The prenatal diagnosis and prognosis of fetal right aortic arch and double aortic arch malformation: A single-center study.

AIM: This study aimed to characterize the pathological types, diagnosis, chromosomal abnormalities, and postnatal clinical manifestations of right and double aortic arch malformations in fetuses. METHODS: In this retrospective study, all fetuses diagnosed with right or double aortic arch anomalies for whom conventional two-dimensional echocardiography combined with spatio-temporal image correlation was performed at our tertiary referral center between December 2012 and December 2021 were included. RESULTS: In total, 234 fetuses with aortic arch abnormalities were identified. Forty-one cases lost to follow-up. One hundred ninety-three cases were included in this study. One hundred eighty-seven cases with right aortic arch. Six cases with double aortic arch. Most cases of right aortic arch with aberrant left subclavian artery (77/101, 76.2%) were isolated lesions, whereas most of those with mirror-image branching (45/75, 60%) were associated with intracardiac or extracardiac anomalies. Chromosomal abnormalities were screened prenatally in 113 fetuses with right aortic arch, among whom three with aberrant left subclavian artery (3/63, 4.8%) and eight with mirror-image branching (8/50, 16%) had chromosome anomalies (p < 0.05). Furthermore, three cases had microdeletion 22q11.2 and these were significantly associated with intracardiac malformations. CONCLUSIONS: Most cases of isolated right aortic arch do not present with clinical symptoms except isolated left subclavian artery and isolated left brachiocephalic trunk. In addition, the risk of chromosomal abnormalities in patients with isolated right aortic arch is very low. We recommend that pregnant women should be informed of the risks and benefits of undergoing invasive prenatal chromosomal detection.

Repair of fungal pseudoaneurysm of the common brachiocephalic trunk.

BACKGROUND AND AIM: To date, little is known about the aneurysms of the bovine aortic arch, known as a "common brachiocephalic trunk (CBT)" from where the left carotid and innominate arteries bifurcate. PATIENT AND RESULTS: Here we report a case of a fungal pseudoaneurysm of the bovine aortic arch in a patient who had prior history of multiple aortic valve replacement, hepatitis C infection, and human immunodeficiency virus infection. A re-operative replacement of the aortic arch repair utilizing a bifurcated graft was successfully performed under deep hypothermia and selective antegrade cerebral perfusion. Pathological examination demonstrated a pseudoaneurysm of the CBT. Intraoperative cultures from the aneurysmal wall showed Aspergillus fumigatus DISCUSSION AND CONCLUSION: we experienced a complex surgical repair of CBT pseudoaneurysm caused by Aspergillus species.

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.

Comparison of 30 Day Stroke and Death in Hybrid Intervention and Open Surgical Reconstruction for the Treatment of Tandem Carotid Bifurcation and Supra-aortic Trunk Disease.

OBJECTIVE: The optimal approach for the treatment of tandem carotid bifurcation and supra-aortic trunk (SAT) disease remains controversial. The hybrid technique of carotid endarterectomy (CEA) with ipsilateral proximal endovascular intervention (IPE) has provided an attractive alternative to CEA with open SAT reconstruction (SATr). However, no studies have compared cohorts treated by these two approaches. METHODS: Using the National Surgical Quality Improvement Program (2005-2017), patients who underwent CEA + IPE and CEA + SATr were identified. Non-occlusive indications were excluded. Primary outcomes included 30 day stroke, death, and their composite (stroke and/or death [SD]). Univariable and logistic regression analyses were performed. RESULTS: In total, 372 patients were identified: 319 CEA + SATr and 53 CEA + IPE. SATr included 19 (5.9%) aorta to carotid bypasses, 22 (6.9%) carotid subclavian transpositions, 96 (30.1%) carotid carotid bypasses, 179 (56.1%) carotid subclavian bypasses, and three (0.9%) SAT endarterectomies. The mean age was 69 ± 10 years. The majority were men (53%), white (85%), and had a history of hypertension (84%). There were no demographic differences between the operative cohorts except that those having CEA + SATr were more likely to have hypertension (86% vs. 74%; p = .031). CEA + SATr had longer operative times and longer hospital length of stay. There were no differences in outcomes between the cohorts: stroke (CEA + SATr 4.1% vs. CEA + IPE 3.8%; p = .92), death (1.6% vs. 0%; p = .36), or SD (5.3% vs. 3.8%; p = .63). After risk adjustment, predictors of SD included symptomatic status (odds ratio [OR] 3.9, 95% confidence interval [CI] 1.1-13.5; p = .034), congestive heart failure (OR 16.5, 95% CI 2.0-136; p = .011), and return to the operating room (OR 8.5, 95% CI 2.3-30.8; p = .001). Operative method was not predictive (p = .63). CONCLUSION: Outcomes following CEA + SATr and CEA + IPE are similar. Although proposed as a safer, less invasive alternative, the hybrid approach did not reduce the risk of operative stroke or death relative to open reconstruction for the treatment of occlusive, tandem carotid/SAT disease. Based upon lesion and patient factors, both may be considered management options in select patients.

