A combined endovascular and open repair of innominate artery bifurcation pseudoaneurysm: a case report.

BACKGROUND: Innominate artery aneurysms (IAAs) are rare and may result in rupture, distal arterial embolization, or local compression without timely treatment. Rupture is the most dangerous of these complications. This article reports a case of innominate artery bifurcation pseudoaneurysm. CASE PRESENTATION: The patient was a 45-year-old man who was admitted to the emergency department due to chest discomfort. The computed tomographic angiography (CTA) imaging indicated the presence of a 3.6*2.4 cm saccular aneurysm in the bifurcation of the innominate artery, involving both the right proximal subclavian and common carotid arteries. The patient's vital signs were normal, there was equal blood pressure in the upper arms and no neurological dysfunction was observed. Gadolinium-enhanced magnetic resonance angiography indicated that the circle of Willis was intact. The treatment involved open surgery combined with endovascular therapy. The external carotid artery was first transposed to the right subclavian artery (RSA) and an 8-mm woven Dacron graft was inserted in the middle. The covered stent graft was then placed in the proximal part of the innominate artery to close the entrance of the aneurysm. Lastly, an occluder was implanted at the origin of the RSA. There were no perioperative or postoperative complications. At 1-year follow-up, no aneurysm was observed on CTA and the right vertebral artery was patent. CONCLUSIONS: This study indicated that the combined use of endovascular therapy and open repair surgery is an effective strategy to treat innominate artery bifurcation pseudoaneurysm.

Color Duplex Ultrasonography for the Evaluation of Innominate, Subclavian, and Common Carotid Artery Stenosis.

OBJECTIVE: This study aimed to validate the efficiency of Doppler ultrasonography for predicting the innominate, subclavian, and common carotid artery stenosis. METHODS: This retrospective multicenter study between 2013 and 2022 enrolled 636 patients who underwent carotid Doppler ultrasonography and subsequent digital subtraction angiography. And 58 innominate artery stenosis, 147 common carotid artery stenosis, and 154 subclavian artery stenosis were included. The peak systolic velocity at innominate, subclavian, and common carotid artery, and velocity ratios of innominate artery to common carotid artery, innominate artery to subclavian artery, and common carotid artery to internal carotid artery were measured or calculated. The threshold values were determined using receiver operating characteristic analysis. RESULTS: The threshold values of innominate artery stenosis were peak systolic velocity >206 cm/s (sensitivity: 82.8%; specificity: 91.4%) to predict ≥50% stenosis and >285 cm/s (sensitivity: 89.2%; specificity: 94.9%) to predict ≥70% stenosis. The threshold values of common carotid artery stenosis were peak systolic velocity >175 cm/s (sensitivity: 78.2%; specificity: 91.9%) to predict ≥50% stenosis and >255 cm/s (sensitivity: 87.1%; specificity: 87.2%) to predict ≥70% stenosis. The threshold values of subclavian artery stenosis were peak systolic velocity >200 cm/s (sensitivity: 68.2%; specificity: 84.4%) to predict ≥50% stenosis and >305 cm/s (sensitivity: 57.9%; specificity: 91.4%) to predict ≥70% stenosis. CONCLUSIONS: Symptomatic patients with ultrasonic parameters of velocity at innominate artery ≥206 cm/s, velocity at common carotid artery ≥175 cm/s, or velocity at subclavian artery ≥200 cm/s need to be considered for further verification and whether revascularization is necessary.

A thyroidea ima artery variation providing collateral circulation to the mediastinum.

The thyroidea ima artery (TIA) is a highly variable arterial deviation of the blood supply to the thyroid gland with critical implications for surgical neck procedures such as tracheostomy. Though relatively common in the population at large (~ 4%), most TIA variations are related to the origin of the artery and whether it emerges from the common sites of the brachiocephalic trunk, aortic arch, and right common carotid artery, or another more unique vessel-as opposed to its dispersion pattern. TIA variants generally supply the thyroid gland, occasionally co-occurring with absent thyroid arteries. Here, we report on a unique case of a four-pronged variation of the TIA discovered during an anatomy laboratory dissection of first-year medical students. This variant originated from the brachiocephalic trunk and had three branches terminating in the thyroid gland and a fourth branch traveling into the thorax to provide accessory circulation in the mediastinum. Specifically, small arterial branches from the inferior TIA branch supplied the anterior pericardium and surrounding adipose tissue, in addition to normal pericardiacophrenic circulation. We discuss the potential embryological and clinical relevance of this unique variation and voice further support for imaging as a requirement before surgical neck procedures to prevent catastrophic bleeding in the event of a TIA variant.

