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

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

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

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

Endovascular stenting of supra-aortic lesions using a transcarotid retrograde approach and flow reversal: A multicenter case series.

OBJECTIVE: Endovascular treatment has largely replaced open reconstruction of proximal brachiocephalic and left common carotid ostial arterial stenoses. The objective of this study was to report the technical feasibility and safety of a flow-based embolic protection system in stenting of single and tandem stenotic lesions of supra-aortic arch vessels. METHODS: All cases used flow-based neuroprotection by the ENROUTE Transcarotid Neuroprotection System (Silk Road Medical, Sunnyvale, Calif). Case specifics, such as the stents used, the details of flow-based neuroprotection, the order in which lesions were treated, and the case-specific exceptions, are detailed in the body of the publication. The primary end point of this study was the occurrence of stroke or transient ischemic attack. RESULTS: Sixteen patients (12 women) with an average age of 68 years (range, 54-83 years) underwent endovascular stenting to treat single (11 patients) or tandem (5 patients) stenotic lesions of supra-aortic arch vessels. A total of 21 lesions were treated: 7 in the innominate artery, 1 in the right common carotid artery, 8 in the left common carotid artery, and 5 in the internal carotid artery (tandem cases). Eleven patients (69%) were symptomatic, and the stenoses of the five asymptomatic patients were identified during routine workup for comorbidities. Technical success was obtained in all cases. There were no strokes or transient ischemic attacks during the 30 days after the procedure. Minor complications included a minor wound dehiscence that healed secondarily without sequelae and a hematoma at the neck incision that resolved spontaneously without further intervention. CONCLUSIONS: The use of a transcarotid retrograde approach with flow-based neuroprotection is technically feasible for the endovascular stenting of single and tandem stenotic lesions of the supra-aortic arch vessels. These data further support the advantages of a transcarotid approach and flow-based neuroprotection to minimize the risk of intraoperative complications and embolic events during and after the procedure.

Stenting for Innominate Artery Stenosis Under Double-Filter Protection of the Anterior and Posterior Circulation via the Right Brachial Artery.

Several protocols for angioplasty and stenting for stenosis of an innominate artery (IA) are reported, but the protocols are sometimes complicated and have disadvantages. We report a case of IA stenosis presenting ischemic symptoms in a 58-year-old woman. Stenting for the IA stenosis was performed through the right femoral artery. The cerebral protection was placed via the right brachial artery, with a filter at the right internal carotid artery and another filter at the right vertebral artery. The symptomatic IA stenosis was resolved without any complications. Regardless of the direction of blood flow, simultaneous protection of both the anterior and posterior cerebral circulation is necessary during IA stenting. Double-filter protection can provide excellent cerebral protection during an IA stenting procedure.

Use of a Dual-Filter Embolic Protection Device for Brachiocephalic Artery Stenting.

A 77-year-old female with peripheral artery disease underwent brachiocephalic artery stenting for right upper extremity claudication. Given a very high atherosclerotic burden seen on CT, a dual-filter embolic protection device (Sentinel, Boston Scientific) was deployed from the right radial artery to protect the right common carotid and subclavian arteries, and therefore the vertebral artery, during the stenting procedure. This case report demonstrates a novel use of this dual-filter device to provide both carotid and vertebral artery embolic protection during brachiocephalic artery intervention.

Innominate to contralateral brachial artery bypass via ministernotomy with anatomic tunneling for critical ischemia of the left upper extremity.

OBJECTIVES: Scarring from prior bypass surgery and irradiation may compromise revascularization options in critical ischemia due to underlying occlusive disease. Occlusive disease of the axillo-brachial artery is particularly difficult to revascularize under such hostile conditions. METHOD: We present a case of a 58-year-old woman presenting with a painful, pulseless, and cool left upper extremity. The patient had a known history of left upper extremity occlusive disease which was managed by subclavian-axillary artery stenting with re-occlusion and subsequent extra-anatomic left carotid-to-proximal brachial artery prosthetic bypass, which was complicated by stroke. The patient had a history of left mastectomy, axillary node dissection, and external beam radiation therapy. When considering revascularization options, the combination of post-radiation changes and scarring of the conventional operative zones for revascularization posed a high risk for complications. We describe a novel approach for such revascularization, where the inflow source was the terminal brachiocephalic artery, outflow to the upper left brachial artery, with anatomic intrathoracic-to-axillary tunneling through the thoracic outlet after verifying the lack of dynamic extrinsic compression at that level. RESULT: The procedure resulted in resolution of the symptoms and the patient continued to do well 2 years later. CONCLUSION: This case shows that anatomic tunneling through the thoracic outlet can be a viable option for upper extremity revascularization when hostile conditions preclude other anatomic tunneling routes or extra-anatomic options.

