicharisesfromtheascendingaortaproximaltothe
originofbrachiocephalicarteriesandterminateseitherinthedescendingaortaor
inthepulmonaryarteriesviathepersistentlypatentarterialduct.
Box48.1
OurConclusionsAfterReviewingtheCases
InvolvingPersistentFifthArchArteriesas
ReportedintheWorldLiterature
▪Bilateralfiftharcharterieshaveneverbeendocumented.
▪Unilateralpartialfiftharcharteryhasbeendemonstratedonlyonceina
developinghumanembryo.
▪Dorsalcollateralchannelsconnectingthefourthandsixtharchesare
common.
▪Toqualifyasthefiftharcharteryanychannelmust:
▪Arisefromtheascendingaortaproximaltothebrachiocephalic
artery
▪Takeaserpentinecourseandlieextrapericardially
▪Terminateinthedorsalaorta,orthroughthesixtharchintothe
pulmonaryarteryorarteries
ProposedInterpretationofReportedCases
ImplicatingFifthArchArtery
▪Double-barreledaorta
▪Noneofthecasesunequivocallyrepresentsthefiftharchartery.
▪Allthecasescanbebetterexplainedbythedorsalcollateral
channels.
▪Aortic-to-pulmonaryconnections
▪Onlyafewcaseswithterminationatpulmonaryarteryconfluence
qualifyforthelabeloffiftharchartery.
▪Extensiveremodelingofthearterialductprovidesanequallyvalid
explanation.
▪Anomalousoriginofthepulmonaryarteryfromtheascending
aortadoesnotrepresentpersistenceofthefiftharchartery.
▪Unusualformsofsystemic-to-pulmonaryarterialconnections
▪Tooinfrequenttodrawfirmconclusions.
▪Reportedcasesbetterexplainedasvariantofcommonarterial
trunkwithpulmonarydominance,oraspersistenceofarterial
duct.
▪Abnormalitiesofthebrachiocephalicarteries
▪Betterexplainedbyextensiveremoldingofaorticarchandits
branches.
Acknowledgments
Ourchapterisbasedheavilyontheaccountweprovidedofthefrequencyofthe
fiftharcharteryaspublishedinCardiologyintheYoung(2015;25:628–646),
togetherwiththesubsequentreportpublishedinAnnalsofPediatricCardiology
(2016;9:62–67).WearegratefultoDr.S.S.Kothari,Dr.AnitaSaxena,thelate
Dr.RajnishJuneja,Dr.SRamakrishnan,Dr.SanjivSharma,andDr.GurpreetS
Gulati,fromtheAllIndiaInstituteofMedicalSciences,NewDelhi,forhelping
uswiththeidentificationofcaseswithpotentialfiftharcharteries.
