Cardiac neural crest cells, which are subset of neural crest cells, contribute to outflow tracts septation, and development of ventricular septum, cardiac valves, and pharyngeal arch arteries. Normal aortic arch development requires an accurate and stepwise remodeling of the various pharyngeal arch arteries that involve elongation, sprouting/splitting, and regression. This resulted in 2-point collateralization with the left vertebral and external carotid arteries. Left external carotid artery branches fill from the hypoplastic left common carotid artery (LCCA) which is diminutive in size through the supraclinoid segment. A hypertrophied left paraspinal artery (short white arrows in Fig. 2 c and d) communicates with left posterior auricular artery, a branch from left external carotid artery. The collateral artery gives off branches to supply the nondominant and hypoplastic left vertebral artery at the lower neck (arrow in Fig. 3c). A moderate sized vessel arises from the left posteromedial wall of the aortic arch (wide black outlined arrow in Fig. 2b and arrow heads in Fig. 2c and d) inferiorly and from the left side which ascends superiorly as a single mediastinal collateral artery (arrows in Fig. 3b, d, e), and provides many collaterals at the left lower neck. The right vertebral artery, which is dominant and hypertrophied, arises from RSA. The second branch vessel from the aorta is the right subclavian artery (RSA). The most anterior branch or the first branch arises from the aorta is the right common carotid artery (RCCA). The origin of left BCA is interrupted from aorta for 3.8 cm (wide arrows in Figs. 2a, c, and d and and3a). Findings included a right sided aortic arch with an ILBA ( Fig. 2). The CTA revealed an abnormal branching pattern of the aortic arch and its great vessels. Further evaluation with a CT angiography (CTA) of the head and neck was obtained. The left vertebral artery showed tardus parvus and a high resistance waveform with retrograde flow. Carotid ultrasound duplex revealed elevated velocities in the right internal carotid artery of 210/78 cm/s and tardus parvus waveforms throughout the left carotid artery. The renal ultrasound was negative for renal artery stenosis or renal parenchymal abnormalities. Renal and carotid ultrasound duplex were obtained as initial workup for hypertension and observed right carotid bruit. The patient's physical examination was normal apart from a right carotid bruit. The patient had no prior history of smoking. The patient denied any history or current symptoms of stroke, transient ischemic attack symptoms, specifically, neither focal arm or leg weakness, slurred speech, and nor facial droop. The patient had a family history of systemic hypertension. A 35-year-old female presented with a recent diagnosis of hypertension.
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