Right-sided aortic arch with isolation of the left innominate artery and hypoplasia of the left internal carotid artery.

PURPOSE: Here, we report a case of the right-sided aortic arch with isolation of the left innominate artery and hypoplasia of the left internal carotid artery. METHODS: A 42-year-old male patient underwent a whole-body computed tomography angiography (CTA) examination upon the clinical suspicion of vasculitis. RESULTS: CTA revealed a right-sided aortic arch with the isolation of the left innominate artery and hypoplasia of the left internal carotid artery. CONCLUSION: The right-sided aortic arch, with the isolation of the left innominate artery, is a scarce vascular variation that may occur with other cardiovascular anomalies such as ventricular septal defect. It can be asymptomatic or can present with symptoms of subclavian steal syndrome. Although its association with the agenesis of the left internal carotid artery has been reported, its association with the hypoplasia of the left internal carotid artery has not been reported previously to the best of our knowledge.

[Repair of Traumatic Brachiocephalic Artery Pseudoaneurysm by Open Surgery:Report of a Case].

The patient is a 56-year-old man. He fell while playing golf and sustained a contusion on his right chest. He fell into hemorrhagic shock during surgery for a right clavicle fracture at a nearby hospital and required cardiac resuscitation. Computed tomography( CT) scan revealed left pneumothorax and right hemothorax, and a contrast-enhanced CT scan revealed a pseudoaneurysm at the brachiocephalic artery origin. He underwent surgery three weeks later. Surgery was performed through a median sternotomy and partial arch replacement (zone 2) with antegrade cerebral perfusion under moderate hypothermia. He was discharged on postoperative day 10 without significant complications.

Clinical outcomes of a balloon-expandable stent for symptomatic obstructions of the subclavian or innominate arteries.

Background: Upper-extremity peripheral arterial disease (PAD) may present with a broad spectrum of signs and symptoms. If an endovascular treatment is planned, percutaneous angioplasty and stent placement may lead to a better patency compared to percutaneous angioplasty alone. We assessed the characteristics and clinical course of patients with upper-extremity PAD who received angioplasty and a balloon-expandable stent. Patients and methods: We analyzed data from consecutive patients treated with angioplasty and placement of a balloon-expandable BeSmooth Peripheral Stent System® (Bentley, Germany) at the Angiology Department (University Hospital Zurich) between 2018 and 2022. The primary outcome was re-intervention at the target lesion within 6 months from index angioplasty and during available follow-up. The study was approved by the local ethical commission. Results: A total of 27 patients were treated. The median age was 70 (Q1-Q3: 60-74) years and 59% were men. The subclavian artery (74%) represented the most frequently treated target lesion, followed by the innominate artery (26%). The mean improvement in blood pressure in the treated arm was 21 (95%CI 7 to 35) mmHg at 24 hours and 29 (95%CI 15 to 43) mmHg at 6 months. At 6 months, 2 (8%) patients required a target lesion re-intervention. During the remaining follow-up period up to 24 months, one of these two patients required additional intervention and a total of 3 (11%) patients died due to sepsis, cancer, and unknown causes, respectively. Conclusions: Percutaneous catheter-based treatment with a balloon-expandable stent for symptomatic upper extremity PAD appeared to be effective and safe.

The combined intrathyroidal course of the brachiocephalic artery, right common carotid artery and right subclavian artery.

PURPOSE: We present an extremely rare vascular variant in which the brachiocephalic artery, right common carotid artery, and right subclavian artery course through the right lobe of the thyroid gland. METHODS: A 54-year-old woman underwent a coronary computed tomography (CT) angiography examination with the suspicion of infective endocarditis. RESULTS: Unexpectedly, the distal brachiocephalic artery, the proximal right common carotid artery, and right subclavian artery had a course through the right lobe of the thyroid gland. Otherwise, the arcus aorta branching pattern was normal. CONCLUSION: The supraaortic major branches seldom have intrathyroidal course. The intrathyroidal course of the right common carotid artery was described previously only in one case. But, to our best knowledge, the combined intrathyroidal course of these three major vessels has not been previously reported. Although asymptomatic, such variations may complicate lower neck procedures involving thyroidectomies and thyroid biopsies if undetected and unreported. So, the awareness of this atypical course while reporting CT examinations is crucial prior to neck interventions.

