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.

Sex estimation using metrics of the innominate: A test of the DSP2 method.

Sex estimation is a critical component of the biological profile, and forensic anthropologists may use a variety of sex estimation methods depending upon the degree of completeness and state of preservation of the skeletal remains being analyzed. The innominate is widely accepted to be the most sexually dimorphic skeletal element. The Diagnose Sexuelle Probabiliste (DSP) method, which uses 10 measurements of the innominate, was introduced in 2005 and updated as DSP2 in 2017. While DSP2 has been reported to have high classification accuracy rates in studies of South American and European populations, the method has not been widely tested in US samples, and few US practitioners incorporate this method into their casework. The goal of this study was to test the reliability and accuracy of DSP2 using a large, modern sample from the US (n = 174). Two observers, blinded from demographic information associated with each specimen, collected the DSP2 metrics. Intra- and interobserver error analyses showed acceptable levels of agreement for all measurements, except for IIMT. Classification accuracies exceeded 95%, with minimal sex bias, for both observers and using various measurement combinations; however, an inclusivity sex bias occurred with more males reaching the 0.95 posterior probability threshold required by DSP2 to provide a sex classification estimate. Based on its high accuracy, forensic anthropologists in the US may consider incorporating DSP2 into their casework, although we recommend excluding IIMT and using SPU with caution. Additional methods will continue to be needed when the posterior probability threshold is not reached.

Double innominate vein in a case with double aortic arch: a case report.

BACKGROUND: Double aortic arch (DAA) is a type of vascular ring, causing stridor and dysphagia owing to compression of the trachea and esophagus. In contrast, double innominate veins, which is a relatively rare venous anomaly, usually does not cause symptoms or require intervention. CASE PRESENTATION: A 2 month-old boy presented with mild stridor and a hoarse voice while crying, and was diagnosed as having DAA, small atrial septal defects and double innominate vein. The double innominate veins, crossing over and underneath the ascending aorta, did not contribute to airway compression. To release the narrow vascular ring caused by the DAA, surgical resection of the atretic side of the arch was performed by lateral thoracostomy at 4 months of age, before the appearance of signs of bronchomalacia. The double innominate veins were left untouched, and open-heart surgery was avoided. CONCLUSIONS: DAA should be suspected if airway symptoms are present in early infancy, particularly if a right aortic arch is noted. It is important not to hesitate to perform diagnostic imaging and release the DAA, as this might prevent or minimize airway complications. However, for double innominate veins, operative release is not necessary unless it interferes with surgical procedures or is causing symptoms.

Comparison of treatment methods in patients with developmental dysplasia of the hip.

Background/aim: This study aimed to compare the results of Pemberton osteotomy (PO), Salter innominate osteotomy (SO), open reduction (OR), and closed reduction (CR) applied in the treatment of developmental dysplasia of the hip (DDH). Materials and methods: Included in the study were 101 hips of 82 patients treated at our orthopedic clinic between 2017 and 2023. The patients were evaluated preoperatively, postoperatively, and at the final follow-up. The results were evaluated based on Barret's clinical and Severin's radiological classifications. Those who developed avascular necrosis (AVN) were evaluated based on Bucholz-Ogden's classification. Results: In terms of the preoperative acetabular angles (AAs), those for hips treated with PO were significantly higher than those of the other three, and those treated with SO were significantly higher than those of the other two (OR and CR) (p < 0.001). There was a significant difference in the final follow-up AAs of those treated with SO and PO compared to those treated with OR and CR (p < 0.001). The best corrections were achieved with PO (average: 27.94 ± 4.89°). There was a significant difference between PO and OR, and PO and CR in terms of the preoperative collodiaphyseal angles (CDAs) (p < 0.05). The greatest decrease was in those treated with PO (average: 22.44 ± 9.45°). AVN developed at various stages in 15 of 79 hips (14.85%) that were treated surgically. While AVN developed at a rate of 22.22% with PO, 18.18% with SO, and 17.85% with OR, no AVN developed in the 22 hips treated with CR. Conclusion: Understanding normal and abnormal values by age is essential for selecting appropriate treatments. Acetabulum-related surgeries should be planned for patients over 1.5 years of age with an AA above 30°. Early diagnosis and CR treatments yield excellent results and low AVN rates. Various DDH treatments in our clinic have shown low AVN rates, indicating safety and efficacy.

Total aortic arch replacement with frozen elephant trunk technique for intramural haematoma of the thoracic aorta.