Lower Rate of Restenosis and Reinterventions With Covered vs Bare Metal Stents Following Innominate Artery Stenting.

PURPOSE: To determine any difference between bare metal stents (BMS) and balloon-expandable covered stents in the treatment of innominate artery atheromatous lesions. MATERIALS AND METHODS: A multicenter retrospective study involving 13 university hospitals in France collected 93 patients (mean age 63.2±11.1 years; 57 men) treated over a 10-year period. All patients had systolic blood pressure asymmetry >15 mm Hg and were either asymptomatic (39, 42%) or had carotid (20, 22%), vertebrobasilar (24, 26%), and/or brachial (20, 22%) symptoms. Innominate artery stenosis ranged from 50% to 70% in 4 (4%) symptomatic cases and between 70% and 90% in 52 (56%) cases; 28 (30%) lesions were preocclusive and 8 (9%) were occluded. One (1%) severely symptomatic patient had a <50% stenosis. Demographic characteristics, operative indications, and procedure details were compared between the covered (36, 39%) and BMS (57, 61%) groups. Multivariate analysis was performed to determine relative risks of restenosis and reinterventions [reported with 95% confidence intervals (CI)]. RESULTS: The endovascular procedures were performed mainly via retrograde carotid access (75, 81%). Perioperative strokes occurred in 4 (4.3%) patients. During the mean 34.5±31.2-month follow-up, 30 (32%) restenoses were detected and 13 (20%) reinterventions were performed. Relative risks were 6.9 (95% CI 2.2 to 22.2, p=0.001) for restenosis and 14.6 (95% CI 1.8 to 120.8, p=0.004) for reinterventions between BMS and covered stents. The severity of the treated lesions had no influence on the results. CONCLUSION: Patients treated with BMS for innominate artery stenosis have more frequent restenoses and reinterventions than patients treated with covered stents.

Anomaly in the Embryogenesis of the Aorta associated with Subclavian Steal Phenomenon.

Congenital aortic arch anomalies are rare and may be associated with other congenital cardiovascular malformations. The authors report a rare case of anomaly in the aortic arch embryogenesis, presenting with a right aortic arch and an isolated innominate artery, associated with the subclavian steal phenomenon. This condition is discussed considering the Edwards hypothetical double embryonic arch and its clinical aspects.

Aorta-innominate bypass through ministernotomy.

Atherosclerotic innominate artery occlusive disease can lead to cerebral and upper extremity ischemia. Innominate artery angioplasty and stenting can be complicated by stent fractures and restenosis; furthermore, this technique is limited in treatment of innominate artery occlusions. Ministernotomy to the second or third intercostal space can be used instead of conventional full sternotomy for open surgical revascularization of the innominate artery with excellent perioperative and long-term outcomes. This series of three consecutive patients highlights the technique of aorta-innominate artery bypass through ministernotomy.

Brachiocephalic Arterial Occlusive Disease Presenting as Limb-Shaking Transient Ischemic Attacks.

Limb-shaking transient ischemic attacks (LSTIAs) are a phenomenon that occurs due to transient hypoperfusion to a cerebral motor territory with a chronically outstripped autoregulatory vascular reserve. First described in 1962 by Miller Fisher, the pathogenesis and the global understanding of this presentation have undergone a significant advancement throughout the years. Typically, patients will present with this syndrome of transient hypoperfusion in the context of extracranial carotid intrinsic vessel stenosis or by intracranial vascular stenosis to select motor pathways. We present within this case report a novel mechanism by which LSTIAs may emerge. Through this knowledge, clinicians may need to consider expansion of their diagnostic breadth to include proximal vasculature luminal integrity.

Upper Extremity Blood Pressure Difference in Patients Undergoing Carotid Revascularisation.