High-riding innominate artery in the neck: A hazardous presentation during surgery.

Aberrant innominate artery lying high in the neck is a rare entity that can be encountered intraoperatively during midline neck surgeries such as thyroidectomy and tracheostomy. Surgeons should be mindful of this entity as injury to the artery can lead to life-threatening haemorrhage. We report a case of a 40 year old female in whom an aberrant innominate artery was identified high in the neck, while performing a total thyroidectomy.

Presentation, Diagnosis and Management of Innominate Artery Thromboembolism.

PURPOSE: Acute thromboembolic disease of the innominate artery (IA) poses a unique set of therapeutic challenges, owing to its contribution to both the cerebral and upper extremity circulation, and risks of distal embolization via the carotid and subclavian arteries, respectively. Herein, we present a 74-year-old female who presents with acute IA thrombus treated successfully with right axillary and common carotid exposure and aspiration catheter-directed mechanical thrombectomy (CDT). Furthermore, an emerging use of CDT and its application in acute thromboembolism are outlined. CASE REPORT: A 74-year-old female with history of right lung transplant for pulmonary fibrosis with severe pulmonary hypertension, and stage IIIA left lung adenocarcinoma status post left lower lobectomy undergoing adjuvant chemotherapy presented with acute IA thrombus and right-sided stroke. She was treated successfully with right axillary and common carotid exposure and aspiration CDT. Computed tomography angiography performed 1 month postoperatively confirmed patent IA with no evidence of residual or recurrent thrombus. CONCLUSION: There are currently no standard guidelines on the management of acute IA thromboembolism, with mostly individual cases reported in the literature describing this rare entity. Nevertheless, this unique clinical entity mandates expeditious diagnostic and therapeutic approaches in order to avoid permanent neurologic deficits from distal embolization. Our case demonstrates that aspiration CDT may be an effective treatment modality for patients with acute IA thrombus.

Prenatal diagnosis of isolation of aortic brachiocephalic artery.

BACKGROUND: Isolated aortic brachiocephalic artery (IABA) is a rare congenital aortic arch anomaly. It is difficult to diagnose IABA prenatally and the prevalence in the prenatal population is unknown. PURPOSE: To evaluate the echocardiographic characteristics and associations in fetuses with IABA. MATERIAL AND METHODS: We retrospectively analyzed all cases of prenatal diagnosis of IABA from January 2012 to November 2020 and reviewed the follow-up results. Copy Number Variation Sequencing (CNV-Seq) was performed using the biological specimens of the of the fetuses and family members. RESULTS: Ten cases (10/45652, 0.022%) of IABA were identified in our center. The prevalence of the cases with isolated left subclavian artery (ILSCA) in the right aortic arch (RAA) population was 0.98% (6/613). The ILSCA was the most common isolated arch branch. All the isolated branches were on the opposite side of aortic arch in all the cases. The "ice stick" sign in the coronal section could be seen in most cases of IABA. Of the 10 cases, 8 (8/10, 80%) were associated with tetralogy of Fallot (TOF). Two cases of IABA were combined with 22q11.2 deletion syndrome. CONCLUSION: IABA is a rare aortic anomaly. ILSCA was the most common isolated arch branch and TOF was the most common associated intra-cardiac anomaly. The "ice stick" sign in the coronal section could indicate a diagnosis of the IABA.

Usefulness of stent placement for innominate artery stenosis via the right brachial artery under protection by balloon guide catheter: a technical case report.

A method of cerebral protection during endovascular treatment for innominate artery stenosis (IAS) has not been established. Herein, we report a case of symptomatic IAS in a 76-year-old woman. A balloon guide catheter (BGC) was inserted through the right brachial artery (BA) and guided distally to the stenosis. The BGC balloon was inflated, and stenting was performed with balloon protection of both the anterior and posterior cerebral circulation, without any complications. Stenting of the IAS with the BGC using the BA approach is useful, as it is a simple technique that can prevent distal embolization.

The value of color Doppler sonography in diagnosis and hemodynamic analysis of innominate artery occlusion.

The occlusion of the innominate artery caused a significant decrease in the distal end of the right subclavian artery and the right common carotid artery, internal carotid artery, and external carotid artery (ECA). Due to the different pressure and the abundant communicating arteries between the ECA and the bilateral vertebral artery (VA), different paths of blood steal in the anterior and posterior circulation occurred.

