Electrophysiological monitoring of the nonrecurrent inferior laryngeal nerve and radiological evaluation of concurrent vascular anomalies.

Purpose: The objective of this study was to characterize the electrophysiological characteristics of nonrecurrent inferior laryngeal nerves (NRILNs) that were dissected via intraoperative neuromonitoring (IONM) and concomitant vascular anomalies in patients with NRILNs. Methods: A retrospective analysis was conducted on 7865 patients who underwent thyroidectomy with IONM at three tertiary referral centers. The study included 42 patients in whom an NRILN was detected. IONM data and postoperative vocal cord (VC) examinations were recorded for all patients. The absence of an initial vagal EMG response and/or a short (<3.5 ms) latency period during the initial vagal stimulation or the inability to identify the RLN within the Beahrs triangle was considered highly suspicious for the presence of an NRILN. Postoperative cross-sectional imaging was performed in 36 out of 42 patients to assess any concurrent vascular anomalies. Results: The prevalence of NRILN was 0.53%. An NRILN was suspected due to EMG findings in 32 (76%) patients and the inability to identify the RLN within the Beahrs triangle in the remaining 10 (24%) patients. The mean right VN latency period was 3.05 ± 0.15 ms. The V1 latency period of the right VN was shorter than 3.5 ms in 39 (93%) and longer than 3.5 ms in 3 (7%) patients. One of these three patients with latency>3.5ms had a large mediastinal goiter. Transient VC paralysis occurred in one (2.4%) patient. Of the 36 patients with postoperative imaging data, 33 (91.4%) had vascular anomalies. All 33 patients had aberrant right subclavian arteries, and 13 (39.4%) also had accompanying additional vascular anomalies. Conclusion: The NRILN is an anatomical variation that increases the risk of nerve injury. Observation of an absent EMG response and/or a short latency period during the initial vagal stimulation facilitates the detection of an NRILN at an early stage of thyroidectomy in the majority of patients.

Association of Subclavian Steal Phenomenon with Prevalence of Contralateral Vertebral Artery Atherosclerotic Stenosis: A Hospital-Based Cohort Study.

AIMS: It is uncertain if there is a connection between subclavian steal phenomenon (SSP) and atherosclerotic stenosis in the opposite vertebral artery (VA). We aimed to explore the association between SSP and the incidence of contralateral vertebral artery stenosis (VAS) in vivo. METHODS: In this prospective registry study, we included patients diagnosed with ＞50% stenosis of proximal subclavian artery (SA) or innominate artery (INA) by digital subtraction angiography (DSA) from our comprehensive stroke center between 2011 and 2022. VAS and SSP was diagnosed by DSA in the resting state. Propensity score matching (PSM) was conducted among all participants and subgroups with a 1:1 ratio according to the presence of SSP. We further conducted sensitivity analysis by dividing all participants into subgroups according to the degree of stenosis and type of SSP. Binomial logistic regression analysis was applied to investigate the association of SSP with contralateral VAS. RESULTS: A total of 774 patients were included in this study and 309 (39.9%) were found with SSP. After PSM, presence of SSP was associated with lower prevalence of contralateral VAS among all participants (OR 0.45; 95% CI 0.31-0.65; p＜0.001). In subgroup analysis, the association was respectively found within left subclavian (LSA) stenosis group (OR 0.43; 95% CI 0.29-0.65; P＜0.001) and right subclavian artery (RSA) / INA stenosis group (OR 0.36; 95% CI 0.19-0.69; P=0.002). CONCLUSIONS: SSP is associated with lower prevalence of contralateral VAS.

Current Advances in Diagnostic and Treatment Approaches for Subclavian Steal Syndrome: A Case Report and Review of the Literature.