INTRODUCTION: Blood pressure (BP) regulation is important in patients with carotid artery atherosclerotic disease. Concomitant subclavian artery stenosis (SAS) might lead to an underestimation of the true systemic BP in the monitoring of these patients. This study aimed to assess the prevalence of the inter-arm BP difference in patients undergoing carotid intervention and its association with ipsilateral significant subclavian stenosis and clinical outcome. METHODS: Bilateral BP measurements and vascular imaging (CTA and MRA) of both subclavian arteries and the innominate artery were assessed in 182 symptomatic patients with carotid artery stenosis undergoing revascularisation in the International Carotid Stenting Study (ICSS). Data were separately analysed according to previously described cutoff values for systolic BP (SBP) differences of ≥10 and <15 mmHg, ≥15 and <20 mmHg, or ≥20 mmHg. Significant SAS was defined as a >50% diameter reduction. RESULTS: Of the 182 patients, 39 (21%) showed an inter-arm difference in SBP >15 mmHg. The mean inter-arm SBP difference associated with ipsilateral SAS was 14 mmHg. SAS was present in 21/182 (12%) patients. Only two patients (1%) had bilateral stenotic disease. An inter-arm SBP difference of ≥20 mmHg was associated with unilateral SAS (RR 11.8; 95% CI 3.2-43.1) with a sensitivity of 23% and a specificity of 98%. Patients were followed up for a median of 4.0 years (IQR 3.0-6.0; maximum 7.5). Risk of stroke or death during follow-up was 20.0% (95% CI 11.1-28.9) in patients with, and 15.1% (95% CI 12.3-17.9) in patients without SAS (p = .561). The hospital stay was longer in patients with significant SAS (5.0 days, SD 4.9 vs. 2.7 days, SD 4.3, p = .035). CONCLUSION: The present study is the first to affirm the clinical need for the measurement of inter-arm BP differences in patients undergoing carotid revascularisation, especially in the post-operative phase in the prevention of cerebral hyperperfusion.

Transcarotid Approach for Retrograde Stenting of Proximal Innominate and Common Carotid Artery Stenosis.

BACKGROUND: To evaluate the hybrid treatment of severe stenosis or occlusion of the proximal innominate artery (IA) and common carotid artery (CCA) via surgical cutdown of the CCA and distal clamping for cerebral protection against thromboembolic events during retrograde stenting. METHODS: Consecutive patients undergoing retrograde stenting of proximal IA and CCA stenosis or occlusion via surgical cutdown of the CCA and with distal clamping for prevention of embolization, with or without concomitant endarterectomy of the carotid bifurcation, between April 1999 and August 2015 were reviewed. Perioperative and long-term outcomes were assessed. RESULTS: Thirty-five patients underwent a total of 36 successful interventions. One patient underwent staged bilateral stenting. Additional concomitant carotid endarterectomy was performed in 13 patients (36%). No new neurological symptoms neither perioperatively nor in-hospital were recorded. Thirty-day follow-up revealed 1 new ipsilateral and 1 new contralateral stroke (6%) with completely patent stents, no reinterventions, and 2 unrelated deaths (6%). Median follow-up was 56 months (range: 1-197). After 5 and 10 years, the Kaplan-Meier estimated overall survival rate was 85% and 52%. Primary assisted patency rate was 94% during follow-up. Overall freedom from reintervention was 91%. Three reinterventions were performed during the first postoperative year. Three new neurological events occurred during follow-up, 1 ipsilateral (3%) and 2 contralateral (6%). The ipsilateral event occurred during the first year and both contralateral events during the second year postoperatively. CONCLUSIONS: The retrograde hybrid approach to proximal IA and CCA disease is a safe procedure with surgical outflow control preventing perioperative stroke in ipsilateral carotid territory. Most relevant in-stent stenoses/occlusions and new neurological events occurred within the first 2 years, suggesting these patients should undergo regular monitoring early postoperatively. High patency rates without further neurological events can be expected thereafter.

Radial forces of stents used in thoracic endovascular aortic repair and bare self-expanding nitinol stents measured ex vivo - Rapid rescue for obstruction of the innominate artery using bare self-expanding nitinol stents.

Purpose Our objective was to compare the radial forces of several stents ex vivo to identify stents suitable for rescue of the unexpected coverage of aortic arch branches in thoracic endovascular aortic repair. Methods We measured the radial forces of two types of self-expanding bare nitinol stents (E-luminexx and Epic) used singly or as double-walled pairs, and of three endoprostheses used in thoracic endovascular aortic repair (TEVAR, Gore c-TAG, Relay, and Valiant) by compressing the stent using an MTS Instron universal testing machine (model #5582). We also examined the compressive effects of the TEVAR endoprostheses and the bare nitinol stents on each other. Results The radial force was greater in the center than at the edge of each stent. In all stents tested, the radial force decreased incrementally with increasing stent diameter. The radial force at the center was two times greater when using two stents than with a single stent. In the compression test, only E-luminexx used as a pair was not compressed after compressing a Relay endoprosthesis by 12 mm. Conclusion Two E-luminexx stents are appropriate to restore the blood flow if a TEVAR endoprosthesis covers the innominate artery following innominate-carotid-left subclavian arterial bypass.

Late Retrograde Migration of a Left Subclavian Artery Chimney Stent-Graft Into the Innominate Artery.

