The Role of Duplex Ultrasound in Assessing AVF Maturation.

BACKGROUND: Arteriovenous fistulas (AVFs) are favored for hemodialysis (HD) access. However, in many instances, AVFs fail to mature. We examined the utility of postoperative color duplex ultrasound (CDU) in assessing AVF maturation and determining the need for balloon-assisted maturation (BAM). METHODS: A total of 633 patients underwent AVF creation at a single institution from 2015 to 2018. A total of 339 patients (54%) underwent CDU at a median of 8 weeks postoperatively. We collected the following parameters: vein diameter, volume flow (VF), peak systolic velocities in arterial inflow and venous outflow, and presence of stealing branches. A peak systolic velocity ratio (SVR) of ≥2 correlated with ≥50% stenosis in venous outflow, and SVR ≥3 correlated with ≥50% stenosis at the anastomosis. AVFs were considered mature when they were successfully cannulated on dialysis. A generalized linear mixed model (GLMM) was created to compare duplex criteria associated with successful use of AVF (maturation) to those AVFs that required further intervention or failed to mature. Fistulography images, the current gold standard, were compared with findings from CDU studies to determine validity of the duplex ultrasound. RESULTS: Of the 339 AVFs with postoperative CDU, 31.3% matured without interventions, 38.3% required BAM, 9.7% thrombosed, and the remaining patients were not yet on HD. Based on GLMM analysis, the probability of AVF maturation increases if CDU demonstrated one of the following: the vein diameter is ≥ 6 (odds ratio [OR] = 38.7), no evidence of stenosis in the venous outflow tract (OR = 35.6), no stealing branches (OR = 21.6) and VF ≥ 675 (OR = 5.0). Fistulography was performed in 195 patents. Sensitivity and specificity for each are as follows: vein diameter (84.3%, 28.6%), stenosis (59.3%, 78.8%), and stealing branches (20.7%, 92.7%). CONCLUSIONS: Postoperative CDU should be considered routine to correct anatomical findings that might limit AVF maturation and identify the need for further interventions.

Acute Arterial Thromboembolism in Patients with COVID-19 in the New York City Area.

BACKGROUND: Coronavirus disease 2019 (COVID-19) predisposes to arterial and venous thromboembolic complications. We describe the clinical presentation, management, and outcomes of acute arterial ischemia and concomitant infection at the epicenter of cases in the United States. METHODS: Patients with confirmed COVID-19 infection between March 1, 2020 and May 15, 2020 with an acute arterial thromboembolic event were reviewed. Data collected included demographics, anatomical location of the thromboembolism, treatments, and outcomes. RESULTS: Over the 11-week period, the Northwell Health System cared for 12,630 hospitalized patients with COVID-19. A total of 49 patients with arterial thromboembolism and confirmed COVID-19 were identified. The median age was 67 years (58-75) and 37 (76%) were men. The most common preexisting conditions were hypertension (53%) and diabetes (35%). The median D-dimer level was 2,673 ng/mL (723-7,139). The distribution of thromboembolic events included upper 7 (14%) and lower 35 (71%) extremity ischemia, bowel ischemia 2 (4%), and cerebral ischemia 5 (10%). Six patients (12%) had thrombus in multiple locations. Concomitant deep vein thrombosis was found in 8 patients (16%). Twenty-two (45%) patients presented with signs of acute arterial ischemia and were subsequently diagnosed with COVID-19. The remaining 27 (55%) developed ischemia during hospitalization. Revascularization was performed in 13 (27%) patients, primary amputation in 5 (10%), administration of systemic tissue- plasminogen activator in 3 (6%), and 28 (57%) were treated with systemic anticoagulation only. The rate of limb loss was 18%. Twenty-one patients (46%) died in the hospital. Twenty-five (51%) were successfully discharged, and 3 patients are still in the hospital. CONCLUSIONS: While the mechanism of thromboembolic events in patients with COVID-19 remains unclear, the occurrence of such complication is associated with acute arterial ischemia which results in a high limb loss and mortality.

Percutaneous fenestrated endovascular aortic graft treatment of aortocaval fistula with aortic pseudoaneurysms secondary to penetrating trauma.

Aortocaval fistula (ACF) is a lethal complication of aortic aneurysmal disease. Traditional treatment of ACF involves open surgical approaches to fistula ligation and repair of the great vessels, with a high mortality secondary to bleeding and cardiac compromise. We present the case of a 28-year-old man with a chronic ACF with concomitant aortic pseudoaneurysms secondary to penetrating trauma treated with a fenestrated endograft.