With newly created therapy devices and cutting-edge diagnostic techniques, we successfully diagnosed and treated subclavian steal syndrome in this case report. This case report is complemented by a literature review that examines the current state of knowledge about diagnostic and treatment options. The patient reported pain and numbness in his left upper arm when raising his arm above his head. On clinical examination, he had good left radial and ulnar pulses while in a sitting position; however, he had absent left ulnar pulses when he raised his hand above his head. Angiography revealed retrograde perfusion of the left vertebral artery and nearly complete occlusion of the ostium of the left subclavian artery. The patient underwent angioplasty and stenting. Immediately after the procedure, the patient reported a reduction in the pain and numbness in his left upper limb by 50%, which completely disappeared at his routine follow-up after one month. The patient was completely asymptomatic during follow-up and had no signs of neurological deficit.

CT Angiography for Aortic Arch Anomalies: Prevalence, Diagnostic Efficacy, and Illustrative Findings.

Aortic arch anomalies encompass a diverse spectrum of conditions. Elucidating the prevalence of these anomalies, their impact on patient wellbeing, and the most effective diagnostic tools are crucial steps in ensuring optimal patient care. This paper aims to explore the various presentations of aortic arch anomalies, emphasizing the remarkable utility of computed tomography (CT) angiography in their definitive diagnosis and characterization. We conducted a retrospective study on patients who were submitted to the CT angiography of the thoracic aorta or supra-aortic trunks, or the contrast-enhanced CT scans of the thorax and/or cervical region between January 2021 and February 2024 in our Hospital. Out of the total of 2350 patients, 18 were diagnosed with aortic arch anomalies, with an average age of approximately 55 years. The aortic arch anomalies identified in the study were as follows: left aortic arch with the aberrant origin of the right subclavian artery, right aortic arch (types I and II), double aortic arch, aortic coarctation, aortic pseudocoarctation, and ductus diverticulum. Although often asymptomatic, aortic arch anomalies require recognition and CT using advanced post-processing techniques is the optimal diagnostic method with the ability to also identify other associated cardiac or vascular malformations.

Radiological diagnosis and emergency endovascular management, and follow-up of a unruptured right subclavian artery aneurysm in an elderly patient: A case report.

Right subclavian artery aneurysms are rare vascular anomalies that can present significant diagnostic and management challenges, especially in elderly patients. We present a case of a 72-year-old female who presented with sudden onset chest pain and was diagnosed with an unruptured right subclavian artery aneurysm with partial thrombus formation. Advanced imaging, including chest X-ray and contrast-enhanced CT scan, confirmed the diagnosis and guided a successful endovascular repair, stabilizing the patient. Follow-up care included regular clinical assessments and imaging studies to monitor the aneurysm's status and detect potential complications. This case underscores the critical role of early radiological diagnosis and prompt intervention in managing subclavian artery aneurysms, highlighting the effectiveness of endovascular techniques in such cases.

Right-sided Aortic Arch with Aberrant Left Subclavian Artery arising from Kommerell's Diverticulum: A case report.

Right-sided aortic arch, first documented by Fioratti and Aglietti in 1763, is a rare variant of the thoracic vascular anatomy present in about 0.1% of the adult population. In half of these cases the left subclavian artery is also aberrant. The aberrant left subclavian artery usually originates from a conical dilatation near its origin from the aorta also known as "Kommerell's diverticulum." Fewer than 80 of these cases have been reported in the literature as far as our web search is concerned. It is usually asymptomatic and diagnosed incidentally during adulthood. We are presenting a 56 years old male patient presented with right side chest and shoulder pain of 1 week duration. The pain exacerbated with motion of the right upper extremity and radiates to his lower back. However, he had no history of cough, shortness of breath, syncope, and dysphagia. The vital signs were in normal range. Pulmonary and cardiovascular exam were unremarkable. The complete blood count (CBC), electrocardiogram (EKG), and echocardiography showed no abnormality. In the adult population a right-sided aortic arch with an aberrant left subclavian artery arising from Kommerell's diverticulum is a rare occurrence often asymptomatic unless aneurysmal disease or compression of mediastinal structures ensues. Even though it is rare and at times an incidental finding, the condition is clinically relevant because of the morbidity caused by the complications. We report a case of Kommerell's Diverticulum of an aberrant left subclavian artery in an adult patient with a right-sided aortic arch. Right-sided aortic arch with aberrant left subclavian artery arising from Kommerell's Diverticulum is quite rare and may remain asymptomatic. On times it may cause symptoms in adulthood often as a result of early atherosclerotic changes of the anomalous vessels, dissection, or aneurysmal dilatation with compression of adjacent structures causing dysphagia, dyspnea, cough, or chest pain. Even though there are no general guidelines for the management of this condition patients need to be informed about the nature and possible outcomes of their condition. Close follow up of asymptomatic patients is one option of management until there are situations which require consideration of surgical intervention.

