Endovascular management of subclavian-steal syndrome in a patient with post-traumatic dissection of an aberrant right subclavian artery.

BACKGROUND: An aberrant right subclavian artery is the most common congenital anomaly of the aortic arch and may cause symptoms due to aneurysmal dilatation, stenosis or occlusion. We present a case of subclavian-steal syndrome due to post-traumatic dissection of an aberrant right subclavian artery. METHODS AND RESULTS: A 50 year-old man presented with dizziness and fainting episodes after exercising his right arm and a systolic blood pressure gradient of 40 mm Hg between the 2 arms. Suspecting a subclavian steal syndrome, a computed tomography angiography was requested which revealed an aberrant right subclavian artery with a severe stenosis proximal to the ostium of the vertebral artery. Transfemoral digital subtraction angiography showed a local dissection of the aberrant right subclavian artery with late retrograde filling of the ipsilateral vertebral artery. The lesion was successfully treated with primary stent implantation (9 mm x 40 mm, LIFESTAR, BARD). On interrogation, the patient recalled an injury to the right arm after falling off a ladder 10 years earlier, as a possible post-traumatic cause for the dissection. He had an uneventful outcome and is symptom-free 12 months down the line. CONCLUSIONS: The combination of post-traumatic dissection of an aberrant right subclavian artery resulting to subclavian steal syndrome is an extremely rare scenario. Endovascular management is a safe, minimally invasive alternative to open surgery.

Endovascular Aortic Repair With Castor Single-Branched Stent-Graft in Treatment of Acute Type B Aortic Syndrome and Aberrant Right Subclavian Artery.

OBJECTIVE: In this retrospective study, we presented the results of Castor single-branched stent-graft in a small series of patients with acute type B aortic syndrome and aberrant right subclavian artery (ARSA). METHODS: Between January 2019 and November 2019, 5 patients were diagnosed with acute type B aortic syndrome and ARSA (4 patients with intramural hematoma and ARSA, 1 patient with type B aortic dissection and ARSA). All the patients underwent thoracic endovascular aortic repair (TEVAR) using Castor single-branched stent-graft. In-hospital and 3-month outcomes were collected. RESULTS: The mean operative time was 116 ± 20.43 minutes (range 90-145). All the TEVAR procedures were successfully performed without conversion to open surgery (100% success rate). All the ARSAs of the 5 patients were revascularized in situ by Castor single-branched stent-grafts. No deaths and complications were observed in the 3-month follow-up. The maximal diameters of diseased aortas in the 4 patients with IMH decreased 3 months after TEVAR. The false lumen in the graft-covered segment was completely thrombosed in the patient with type B aortic dissection. CONCLUSIONS: Castor single-branched stent-graft may be a good choice in treatment of acute type B aortic syndrome and aberrant right subclavian artery.

Association of Kidney Disease With Abnormal Cardiac Structure and Function Among Ugandans With HIV Infection.

BACKGROUND: People with HIV (PWH) are at an increased risk of both heart and kidney disease, but the relationship between kidney disease and cardiac structure and function in this population has not been well studied. In particular, whether the relationship between kidney disease and cardiac structure and function is stronger for PWH compared with uninfected controls is unknown. METHODS: One hundred PWH on antiretroviral therapy were compared with 100 age-matched and sex-matched controls without HIV in Uganda. Multivariable regression models were used to examine associations between creatinine-based and cystatin C-based estimated glomerular filtration rate (eGFR), albumin-creatinine ratio, and echocardiographic measures of cardiac structure and function. RESULTS: PWH had lower eGFRcr (ß -7.486, 95% confidence interval: -13.868 to -1.104, P = 0.022) and a higher rate of albumin-creatinine ratio ≥30 (odds ratio 2.146, 95% confidence interval: 1.027 to 4.484, P = 0.042) after adjustment for traditional risk factors. eGFR was inversely associated with both left ventricular mass index and diastolic dysfunction in adjusted models but not with systolic function. Albuminuria was associated with more diastolic dysfunction among PWH but not controls (P for interaction = 0.046). The association of HIV with a higher left ventricular mass index (P = 0.005) was not substantially affected by adjusting for eGFRcr. CONCLUSION: Among Ugandans, eGFR is associated with elevated LV mass and diastolic dysfunction. The association between albuminuria and diastolic dysfunction is particularly strong for PWH.