New predictors of complications in carotid body tumor resection.

OBJECTIVE: This study examined the relationship between two new variables, tumor distance to base of skull (DTBOS) and tumor volume, with complications of carotid body tumor (CBT) resection, including bleeding and cranial nerve injury. METHODS: Patients who underwent CBT resection between 2004 and 2014 were studied using a standardized, multi-institutional database. Demographic, perioperative, and outcomes data were collected. CBT measurements were determined from computed tomography, magnetic resonance imaging, and ultrasound examination. RESULTS: There were 356 CBTs resected in 332 patients (mean age, 51 years; 72% female); 32% were classified as Shamblin I, 43% as Shamblin II, and 23% as Shamblin III. The mean DTBOS was 3.3 cm (standard deviation [SD], 2.1; range, 0-10), and the mean tumor volume was 209.7 cm3 (SD, 266.7; range, 1.1-1642.0 cm3). The mean estimated blood loss (EBL) was 257 mL (SD, 426; range, 0-3500 mL). Twenty-four percent of patients had cranial nerve injuries. The most common cranial nerves injured were the hypoglossal (10%), vagus (11%), and superior laryngeal (5%) nerves. Both Shamblin grade and DTBOS were statistically significantly correlated with EBL of surgery and cranial nerve injuries, whereas tumor volume was statistically significantly correlated with EBL. The logistic model for predicting blood loss and cranial nerve injury with all three variables-Shamblin, DTBOS, and volume (R2 = 0.171, 0.221, respectively)-was superior to a model with Shamblin alone (R2 = 0.043, 0.091, respectively). After adjusting for Shamblin grade and volume, every 1-cm decrease in DTBOS was associated with 1.8 times increase in risk of >250 mL of blood loss (95% confidence interval, 1.25-2.55) and 1.5 times increased risk of cranial nerve injury (95% confidence interval, 1.19-1.92). CONCLUSIONS: This large study of CBTs demonstrates the value of preoperatively determining tumor dimensions and how far the tumor is located from the base of the skull. DTBOS and tumor volume, when used in combination with the Shamblin grade, better predict bleeding and cranial nerve injury risk. Furthermore, surgical resection before expansion toward the base of the skull reduces complications as every 1-cm decrease in the distance to the skull base results in 1.8 times increase in >250 mL of blood loss and 1.5 times increased risk of cranial nerve injury.

Feasibility of a proposed randomized trial in patients with uncomplicated descending thoracic aortic dissection: Results of worldwide survey.

The trial we propose will be the first multicenter, randomized, trial investigating the role of thoracic endovascular aortic repair (TEVAR) of uncomplicated type B aortic dissection (TBAD) compared to conservative (medical) management. To document the current management approaches for uncomplicated TBAD, we performed an international survey in 130 centers (in US and worldwide), of whom 114 (89%) responded. Sixty-three (54.8%) respondents do not routinely stent uncomplicated TBAD, and 43 (37.4%) perform TEVAR based on various imaging criteria. One hundred and one respondents (88.6%) agreed that equipoise was present. Almost all respondents agreed that demonstrating an improvement in major aortic complication-free survival with TBAD would lead to change in practice. The results of the survey demonstrate that a major randomized trial to determine the optimal management strategy for uncomplicated TBAD is warranted.

Gender Differences in Aortic Neck Morphology in Patients with Abdominal Aortic Aneurysms Undergoing Elective Endovascular Aneurysm Repair.

BACKGROUND: Previous studies have demonstrated that women tend to have adverse aortic neck morphology leading to exclusion of some women from undergoing endovascular aneurysm repair (EVAR). The objective of this study is to investigate differences in aortic neck morphology in men versus women, changes in the neck morphology and sac behavior after EVAR, and investigate how these features may influence outcomes. METHODS: We conducted a retrospective review of elective EVARs (2004-2013). We excluded patients who underwent elective EVAR with no postoperative imaging available and those patients with fenestrated repairs. Using TeraRecon and volumetric analysis, several features were investigated. These included percent thrombus, shape, length, angulation of the neck, and changes in neck and abdominal aortic aneurysm diameter. RESULTS: A total of 146 patients were found to meet inclusion criteria (115 men and 31 women) with similar baseline characteristics. Neck angulation was greater in women (23.9° vs. 13.5°; P < 0.028). The percent thrombus in women was higher than men (35.4% vs. 31%; P < 0.02). Abdominal aneurysm's were smaller in women at 1 year (4.2 cm vs. 5.1 cm; P < 0.002), and secondary interventions were higher in men (11.3% vs. 0%; P < 0.05). Other features such as neck shape, changes in neck diameter, neck length, and percent oversizing of graft where not statistically different between genders. CONCLUSIONS: Gender differences in neck characteristics and changes in neck morphology do not appear to adversely affect EVAR outcomes. Longer follow-up is necessary to further assess whether these findings are clinically durable.