A Unique Association of Right-Sided Aortic Arch With Kommerell's Diverticulum, Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia, and Typical Carcinoid: A Case Report.

Our case presents a unique occurrence marking the first documentation of a connection between a typical carcinoid in the context of diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) and vascular anomalies, including a right-sided aortic arch with Kommerell's diverticulum. Kommerell's diverticulum is a rare congenital anomaly. The lusoria subclavian artery, another developmental anomaly, arises from the right aortic arch instead of the typical left side. Neuroendocrine cells may contribute to lung disease pathogenesis by altering their physiology before clinical symptoms appear. A 56-year-old woman with an unyielding chronic cough underwent diagnostic evaluation, unveiling rare vascular anomalies alongside a pulmonary nodule. Radiological investigations disclosed a solid nodule in the middle lobe, accompanied by proximal right-sided aortic arch ectasia and an aberrant left subclavian artery. Following multidisciplinary deliberation, thoracic and vascular surgeons elected for surgical nodule resection. Utilizing uniportal video-assisted thoracoscopic surgery, the procedure revealed the anomaly of the right-sided aortic arch. Preliminary histological examination indicated a low-grade pulmonary carcinoid, obviating the need for further lymphadenectomy due to its low malignancy potential. Subsequent histological analysis confirmed a well-differentiated neuroendocrine tumor G1 consistent with typical carcinoid within a DIPNECH framework. Currently, the patient is in follow-up. This case underscores the importance of multidisciplinary evaluation and tailored surgical approaches for managing patients with rare vascular anomalies and pulmonary nodules, emphasizing the requisite comprehensive preoperative assessment and collaborative efforts among diverse medical specialties to optimize outcomes.

Subclavian Artery Injury During Lung Tumor Resection.

An open penetrating injury of the subclavian artery is an extremely rare catastrophic situation in thoracic surgery. We experienced a 57-year-old case of iatrogenic subclavian artery injury during the resection of a lung tumor. The injury occurred during the dissection of the adhesion between the stapling site of the previous bullectomy and the chest wall. Systolic blood pressure dropped below 50 mmHg immediately after the injury. Following primary hemostasis achieved with suture closure, the site of injury was sufficiently exposed and successfully repaired.

Navigating the Unexpected: Dysphagia Lusoria Complicates Severe Pneumonia With Parapneumonic Effusion.

Managing pneumonia, especially when complicated by underlying anatomical anomalies, presents unique challenges that require a nuanced and multidisciplinary approach. Dysphagia lusoria, a rare vascular anomaly where the right subclavian artery originates aberrantly, can coexist with other thoracic conditions, complicating both diagnosis and treatment. Understanding the interplay between such anomalies and common infections like pneumonia is crucial for optimal patient outcomes. This case report describes a 33-year-old male with a history of recurrent pneumonia in the past who presented to the emergency department (ED) with right flank pain and dyspnea persisting for one week. Initial investigations revealed moderate parapneumonic pleural effusion and right lower lobe pneumonia. At the time, an aberrant origin of the right subclavian artery (ARSA) (dysphagia lusoria) was incidentally detected on imaging. The patient's management included antibiotic therapy tailored for pneumonia and the placement of a chest tube for pleural effusion drainage. Despite intermittent dysphagia, surgical intervention for dysphagia lusoria was deferred due to its minimal impact on daily functioning. The patient improved significantly with supportive care and antibiotics, highlighting the complexity of managing pneumonia complicated by anatomical anomalies. This case underscores the importance of multidisciplinary management and tailored treatment strategies in addressing intricate clinical scenarios.

