[Right aortic arch with mirror image branching : a rare cause of dysphagia]. / L'image du mois. Arc aortique droit avec image en miroir : une cause rare de dysphagie.

We report the case of a 36-year-old female whose dysphagia revealed a congenital anomaly of the thoracic aorta: the right aortic arch with mirror image branching. This is a rare embryonic developmental anomaly where the aorta wraps around the right bronchus and the supra-aortic trunks emerge from the arch in the opposite order to normal. Most of the patients are asymptomatic unless there is a significant compression of mediastinal structures. Major compression of the esophagus or trachea, aneurysmal disease, dissection of the thoracic aorta, or the presence of a Kommerell diverticulum larger than 2 cm may require a surgical repair. There is no standard treatment and it must be adapted to the clinical presentation and the anatomic configuration of each patient. Our patient did not receive any treatment for her condition.

Nous rapportons le cas d'une patiente de 36 ans dont le tableau de dysphagie a permis de mettre en évidence une anomalie congénitale de l'aorte thoracique : l'arc aortique droit avec image en miroir. Il s'agit d'une anomalie de développement embryonnaire rare où l'aorte s'enroule autour de la bronche souche droite et où les troncs supra-aortiques émergent de la crosse dans l'ordre inverse et opposé à la normale. La grande majorité des patients est asymptomatique, à moins qu'il existe une compression des structures médiastinales. Une compression majeure de l'oesophage ou de la trachée, une maladie anévrismale, une dissection de l'aorte thoracique ou la présence d'un diverticule de Kommerell de plus de 2 cm peuvent justifier une sanction chirurgicale. Il n'y a pas de traitement standard et celui-ci doit être adapté à la présentation clinique et à la configuration anatomique du patient. Notre patiente n'a bénéficié d'aucun traitement pour son affection.

Image fusion guidance for left subclavian artery in situ fenestration during thoracic endovascular repair.

OBJECTIVES: To evaluate the feasibility and clinical benefit of utilizing image fusion for thoracic endovascular repair (TEVAR) with in situ fenestration (ISF-TEVAR). MATERIALS AND METHODS: Between January 2020 and December 2020, we prospectively collected 18 consecutive cases with complex thoracic aortic lesions who underwent image fusion guided ISF-TEVAR. As a control group, 18 patients were collected from historical medical records from June 2019 to December 2019. The fusion group involved the use of 3D fusion of CTA and fluoroscopic images for real-time 3D guidance, and the control group involved the use of only regular fluoroscopic images for guidance. The total contrast medium volume, hand-injected contrast medium volume, overall operative time, radiation dose and fluoroscopy time were compared between the two groups. Accuracy was measured based on preoperative CTA and intraoperative digital subtraction angiography. RESULTS: 3D fusion imaging guidance was successfully implemented in all patients in the fusion group. Hand-injected contrast medium volume and overall operative time were significantly lower in the fusion group than in the control group (p = .028 and p = .011). Compared with the control group, the fusion group showed a significant reduction in time and radiation dose-area product (DAP) for fluoroscopy (p = .004 and p = .010). No significant differences in total radiation dose (DAP) or total contrast medium volume were observed (p = .079 and p = .443). Full accuracy was achieved in 8 cases (44%), with a mean deviation of 2.61 mm ± 3.1 (range 0.0-8.4 mm). CONCLUSIONS: 3D image fusion for ISF-TEVAR was associated with a significant reduction in hand-injected contrast medium, time and radiation exposure for fluoroscopy and overall operative time. The image fusion guidance showed potential clinical benefits towards improved treatment safety and accuracy for complex thoracic endovascular interventions.

Contralateral Thoracotomy With Extracorporeal Circulation for Reoperative Resection of a Kommerell Diverticulum.