Acute Aortic Dissection and Intramural Hematoma: A Systematic Review.

IMPORTANCE: Acute aortic syndrome (AAS), a potentially fatal pathologic process within the aortic wall, should be suspected in patients presenting with severe thoracic pain and hypertension. AAS, including aortic dissection (approximately 90% of cases) and intramural hematoma, may be complicated by poor perfusion, aneurysm, or uncontrollable pain and hypertension. AAS is uncommon (approximately 3.5-6.0 per 100,000 patient-years) but rapid diagnosis is imperative as an emergency surgical procedure is frequently necessary. OBJECTIVE: To systematically review the current evidence on diagnosis and treatment of AAS. EVIDENCE REVIEW: Searches of MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials for articles on diagnosis and treatment of AAS from June 1994 to January 29, 2016, were performed. Only clinical trials and prospective observational studies of 10 or more patients were included. Eighty-two studies (2 randomized clinical trials and 80 observational) describing 57,311 patients were reviewed. FINDINGS: Chest or back pain was the most commonly reported presenting symptom of AAS (61.6%-84.8%). Patients were typically aged 60 to 70 years, male (50%-81%), and had hypertension (45%-100%). Sensitivities of computerized tomography and magnetic resonance imaging for diagnosis of AAS were 100% and 95% to 100%, respectively. Transesophageal echocardiography was 86% to 100% sensitive, whereas D-dimer was 51.7% to 100% sensitive and 32.8% to 89.2% specific among 6 studies (n = 876). An immediate open surgical procedure is needed for dissection of the ascending aorta, given the high mortality (26%-58%) and proximity to the aortic valve and great vessels (with potential for dissection complications such as tamponade). An RCT comparing endovascular surgical procedure to medical management for uncomplicated AAS in the descending aorta (n = 61) revealed no dissection-related deaths in either group. Endovascular surgical procedure was better than medical treatment (97% vs 43%, P < .001) for the primary end point of "favorable aortic remodeling" (false lumen thrombosis and no aortic dilation or rupture). The remaining evidence on therapies was observational, introducing significant selection bias. CONCLUSIONS AND RELEVANCE: Because of the high mortality rate, AAS should be considered and diagnosed promptly in patients presenting with acute chest or back pain and high blood pressure. Computerized tomography, magnetic resonance imaging, and transesophageal echocardiography are reliable tools for diagnosing AAS. Available data suggest that open surgical repair is optimal for treating type A (ascending aorta) AAS, whereas thoracic endovascular aortic repair may be optimal for treating type B (descending aorta) AAS. However, evidence is limited by the paucity of randomized trials.

Screening for abdominal aortic aneurysm.

Guidelines are systematically developed statements to assist patients and providers in choosing appropriate health care for specific clinical conditions. Consensus exists across guidelines on one-time screening of elderly men to detect and treat abdominal aortic aneurysm (AAA) ≥5.5 cm. However, the recommendations regarding other age groups, imaging intervals for small AAAs, inclusion of women, and cost-effectiveness have not been universally adopted. As many countries are considering the initiation of an AAA screening program, this is an overview on the current status of such programs.

Neurovascular compromise due to true brachial artery aneurysm at the site of a previously ligated arteriovenous fistula: Case report and review of literature.

True arterial aneurysms of the upper extremity are rare. The case described is that of a 48-year-old man presenting with median neuropathy and distal vascular compromise 4 years after ligation of a brachiocephalic arteriovenous fistula. We describe our approach and present a review of the relevant literature.

Endovascular-first approach is not associated with worse amputation-free survival in appropriately selected patients with critical limb ischemia.