Intermittent absent and reversed umbilical artery flows in appropriately grown monochorionic diamniotic twins in relation to proximate cord insertion: A harmful combination?

OBJECTIVE: To compare the prevalence of intermittent absent or reversed end-diastolic flow (iAREDF) in the umbilical artery in appropriately grown monochorionic diamniotic (MCDA) pregnancies with and without proximate cord insertion (PCI), and to evaluate pregnancy outcome. METHODS: The prevalence of iAREDF in MCDA pregnancies with PCI (n = 11) was compared with a control group without PCI (n = 33). PCI was defined as a distance between the cord insertions below the fifth percentile. Placental sharing, number, and diameter of anastomoses were assessed by placental examination. Pregnancy outcome was evaluated. RESULTS: iAREDF was present in 7/11 PCI pregnancies, compared with 0/33 in the control group (P ≤ .01). All PCI pregnancies and 94% of controls had arterioarterial (AA)-anastomoses (P = .56), the diameter was larger in the PCI group, respectively 3.3 vs 2.1 mm (P = .03). Three cases with iAREDF had adverse outcome, two resulted in fetal death of which one with brain damage in the co-twin, another underwent early premature emergency section for fetal distress. CONCLUSION: iAREDF occurs in a large proportion of MCDA pregnancies with PCI and is related to the diameter of the AA anastomosis. We hypothesize that iAREDF in appropriately grown MCDA twin pregnancies reflects an unstable hemodynamic balance with an increased risk for fetal deterioration. Whether outcome in these pregnancies can be improved by altered management requires further investigation.

Dysphagia Lusoria: Is the Dysmotility Connection Illusory or Real?

Dysphagia lusoria is rare embryologic defect of the aortic arch vasculature characterized by an aberrant retro-esophageal course of the right subclavian artery (RSA), comprising a vascular sling. This may manifest clinically with symptoms of dysphagia or reflux. Given the rarity of this pathology, there remains uncertainty regarding the most effective treatment algorithm. Vascular decompression procedure surgery is often used to rectify the aberrant vascular morphology. However, a low percentage of aberrant arteries result in trachea-esophageal symptoms. As such, we suggest (1) one must exclude co-morbid esophageal motility disorders in patients with dysphagia; and (2) aberrant RSA may be a cause of dysphagia, so-called dysphagia lusoria, but represents an unlikely mechanism, since this morphological arrangement typically does not result in a highly constrictive, circumferential vascular ring. It follows, therefore, that directly addressing the esophageal motility issue should take precedence over complex and potentially noncurative vascular procedures directed to the aberrant RSA. However, the presence of marked aneursymal dilation of the aberrant RSA, and/or the presence of a bicarotid (socalled bovine) trunk, would favor vascular repair in the clinical decision-making due to the elevated risk of rupture and more severe esophageal compression in these specific situations.

Symptomatic Aberrant Right Subclavian Artery: Advantages of a Less Invasive Surgical Approach.

We present the case of a 33-year-old woman with a non-aneurysmal, symptomatic aberrant right subclavian artery (ARSA) traveling posterior to the esophagus, as demonstrated on chest computed tomography (CT) scans. She was treated with a less invasive surgical approach: closure of the anomalous vessel close to its origin from the aortic arch, through a left thoracoscopic procedure, followed by right common carotid-subclavian artery transposition via an open right supraclavicular approach. This method avoids the postoperative morbidity associated with open thoracic surgery and allows a clear identification of the anatomic structures minimizing possible procedure-related complications as a long residual arterial stump.

Long-term performance of bicuspid and quadricuspid aortic valves: Similarities and differences.