Preliminary experience of the isolate left subclavian artery in-situ fenestration during 'zone 2' thoracic endovascular aortic repair.

OBJECTIVES: To evaluate the results of isolated left subclavian artery in-situ fenestration (ISF) during 'zone 2' thoracic endovascular aortic repair (TEVAR) using a new adjustable needle puncturing device system. METHODS: It is a multicentre, retrospective, physician-initiated cohort study of patients treated from 28 July 2021 to 3 April 2024. Inclusion criteria were isolate left subclavian artery revascularization for elective or urgent/emergent 'zone 2' TEVAR. The primary outcome was technical success and freedom from ISF TEVAR-related reintervention or endoleak. RESULTS: We treated 50 patients: 28 (56.0%) atherosclerotic thoracic aneurysms, 12 (24.0%) type B aortic dissection and 10 (20.0%) penetrating aortic ulcers. Elective intervention was carried out in 46 (92.0%) cases. ISF was successful in all cases, with a procedural primary technical success in 47 (94.0%) cases. The median time of intervention was 184 min (interquartile range 135-220) with a median fenestration time of 20 min (interquartile range 13-35). Operative mortality did not occur. We observed 1 case of spinal cord ischaemia and 2 cases of bilateral posterior non-disabling stroke. Mortality at 30 days occurred in 1 (2.0%) patient (not aorta-related). The median follow-up was 4 months (interquartile range 1-12.25). Bridging stent graft patency was 100% with no ISF-related endoleak. ISF-related reintervention was never required. CONCLUSIONS: ISF TEVAR using the Ankura™-II device with the self-centring adjustable needle system showed high technical success, promising stability and stable aortic-related outcomes. Owing to these results, it represents a safe and effective alternative for standard 'zone 2' TEVAR.

A rare subclavian artery aneurysm potentially misidentified as the internal jugular vein in ultrasound-guided central venous catheterization-a case report.

Background: Central venous catheterization by anesthesiologists carries risks such as accidental arterial puncture. This case report highlights a rare subclavian artery aneurysm (SAA) detected during ultrasound-guided internal jugular vein (IJV) access, emphasizing the importance of recognizing anatomical variations. Case: An 88-year-old female with hypertension and atrial fibrillation was scheduled for lumbar laminectomy and posterior fusion. Preoperative evaluation revealed right lower lobe atelectasis and mild aortic sclerosis. During ultrasonography for right IJV catheterization, two vessels of different diameters were observed on the common carotid artery's (CCA's) lateral side. The larger vessel disappeared at the upper neck level, showing arterial pulsation on Color Doppler. Postoperative neck computed tomography confirmed a right SAA and a 5-mm saccular aneurysm in the left intracranial artery. The patient had no vascular disease, trauma, or relevant family histories. Conclusions: Anesthesiologists should be aware of anatomical variations during IJV catheterization. Ultrasound with Doppler is crucial for accurate artery identification.

Bow Hunter Phenomenon From Advanced Cerebrovascular Disease Treated With Subclavian Artery Stenting and Carotid Endarterectomy.

Bow Hunter syndrome (BHS) is a rare disorder characterized by mechanical occlusion of the vertebral artery (VA) during neck rotation, resulting in symptomatic, transient, and positional vertebrobasilar insufficiency. We describe a case of a 76-year-old female who presented with dizziness and right ear tinnitus triggered by right head rotation. Her symptoms would immediately resolve upon returning her head to the neutral position. CT angiogram showed 80% stenosis of the left subclavian artery origin, 50%-70% stenosis of the proximal right internal carotid artery (ICA), and near occlusive stenoses of the origins of the bilateral VAs. After failing conservative management, the patient was treated with left subclavian artery stenting, followed by a right carotid endarterectomy (CEA) 6 weeks later. Follow-up at 1 month showed resolution of paroxysmal symptoms and no neurological sequelae. To our knowledge, there have not yet been reported cases of patients with concurrent BHS, subclavian artery stenosis, and carotid artery stenosis. We suggest that global revascularization via subclavian artery stenting and CEA may be considered as treatment for patients with BHS complicated by other cerebrovascular disease secondary to stenoses of the ICA and subclavian artery. This approach obviates the need for more complex surgery or endovascular intervention of the VA.

