IL-1ß Inhibition Partially Negates the Beneficial Effects of Diet-Induced Atherosclerosis Regression in Mice.

BACKGROUND: Thromboembolic events secondary to rupture or erosion of advanced atherosclerotic lesions is the global leading cause of death. The most common and effective means to reduce these major adverse cardiovascular events, including myocardial infarction and stroke, is aggressive lipid lowering via a combination of drugs and dietary modifications. However, we know little regarding the effects of reducing dietary lipids on the composition and stability of advanced atherosclerotic lesions, the mechanisms that regulate these processes, and what therapeutic approaches might augment the benefits of lipid lowering. METHODS: Smooth muscle cell lineage-tracing Apoe-/- mice were fed a high-cholesterol Western diet for 18 weeks and then a zero-cholesterol standard laboratory diet for 12 weeks before treating them with an IL (interleukin)-1ß or control antibody for 8 weeks. We assessed lesion size and remodeling indices, as well as the cellular composition of aortic and brachiocephalic artery lesions, indices of plaque stability, overall plaque burden, and phenotypic transitions of smooth muscle cell and other lesion cells by smooth muscle cell lineage tracing combined with single-cell RNA sequencing, cytometry by time-of-flight, and immunostaining plus high-resolution confocal microscopic z-stack analysis. RESULTS: Lipid lowering by switching Apoe-/- mice from a Western diet to a standard laboratory diet reduced LDL cholesterol levels by 70% and resulted in multiple beneficial effects including reduced overall aortic plaque burden, as well as reduced intraplaque hemorrhage and necrotic core area. However, contrary to expectations, IL-1ß antibody treatment after diet-induced reductions in lipids resulted in multiple detrimental changes including increased plaque burden and brachiocephalic artery lesion size, as well as increasedintraplaque hemorrhage, necrotic core area, and senescence as compared with IgG control antibody-treated mice. Furthermore, IL-1ß antibody treatment upregulated neutrophil degranulation pathways but downregulated smooth muscle cell extracellular matrix pathways likely important for the protective fibrous cap. CONCLUSIONS: Taken together, IL-1ß appears to be required for the maintenance of standard laboratory diet-induced reductions in plaque burden and increases in multiple indices of plaque stability.

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.

Considerations on the morphology of the thyroid ima artery.

PURPOSE AND BACKGROUND: Detailed knowledge of the thyroid ima artery is essential for surgeons consequently we conducted an analysis investigating the arterial vasculature of the thyroid gland in 290 cases by dissection of formalin-fixed cadavers and by studying computed tomography angiographies. METHODS: Our study was conducted on 82 cases obtained from the dissection of formalin-fixed cadavers while 208 cases were computed tomography angiographies. The following aspects were observed: the frequency of the thyroid ima artery, its origin, course, and diameter. All were studied, comparing right to left and according to sex. RESULTS: Following the study of thyroid gland vasculature on a number of 290 cases, the thyroid ima artery was discovered in 16 cases (5.52% of cases), from which 3.45% of cases were in male subjects, and 2.07% of cases in female subjects. Of these, 4.14% of the total cases were left thyroid ima artery, and 1.38% of cases were on the right, found only in female subjects. In 5.17% of the total cases, the thyroid ima artery originated from the aortic arch, of which 3.45% were in the male sex and 1.72% were in the female sex. In one case only (0.35%) in the female sex did the thyroid ima artery originate from the brachiocephalic trunk. In 2.76% of cases, the thyroid ima artery existed with a left-sided inferior thyroid artery originating from the subclavian artery, either directly or from a thyrocervical trunk. CONCLUSIONS: The thyroid ima artery has proven to be one of the highly variable arteries in terms of its presence and origin and the knowledge surrounding it is useful for surgical interventions.

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.

Changes in the Relative Displacement between the Supra-Aortic Branches with Age.