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.

Aortic dissection extending from the brachiocephalic artery during transradial coronary catheterization: a case report.

BACKGROUND: Iatrogenic acute aortic dissection (AD) is an extremely rare but devastating complication during cardiac catheterization. It can be treated conservatively if it develops in a retrograde form or manifests as an intramural hematoma (IMH) with a micro-intimal tear in the absence of instability. However, only a few reports exist on its natural course and long-term outcomes. CASE PRESENTATION: A 78-year-old woman presented to the emergency department with acute chest discomfort. Elective cardiac catheterization was performed via the right radial artery. The patient's brachiocephalic artery was so tortuous that the hydrophilic soft guidewire had to be exchanged for a stiffer one. However, the stiff wire caused the dissection of a tortuous brachiocephalic artery that extended from the sinuses of Valsalva to the proximal descending aorta. Emergent computed tomography showed crescentic aortic wall thickening without a dissection flap. The patient had cardiac tamponade and a gradually thickening thrombosed false lumen. Although the patient was unstable during the first 2 weeks, she was stabilized during hospital stay with only conservative treatment. Consequently, she has been well for over 5 years. CONCLUSIONS: Even though the patient showed ominous findings, a good prognosis was expected because the AD was mainly retrograde. Furthermore, the thrombosed false lumen mimicked an IMH on imaging. To the best of our knowledge, this is the first report of an extensive iatrogenic AD originating from the brachiocephalic artery during right transradial catheterization that was treated conservatively despite clinical instability.

Real-time confirmation of tracheal decompression.

AIMS: The primary objective was to highlight the role of intraoperative bronchoscopic guidance during the management of central airway obstruction. MATERIALS & METHODS: A 6-month-old child presented with recurrent chest infections due to innominate artery compression of distal trachea. Aortopexy was performed under real-time bronchoscopic guidance. RESULTS: Intraoperative bronchoscopic guidance helped in confirm a successful release of the central airway obstruction. DISCUSSION: When operations similar to aortopexy are performed for release of airway obstructions, intraoperative bronchoscopic guidance is a valuable tool for confirming a successful outcome. CONCLUSION: The successful surgical management of central airway obstruction due to an innominate artery compression of the distal trachea under real-time bronchoscopic guidance in a 6-month-old child is described.

Total reversal of internal carotid blood flow in a patient with severe stenosis of the brachiocephalic trunk.

Occlusions and severe stenoses of the innominate artery (brachiocephalic trunk) are rare and present with a wide variety of clinical manifestations, with hemispheric, vertebrobasilar and right upper limb ischemic symptoms. The most common cause is atherosclerosis. Duplex scanning may show right vertebral artery flow reversal, diminished subclavian flow, and several patterns of right carotid flow disturbance, including slow flow, partial flow reversal during the cardiac cycle and even complete reversal of flow in the internal carotid artery, which is a very uncommon finding. Herein, the authors describe the case of a female patient who was a heavy smoker, had severe stenosis of the brachiocephalic trunk, and had episodes of collapse. Besides the subclavian steal and partial flow reversal in the common carotid artery, duplex scanning also showed high-velocity reversed flow in the internal carotid artery during the entire cardiac cycle, a finding that is not reported in the literature at this magnitude.

Post-operative Infection of Prosthetic Materials or Stents Involving the Supra-aortic Trunks: A Comprehensive Review.