While bicuspid aortic valve (BAV) is a common congenital cardiac anomaly, quadricuspid aortic valve (QAV) is rare. The usual three-leaflet aortic valve is characterized by engineering advantages with superior long-term performance, and thus, degenerative changes and significant functional deterioration appear at advanced age. AIM: Evaluation of long-term performance, similarities, and differences between QAV and BAV. METHODS: Screening of 19 000 consecutive echocardiographic studies was performed. RESULTS: BAV was reported in 131 subjects with a prevalence of 0.7%, while QAV was seen in 11 with a prevalence of 0.06%, P < .00001. Age of BAV patients was younger, 45 ± 20 years vs 62 ± 17 years in QAV, P < .05, with higher proportion of females in those with QAV, 40% vs 30%. Chamber diameters were similar in both groups. Higher atrial contraction-A-wave mitral peak velocities and longer E-wave deceleration times were found in subjects with QAV, P < .05 for both. Dilated ascending aorta was found in 25% of patients with BAV and in 18% of those with QAV, P = .2. Moderate and severe aortic valve stenosis were found in 21% of patients with BAV and in 27% of those with QAV, P = ns. More than moderate aortic regurgitation was found in 15.5% of BAV patients and in 9% of QAV, P = ns. Aortic valve infective endocarditis was found in 1.5% of BAV patients and in 9% of those with QAV. CONCLUSIONS: BAV is a common congenital anomaly, while QAV is rare. Similar prevalence of significant valve disease and aortopathy was found in both anomalies, though at younger age in BAV patients.

Circulatory emergencies in the delivery room.

The transition from fetal to neonatal life is a dramatic and complex process involving extensive physiologic changes, which are most obvious at the time of birth. Individuals who care for newly born infants must monitor the progress of the transition and be prepared to intervene when necessary. In the majority of births, this transition occurs without a requirement for any significant assistance. If newborns require assistance, the majority of the time respiratory support is all that is required. In some instances, however, there are circulatory emergencies that need to be rapidly identified or there may be dire consequences including death in the delivery room. This chapter will review various pathologies that are circulatory emergencies, and discuss how to assess them. We will also review new technologies which may help providers better understand the circulatory status or hemodynamic changes in the delivery room including heart rate, cardiac output, cerebral oxygenation and echocardiography.

Major adverse cardiovascular events in people with chronic kidney disease in relation to disease severity and diabetes status.

Diabetes plays an important role in the complex relationship between chronic kidney disease (CKD) and cardiovascular disease. This retrospective observational study compared the influence of estimated glomerular filtration rate (eGFR) and proteinuria on the risk of major adverse cardiovascular event (MACE; myocardial infarction or stroke) in CKD patients with and without diabetes. Data were from a linked database of UK electronic health records. Individuals with CKD and no prior MACE were classified as type 1 diabetes (T1DM; n = 164), type 2 diabetes (T2DM; n = 9,711), and non-diabetes (non-DM; n = 75,789). Monthly updated time-dependent Cox proportional hazard models were constructed to calculate adjusted hazard ratios (aHRs) for progression to MACE from first record of abnormal eGFR or proteinuria (index date). In non-DM, aHRs (95% CIs) by baseline eGFR category (referent G2) were G1: 0.70 (0.55-0.90), G3a: 1.28 (1.20-1.35), G3b: 1.64 (1.52-1.76), G4: 2.19 (1.98-2.43), and G5: 3.12 (2.44-3.99), and by proteinuria category (referent A1) were A2: 1.13 (1.00-1.28), A2/3 (severity indeterminable): 1.58 (1.28-1.95), and A3: 1.64 (1.38-1.95). In T2DM, aHRs were G1: 0.98 (0.72-1.32), G3a: 1.18 (1.03-1.34), G3b: 1.31 (1.12-1.54), G4: 1.87 (1.53-2.29), G5: 2.87 (1.82-4.52), A2: 1.22 (1.04-1.42), A2/3: 1.45 (1.17-1.79), and A3: 1.82 (1.53-2.16). Low numbers in T1DM precluded analysis. Modelling T2DM and non-DM together, aHRs were, respectively, G1: 3.23 (2.38-4.40) and 0.70 (0.55-0.89); G2: 3.18 (2.73-3.70) and 1.00 (referent); G3a: 3.65 (3.13-4.25) and 1.28 (1.21-1.36); G3b: 4.01 (3.40-4.74) and 1.65 (1.54-1.77); G4: 5.78 (4.70-7.10) and 2.21 (2.00-2.45); G5: 9.00 (5.71-14.18) and 3.14 (2.46-4.00). In conclusion, reduced eGFR and proteinuria were independently associated with increased risk of MACE regardless of diabetes status. However, the risk of MACE in the same eGFR state was 4.6-2.4 times higher in T2DM than in non-DM.