Reoperative vascular ring surgery is uncommon. Standard redo ipsilateral thoracotomy may present technical challenges and risks. We describe a patient with right aortic arch, aberrant left subclavian artery, and a Kommerell diverticulum in whom previous vascular ring division via left thoracotomy did not relieve dysphagia. Three years after the unsuccessful operation, left subclavian-carotid transposition via supraclavicular incision followed by resection of the Kommerell diverticulum via right thoracotomy with extracorporeal circulation relieved symptoms. Contralateral thoracotomy with extracorporeal circulation provides a safe, alternative approach to redo ipsilateral thoracotomy for resection of a symptomatic Kommerell diverticulum. We review the literature on the incidence, surgical indications, and operative approaches to manage symptoms from a Kommerell diverticulum.

Comparative study of left vertebral artery revascularization in patients with and without aberrant left vertebral anatomy.

OBJECTIVE: Left vertebral artery revascularization is indicated in surgery involving zone 2 of the aortic arch and is typically accomplished indirectly via subclavian artery revascularization. For aberrant left vertebral anatomy, direct revascularization is indicated. Our objective was to compare the outcomes of direct vertebral artery revascularization with indirect subclavian artery revascularization for treating aortic arch pathology and to identify predictors of mortality. METHODS: A retrospective cohort study was conducted at a single tertiary hospital, including patients who underwent open or endovascular vertebral artery revascularization from 2005 to 2022. Those who underwent direct vertebral revascularization were compared with those who were indirectly revascularized via subclavian artery revascularization. The outcomes of interest were a composite outcome (any of death, stroke, nerve injury, and thrombosis) and mortality. Univariate logistic regression models were fitted to quantify the strength of differences between the direct and indirect revascularization cohorts. Cox regression was used to identify mortality predictors. RESULTS: Of 143 patients who underwent vertebral artery revascularization, 21 (14.7%) had a vertebral artery originating from the aortic arch. The median length of stay was 10 days (interquartile range, 6-20 days), and demographics were similar between cohorts. The incidence of composite outcome, bypass thrombosis, and hoarseness was significantly higher in the direct group (42.9% vs 18.0%, P = .019; 33.3% vs 0.8%, P < .0001; 57.1% vs 18.0%, P < .001, respectively). The direct group was approximately three times more likely to experience the composite outcome (odds ratio, 3.41; 95% confidence interval, 1.28, 9.08); similarly, this group was approximately six times more likely to have hoarseness (odds ratio, 5.88; 95% confidence interval, 2.21, 15.62). There was no significant difference in mortality rates at 30 days, 1, 3, 5, and 10 years of follow-up. Age, length of hospital stay, and congestive heart failure were identified as predictors of higher mortality. After adjusting for these covariates, the group itself was not an independent predictor of mortality. CONCLUSIONS: Direct vertebral revascularization was associated with higher rates of composite outcome (death, stroke, nerve injury, and thrombosis), bypass thrombosis and hoarseness. Patients with aberrant vertebral anatomy are at higher risks of these complications compared with patients with standard arch anatomy. However, after adjusting for other factors, mortality rates were not significantly different between the groups.

A novel wire-guided prefenestration technique for patients with type B aortic dissection: A case report.

RATIONALE: Acute type B aortic dissection (ABAD) is a fatal and severe cardiovascular disease. There are various strategies for dissection involving the left subclavian artery, but limited by the variety and cost of stents, the treatment brings certain obstacles. The aim of this study is to evaluate the effectiveness and safety of the wire-guided prefenestration technique for treating left subclavian artery involvement in patients with arterial dissection. PATIENT CONCERNS: A 48-year-old man was transferred to our hospital due to persistent chest and back pain that had lasted for 6 hours. DIAGNOSES: Preoperative computed tomography angiogram (CTA) of the thoracic and abdominal aorta diagnosed with ABAD that affected his left subclavian artery, who needed emergency endovascular treatment due to malperfusion of the lower limb arteries. INTERVENTIONS: To perform the procedure, a guide wire was inserted through the left brachial artery, exited through the right femoral artery, and then entered the pre-fenestrated hole leading to the main stent. The stent was released while the guide wire was in position, and the left subclavian artery was reconstructed using viabahn. OUTCOMES: Thoracic endovascular aortic repair was successfully completed for ABAD. A follow-up CT angiogram of the thoracic and abdominal aorta revealed positive vascular remodeling and no signs of significant internal leakage after one month. LESSONS: This innovative approach offers a secure and efficient treatment option for aortic dissection in individuals who have undergone left subclavian artery reconstruction.