Development and Multicenter, Multiprotocol Validation of Neural Network for Aberrant Right Subclavian Artery Detection.

PURPOSE: This study aimed to develop and validate a convolutional neural network (CNN) that automatically detects an aberrant right subclavian artery (ARSA) on preoperative computed tomography (CT) for thyroid cancer evaluation. MATERIALS AND METHODS: A total of 556 CT with ARSA and 312 CT with normal aortic arch from one institution were used as the training set for model development. A deep learning model for the classification of patch images for ARSA was developed using two-dimension CNN from EfficientNet. The diagnostic performance of our model was evaluated using external test sets (112 and 126 CT) from two institutions. The performance of the model was compared with that of radiologists for detecting ARSA using an independent dataset of 1683 consecutive neck CT. RESULTS: The performance of the model was achieved using two external datasets with an area under the curve of 0.97 and 0.99, and accuracy of 97% and 99%, respectively. In the temporal validation set, which included a total of 20 patients with ARSA and 1663 patients without ARSA, radiologists overlooked 13 ARSA cases. In contrast, the CNN model successfully detected all the 20 patients with ARSA. CONCLUSION: We developed a CNN-based deep learning model that detects ARSA using CT. Our model showed high performance in the multicenter validation.

Vascular Ring Surgical Repair: Re-Implantation of the Left Subclavian Artery into the Left Carotid Artery in a Pediatric Patient.

Vascular rings are a rare congenital anomaly of the aortic arch, in which a ring-shaped structure forms, surrounding the trachea and/or esophagus, potentially causing compression. We describe the case of a 14-month-old female patient with failure to thrive secondary to dysphagia, and a vascular ring formed by a right aortic arch, an aberrant left subclavian artery, and a left ligamentum arteriosum. Surgical repair involved ligamentum arteriosum division, Kommerell's diverticulum obliteration, and left subclavian artery re-implantation into the left carotid artery. Endoscopy and EndoFLIPTM evaluated the intraoperative improvement in esophageal narrowing and impedance, respectively. The postoperative period was uneventful, and follow-up visits demonstrated dysphagia resolution and a patent re-implanted left subclavian artery.

[Single Center Experience in Surgical Treatment of Extracranial Supra-Aortic Aneurysms].

Objective To evaluate the effect of surgical treatment on extracranial supra-aortic aneurysms and summarize the experience. Methods The clinical data of 10 patients undergoing surgical treatment of extracranial supra-aortic aneurysms from May 2019 to November 2023 in the Department of Vascular Surgery of Beijing Tiantan Hospital affiliated to Capital Medical University were collected.The 10 patients included 5 patients with internal carotid artery aneurysm,2 patients with subclavian artery aneurysm,2 patients with vertebral artery aneurysm,and 1 patient with internal carotid artery aneurysm combined with ipsilateral subclavian artery aneurysm.The surgical indications,surgical regimens,clinical efficacy,and complications were retrospectively analyzed. Results All the 10 patients underwent surgery successfully,with the surgery duration range of 60-420 min and the median surgery duration of 180.0 (121.5,307.5) min.Intraoperative bleeding volume varied within 30-400 mL,with a median of 90 (50,125) mL.The time of carotid artery blocking and vertebral artery blocking varied within the ranges of 10-20 min and 20-30 min,with the medians of 15.0 (11.5,16.3) min and 25.0 (15.0,22.5) min,respectively.No cardiac accident,cerebral infarction,or cerebral hemorrhage occurred during the perioperative period.The 10 patients were followed up for 3-58 months,with the median follow-up time of 8.5 (5.3,17.0) months.One patient with subclavian artery aneurysm developed artificial vessel occlusion 20 months after surgery.One patient with internal carotid artery aneurysm developed distal carotid artery stenosis 6 months after surgery. Conclusion Surgical treatment should be actively adopted for extracranial supra-aortic aneurysms,and individualized surgical regimens should be designed according to patient conditions.