PURPOSE: To report an uncommon case of chimney stent-graft migration in the aortic arch. CASE REPORT: A 29-year-old man presented with chronic left arm hyposthenia after late displacement and thrombosis of a left subclavian artery (LSA) chimney graft that migrated retrogradely into the innominate artery 2 years after deployment. The self-expanding LSA chimney was placed during a redo procedure to repair a pseudoaneurysm and type I endoleak after an index emergency thoracic endovascular aortic repair for traumatic aortic rupture 1 year earlier. The patient was successfully treated in an elective procedure via a median sternotomy, with arch aortotomy under circulatory arrest to remove the proximal end of the thrombosed chimney graft from the ostium of the innominate trunk. Three months later, a left carotid-to-subclavian bypass was performed to restore flow to the left arm. CONCLUSION: Migration of the proximal end of an overly long chimney graft that moved freely in the aortic arch exposed the patient to a high risk of stroke and death. Because of the high-risk situation, open repair under circulatory arrest was elected to remove the proximal end of the chimney graft, with no major complications.

Outcomes of the Endovascular Treatment for the Supra-Aortic Trunks Occlusive Disease: A 14-Year Monocentric Experience.

BACKGROUND: Endovascular treatment of proximal supra-aortic trunks (SAT) has become a safe and reliable alternative to conventional open surgery, with a lower morbimortality rate and good short- and middle-term patency rates. The aim of our study was to assess the long-term results of endovascular treatment of proximal lesions of the SAT (brachiocephalic trunk, common carotid artery, and subclavian artery) and identify predictive risk factors of restenosis. METHODS: From 1999 to 2013, 67 consecutive stenotic lesions of the proximal SAT were treated by angioplasty (13.4%) or stenting (86.6%) in 63 patients with a mean age of 65.5 years (40-87). Procedures were performed under general (69%), local (24%), or locoregional (7%) anesthesia, with percutaneous puncture (47.8%) or open access (52.2%). Patients were followed up for 3, 6, and 12 months, and then every year with clinical examination, Doppler ultrasound and if required an angio-CT scan. RESULTS: The technical success rate was 98.5%. There was no postoperative death or strokes. One myocardial infarction occurred at day 2. There were 2 access complications: a nonsurgical hematoma after brachial access and a brachial thrombosis postpuncture. The mean follow-up was 4.5 years (2-163 months). The primary- and assisted-patency rates were 90.1%, 86.4%, 77.9% and 93.3%, 91.4%, 82.9% at 1, 2, and 5 years, respectively. Eleven restenosis (16.4%) occurred at 28.5 months (3, 0-112, 0) of follow-up. Four of them required an endovascular repair and 3 required a surgical one. The restenosis rate was 17.5% in the stented group on average at 30.2 months of follow-up (range, 3.0-112.0) and 10% in the group of patients with angioplasty alone at 8 months of follow-up, without significant statistically difference (P = 0.9). No predictive risk factor of restenosis was statistically identified. CONCLUSIONS: The endovascular treatment of proximal stenosis of SAT is a safe, reliable, and efficient technique with a low morbidity and mortality. The long-term results are good, but restenosis can occur. Long-term follow-up should be performed to detect and treat restenosis.

Tracheoinnominate Fistula: Endovascular Treatment with a Stent Graft in a 4-Year-Old Child.

A 4-year-old boy presented with acute and profuse bleeding at the tracheostomy site. An emergency angiography was performed and identified a pseudoaneurysm at the innominate artery. A selective catheterization of the artery was executed and 2 Advanta V12 balloon-expandable covered stents were implanted in an overlapping manner to occlude the pseudoaneurysm. Final angiography demonstrated patency of the innominate artery and no signs of bleeding. The patient had no postoperative complications and no further bleeding during follow-up. A contrasted computed tomography scan was performed after 20 days and demonstrated no signs of pseudoaneurysm or bleeding. After 4 months, the patient was readmitted to tracheal dilatation and change of T-tube and died of respiratory complications.

Combined Carotid Endarterectomy and Retrograde Stenting of the Supra-Aortic Trunk: Does Cervical Block Offer Advantages?