Surgical treatment for right-side aortic arch concomitant with Kommerell's diverticulum: techniques selection and follow-up results.

BACKGROUND: Right-side aortic arch concomitant with Kommerell's diverticulum (KD) is a rare and complex ailment, and there is no consensus on the optimal strategy to deal with this congenital anomaly. We retrospectively analyzed and summary of the cases treated in our center with individual treatment methods for different situations. METHODS: Between September 2018 and December 2021, 10 patients experienced surgical therapy at our institution who presented with a Kommerell's diverticulum arising from an aberrant subclavian artery from the right-side aortic arch. Four main surgical techniques were applied to those patients: 1. total arch replacement with frozen elephant trunk implantation (n = 2); 2. hybrid procedure combining open arch repair and endovascular intervention (n = 1); 3. total endovascular repair using thoracic endovascular aortic repair (TEVAR) with or without left subclavian artery (LSCA) revascularization (n = 6); 4. direct repair underwent endoaneurysmorrhaphy. Clinical characteristics and outcomes were collected. RESULTS: The mean age of these 10 patients was 56.5 years (range 29-79 years) and only 1 woman. The pathology includes aortic dissection (n = 6) and aneurysm (n = 4). The mean diverticulum size was 41.4 [24.2-56.8] mm. There were no in-hospital deaths, and the median hospital stay was 22 [15-43] days. During the follow-up period (21.4 months, 1-44 months), one died of an unknown cause and one died of esophageal fistula. Two patients underwent second-stage endovascular intervention for distal lesion. And none of the patients had endoleak during the follow-up period. CONCLUSIONS: Each of the procedures we have mentioned here has its advantages and disadvantages; individualized treatment should meet the appropriate indications. A single-branched stent graft is feasible and effective in the treatment of aortic disease combined with Kommerell's diverticulum.

Modified transmanubrial approach for complicated type 1 cervical rib resection requiring subclavian artery reconstruction.

The transmanubrial musculoskeletal sparing approach (TMA) is commonly used for resecting apical lung tumours with vascular involvement. Non-neoplastic conditions which might require surgical exploration of the thoracic outlet include the 'cervical rib', a clinical condition consisting of an additional rib forming above the first rib and growing from the base of the neck just above the clavicle. Type 1 cervical rib-when a complete cervical rib articulates with the first rib or manubrium of the sternum-is the most challenging scenario where the subclavian artery can be damaged by continuous compression due to the narrow space between clavicle, first rib and supernumerary cervical rib, requiring prosthetic reconstruction of the involved tract. Here, we describe a modified TMA in which the incision in the neck is conducted posteriorly to the sternocleidomastoid muscle, thus allowing safe dissection of the superior and middle trunk of the brachial plexus.

Outcomes of Surgical Repair of Aberrant Subclavian Arteries in Adults.