Be Aware of Aberrant Right Subclavian Artery Origin Before Aortic Coarctation Stenting: A Case Report Study.

The subclavian steal syndrome (SSS), also called subclavian steal steno-occlusive disease, is defined as reversal of the vertebral artery flow secondary to significant hemodynamically ipsilateral occlusion or stenosis of the proximal subclavian artery. It is usually seen secondary to atherosclerosis and aberrant right subclavian artery (ARSA), resulting in SSS which is even less common. Aberrant right subclavian artery is a kind of vascular anomaly associated with coarctation of the aorta (CoA). It usually originates from the descending aorta distal to the site of CoA. Here, we present a young man who was a case of ARSA and CoA. He developed SSS after transcatheter aortic stenting secondary to unusual origin of ARSA from the site of CoA. Awareness of this rare anomaly helps to overcome this complication in patients undergoing interventional stenting for CoA and ARSA with anomalous origin.

Midterm Outcomes of Endovascular Repair for Stanford Type B Aortic Dissection with Aberrant Right Subclavian Artery.

PURPOSE: To evaluate the early and midterm outcomes of endovascular repair of Stanford type B aortic dissection (TBAD) with an aberrant right subclavian artery (ARSA). MATERIALS AND METHODS: From November 2012 to July 2018, 15 patients (13 male, 2 female) who had TBAD with ARSA underwent total endovascular repair, including thoracic endovascular aortic repair (TEVAR), left subclavian artery (LSA) chimney technique, LSA fenestration technique, and double chimney technique (LSA chimney and ARSA periscope). The mean age was 55 years. Kommerell diverticulum (KD) occurred in 2 patients, which were covered by means of oversized aortic stents. All patients had preoperative imaging examinations for assessing cerebral blood flow and the dominant vertebral arteries. RESULTS: All procedures were completed successfully. There was no in-hospital mortality. The mean procedural time was 98 ± 40 minutes (range 50-190). The mean preoperative diameters of the maximum descending aorta, false lumen, and true lumen in the descending aorta versus postoperative were 37 ± 10 mm (range 28-67), 18 ± 9 mm (range 9-41), and 19 ± 6 mm (range 10-35) versus 34 ± 9 mm (range 25-64), 5 ± 8 mm (range 0-28), and 28 ± 5 mm (range 19-37), respectively. Right upper extremity weakness was observed in 2 patients, which recovered gradually during follow-up. Immediate type Ia endoleak was detected in 1 patient. The mean follow-up time was 33 ± 20 months. During follow-up, no ARSA steal syndrome, spinal cord ischemia, or strokes were not observed. CONCLUSIONS: Endovascular treatment for TBAD with ARSA was feasible and safe with a satisfactory midterm follow-up outcome.

Effectiveness of Cardiovascular Evaluations and Interventions on Fall Risk: A Scoping Review.