Incidental Finding of Arteria Lusoria.

The arteria lusoria or retroesophageal right subclavian artery is the most common malformation of the aortic arch. It may be discovered with some symptoms of airway and/or esophageal compression, such as dyspnea or dysphagia, but in most cases it is an asymptomatic pathology. We report a case of a 3 months old patient diagnosed with Down syndrome who was admitted for pulmonary infection with incidental finding of retrooesophageal right subclavian artery.

Unusual morphology of an aberrant right subclavian artery: a case report and systematic review of cadaveric studies .

BACKGROUND: An aberrant right subclavian artery (ARSA) is a rare vascular anomaly defined by the origin of the right subclavian artery from the aorta, distal to the left subclavian artery (LSA). An ARSA was found in an 83-year-old female during cadaveric dissection for anatomy teaching, which had an unusually narrow lumen compared to previously reported cases. MATERIALS AND METHODS: The specific morphology of this ARSA variant was characterised by further dissection and measurements. A systematic review of cadaveric case reports with quantitative evaluation of ARSA dimensions was conducted for comparison with this case. RESULTS: This ARSA variant exhibited an unusually narrow lumen (8.22 mm²) compared to the LSA (152.55²), with an ARSA: LSA ratio of 0.24. The systematic review included 17 studies with 23 cases of ARSAs. Of these cases, 20 contained details of ARSA diameter, 19 of which were wider than in this case. In all studies where both ARSA and LSA diameters were measured, ARSA was found to be significantly wider than LSA (mean ratio of ARSA to LSA: 1.49, range: 1.09-2.00). Several other variations were reported in these studies, such as concomitant aortic arch branch anomalies and differing origins of ARSA as defined by vertebral level and relation to the aortic arch. CONCLUSIONS: This case report presents an unusually narrow ARSA which has not been previously described in the literature. As there is limited evidence on how ARSA morphology affects clinical outcomes, further research is needed to better inform management of ARSAs.

Hemodynamic changes for half cover left subclavian artery ostium during thoracic endovascular aortic repair.

Purpose: Some clinicians use endografts to cover half the left subclavian artery (LSA) ostium to cure some cases with insufficient proximal landing zone (PLZ) in thoracic endovascular aortic repair (TEVAR) treatment. We used computational fluid dynamics (CFD) to study the hemodynamic changes in the LSA because they may cause acute thrombosis or arteriosclerosis. Methods: The digital model of the aortic arch was established and named model A, which only included the supraarch branch of the LSA. By directly covering half of the LSA ostium, which was named as model B. All established models were imported into the Gambit grid division software for grid division and were subsequently imported into the Fluent software for hemodynamic numerical simulation and calculation to analyze the related changes in LSA hemodynamic parameters after stent implantation. Results: Under the same aortic inlet flow, in model B, the local blood flow velocity of the LSA ostium increased and the whole blood flow velocity at the distal end decreased. The average wall shear stress (WSS) of the LSA was significantly decreased. Meanwhile there was an obvious turbulent flow in the LSA lumen, and the related blood flow state was disordered. Conclusion: CFD research confirmed that the implantation of an endograft covering half the LSA ostium can cause obvious hemodynamic changes, which is likely to cause a long-term arteriosclerosis or acute thrombosis of the LSA, finally increasing the risk of stroke. Once this operation is performed in some specific clinical cases for simplicity and economy, it seems that we should actively antiplatelet and follow up regularly.

First-in-men experience with a novel frozen elephant trunk prosthesis featuring an endovascular side branch for left subclavian artery connection.