BACKGROUND: Symptoms, imaging characteristics, and early and midterm surgical outcomes for aberrant subclavian arteries (ASCA) are not well defined in the adult population. METHODS: A single-institution retrospective review was conducted of adults undergoing surgical repair of ASCA and descending aorta origin/Kommerell diverticulum (KD) from January 1, 2002, to December 31, 2021. Symptom improvement and differences in imaging characteristics between anatomic groups and the number of symptoms were assessed. RESULTS: Mean age was 46 ± 17 years. There were 23 of 37 left aortic arches with right ASCA (62%) and 14 of 37 right aortic arches with left ASCA (38%). Of these, 31 of 37 (84%) were symptomatic, and 19 of 37 (51%) had KD size/growth meeting criteria for surgical repair. KD aortic origin diameter was larger in more symptomatic patients: 20.60 mm (interquartile range [IQR], 16.42-30.68 mm) in patients with ≥3 symptoms vs 22.05 mm (IQR, 17.52-24.21 mm) for 2 symptoms vs 13.72 mm (IQR, 12.70-15.95 mm) for 1 symptom (P = .018). Aortic replacement was required in 22 of 37 (59%). There were no early deaths. Complications occurred in 11 of 37 (30%): vocal cord dysfunction (4 of 37 [11%]), chylothorax (3 of 37 [8%]), Horner syndrome (2 of 37 [5%]), spinal deficit (2 of 37 [5%]), stroke (1 of 37 [3%]), and temporary dialysis requirement (1 of 37 [3%]). Over a median follow-up of 2.3 years (IQR, 0.8-3.9 years), there was 1 endovascular reintervention and no reoperations. Dysphagia and shortness of breath resolved in 92% and 89%, respectively, whereas gastroesophageal reflux persisted in 47%. CONCLUSIONS: The KD aortic origin diameter correlates with the number of symptoms, and surgical repair of ASCA and descending aorta origin/KD effectively relieves symptoms, with low rates of reintervention. Given the operative complexity, surgical repair should be performed in patients meeting size criteria or with significant dysphagia or shortness of breath symptoms.

Association and Repair of Right Aortic Arch With Aberrant Left Subclavian Artery With Subclavian Stenosis.

Surgical repair of right aortic arch and aberrant left subclavian artery has traditionally involved ligamentum division. Such patients can have stenosis at the origin of the aberrant subclavian artery either at the time of presentation or later. The more recently popularized repair involving resection of Kommerell diverticulum with transfer of the subclavian artery to the left carotid artery allows resection of the stenotic segment and serves as an effective treatment for subclavian stenosis as well. We present three cases of early repair of this arch anomaly with associated subclavian stenosis repaired successfully in that manner.

Acute successful management of a chainsaw injury to the roof of the left chest.

This case report chronicles the experience of prompt resuscitation, beginning with the patient, and immediate surgery following the fatal malfunction of a chainsaw. The injuries were atypical for chainsaw injuries and involved total transection of the left subclavian artery and vein, total transection of the left brachial plexus and laceration to the apex of the left lung, among other injuries. A coordinated effort allowed for successful repair of the life- and limb-threatening injuries so that the patient could return to his young family in time for his 40th birthday.

Mid-term efficacy of castor stent and in situ fenestration stent in the treatment of type B aortic dissection involving the left subclavian artery: A retrospective single-center study.

To evaluate the midterm efficacy of the Castor stent (CS) versus in situ fenestration (ISF) for reconstructing the left subclavian artery (LSA) in patients with type B aortic dissection (TBAD). Between July 2017 and July 2022, a total of 247 patients with TBAD were enrolled. One hundred thirty-seven patients were treated using CSs (group A), while the remaining 110 patients received ISFs (group B). Data of the two groups were retrospectively analyzed. The success rates of surgery were 99.3% and 95.5% in groups A and B (p = .053), There were no deaths during hospitalization. During surgery, group B showed a longer surgical duration [68.0 (66.0, 77.0) vs. 62.0 (59.0, 66.0) min, p < .001] and intraoperative fluoroscopy time [18.0 (16.0, 20.0) vs. 16.0 (14.0, 18.0) min, p < .001] than group A. The follow-up duration was similar for both groups (44.0 vs. 43.0 months, p = .877), and no patient died. Stent-related complications were significantly lower in group A than in group B (1.5% vs. 8.4%, p = .009). Group A had fewer instances entry flow (0.7% vs. 4.7%, p = .048) and stent stenosis (0.7% vs. 2.8%, p = .206) than group B. All reintervention cases (4.7%) were from group B (p = .011). The rate of false aortic lumen thrombosis was significantly higher in group A than in group B (84.6% vs. 72.9%, p = .024). Both CSs and ISFs are evidently safe, feasible, and effective in achieving positive early outcomes in patients undergoing treatment for TBAD. Notably, at midterm follow-up, CSs appeared to be superior to ISF in terms of reducing stent-related complications and minimizing the need for reintervention.