BACKGROUND: Atherosclerosis of the carotid artery is a major source of stroke. In some cases, atherosclerosis occurs at several positions within the carotid artery. Carotid endarterectomy (CEA) in combination with retrograde balloon angioplasty and stenting of a brachiocephalic or common carotid artery stenosis has been described as efficacious and safe procedure to prevent stroke in these cases. The aim of this study was to analyze the impact of anesthetic techniques on hemodynamic factors, operation time, duration of clamping, and postoperative pain. METHODS: A retrospective analysis of patients undergoing CEA in combination with retrograde stenting under either general anesthesia (GA) or cervical block (CB) was carried out. Preoperative risk factors were analyzed as well as operating and cross-clamping time, hemodynamic factors, perioperative complications, postoperative pain, application of pain killers, and duration of intensive care unit (ICU) and hospital stay. RESULTS: Operating (GA: 193 ± 91 min vs. CB: 125 ± 52 min, P = 0.029) and cross-clamping time (GA: 34 ± 12 min vs. CB: 26 ± 9 min, P < 0.001) were shorter under CB. Patients under CB were hemodynamically more stable and required less norepinephrine (GA: 1.1 ± 0.6 mg vs. CB: 0.1 ± 0.1 mg, P < 0.001) and crystalloids (GA: 2,813 ± 1,173 mL vs. CB: 1,088 ± 472 mL, P < 0.001). Postoperative pain levels (GA: numeric rating scale 4.3/10 vs. 2.0/10; P = 0.004) and requirement of pain killers were also lower within the CB group. CONCLUSIONS: Synchronous CEA and retrograde balloon angioplasty and stenting of a brachiocephalic or common carotid artery stenosis under CB is associated with reduction of operating and cross-clamping time, improved hemodynamical stability, lower postoperative pain, shorter ICU and hospital stay, and it offers the advantage of a continuous neurological monitoring.

Open reconstructions for symptomatic atherosclerotic lesions of the supra-aortic vessels: thirty years results from two university hospitals.

BACKGROUND: Atherosclerotic lesions at the origin of common carotid, subclavian, and innominate arteries are causes for brain and hand ischemic symptoms. Surgical reconstructions of symptomatic cases remain the golden standard treatment, although the endovascular approach has been promising as well. In this retrospective study, long-term results of open reconstructions from 2 University Hospitals are presented. METHODS: Through a 30-year period, prospective data of 107 patients, suffering from symptomatic atherosclerotic supra-aortic artery disease, were retrospectively reviewed and included in this study. Demographic data, arterial risk factors, presenting symptoms and signs, diagnostic evaluation, operative treatment and complications, resolution of symptoms, redo surgery, and overall mortality were analyzed. RESULTS: Eighty-one patients were operated on for subclavian, 14 for innominate, and 12 for common carotid severe lesions, through an extra-thoracic reconstruction (91 patients) or a transthoracic one (16 patients). Perioperative mortality was null although morbidity was 16.8%, and primary perioperative patency was 97.2% (secondary patency 100%). The cumulative primary patency was 95.3%, 90.7%, and 86.0% at 5, 10, and 15 years, respectively. The mean time of patency was 214.6 months (95% confidence interval = 198.5-230.6), with no difference between transthoracic and extrathoracic reconstructions (P = 0.278). CONCLUSIONS: Open reconstructions remain a therapeutic strategy with a considerably low perioperative morbidity/mortality offering excellent long-term results regarding patency of the reconstructions and clinical resolution of the symptoms. However, in the modern era of the endovascular techniques, we need more studies for establishing anatomic and clinical criteria regarding patient selection for endovascular angioplasty/stenting or open repair.

Operative technique for tracheo-innominate artery fistula repair.

Tracheo-innominate artery fistula is fatal unless treated surgically. We describe our surgical approach and results in seven patients. The average patient age was 15.7 years; all patients had prior severe neurological deficits. Three of seven patients were in hemorrhagic shock; control of preoperative bleeding was achieved with tracheostomy tube cuff overinflation. The innominate artery and the trachea were exposed through a collar incision and partial upper sternotomy. The innominate artery was divided at the aortic arch and at the bifurcation, with one exception. Cerebral blood flow was monitored by the blood pressure difference in the bilateral upper extremities and by near-infrared spectroscopy. The tracheal fistula was left adherent to the innominate artery in all but one patient. All patients were discharged without new neurologic deficits or severe morbidity. Overall survival was 84% at 37 months, without any vascular, tracheal, or neurological events.

Successful hybrid management of extensive thromboembolism of the innominate trunk, right subclavian artery, bilateral common carotid artery, and pulmonary embolism.

Symptomatic acute carotid occlusion demands treatment, but the exact treatment to be provided in the case of acute occlusion of 3 supra-aortic vessels is not well established. Herein, we describe the successful emergency hybrid management of a massive thromboembolic occlusion of the right subclavian artery, common carotid artery, and innominate trunk, associated with left arm hemiparesis, motor aphasia, and confusion, and extensive pulmonary embolism. The diagnostic work-up and the hybrid surgical strategy adopted are described. Neurologic symptoms had completely regressed at discharge and the patient was free of any complications at the 3-month follow-up.