BACKGROUND: This study aimed to determine the normal ranges for the height and deflection angle of the aortic arch and the displacement distances between the supra-aortic branches in relation to age, sex, body mass index (BMI), and body surface area (BSA) in adults without aortic disease using non-contrast chest computed tomography (CT). METHODS: The CT scans of 700 patients were analyzed. We measured the height and deflection angle of the aortic arch based on the lower level of the pulmonary artery bifurcation. The displacement distances between the supra-aortic branches in the coronal and sagittal planes were measured, and the deflection angles between these branches were calculated. Multiple linear regression analysis was used to investigate the associations of age, sex, BMI, and BSA with these aortic arch parameters. RESULTS: The height of the aortic arch was significantly higher (74 ± 15 mm vs. 65 ± 12 mm, P < 0.001) and the left-posterior displacement distance of the left subclavian artery (LSA) to the innominate artery (IA) was greater in men than that in women. The height and deflection angle of the aortic arch increased with age. The distance by which the LSA was shifted to the left posterior of the left common carotid artery and to the left of the IA increased with age. CONCLUSIONS: The normal aging process is accompanied by morphological changes in the aortic arch and relative displacement between the supra-aortic branches. Identifying these parameters could lead to a comprehensive understanding of the anatomy and morphology of the aortic arch.

Transcarotid artery revascularization in reverse for innominate artery stenosis.

Stenotic lesions of the supra-aortic vessels have been reported in 2-6% of patients presenting with corresponding symptoms. In the past, these lesions have been treated with open surgical techniques. More recently, endovascular treatment approaches have been proposed for occlusive lesions in the innominate (IA) or common carotid (CCA) arteries. Retrograde stenting of IA and CCA lesions using flow reversal has been described in a retrospective case series; however, a modification of their technique is proposed. Case Presentation: The patient is a 68-year-old male with symptoms of right upper extremity claudication. CT angiogram revealed critical stenosis of the innominate artery and high-grade stenosis of the right subclavian artery. The patient consented to retrograde stenting of the innominate stenosis with neuroprotection using flow reversal or transcarotid revascularization (TCAR) in reverse. Surgical cut-down was performed of the carotid bifurcation, and a U-stitch was placed on the anterior wall of the distal common carotid artery. Flow reversal was achieved by connecting the arterial sheath to the venous sheath. The innominate lesion was crossed, primarily stented with a VBX stent, and post-dilated with a non-compliant balloon. Just prior to crossing the lesion and primary stent placement, the vessel loop around the common carotid and internal carotid arteries were pulled up to ensure neuroprotection while the stent was expanded. This was continued for two minutes before restoring antegrade flow first in the external carotid and then in the internal carotid artery. There were no adverse events. At one month follow-up, the patient reported no right arm claudication symptoms. TCAR for the proximal lesion as described in other case series may not adequately attain flow based neuroprotection. Under that circumstance, the arterial sheath is acting as a conduit to deliver the stent. Risk of embolization to the brain may not be mitigated when the proximal lesion is stented and antegrade flow restored.

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.

Considerations on the origin of the inferior thyroid artery emerging from the subclavian artery determined by CT examination.

PURPOSE AND BACKGROUND: The specialized literature has a low degree of information regarding the origin of the inferior thyroid artery (ITA). Our study was performed on computed tomography angiographies (CTAs), and the following aspects were observed: the origin of the ITA from the subclavian artery (SCA) or thyrocervical trunk (TCT), taking note of the distance of the origin of the ITA in relation to the origin of the SCA or the corresponding TCT, as well as the origin of the ITA, comparing right to left and according to gender. METHODS: Our study was realized on a total of 108 ITA (64 on the right side and 44 on the left, with 48 in male subjects and 60 in females), analyzed on CTA. RESULTS: From the 108 arteries, we found the origin of ITA directly from the SCA in 31.48% of cases, and in 68.52% from the TCT. The distance between the origin of the right SCA and the origin of the corresponding ITA, was between 29.1 and 53.1 mm, while on the left side, the same distance was between 43.7 and 68.1 mm. The distance between the right TCT and the origin of the right SCA, was between 22.5 and 75.0 mm, and for the left side, it's between 48.7 and 56.8 mm. CONCLUSIONS: The inferior thyroid artery is one of the arteries most susceptible to variations in terms of origin and size. With differences between the two sides (right and left), as well as differences related to gender.