[Treatment of atherosclerotic lesion of the first segment of subclavian artery]. / Lechenie ateroskleroticheskogo porazheniya pervogo segmenta podklyuchichnoi arterii.

Severe subclavian artery lesion is an important medical and social problem worsening the quality of life and leading to dire consequences. Vertebrobasilar insufficiency is the main syndrome of lesion of the first segment of subclavian artery. About 20% of all ischemic strokes occur in vertebrobasilar basin. At present, surgical treatment of asymptomatic patients with severe lesion of the 1st segment of subclavian artery is still debatable. Open surgery is optimal for occlusion of this vascular segment. Carotid-subclavian transposition is a preferable option with favorable in-hospital and long-term results. However, carotid-subclavian bypass is an equivalent alternative in case of difficult transposition following anatomical and topographic features of vascular architectonics. Endovascular treatment is preferable for isolated subclavian artery stenosis and should certainly include stenting.

Total arch replacement with frozen elephant trunk technique for Kommerell's diverticulum with a right-sided aortic arch and aberrant left subclavian artery.

BACKGROUND: Kommerell's diverticulum with a right-sided aortic arch and aberrant left subclavian artery is uncommon. We perforemed a single-stage procedure with the frozen elephant trunk technique. CASE PRESENTATION: A 62-year-old man underwent aortic dissection a year ago, and computerized tomographic angiography performed at that time revealed a right aortic arch, Kommerell's diverticulum (42 mm), and an aberrant left subclavian artery. We performed one-stage repair through median sternotomy. The cervical branches were exposed during the operation, and a deep hypothermic circulatory arrest with antegrade cerebral perfusion was established. The aorta was transected distally to the origin of the left carotid artery. We inserted a stent graft into the aorta, followed by peripheral anastomosis using a premade 5-branch Dacron graft. The right subclavian artery and the aorta were reconstructed, and the remaining cervical branches were reconstructed after the cross-clamp had been released. CONCLUSIONS: Total arch replacement through median sternotomy was performed for the right aortic arch, Kommerell's diverticulum, and aberrant left subclavian artery. The frozen elephant trunk technique is allowed to perform a one-stage operation safely.

Surgical bypass to the left subclavian artery: an extra-anatomical transpleural approach.

A distal anastomosis in zone 3 is technically demanding during the frozen elephant trunk procedure. Proximalization of the distal anastomosis to zone 2 with subsequent revascularization of the left subclavian artery is an attractive alternative. This video tutorial describes the technique of an extra-anatomical bypass from the aortic prosthesis to the infraclavicular left subclavian (axillary) artery in arch replacement with the distal aortic graft anastomosis in zone 2.

Experience with the Ankura Thoracic Stent Graft and In-situ Fenestration for the Left Subclavian Artery with the Fu-Through Needle - a Technical Overview and Comparison to Similar Endovascular Techniques.