OBJECTIVE: Cardiovascular abnormalities are consistently associated with fall risk in older people. However, little research has been done to assess the effect of cardiovascular interventions on fall risk. The aim of this scoping review is to explore the current literature on the effectiveness of cardiovascular evaluations and interventions in reducing fall risk in older people. DESIGN: Scoping review. DATA SOURCES: Medline, Cochrane Library, and WHO ICTRP Search Portal were systematically searched. SELECTION CRITERIA: Randomized controlled trials (RCTs) and intervention studies of community-dwelling adults aged ≥50 years or with a mean age of >60 years that assessed the effect of a cardiovascular assessment and interventions in reducing fall risk. Key search concepts were "falls" and "aged", and terms for different cardiovascular evaluations and interventions were included. The Cochrane Checklist for risk of bias and the ROBINS-I tool were used to assess the quality of the studies. RESULTS: Seven studies were included. The majority showed a reduction in falls after cardiovascular evaluation and intervention. Two out of four studies that focused on carotid sinus hypersensitivity (CSH) as a modifiable cardiovascular risk factor for falls, showed a significant reduction in falls after pacemaker implantation. Two studies that looked at sinus node dysfunction (SND) both showed a significant reduction in falls after pacemaker implantation. One study showed that 33% of the patients experienced a fall after cardiovascular evaluation and intervention, whereas all patients fell before assessment. CONCLUSIONS: The majority of the included studies showed a reduction in falls after the intervention. However, the number of published papers regarding the effect of cardiovascular assessment and interventions on falls is small. A standardized assessment of cardiovascular risk factors may be essential in preventing falls in older adults and could consequently reduce injuries, loss of quality of life, deaths, and fall-related expenditures.

A Smart Wireless Ear-Worn Device for Cardiovascular and Sweat Parameter Monitoring During Physical Exercise: Design and Performance Results.

Wearable biomedical technology has gained much support lately as devices have become more affordable to the general public and they can easily interact with mobile phones and other platforms. The feasibility and accuracy of the data generated by these devices so as to replace the standard medical methods in use today is still under scrutiny. In this paper, we present an ear-worn device to measure cardiovascular and sweat parameters during physical exercise. ECG bipolar recordings capture the electric potential around both ears, whereas sweat rate is estimated by the impedance method over one segment of tissue closer to the left ear, complemented by the measurement of the lactate and pH levels using amperiometric and potentiometric sensors, respectively. Together with head acceleration, the acquired data is sent to a mobile phone via BLE, enabling extended periods of signal recording. Results obtained by the device have shown a SNR level of 18 dB for the ECG signal recorded around the ears, a THD value of -20.46 dB for the excitation signal involved in impedance measurements, sweat conductivity of 0.08 S/m at 1 kHz and sensitivities of 50 mV/pH and 0.8 µA/mM for the pH and lactate acquisition channels, respectively. Testing of the device was performed in human subjects during indoors cycling with characteristic level changes.

Feasibility and Health Effects of a 15-Week Combined Exercise Programme for Sedentary Elderly: A Randomised Controlled Trial.

There is strong evidence that considerable health benefits can be achieved even with small amounts of physical activity. However, getting people to exercise regularly is a major challenge not least in the elderly population. This study investigated the feasibility and physiological health effects of a pragmatic 15-week exercise programme for sedentary elderly. In a single-blind randomised controlled trial, 45 sedentary 60-83-year-olds (25 women, 20 men) were randomly assigned (2:1 ratio) to a training group (TG, n=30) or a control group (CG, n=15). The training in TG consisted of a combination of exercise modalities (i.e., strength, aerobic fitness, stability, and flexibility training) performed once a week as supervised group-based training and a weekly home-based training for 15 weeks. Feasibility outcomes were exercise intensity, adherence, and adverse events. The primary outcome was change in aerobic fitness (VO2max/kg). Adherence was high (81%) for the supervised exercise and low (0%) for the home-based exercise. No acute injuries occurred in TG, but 4 subjects (13%) reported considerable joint pain related to training. Average heart rate (HR) during the supervised training was 104±12 beats/min (69.3±8.0%HRmax), with 3.9±7.3% of training time >90%HRmax. Intention-to-treat analyses revealed no between-group differences for aerobic fitness (P=0.790) or any secondary cardiovascular outcomes at 15-week follow-up (resting HR or blood pressure; P>0.05). Compared to CG, bodyweight (-2.3 kg, 95% CI -4.0 to -7.0; P=0.006), total fat mass (-2.0 kg, 95% CI -3.5 to -0.5; P=0.01), and total fat percentage (-1.6%, 95% CI -2.8 to -0.3; P=0.01) decreased in TG. The group-based supervised training had high adherence and moderate exercise intensity, whereas the home-based training was not feasible in this study population. This exercise programme performed once a week did not improve aerobic fitness. Thus, supervised training with more vigorous intensity control appears advisable. Clinical Study registration number is H-15016951.