OBJECTIVE: Endovascular interventions for critical limb ischemia are associated with inferior limb salvage (LS) rates in most randomized trials and large series. This study examined the long-term outcomes of selective use of endovascular-first (endo-first) and open-first strategies in 302 patients from March 2007 to December 2010. METHODS: Endo-first was selected if (1) the patient had short (5-cm to 7-cm occlusions or stenoses in crural vessels); (2) the disease in the superficial femoral artery was limited to TransAtlantic Inter-Society Consensus II A, B, or C; and (3) no impending limb loss. Endo-first was performed in 187 (62%), open-first in 105 (35%), and 10 (3%) had hybrid procedures. RESULTS: The endo-first group was older, with more diabetes and tissue loss. Bypass was used more to infrapopliteal targets (70% vs 50%, P = .031). The 5-year mortality was similar (open, 48%; endo, 42%; P = .107). Secondary procedures (endo or open) were more common after open-first (open, 71 of 105 [68%] vs endo, 102 of 187 [55%]; P = .029). Compared with open-first, the 5-year LS rate for endo-first was 85% vs 83% (P = .586), and amputation-free survival (AFS) was 45% vs 50% (P = .785). Predictors of death were age >75 years (hazard ratio [HR], 3.3; 95% confidence interval [CI], 1.7-6.6; P = .0007), end-stage renal disease (ESRD) (HR, 3.4; 95% CI, 2.1-5.6; P < .0001), and prior stroke (HR, 1.6; 95% CI, 1.03-2.3; P = .036). Predictors of limb loss were ESRD (HR, 2.5; 95% CI, 1.2-5.4; P = .015) and below-the-knee intervention (P = .041). Predictors of worse AFS were older age (HR, 2.03; 95% CI, 1.13-3.7; P = .018), ESRD (HR, 3.2; 95% CI, 2.1-5.11; P < .0001), prior stroke (P = .0054), and gangrene (P = .024). CONCLUSIONS: At 5 years, endo-first and open-first revascularization strategies had equivalent LS rates and AFS in patients with critical limb ischemia when properly selected. A patient-centered approach with close surveillance improves long-term outcomes for both open and endo approaches.

Use of preoperative magnetic resonance angiography and the Artis zeego fusion program to minimize contrast during endovascular repair of an iliac artery aneurysm.

BACKGROUND: A 61-year-old man with a previous endovascular repair and stage 5 chronic kidney disease presented with a symptomatic 4.5-cm left internal iliac artery aneurysm. The decision was made to proceed with endovascular repair. METHODS: The preoperative magnetic resonance angiography (MRA) scan was linked to on-table rotational imaging using the Artis zeego Fusion program (Siemens AG, Forchheim, Germany). Using the fused image as a road map, we undertook coil embolization of the left internal iliac artery, and a tapered stent graft was extended from the previous graft into the external iliac artery. RESULTS: Completion angiography revealed exclusion of the aneurysm sac. Three milliliters of contrast were used throughout the procedure. A follow-up magnetic resonance angiography scan at 1 month and duplex ultrasonography at 1 year revealed continued exclusion of the aneurysm sac. The patient's renal function remained unchanged. CONCLUSIONS: This case shows that in a patient with severe chronic kidney disease, fusion of preoperative imaging with intraoperative rotational imaging is feasible and can limit significantly the amount of contrast used during a complex endovascular procedure.

Open surgical management of complications from indwelling radial artery catheters.