OBJECTIVE: The aim of this paper was to provide recommendations for diagnosis and management in the setting of infection following open or endovascular reconstructions of the supra-aortic trunks. METHODS: A review of the Medline database was performed from 1997 to 2017 by a combined strategy of MeSh terms. RESULTS: The literature search identified 49 publications: 36 studies addressing prosthetic material infections and 13 studies addressing stent infections. A total of 140 cases of prosthetic material infections were reported, mostly involving carotid patches. Surgical treatment was mostly based on complete removal of the infected material followed by in situ arterial reconstruction (86 cases, 62.3%). Peri-operative complications included cranial nerve injury in 17 cases (12.5%), stroke in eight (6.7%), bleeding in four (2.9%), re-infection in five (3.6%), and cardiac failure in three cases (2.2%). Stent infections were reported in 12 patients: eight carotid stents, three subclavian stents and one tandem brachiocephalic subclavian stent. Treatment was not described for one case, was conservative in one case, consisted of stent removal with venous reconstruction in six cases, stent removal without reconstruction because of carotid thrombosis in two cases, and carotid embolisation in two cases. Complications included intra-operative death in one case (9.1%), stroke in two (18.2%), reinfection in one (9.1%), bleeding in one (9.1%), and cardiac failure in one case (9.1%). CONCLUSION: Appropriate pre-operative imaging is mandatory and treatment modality should be determined by patient condition. Complete removal of the infected material, followed by in situ arterial reconstruction with venous material seems advisable, despite high morbidity. However, alternative strategies may be considered for fragile and high risk patients. A multidisciplinary approach is mandatory to ensure optimum results.

Prevalence of major vessels anterior to the trachea at sites of potential front-of-neck emergency airway access in adults.

BACKGROUND: Several case reports have described anatomical variations that can cause difficulty with front-of-neck airway access, such as major vessels anterior to the trachea. The prevalence of these anomalies is unknown. METHODS: We screened 500 consecutive thoracic computed tomography (CT) scans in adult patients performed independently in any public hospital in Western Australia. The prevalence of major vessels anterior to the trachea in the anterior triangle of the neck was determined. RESULTS: In the suprasternal notch, 264 CT scans (53%) demonstrated part of a major vessel anterior to the trachea, most commonly the brachiocephalic artery. At 10, 20, and 30 mm above the suprasternal notch, respectively, 126 (25%), 48 (9%), and 5 (1%) CT scans showed a major vessel anterior to the trachea. None showed a major vessel anterior to the cricothyroid membrane. In the suprasternal notch, a major vessel was anterior to the trachea in 10 of 120 CT scans (8%) that had a manubrio-cricoid distance <25 mm, and 108 of 116 CT scans (93%) that had a manubrio-cricoid distance >50 mm. In a logistic-regression model, increased length of trachea above the manubrium was a strong predictor of major vessels anterior to the trachea in the suprasternal notch, whilst sex, age, thoracic kyphosis, tracheal diameter, and the origin of the brachiocephalic artery were not strong predictors. CONCLUSIONS: It is common for patients to have some portion of a major vessel anterior to the trachea at sites where an emergency tracheostomy might be performed.

Mycotic innominate artery aneurysm repair using a bovine pericardial bifurcation prosthesis.

We report the use of a bovine pericardial bifurcation prosthesis to repair a mycotic innominate artery aneurysm.

Prenatal Ultrasonic Diagnosis and Prognostic Analysis of Isolated Left Subclavian Artery (ILSCA) and Left Brachiocephalic Trunk (ILBCT) Malformation.