Presenting this video tutorial, we want to demonstrate a step-by-step surgical approach to acute intramural haematoma of the thoracic aorta without a definite entry tear. Limited by the aortic valve proximally, the intramural haematoma involved the aortic root, ascending aorta, aortic arch, including adjacent parts of supra-aortic branches, and descending aorta extending to the diaphragmatic level. The operative strategy involved urgent total aortic arch replacement with the frozen elephant trunk technique and anatomical reimplantation of the three supra-aortic vessels. The direct open over-the-wire technique was used to cannulate the right axillary artery, and standard venous cannulation was performed while brain protection was achieved with bilateral selective antegrade cerebral perfusion.

Retrospective analysis of 1028 ultrasound-guided central vascular access in neonates and children.

BACKGROUND: The use of real-time ultrasound has become the standard of care for percutaneous central venous access and shown to decrease overall number of attempts and complication rates. MATERIAL AND METHOD: A retrospective analysis of a prospective database was done focusing on three types of central access: non-tunneled, tunneled, and implantable, placed via ultrasound-guided Brachiocephalic Vein (BCV) between January 2019 and January 2023. Data were recorded: gender, age, weight, side (left or right), number of puncture attempts, arterial puncture, change of operator or puncture side, and mechanical complications (pneumothorax and hemothorax). RESULTS: A total of 1028 non-tunneled, tunneled, and implantable central lines were placed. Five hundred and eighty seven were Male. The children were aged from 0 to 18 years and their weights ranged from 1 to 113 kg. Nine hundred and thirty-five were left BCV. Right BCV was cannulated in 93 patients. Failure to cannulate left BCV was recorded in seven cases. Three arterial punctures were recorded. Cannulation success rate was 97.2% (999/1028) and was higher in left BCV than right BCV (p < 0.001). DISCUSSION: Based on the above, we believe that ultrasound-guided BCV is an easy and secure method to cannulate children, in our series left BCV showed a higher cannulation success rate rather than right BCV.

Brachiocephalic Artery Access Without Sternotomy in Older Asian Patients Undergoing Transcatheter Aortic Valve Replacement.

There are numerous approaches for transcatheter aortic valve replacement (TAVR); however, access-related complications remain a point of concern. We analyzed consecutive patients who underwent TAVR for severe aortic stenosis via the brachiocephalic artery (BCA) without sternotomy (TBc group, n = 10) and via the trans-ascending aortic (TAo group, n = 8). The median BCA diameter and distance between the access point and suprasternal notch or superior margin of the clavicle were 11.3 mm and 8.3 mm, respectively. No patients in the TBc group underwent a partial sternotomy. Compared with the TAo group, the TBc group exhibited a shorter mean procedure time and lower blood loss volume as well as shorter duration of hospitalization. TAVR through the BCA may be a safe and feasible alternative for ascending aorta access. Studies with longer follow-up analysis and more patients are warranted to confirm our findings.

Innominate Vein Thrombosis: A Case Report and Literature Review.

The brachiocephalic vein (BCV), also known as the innominate vein, is a central vein in the upper chest formed by merging the internal jugular and subclavian veins. It plays a crucial role in venous return from the head, neck, and upper extremities and is significant in procedures such as pacemaker and implantable cardioverter-defibrillator (ICD) placement, chemotherapy ports, and central venous catheter insertions. The presence of foreign bodies and local malignancy are major risk factors for thrombosis in the BCV. As part of the deep venous system, BCV thrombosis (BCVT) is a rare condition but can lead to serious complications like superior vena cava syndrome and, rarely, pulmonary embolism. This case report presents an 82-year-old woman with a history of heart failure with reduced ejection fraction, coronary artery disease, atrial fibrillation, HIV, pulmonary embolism, systemic lupus erythematosus, and breast cancer who required an ICD placement due to persistent systolic dysfunction. During the procedure, chronic BCVT leading to the stenosis was incidentally discovered, necessitating urgent vascular intervention to establish venous patency. The patient's complex medical history, including previous chemotherapy through a central venous catheter, contributed to the risk factors for BCVT. The multidisciplinary approach led to successful ICD placement and the reinstatement of anticoagulation therapy. This case underscores the rarity and severity of BCVT and highlights the importance of pre-procedural imaging, such as CT venography, in patients with multiple risk factors. Additionally, the report suggests considering leadless ICD technology for patients with limited venous access to avoid complications. The findings emphasize the critical need for thorough evaluation and planning in complex cases to ensure successful outcomes.

[The value of revascularisation of atherosclerotic lesions of the innominate artery at the asymptomatic stage of the disease]. / Znachenie revaskulyarizatsii pri ateroskleroticheskikh porazheniyakh brakhiotsefal'nogo stvola na asimptomnoi stadii zabolevaniya.

