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A combination of absent brachiocepahlic trunk and anomalous left circumflex artery with a retro-esophageal right subclavian artery is an extremely rare finding. This can clinically manifest as episodic dysphagia and chest pain. Routine coronary angiography via femoral access could be misleading and right radial access in such cases can be particularly challenging and has never been reported in literature before.  We present a case of a 42-year-old female with symptoms of chest, back, and left neck pain. She also complained of occasional dysphagia, dizziness, and palpitations. Physical examination revealed a regular heart rhythm with no vascular bruits. An electrocardiogram (EKG) only showed normal sinus rhythm and incomplete right bundle branch block. Noninvasive testing included an echocardiogram and previously done exercise stress test, and myocardial perfusion scans were noted to be normal. A diagnostic cardiac catheterization via right radial approach was performed to delineate her coronary anatomy and rule out ischemic etiology. This led to diagnosis of anomalous coronary anatomy (retro-esophageal right subclavian artery arising from descending aorta in association with an anomalous right circumflex artery with absent innominate artery) through a technically difficult and risky procedure. Significant vessel tortuosity and abnormal catheter angulations were encountered and were overcome by using specific catheters. Meticulous use of 6 French MP, WR, JL, and JR4 catheters along with an exchange length wire was required to negotiate the anatomical variations and complete the coronary angiogram via right radial artery.  From a procedural stand-point, coronary angiography via right radial access in presence of such rare anatomical variations can be particularly challenging. Routine femoral catheterization may fail to depict this important anatomical variation.  Coronary angiogram via right radial access in the presence of a combination of anatomical variations of great vessels and anomalous coronary arteries is particularly challenging from a procedural stand point due to vessel tortuosity and shape of catheters. Choice of anatomically appropriate diagnostic catheters and specific maneuvers are imperative in these coronary angiographic procedures.

Diagnostic Challenge in a Symptomatic Patient of Arteria Lusoria with Retro-esophageal Right Subclavian Artery and Absent Brachiocephalic Trunk