Right vertebral artery arising from the right common carotid artery with an absent brachiocephalic trunk.

The right and left vertebral arteries are the first branches of the ipsilateral subclavian arteries. However, in the presence of anatomical variation due to complex embryogenesis, the vertebral artery can arise directly from the aortic arch or any of its major branches. The atypical origin of the vertebral artery is commonly associated with the left vertebral artery. Anatomical variation in the origin of the right vertebral artery is rare. Most available reports are case reports from international studies. We report on a case of right vertebral artery arising from the ipsilateral common carotid artery with an absent brachiocephalic trunk in a South African patient examined by digital subtraction angiography. Reports on anatomical variations are of diagnostic importance prior to surgical interventions or endovascular treatment of cerebrovascular diseases such as cerebral aneurysms and arteriovenous malformations.

[Total Arch Replacement due to Tracheal Compression by Brachiocephalic Artery with Bovine Aortic Arch:Report of a Case].

A 78-year-old female presented to our institution with a dry cough and dyspnea. Chest computed tomography( CT) revealed tracheal stenosis caused by compression from a brachiocephalic artery with a bovine aortic arch. Subsequently, surgery was performed in which the brachiocephalic artery was resected, and a total arch replacement using a four-branched graft was completed. We paid particular attention to the graft branches, making sure to avoid contact with the trachea. Both the patient's cough and dyspnea dissipated after the surgery, and a CT revealed the tracheal stenosis had been completely relieved. The patient has remained in good condition for the past three years since the surgery showing no respiratory symptoms or thoracic aortic disease. Because the bovine aortic arch is a known risk factor for thoracic aortic disease, rather than simply reconstructing the brachiocephalic artery, we chose a more aggressive surgical treatment to prevent any possible future thoracic aortic disease.

[Vascular Prosthesis Perforation Caused by a Stent Graft Inserted into the Innominate Artery after Total Aortic Arch Replacement].

The patient was a 60-year-old woman who underwent thoracoabdominal aorta replacement for type B aortic dissection three years ago and aortic root replacement and total aortic arch replacement due to asymptomatic type A aortic dissection two years previously. Her clinical course was uneventful until follow-up computed tomography (CT) disclosed anastomotic insufficiency in the innominate artery and left main coronary artery stenosis owing to hematoma. Emergent percutaneous coronary intervention and stent graft insertion into the innominate artery were performed successfully. Seven months later, however, CT scan revealed a perforation in the posterior wall of the artificial graft damaged by the edge of the implanted stent graft. The patient underwent open surgery and perforation of artificial graft was sutured and redundant stent graft edge was resected. Artificial graft damage by stent graft placement is rare to date, but may increase in the future in accordance with broader application of endovascular treatment.

Coil Embolization of Tributaries of Brachiocephalic Fistula is Effective in the Management of Vascular Steal.

BACKGROUND: To determine if an aggressive approach to occlude all or majority of the tributaries of the cephalic vein is effective in eliminating signs and symptoms of vascular steal in patients with brachiocephalic fistula. METHODS: Retrospective chart review over a 15-month period of all patients managed with coil embolization of tributaries of brachiocephalic fistulae. RESULTS: A total of 19 patients (11 females, age 65 ± 9.7 years), presented with signs and symptoms of vascular steal. All patients had a brachiocephalic fistula with a 6.3 month average fistula age. Overall, a total of 111 coils were used to occlude 42 tributaries. Two patients had concomitant surgical ligation of 3 tributaries. Postoperative pain at the site of coiled tributaries was reported by two patients. A single patient suffered a major postprocedure complication (delayed hypotension), requiring hospital admission. All but one patient had significant improvement in symptoms of vascular steal postintervention. CONCLUSIONS: An aggressive approach to coil embolization of all major tributaries of a brachiocephalic fistula is effective in eliminating signs and symptoms of vascular steal.

Post-operative Recurrent Ascending Aortic Pseudoaneurysm with Aorto-cutaneous Fistula- Endovascular management with an In-situ Stent-Graft Fenestration for the Innominate Artery.

Ascending aortic pseudoaneurysm is a known complication of previous cardiac surgery that needs surgical or endovascular intervention. The presence of arch branches complicates the later approach necessitating additional procedures, either hybrid surgical or endovascular modification of the grafts. We describe a patient who developed an ascending aortic pseudoaneurysm after mitral valve replacement, which recurred after surgical patch closure with the formation of a cutaneous fistula. This high-risk patient was managed by an endovascular approach with in-situ fenestration for the innominate artery by a simple technique.