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.

Investigating the Association between Aortic Arch Variants and Intracranial Aneurysms.

BACKGROUND: There is an association between anterior cerebral artery vessel asymmetry and anterior communicating artery aneurysm, presumably based on flow dynamics. The purpose of this study is to investigate the potential relationship between aortic arch branching patterns and incidence of intracranial aneurysm. METHODS: This study included patients scanned over 1 year at our tertiary care center who underwent high-resolution imaging (computed tomography angiography or digital subtracted angiogram) of the head and neck arteries, aortic arch, and superior mediastinum. Exclusion criteria included patients with suboptimal images. Patient age, gender, aortic arch branching pattern, and the presence, location, and number of aneurysms were documented. RESULTS: Among the 1082 patients analyzed, 250 (23%) patients had a variant aortic arch branching pattern, 22 (8.8%) of whom had aneurysms. There were 104 patients with 126 aneurysms, with majority of patients with normal aortic arch branching pattern (n = 82, 79%). The most common variant was a common origin of the left common carotid artery and brachiocephalic trunk with or without direct origin of the left vertebral artery. Twenty-two patients with aneurysms had an aberrant aortic arch (21%), compared to 232 patients without an aneurysm (24%). Fischer exact test showed no statistically significant difference between the incidence of aneurysm with different aortic arch variant groups (two-tailed p-value = 0.715). CONCLUSION: To our knowledge, this is the first study to examine the association between aortic arch branching patterns and incidence of intracranial aneurysm. No significant association was found between aortic arch branching pattern and the incidence of intracranial aneurysm.

Partial Claviculectomy to Relieve Tracheal Compression in an Adult Male with Osteomesopyknosis.

BACKGROUND: The clavicle is a long bone that forms the anterior border of the thoracic inlet. Anatomic abnormalities of the clavicle can lead to compression of the innominate artery and trachea due to mass effect. These anatomic abnormalities can be amenable to surgical resection, which can provide complete resolution of symptoms. METHODS: We present a case of tracheal compression by the innominate artery in an adult man, caused by a clavicular abnormality due to an underlying bone mineralization disorder, corrected by partial resection of the right clavicle. RESULTS: The patient underwent successful open surgical resection of his right clavicular head leading to resolution of his tracheal compression by the innominate artery. CONCLUSIONS: We believe that this is the first description of tracheal compression due to osteomesopyknosis. This case demonstrates that compression of the innominate artery due to a clavicular abnormality can be safely corrected via open surgical resection.

The "Skewer Technique" for Stentgraft Delivery in the Aortic Arch: Advancing the Dilatator in The Innominate Artery Over a Right Femoro-Brachial Through-And-Through Wire.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is the preferred treatment for different aortic pathologies, because it has reduced mortality and morbidity rates. However, TEVAR is not feasible in all cases due to aortic angulations, the hemodynamics of the aortic arch and narrow or tortuous iliofemoral access. Therefore, different adjuvant techniques, such as iliac percutaneous transluminal angioplasty, iliathrough-and-through guidewires and external transapical guidewires have been previously reported. Herein we describe the Skewer Technique for successful TEVAR delivery, through a right-brachial-femoral through-and-through guidewire and advancement of the delivery system into the innominate artery. METHODS: A 38-year-old male presented with a symptomatic 11.5cm thoracic aneurysm with involvement of the left-subclavian artery ostium. The patient underwent left carotid-subclavian bypass and a TEVAR. Due to the huge size of the aneurysm a left-brachial-right femoral artery through-and-through guidewire was established. However, the achievement of a stable position for the deployment of the stentgraft was not possible. Eventually, the exclusion of the aneurysm was done with a right brachio-femoral through-and-through wire, inserting the proximal part of the delivery system into the innominate artery. CONCLUSIONS: The use of adjuvant techniques such as a through-and-through right brachial-femoral guidewire with advancement of the endograft delivery system in the innominate artery (Skewer Technique) represents a useful alternative option in cases where the angulations of the aortic arch impede the deployment of the stent graft using conventional techniques.

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.

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.