BACKGROUND: Cannulation of the radial artery is frequently performed for invasive hemodynamic monitoring. Complications arising from indwelling catheters have been described in small case series; however, their surgical management is not well described. Understanding the presentation and management of such complications is imperative to offer optimal treatment, particularly because the radial artery is increasingly accessed for percutaneous coronary interventions. METHODS: We conducted a retrospective review to identify patients who underwent surgical intervention for complications arising from indwelling radial artery catheters from 1997 to 2011. RESULTS: We identified 30 patients who developed complications requiring surgical intervention. These complications were categorized into ischemic and nonischemic, with 15 patients identified in each cohort. All patients presenting with clinical hand or digital ischemia underwent thrombectomy and revascularization. Complications in the nonischemic group included three patients with deep abscesses with concomitant arterial thrombosis, two with deep abscesses alone, and 10 with pseudoaneurysms. Treatment strategy in this group varied with the presenting pathology. Among the entire case series, three patients required reintervention after the initial surgery, all in individuals initially presenting with ischemia who developed recurrent thrombosis of the radial artery. There were no digital or hand amputations in this series. However, the overall in-hospital mortality in these patients was 37%, reflecting the severity of illness in this patient cohort. Three patients who were positive for heparin-induced thrombocytopenia antibody had 100% mortality compared with those who were negative (P = .04, Fisher exact test). In-hospital mortality was higher in patients presenting with initial ischemia than in those with nonischemic complications (53% vs 20%; P = .06). Among 10 patients who presented with pseudoaneurysms, five (50%) were septic at presentation with positive blood cultures, and six (60%) had positive operating room cultures. Staphylococcus aureus was identified as the causative organism in all of these patients. CONCLUSIONS: Complications of radial artery cannulation requiring surgical intervention can represent infectious and ischemic sequelae and have the potential to result in major morbidity, including digital or hand amputation and sepsis, or death. Although surgical treatment is successful and often required in these patients to treat severe hand ischemia, hemorrhage, or vascular infection, these complications tend to occur in critically ill hospitalized patients with an extremely high mortality. This must be taken into consideration when planning surgical intervention in this patient cohort. Finally, radial arterial cannulation sites should not be overlooked when searching for occult septic sources in critically ill patients.

Preoperative relative abdominal aortic aneurysm thrombus burden predicts endoleak and sac enlargement after endovascular anerysm repair.

BACKGROUND: Endoleak and sac growth remain unpredictable occurrences after EVAR, necessitating regular surveillance imaging, including CT angiography. This study was designed to identify preoperative CT variables that predict AAA remodeling and sac behavior post-EVAR. METHODS: Pre- and postoperative CT scans from 136 abdominal aortic aneurysms treated with EVAR were analyzed using M2S (West Lebanon, NH) software for size measurements. Preoperative total sac volume and proportion of thrombus and calcium in the sac were assessed. Sac change was defined as a 3-mm difference in diameter and a 10-mm3 difference in volume when compared with preoperative measurements. Univariate analysis was performed for age, gender, AAA size, relative thrombus/calcium volume, device type, presence of endoleak, and the effects on sac size. RESULTS: Gender, device type, age, AAA size, and percent calcium were not predictive of sac change post-EVAR. Increased proportion of thrombus on pre-EVAR resulted in a greater likelihood of sac shrinkage (P=0.002). Patients with aneurysms that grew on postoperative CT scan had less sac thrombus on pre-EVAR (mean 27.5%) than patients without evidence of endoleak (mean 41.9%, P<0.0001). Only 2 of 30 patients with >50% pre-EVAR thrombus developed endoleak. A>50% thrombus burden resulted in endoleak in significantly fewer patients (6.7%) compared with those who had <50% thrombus (43.1%). CONCLUSIONS: The proportion of thrombus on preoperative CT may predict sac behavior after EVAR and development of an endoleak. Greater than 50% thrombus appears to predict absence of endoleak after EVAR. Aneurysms with large thrombus burden are less likely to grow and may require less vigilant postoperative surveillance than comparable AAA with relatively little thrombus.

Initial Thoracic Endovascular Aortic Repair vs Medical Therapy for Acute Uncomplicated Type B Aortic Dissection.