OBJECTIVE: To analyze the natural course of asymptomatic atherosclerotic lesions of the innominate artery and to study the long-term results of surgical interventions performed at the asymptomatic stage and to compare them with similar results at the symptomatic stage of the disease. MATERIAL AND METHODS: The analysis of the natural course of the disease was performed in 74 asymptomatic patients who were divided into 3 groups depending on the initial degree of severity of the stenosis of the innominate artery: insignificant stenoses (less than 50%), moderate stenoses (50-69%) and haemodynamically significant lesions (70% and more). The analysis of the long-term results of surgical treatment was performed in 62 patients, in 29 of whom intrathoracic reconstructions were performed at the asymptomatic stage of the disease, in 33 - at the symptomatic stage. RESULTS: Cumulative freedom from stroke by the 10th year of follow-up was significantly higher in patients with insignificant stenoses and amounted to 100% in the groups of moderate stenoses and hemodynamically significant lesions - 25% and 0, respectively (log-rank p=0.000). Neurological fatality in patients with hemodynamically significant (initial or developed) lesions was 26.3%, while in patients with hemodynamically insignificant lesions it was 0 (log-rank p=0.004), which is confirmed by cumulative indices (log-rank p=0.008). Asymptomatic innominate artery reconstructions were associated with a lower incidence of stroke: the long-term incidence of stroke in such patients was 3.4%, while in initially symptomatic patients it was 18.2% (p=0.038). Initial degree II or IV cerebrovascular insufficiency was a predictor of stroke in the long-term period (OR=1.71; p=0.000). The cumulative freedom from stroke in asymptomatic patients by the 20th year of follow-up was 95% compared with 74% in symptomatic patients (log-rank p=0.032). CONCLUSION: Surgical interventions in asymptomatic hemodynamically significant lesions of the innominate artery should be performed to prevent primary cerebral circulatory disorders.

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.

Bipedalism or bipedalisms: The os coxae of StW 573.

There has been a long debate about the possibility of multiple contemporaneous species of Australopithecus in both eastern and southern Africa, potentially exhibiting different forms of bipedal locomotion. Here, we describe the previously unreported morphology of the os coxae in the 3.67 Ma Australopithecus prometheus StW 573 from Sterkfontein Member 2, comparing it with variation in ossa coxae in living humans and apes as well as other Plio-Pleistocene hominins. Statistical comparisons indicate that StW 573 and 431 resemble humans in their anteroposteriorly great iliac crest breadth compared with many other early australopiths, whereas Homo ergaster KNM WT 15000 surprisingly also has a relatively anterioposteriorly short iliac crest. StW 573 and StW 431 appear to resemble humans in having a long ischium compared with Sts 14 and KNM WT 15000. A Quadratic Discriminant Function Analysis of morphology compared with other Plio-Pleistocene hominins and a dataset of modern humans and hominoids shows that, while Lovejoy's heuristic model of the Ardipithecus ramidus os coxae falls with Pongo or in an indeterminate group, StW 573 and StW 431 from Sterkfontein Member 4 are consistently classified together with modern humans. Although clearly exhibiting the classic "basin shaped" bipedal pelvis, Sts 14 (also from Sterkfontein), AL 288-1 Australopithecus afarensis, MH2 Australopithecus sediba and KNM-WT 15000 occupy a position more peripheral to modern humans, and in some analyses are assigned to an indeterminate outlying group. Our findings strongly support the existence of two species of Australopithecus at Sterkfontein and the variation we observe in os coxae morphology in early hominins is also likely to reflect multiple forms of bipedality.

Y-shaped graft replacement of an isolated innominate artery aneurysm via the transmanubrial approach.

We report the rare case of an obese woman with a 32-mm isolated innominate artery aneurysm. Due to the deep location of the aneurysm within the thoracic inlet, we selected a transmanubrial osteomuscular sparing approach to obtain a clear field of vision. During the aneurysmectomy and reconstruction with a Y-shaped graft, we performed a temporary bypass using a contralateral leg of the graft to the right common carotid artery. Through these techniques, we successfully achieved complete resection and reconstruction of the aneurysm without the need for cardiopulmonary bypass.

A case of right aortic arch type II combined with Kommerell's diverticulum and left innominate vein beneath the aortic arch.

The combination of the right aortic arch and aberrant left subclavian artery (ALSA) with Kommerell's diverticulum (KD) is rare to coexist with the left innominate vein (LINV) beneath the aortic arch. It escalates the surgical risk undoubtedly and increases the difficulty of clinical procedures. We report one case diagnosed by Ultrasound and Computed Tomography Angiography (CTA).

Isolation of the left innominate artery: When to operate?