The purpose of the study was to explore the prognosis, as well as antenatal ultrasonic features of isolated left subclavian artery (ILSCA) and isolated left brachiocephalic trunk (ILBCT) malformations, in order to improve prognosis and provide guidance for prenatal diagnosis. The origin and routing of cephalic and cervical vessels were observed in patients diagnosed with right aortic arch or right arterial duct arch in our hospital from March 2015 to March 2017, and the spectrum features related to ILSCA and ILBCT were analyzed. Fetuses diagnosed as ILSCA, or, and ILBCT were followed up for 3 months after birth. At the same time, a literature review was carried out for ILBCT and ILSCA in Pubmed. In our study, two cases with ILSCA and ILBCT were both diagnosed prenatally. They are not accompanied by other congenital malformations or chromosome abnormalities. No abnormality was found during postnatal follow-up except that left radial pulsation was weakened and blood pressure of the left upper limb decreased in baby with ILSCA. In baby with ILBCT, in addition to these abnormal changes, the left common carotid artery pulse disappearance too. In pubmed, three of 12 ILSCA or ILBCT did not have other congenital malformation or chromosome abnormalities. They were not diagnosed until the age of 3, 10, and 47 because of school exams or atypical symptoms, such as headaches, chest pain. Symptom of ILBCT or ILSCA without other abnormality is silent, and therefore they cannot be diagnosed timely after birth prenatal diagnosis is necessary for they can be treated in time.

Partial sternotomy for management of iatrogenic brachiocephalic trunk injury during tracheotomy.

The median thoracotomy is an access incision made longitudinally through the sternum and variants can be subdivided into total vertical and partial upper or partial lower vertical incisions. In surgical practice, using a partial median sternotomy is an alternative option that causes less surgical aggression. The brachiocephalic artery is one of the thoracic vessels most often affected in traumas and it can be accessed via a median sternotomy. This report describes use of an upper partial sternotomy to provide access in a case of traumatic iatrogenic injury of the brachiocephalic trunk.

Right aortic arch analysis - Anatomical variant or serious vascular defect?

BACKGROUND: The right-sided aortic arch (RAA) is a rare congenital defect of the aorta. The aim of the study was to assess the occurrence of RAA in diagnoses performed by the University Radiology Department and analyze the frequency of concomitant vascular abnormalities. METHODS: The database of the Radiology Department was retrospectively analyzed between January 2008 and May 2016 with the keyword "right aortic arch". Twenty patients with this diagnosis were identified from a total of 11,690 CT examinations of the chest area, 19,623 CT examinations of brain-supplying vessels, and 1863 MRI examinations of the heart and aortic arch or brain-supplying arteries. The type of aortic arch, the occurrence of Kommerell's diverticulum and possible other vascular abnormalities, such as stenosis, kinking or occlusion, were then investigated. RESULTS: The analysis identified nine patients with type I and 11 patients with type II RAA. Eight of the 11 type II patients presented Kommerell's diverticulum. Concomitant vascular abnormalities were detected in four patients with type II RAA. In two cases, the right common carotid artery (RCCA) was narrowed by up to 80%, with steal phenomenon confirmed in one of them. In the second coincident right subclavian artery (RSA) stenosis was depicted. In two other cases, the aberrant left subclavian arteries (ALSA) were found to be narrowed at the level of origin by up to 70%. One patient was found with type B aortic dissection including ALSA and Kommerell's diverticulum. CONCLUSIONS: Our observations indicate that concomitant vascular abnormalities may occur more often than reported in literature. Patients diagnosed with type II RAA should be examined with Doppler ultrasonography to identify coincident vascular disorders, especially stenosis of the common carotid arteries or subclavian arteries.

Should we change the cannulation site for right subclavian artery cannulation? An experimental study with a newly designed cannula.

BACKGROUND:: In this experimental study, we primarily aimed to show the hemodynamic effects and superiority of this newly designed cannula for perfusion compared to standard subclavian cannulation. The new cannula (Figure 1) allows bidirectional axial flow and it directly fits in the brachiocephalic trunk (innominate artery). METHODS:: We used a cardiopulmonary bypass roller pump, reservoir, 3/8- 1/2- 1/4-inch Y-connectors and tubing set. Lines were set as seen in Figures 2, 3, 4 and 5. The anatomy of the aorta (ascending, arch, branches, descending) was mimicked, using tubing sets with different sizes and the connectors yielding similar angles and configurations. In this experimental vascular system, systemic vascular resistance was created with partial clamping of the common tubing set. The cannulation sites were created in the subclavian artery and the innominate artery. Perfusion was established with the same pump rate and the same occlusion pressures (systemic vascular resistance). The pressure readings were obtained in the right carotid artery, the left carotid artery and the left subclavian artery. RESULTS:: These experimental models of vasculature allowed us to measure pressures in the carotid system for different cannulation set-ups, using both our newly designed double-outflow cannula, which was introduced via the innominate artery, and the standard arterial cannula, which was introduced via the subclavian artery. Higher pressure recordings were obtained in the carotid system with the new cannula introduced through innominate artery. CONCLUSION:: Higher cerebral perfusion readings were obtained with our newly designed bidirectional cannula introduced via the innominate artery compared to standard cannulation through the right subclavian artery.