Long-term Outcome of Axillo-axillary Bypass in Patients with Subclavian or Innominate Artery Stenosis.

BACKGROUND: Subclavian or innominate artery stenosis (SAS) may cause upper extremity and cerebral ischemia. In patients with symptomatic subclavian or innominate artery stenosis, percutaneous transluminal angioplasty is the treatment of first choice. When percutaneous transluminal angioplasty is technically restricted or unsuccessful, an extrathoracic bypass grafting, such as an axillo-axillary bypass can be considered. The patency rate of axillo-axillary bypass is often questioned. The aim of this study was to assess long-term outcomes of patients undergoing axillo-axillary bypass for subclavian or innominate artery stenosis (SAS) and to provide a literature overview. METHODS: In this single-center study, data from patients who underwent axillo-axillary bypass for symptomatic SAS between 2002 and 2018 were retrospectively analyzed. Bypass material was Dacron® (54%) or polytetrafluoroethylene (PTFE) (46%). Primary outcome was graft patency and secondary outcome was the occurrence of mortality and stroke. In addition, a systematic literature search was performed in MEDLINE and EMBASE databases including all studies describing patency of axillo-axillary bypass. RESULTS: In total, 28 axillo-axillary bypasses had been performed. Cumulative primary, primary-assisted, and secondary patency rates at one year were 89%, 93%, and 96%, respectively. Cumulative primary, primary-assisted, and secondary patency rates at five years were 76%, 84%, and 87%, respectively. The primary-assisted patency rates at five years for Dacron® and PTFE were 93% and 73%, respectively. A total of four primary axillo-axillary bypass occlusions occurred (14%), with a mean of 12 months (range, 0.4-25) after operation. The 30-day mortality was 7%; one patient died after a stroke and one died of a myocardial infarction. At the first postoperative follow-up control, 22 of the 26 remaining patients (85%) had relief of symptoms. The literature search included 7 studies and described a one-year primary patency range of 93-100% (n = 137) and early postoperative adverse events included death (range, 0-13%) and stroke (range, 0-5%). CONCLUSIONS: Patency rates of axillo-axillary bypasses for patients with a symptomatic SAS are good. However, the procedural complication rate in this series is high and attention should be paid to intervention indication.

Anatomical and positional variants of the brachiocephalic trunk in a Mexican population.

BACKGROUND: Brachiocephalic trunk (BCT) variants may have a clinical impact during surgical procedures, some of which could be fatal. The objective of this study was to classify height positions of the BCT and report their prevalence in a Mexican population. METHODS: Patients: A retrospective, descriptive, observational, and cross-sectional was performed using computed tomography angiography (CTA) of adult (> 18 years of age) patients, without gender distinction, of Mexican origin. Measuring techniques were standardized using the suprasternal notch to analyze linear and maximum heights, linear and curved lengths, and the vertebral origin and bifurcation levels of the BCT. RESULTS: A total of 270 CTA were obtained (66.7% men and 33.3% women). A high position of BCT was present in 64.81% (n 175/270). The mean linear medial height was 0.58 ± 1.91 cm, the maximum height of the free edge was 3.85 ± 2.04 cm, side length of the midline at the maximum height of the free edge was 1.46 ± 2.59, linear length 3.72 ± 0.70, and a curve length 3.99 ± 0.79. The BCT origin was most predominant at the T3 (57.9%) and T4 (27.0%) vertebral levels, with the bifurcation at T2 (57.9%) and T1 (36.2%). CONCLUSIONS: There is a high prevalence of high position BCT in our population. Patients should be assessed before any procedures in the area, due to the potential risk of complications.

Innominate artery dissection due to selective cerebral antegrade perfusion.

We present the first case of successfully treated innominate artery dissection as a complication of selective cerebral antegrade perfusion during reoperative aortic valve and hemiarch replacements. Innominate artery dissection was suspected based on unilateral decreases in the right radial arterial pressure and right cerebral oximetry value. Intraoperative ultrasonography demonstrated minimal flow in the right internal carotid. A right aortoaxillary bypass graft was performed leading to immediate improvements in the right radial arterial pressure waveform and right cerebral oximetry. The patient was discharged neurologically intact on postoperative day six.