A Narrative Review of Cardiovascular Abnormalities After Spontaneous Intracerebral Hemorrhage.

BACKGROUND: The recommended cardiac workup of patients with spontaneous intracerebral hemorrhage (ICH) includes an electrocardiogram (ECG) and cardiac troponin. However, abnormalities in other cardiovascular domains may occur. We reviewed the literature to examine the spectrum of observed cardiovascular abnormalities in patients with ICH. METHODS: A narrative review of cardiovascular abnormalities in ECG, cardiac biomarkers, echocardiogram, and hemodynamic domains was conducted on patients with ICH. RESULTS: We searched PubMed for articles using MeSH Terms "heart," "cardiac," hypertension," "hypotension," "blood pressure," "electro," "echocardio," "troponin," "beta natriuretic peptide," "adverse events," "arrhythmi," "donor," "ICH," "intracerebral hemorrhage." Using Covidence software, 670 articles were screened for title and abstracts, 482 articles for full-text review, and 310 extracted. A total of 161 articles met inclusion and exclusion criteria, and, included in the manuscript. Cardiovascular abnormalities reported after ICH include electrocardiographic abnormalities (56% to 81%) in form of prolonged QT interval (19% to 67%), and ST-T changes (19% to 41%), elevation in cardiac troponin (>0.04 ng/mL), and beta-natriuretic peptide (BNP) (>156.6 pg/mL, up to 78%), echocardiographic abnormalities in form of regional wall motion abnormalities (14%) and reduced ejection fraction. Location and volume of ICH affect the prevalence of cardiovascular abnormalities. Prolonged QT interval, elevated troponin-I, and BNP associated with increased in-hospital mortality after ICH. Blood pressure control after ICH aims to preserve cerebral perfusion pressure and maintain systolic blood pressure between 140 and 179 mm Hg, and avoid intensive blood pressure reduction (110 to 140 mm Hg). The recipients of ICH donor hearts especially those with reduced ejection fraction experience increased early mortality and graft rejection. CONCLUSIONS: Various cardiovascular abnormalities are common after spontaneous ICH. The workup of patients with spontaneous ICH should involve 12-lead ECG, cardiac troponin-I, as well as BNP, and echocardiogram to evaluate for heart failure. Blood pressure control with preservation of cerebral perfusion pressure is a cornerstone of hemodynamic management after ICH. The perioperative implications of hemodynamic perturbations after ICH warrant urgent further examination.

Simple Endovascular Repair for Symptomatic Aberrant Right Subclavian Artery in a Debilitated Patient.

We report a simple endovascular repair for symptomatic aberrant right subclavian artery (ARSA) in an 11-year-old girl. She had undergone tracheostomy due to hypoxic encephalopathy after cardiac surgery and suffered from dyspnea. Computed tomography revealed tracheal stenosis caused by a vascular ring made with an ARSA and the right common carotid artery. Transcatheter ARSA embolization using an Amplatzer vascular plug and coils was performed. Symptoms improved within a few days after this intervention and no complications such as upper extremity ischemia were encountered. Computed tomography showed the ARSA around the trachea had reduced in size and tracheal stenosis was improved.

Dissected aberrant right subclavian artery with Kommerell diverticulum.

Aberrant right subclavian artery is the most frequent anomaly of the aortic arch, and in 60% of cases is associated with Kommerell diverticulum. It is usually asymptomatic but may present with dysphagia or asthma due to esophageal and tracheal compression. Indications for surgical repair have not been established; however, when Kommerell diverticulum is complicated by aortic dissection the treatment is surgery. We present the case of a 54-year-old man with thoracic pain due to dissection of an aberrant right subclavian artery associated with Kommerell diverticulum. Elective surgical treatment was performed.