Brachiocephalic trunk damage resulted from percutaneous tracheotomy.

The paper presents a rare case of injury to the brachiocephalic trunk wall during percutaneous tracheotomy. The complication developed in a post-cardiac arrest patient in a poor general condition. During hospitalization in the Intensive Care Unit, the patient suffered a haemorrhage directly from and around the endotracheal tube. After another episode of massive bleeding the patient died. The autopsy found that the source of the bleeding was injury to the brachiocephalic trunk.

Thyroidea Ima Artery in Cadavers of a Medical College in Nepal: A Descriptive Cross-sectional Study.

INTRODUCTION: Thyroidea ima artery is a variant arterial branch of arch of aorta supplying the thyroid gland. Understanding the anatomic variances and correctly identifying the thyroidea ima artery is crucial to preventing serious complications both before and after neck surgery. The aim of this study was to find out the prevalence of thyroidea ima artery in cadavers of a medical college in Nepal. METHODS: A descriptive cross-sectional study was carried out at the department of anatomy in Janaki Medical College, Dhanusha, Nepal from 27 December 2022 to 30 June 2023 after ethical clearence from the same institution. Origin of thyroidea ima artery was observed, recorded and photographed. Convenience sampling method was used. Data was analyzed using Microsoft Excel. RESULTS: Out of 35 cadavers, thyroidea ima artery was present in 2 (5.71%), arising from brachiocephalic trunk just proximal to its bifurcation and there was absence of inferior thyroid artery. CONCLUSIONS: Findings from our study showed that thyroidea ima artery originated from brachiocephalic trunk with absence of inferior thyroid artery.

Flowreversal in the left internal jugular vein due to a prominent brachiocephalic trunk: A case report.

Reversal of blood flow has only been reported in the left internal jugular vein following interventions such as central venous catheter, dialysis shunt placement, or external compression from a tumor. We describe a rare case of chronic headache and hearing loss due to flow reversal in the left internal jugular vein and compensatory massive dilation of the right internal jugular vein. Flow reversal was caused by a prominent brachiocephalic trunk with subseqent compression of the vena brachiocephalica sinistra. Vascular anomalies and associated venous bypass circulation may be considered as a rare cause of non-specific malaise. Restoration of the physiological direction of blood flow should be discussed on an interdisciplinary basis given the unpredictable haemodynamic consequences.

Minimally invasive approach to managing brachiocephalic trunk cannulation complicating central venous catheterization: a case report.

BACKGROUND: Central venous catheterization, crucial for device insertion, monitoring, medication, and fluid resuscitation, commonly uses the subclavian, internal jugular, and femoral veins. Despite its general safety, complications like arterial puncture can be life-threatening, requiring rapid diagnosis and treatment. CASE PRESENTATION: A 74-year-old woman in the recovery phase of cerebral infarction underwent right subclavian vein catheterization. The catheter was mistakenly placed in the brachiocephalic trunk, with its tip in the ascending aorta, as confirmed by computed tomography (CT) and digital subtraction angiography (DSA). With the high surgical risk and the complexity of endovascular treatment, catheter replacement was chosen. One month after the initial placement, the catheter was replaced with a smaller one, and another month later, it was retracted without complications. Follow-up CT and DSA revealed no leakage, with the patient's vitals remaining stable. A three-month post-discharge phone follow-up confirmed the patient's continued stability. CONCLUSION: This case demonstrates the effective use of a catheter replacement technique as a minimally invasive repair method when other options are impractical. Ultrasound guidance is also recommended to improve the procedure's accuracy and safety.

Pseudo-mediastinal tumor: Brachiocephalic artery buckling.

Buckling of the brachiocephalic artery is an important cause of unusual chest x-ray findings which resemble those of a mediastinal tumor. The possibility of a vascular anomaly should be kept in mind whenever a chest x-ray demonstrates an abnormal mediastinal opacity, especially in elderly female patients with hypertension.