OBJECTIVES: The objective of this study was to enhance the efficiency of aortic arch replacement through the development of a novel frozen elephant trunk (FET) prosthesis with an endovascular side branch for left subclavian artery (LSA) connection. After successful pre-clinical testing, the feasibility and safety of implementing this innovative prosthesis in human subjects were investigated. METHODS: Between September 2020 and September 2021, 4 patients (mean age 67) with conditions such as penetrating ulcer, non A-non B aortic dissection and chronic arch aneurysm underwent surgery utilizing the customized device. Surgeries were performed under high moderate hypothermia (27°C), employing bilateral selective antegrade cerebral perfusion (SACP) and distal aortic perfusion. Anastomosis of the FET prosthesis with the aortic arch occurred in zone 1, followed by separate reimplantation of the left common carotid artery and the brachiocephalic artery. RESULTS: All patients were discharged in good clinical condition. The mean aortic cross-clamp, antegrade selective cerebral perfusion and distal aortic perfusion times were 111, 71 and 31 min, respectively. Endovascular extension of the side branch for the LSA was required in all cases to prevent endoleak formation. One patient received a stent graft extension at the end of the operation, while 2 others underwent the procedure during their hospital stay. One patient was diagnosed with an endoleak at the first follow-up after 3 months, and endoleak sealing was achieved via the brachial artery with an extension stent graft. CONCLUSIONS: Preliminary clinical outcomes suggest that the newly designed FET prosthesis shows promise in simplifying total arch replacement. These initial findings provide a foundation for planned clinical studies to further assess the effectiveness of this modified surgical hybrid graft, with particular attention to the length and diameter of the LSA sidearm.

Factors Affecting Compression of the Left Subclavian Artery Bridging Stent In Zone 2 Fenestrated Endovascular Arch Repair.

INTRODUCTION: Left subclavian artery (LSA) preservation during thoracic endovascular aortic repair (TEVAR) has been related to low morbidity. This study investigated the incidence of LSA stent compression in patients managed with fenestrated endovascular arch repair (f-Arch) and evaluated the impact of anatomic and technical factors on LSA stent outcomes. METHODS: A single-center retrospective analysis of patients managed with single-fenestration devices (Cook Medical, Bloomington, IN, USA) for LSA preservation, between January 1, 2012 and November 30, 2023, was conducted. Anatomic (arch type, bovine arch, distance between the LSA and most proximal bone structure, left common carotid artery and aortic lesion, take-off angle, diameter, thrombus, calcification, dissection, tortuosity) and technical parameters (stent type, diameter, length, relining, post-dilation) were evaluated. Stent compression was any ≥50% stenosis (using center luminal line) of the stent compared with its initial diameter. Clinical outcomes included stroke and upper limb ischemia at 30 days and follow-up. Technical outcomes included stent compression and need for reintervention. RESULTS: Fifty-four cases were included. Only balloon-expandable covered stents were used, and relining during the index procedure was performed in 18%. No stroke or arm ischemia was recorded. One stent compression was detected at 30 days. During follow-up, no stroke or arm ischemia was diagnosed. Nine cases (18%) presented stent compression, with a mean time of stent-compression diagnosis at 18 months (interquartile range [IQR]=37, range=1-58 months) after the index procedure. Five (56%) underwent secondary relining. Follow-up after reintervention was uneventful. Lower distance to the nearest bone structure (compression group [CG]: 11.7±8.9 mm vs non-compression group [NCG]: 23.0±7.8 mm, p=0.003) and higher tortuosity index (CG: 1.3±0.4 vs NCG: 1.2±0.1, p=0.03) were associated with LSA stent compression. CONCLUSION: LSA stent compression in patients managed with f-Arch affected 1 in 5 cases, without clinical consequences. Distance to the nearest bone structure and higher tortuosity were associated with LSA stent compression. CLINICAL IMPACT: Fenestrated endovascular arch repair for the preservation of the left subclavian artery (LSA) in patients needing landing within the aortic arch has been performed with encouraging outcomes. This analysis showed that LSA stent compression is met in 18% of patients, without though any clinical consequence. Pre-operative anatomic parameters, as lower distance to the nearest bone structure and higher tortuosity index affect negatively LSA stent performance while stent parameters seem to have no impact.