Thoracic endovascular aortic repair (TEVAR) is a widespread minimally invasive procedure prevalently used to treat thoracic aortic pathologies. However, when the left subclavian artery (LSA) is involved in the pathology, a more complex surgical approach is required to guarantee the perfusion of the vertebral and brachial arteries. In fact, coverage of the LSA has been proven to be associated with a higher risk of stroke, spinal cord ischemia, and arm ischemia.Historically, carotid-subclavian bypass or subclavian transposition has been the only treatment options to restore the perfusion of the LSA. For the past 10 years, different endovascular techniques have been implemented in the endovascular armamentarium to reduce the risk of complications related to surgical treatment such as infection, bleeding, and chylothorax.Currently, physician-modified grafts, in situ fenestration, chimneys, and branched or fenestrated devices are available. The aim of this overview is to describe the technique with the Ankura thoracic stent graft and in situ fenestration with the Futhrough needle and thus to shed light on the different approaches by comparing their pros and cons.

Extra-anatomical left common carotid and subclavian artery bypass followed by aortic arch replacement with frozen elephant trunk.

BACKGROUND: Total arch replacement (TAR) using a frozen elephant trunk (FET) allows for simultaneous treatment of the aortic arch and descending aortic pathology via median sternotomy. In addition, an extra-anatomical bypass performed between the left common carotid artery (CCA) and subclavian artery (SCA) prior to TAR allowed further proximalisation of the FET prosthesis, facilitated distal anastomosis of the TAR and spared the demanding left subclavian artery (LSA) anastomosis in the deep thorax. We investigated the efficacy of this debranching-first technique, followed by TAR using a frozen elephant trunk, as a two-stage operation for extensive thoracic aortic aneurysms in high-risk patients. METHODS: Forty-nine consecutive patients with diffuse degenerative aneurysms from the aortic arch to the descending aorta or chronic aortic dissection who underwent left common carotid to subclavian artery bypass followed by TAR using a frozen elephant trunk and subsequent thoracic endovascular aortic repair between 2016 and 2021 were analysed. The baseline characteristics and clinical outcomes were assessed. The estimated overall survival, 5-year aortic event-free survival, and aortic reintervention rates were analysed. RESULTS: The average European System for Cardiac Operative Risk Evaluation (EuroSCORE II) was 4.7 ± 2.5. The operative mortality rate was 4.1%, with no paraplegia events. The estimated 5-year overall survival, cumulative aortic-related mortality rates were 76.8% and 2%, respectively. The estimated 5-year overall cumulative aortic reintervention rate, including the intended intervention, was 31.3%. The estimated 5-year cumulative rate of non-intended reintervention was 4.5%. CONCLUSIONS: The assessed technique enables a less technically demanding surgery with reasonable outcomes. The estimated 5-year aortic event-free survival and reintervention rates were acceptable, suggesting that multiple stages of alternative open and endovascular interventions, such as this technique, may reduce the morbidity and mortality rates of high-risk patients with diffuse thoracic aortic aneurysm. UMIN-CTR (University hospital Medical Information Network-Clinical Trial Registry) https://center6.umin.ac.jp/cgi-open-bin/ctr_e/index.cgi Clinical registration number: UMIN000051531.

[Surgical treatment of aberrant subclavian artery]. / Khirurgicheskoe lechenie aberrantnoi podklyuchichnoi arterii.

OBJECTIVE: To determine the indications and optimal surgical treatment of aberrant subclavian artery. MATERIAL AND METHODS: There were 3 patients with aberrant subclavian artery with clinical manifestations such as dysphagia, shortness of breath, weight loss, cough and chest pain between 2005 and 2020. Right-and left-sided aberrant artery was observed in 2 and 1 case, respectively. Supraclavicular unilateral or bilateral access depended on the side of aberrant artery. Carotid-subclavian anastomosis was performed. RESULTS: All patients were discharged without any symptoms. CONCLUSION: Close location of aberrant subclavian artery to common carotid artery can disturb circulation in brain and upper limb. Abnormal discharge of subclavian artery can cause compression of nearby organs (esophagus, trachea). Abnormal vascular discharge does not always have clinical manifestations that do not require surgical correction. Only symptomatic patients are subjects to surgical correction of aberrant subclavian artery. Knowledge of variant anatomy of supra-aortic vessels can minimize the risk of complications.