Importance: Thoracic endovascular aortic repair (TEVAR) has increasingly been used for uncomplicated type B aortic dissection (uTBAD) despite limited supporting data. Objective: To assess whether initial TEVAR following uTBAD is associated with reduced mortality or morbidity compared with medical therapy alone. Design, Setting, and Participants: This cohort study included Centers for Medicare & Medicaid Services inpatient claims data for adults aged 65 years or older with index admissions for acute uTBAD from January 1, 2011, to December 31, 2018, with follow-up available through December 31, 2019. Exposures: Initial TEVAR was defined as TEVAR within 30 days of admission for acute uTBAD. Main Outcomes and Measures: Outcomes included all-cause mortality, cardiovascular hospitalizations, aorta-related and repeated aorta-related hospitalizations, and aortic interventions associated with initial TEVAR vs medical therapy. Propensity score inverse probability weighting was used. Results: Of 7105 patients with eligible index admissions for acute uTBAD, 1140 (16.0%) underwent initial TEVAR (623 [54.6%] female; median age, 74 years [IQR, 68-80 years]) and 5965 (84.0%) did not undergo TEVAR (3344 [56.1%] female; median age, 76 years [IQR, 69-83 years]). Receipt of TEVAR was associated with region (vs South; Midwest: adjusted odds ratio [aOR], 0.66 [95% CI, 0.53-0.81]; P < .001; Northeast: aOR, 0.63 [95% CI, 0.50-0.79]; P < .001), Medicaid dual eligibility (aOR, 0.76; 95% CI, 0.63-0.91; P = .003), hypertension (aOR, 1.26; 95% CI, 1.03-1.54; P = .03), peripheral vascular disease (aOR, 1.24; 95% CI, 1.02-1.49; P = .03), and year of admission (2012, 2013, 2014, and 2015 were associated with greater odds of TEVAR compared with 2011). After inverse probability weighting, mortality was similar for the 2 strategies up to 5 years (hazard ratio [HR], 0.95; 95% CI, 0.85-1.06), as were aorta-related hospitalizations (HR, 1.12; 95% CI, 0.99-1.27), aortic interventions (HR, 1.01; 95% CI, 0.84-1.20), and cardiovascular hospitalizations (HR, 1.05; 95% CI, 0.93-1.20). In a sensitivity analysis that included deaths within the first 30 days, initial TEVAR was associated with lower mortality over a period of 1 year (adjusted HR [aHR], 0.86; 95% CI, 0.75-0.99; P = .03), 2 years (aHR, 0.85; 95% CI, 0.75-0.96; P = .008), and 5 years (aHR, 0.87; 95% CI, 0.80-0.96; P = .004). Conclusions and Relevance: In this study, 16.0% of patients underwent initial TEVAR within 30 days of uTBAD, and receipt of initial TEVAR was associated with hypertension, peripheral vascular disease, region, Medicaid dual eligibility, and year of admission. Initial TEVAR was not associated with improved mortality or reduced hospitalizations or aortic interventions over a period of 5 years, but in a sensitivity analysis that included deaths within the first 30 days, initial TEVAR was associated with lower mortality. These findings, along with cost-effectiveness and quality of life, should be assessed in a prospective trial in the US population.

Presentation and management of carotid artery aneurysms and pseudoaneurysms.

OBJECTIVE: The objective of this study was to review a single-institution contemporary experience with extracranial aneurysms of the carotid artery. METHODS: A retrospective review was conducted of patients evaluated for an aneurysm of the extracranial carotid artery from 2005 to 2010. Demographics, presentation, and operative management were reviewed. The mean follow-up was 22 months (range, 1-58 months). RESULTS: Over the study period, 16 aneurysms and pseudoaneurysms were identified in 15 patients. Of these, 14 aneurysms (in six men and eight women with mean age of 63 years) underwent surgical repair. The mean aneurysm size was 2.45 cm (range, 0.8-5 cm). One aneurysm (7.1%) was associated with neurologic symptoms, and 13 were asymptomatic. The underlying etiology was trauma in five (35.7%), prior carotid endarterectomy in five (35.7%), and degenerative atherosclerosis in four (28.6%). Aneurysms were isolated to the common carotid artery in six (42.9%), internal carotid artery in five (35.7%), and carotid bifurcation in three (21.4%). Five patients underwent aneurysmectomy with primary repair, seven underwent repair with an interposition graft, one required an innominate to common carotid artery bypass, and one patient had a plication and patch angioplasty. No mortalities or neurologic events were documented within 30 days. One patient had transient cranial nerve palsy. One patient required reintervention at 4 months for stenosis of the bypass graft, and one patient died at 10 months from an unrelated condition. There were no neurologic events on follow-up. CONCLUSIONS: Carotid artery aneurysms and pseudoaneurysms are uncommon and usually asymptomatic. Prior trauma and carotid surgery were common etiologies. The location of the aneurysms was equally distributed between the internal and common carotid arteries. Surgical repair was safe and effective with no significant morbidity or mortality and good midterm stroke prevention.

Aberrant left subclavian artery associated with a Kommerell's diverticulum and a left-sided aortic arch.

Kommerell's diverticulum is most commonly associated with either an aberrant left subclavian artery from a right-sided aortic arch or an aberrant right subclavian artery from a left-sided aortic arch. We describe an exceedingly rare case of an aberrant left subclavian artery arising from a Kommerell's diverticulum in a patient with a left-sided aortic arch, the "nonaberrant aberrant left subclavian artery."