A right aortic arch with an isolated left innominate artery from the pulmonary artery is an exceedingly rare congenital cardiac malformation. We describe the management and complex surgical timing considerations in two such cases, successfully operated on day 4 and 7 months of age, including the use of cranial ultrasound as a helpful tool to guide decision-making. We also describe the first reported association of this defect with a 4q25 deletion encompassing the LEF1 gene.

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.

From Data to Design: Constructing Scapula and Hip Bone Through Online Datasets, Open-Source Software and 3D Printers.

Introduction Human skeletons and bones are essential for medical and allied sciences students. Nowadays, it is becoming challenging to procure bone legally, resulting in medical students' inadequacy of bone. Plaster-of-Paris or resin bone models sold on the market are less detailed than real bones. Aims and objectives This study aims to create a three-dimensional (3D)-printed human bone model with free, open-source software and fused deposition modelling (FDM) 3D printers, compare its accuracy with the original bones and validate it with a textbook description. Methods Scapula and hip bone models were produced using open-source software 3D Slicer from computed tomography (CT) data from the "New Mexico Decedent Image Database". After automated segmentation, bones were edited manually with tools in a 3D Slicer (https://www.slicer.org/) and Meshmixer software (Autodesk Inc., San Rafael, California, United States) and 3D bone models were printed using polylactic (PLA) filament. Results and discussions 3D digital models of both bones were successfully created with the maximum possible accuracy with an FDM 3D printer. A 3D digital replica of the scapula obtained after segmentation retained most anatomical features except for the glenoid cavity, as the head of the humerus obscured the glenoid cavity. The 3D digital skeleton of the hip bone retained all anatomical features except articulating surfaces, such as the acetabulum and auricular surface ilium, which were obscured by the head of the femur and sacrum. A few morphological features of both bones differed from the original dry bone, and a few finer details were unclear in the iliac fossa and ischium. After manual editing and post-processing, the final physical model obtained has all the features. Conclusions We conclude that it is possible to produce anatomically accurate models with the greatest possible resemblance and accuracy to the original bones using free and open-source data with an FDM 3D printer.

Partial upper median sternotomy for anterior aortopexy for innominate artery compression syndrome: a case series.

Background: Innominate artery compression syndrome (IAS) is caused by an abnormally originating innominate artery compressing the trachea anteriorly. One option to relieve such compression is an anterior aortopexy (AA). We describe our technique of an AA via a partial upper median sternotomy. Case Description: Nine consecutive patients underwent AA for IAS via a partial upper median sternotomy from July 2017 to November 2020 at two US teaching hospitals. The median age was 9 months [interquartile range (IQR), 3-16.5 months]. The male to female ratio was 1.25. All patients had >70% compression by flexible bronchoscopy. Two patients had previous surgeries. The median follow-up was 6 months (IQR, 4-8.5 months). The indications for the operation were: acute life-threatening events (ALTEs) (4/9 patients), recurrent intubation (4/9), and severe stridor with >70% luminal reduction (1/9). Technical success (defined as ≤20% residual stenosis) was achieved in 78% (7/9) of the patients. The two patients with unsuccessful AAs required either a tracheal resection or an innominate artery reimplantation. Both achieved full symptom resolution. Overall, 78% (7/9) of patients experienced full symptom resolution. Of the two patients without full symptom resolution, one had mild stridor at 6 months post-operation. The other patient without full resolution is awaiting further vocal cord surgery for an associated glottic pathology. Conclusions: A partial upper sternotomy provides a very versatile approach to an AA for IAS. In addition to facilitating an adequate AA, a partial upper sternotomy provides options for direct tracheal surgery or an innominate artery reimplantation in case an optimal result is not obtained by an AA.

Off-the-Shelf, Hybrid, Innominate Chimney Thoracic Endovascular Aneurysm Repair for Treatment of Mycotic Thoracic Aortic Aneurysm: A Case Report.

Mycotic thoracic aortic aneurysm (MTAA) is a disease that is difficult to treat and often lethal. Open repair has high morbidity and mortality risks; additionally, thoracic endovascular aneurysm repair (TEVAR) often requires innovative techniques. We report the use of an innominate artery chimney endovascular aneurysm repair (ChEVAR) with carotid-carotid and carotid-left subclavian artery bypass for a time-sensitive Salmonella-related MTAA. A symptomatic type 1a endoleak was discovered and promptly and successfully treated. This report shows that the use of innominate artery ChEVAR to treat MTAA is feasible and safe, although the procedure is rarely performed, even in large series. We hypothesize that prophylactic gutter embolization is a feasible option in view of the high endoleak risks in such cases, although further evidence is required to support this.