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Background/objective: Target vessels related complications are one of the most important 'Achille's heel' of complex thoracoabdominal endovascular procedures. The aim of this report is to describe a case of spontaneous bridging stent-graft (BSG) delayed expansion in a patient treated for type III mega-aortic syndrome, associated with aberrant right subclavian artery and independent origin of the two common carotid arteries., Methods: The patient underwent different surgical procedures (ascending aorta replacement with carotid arteries debranching, bilateral carotid-subclavian bypass with subclavian origins embolization and TEVAR in zone 0, associated with a multibranched thoracoabdominal endograft deployment). Visceral vessels stenting was performed using balloon-expandable BSGs for celiac trunk, superior mesenteric artery and right renal artery, while for the left renal artery a 6 × 60 mm self-expandable BSG was deployed.The first follow-up (FU) by computed tomography angiography (CTA) showed a severe compression of the left renal artery BSG. Considering the challenging access to the directional branches (SAT's debranching and a tightly curve of the steerable sheath inside the branched main body), a conservative treatment was considered, performing a control CTA after 6-months., Results: Six months later, the CTA demonstrated a spontaneous expansion of the BSG, with a two-fold increase in the minimum stent diameter, excluding the need for new reinterventions such as angioplasty or BSG relining., Conclusions: Directional branch compression is a frequent complication during BEVAR; however, in this case, it spontaneously resolved after 6 months, without the need for secondary adjunctive procedures. Further studies on predictor factors for BSG related adverse events and regarding spontaneous delayed BSGs' expansion mechanisms are needed., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Ocular Ischemic Syndrome (OIS) is a rare, vision threatening condition associated with severe carotid artery disease. There are few cases of OIS reported in the literature., Methods: We present the case of a 54-year-old male with history of multiple previous carotid interventions including a right carotid stent, who presented with right-sided OIS., Results: CTA and angiogram showed a severe calcific plaque causing restenosis of the right carotid stent, with a patent right internal carotid artery (ICA) in the very distal neck. The right common carotid artery (CCA) was patent but diseased with ulcerated plaque extending proximally to below the level of the clavicle. The left CCA was chronically occluded from its origin all the way to the bifurcation. Given our patient's surgical history, the imperative to revascularize the ipsilateral carotid, and a diffusely diseased ipsilateral CCA, he was successfully treated with an ipsilateral subclavian to internal carotid bypass., Conclusion: There is paucity of data regarding the best approach for carotid revascularization in OIS. This case report discusses our unique perioperative decision making as well as relevant literature., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Introduction: The in situ fenestration (ISF) technique consists of maintaining the patency of the aortic branch after the endoprosthesis is already in place as a viable, effective, and fast-performing alternative to revascularize the aortic arch arteries., Objective: To report the experience with a series of cases of endovascular treatment of Acute Aortic Syndromes involving the aortic arch, using the ISF technique in a specialized center., Methods: We analyzed data collected from patients treated with ISF during TEVAR for Acute Aortic Syndromes involving the aortic arch from June 2020 to January 2022, assessing perioperative outcomes, including immediate and late success rates, complications, morbidity and mortality, and short and medium term aortic branch patency., Results: Of the 11 patients eligible for the ISF procedure, 9 were successful, with a technical success rate of 81%. No patient had a type 1A endoleak related to fenestration. There was complete thrombosis of the false lumen in the thoracic aorta in 77% cases. No death was related to the fenestration technique., Conclusion: ISF as feasible and with a high rate of technical success and good results in the short and medium term. Prospective studies with long-term clinical follow-up are still needed to fully assess the durability of these unreinforced fenestrations., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: An aberrant right subclavian artery (ARSA) is one of the most common anatomic variants of the aortic arch. The combination of an ARSA and a transection is naturally rare., Methods: This case report describes the treatment of a transection in the presence of an ARSA and the follow-up of two years., Results: We successfully treated the contained rupture with a stentgraft. Both subclavian arteries had to be covered in the emergency setting. At the two-year follow-up, the patient did not suffer from any neurological impairment., Conclusions: In emergency settings, primary cover of both subclavian arteries with a stentgraft can be performed in individual cases after risk assessment. Severe complications such as development of upper limb ischaemia, ASAS or reduced perfusion of the posterior cerebral circulation should be considered in treatment planning., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: Subclavian artery aneurysms (SAA) are rare and usually involve the proximal segment of the artery. In this setting traditional surgical treatment or hybrid procedures are associated with significative morbidity rate so that new endovascular solutions are preferred., Methods: Authors report a case of a patient with an intrathoracic left SAA involving the aortic arch's outer curve. Patient's comorbidities contraindicated open surgical treatment while anatomical issues were not favourable to hybrid or standard endovascular solutions. Thus a single-branched custom-made thoracic stent-graft (Castor, MicroPort Medical, Shanghai, China) was implanted., Results: Technical success was achieved with no intra-operative complications and technical steps of the procedure are accurately described.A pre-discharge CT scan showed the correct position of the endograft, complete aneurysm exclusion and branch patency., Conclusion: Single-branched thoracic stentgrafts could be a good option in unfavourable anatomies with supra-aortic vessels disease involving the aortic arch, with good results in terms of morbidity and early outcomes., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objectives: Inadvertent arterial catheterization can occur during transjugular central venous catheter insertion and should be promptly treated to prevent serious consequences. Although many treatment modalities are available, no exist guidelines regarding the selection of treatment. We aimed to describe our experience with the treatment of 11 patients who underwent inadvertent cervical arterial catheterization and propose an algorithm for the selection of treatment methods., Methods: We retrospectively identified all patients who were treated for inadvertent arterial catheterization at our center between January 2016 and March 2021. We reviewed patient profiles, images, treatment methods, and follow-up data., Results: Eleven patients were included (eight men and three women, age: 36-73 years). Ten catheter misplacements were in the right common carotid artery. The remaining catheter was inserted into the right subclavian artery after penetrating the right common carotid artery. Two catheters were 5-Fr and nine catheters were 11.5-Fr. Two patients underwent manual compressions, three underwent open surgery, three underwent stent-graft repairs, and four underwent Perclose Proglide closure. Clinical success was achieved in all 11 patients. Primary technical success was achieved in 10 patients. In one patient, unsuccessful manual compression was followed by successful stent-graft repair; the manual compression failed to prevent bleeding, possibly because of the long-term oral administration of aspirin for coronary heart disease. The mean follow-up was 5.4 months (range, 1-12 months). The overall mortality rate was zero, and no vascular or neurological events occurred., Conclusions: The existing data show that the current protocol for the treatment of inadvertent cervical arterial catheterization at our center is safe and effective. However, the data are insufficient and require further clinical validation.

Objectives: Inadvertent subclavian artery cannulation during attempted subclavian central venous access is more likely to occur during rushed trauma resuscitations when anatomic landmarks are used for placement. Traditional supraclavicular and infraclavicular approaches for direct repair of the resultant arteriotomy are painful, morbid procedures that should be replaced with more minimally invasive techniques., Methods: This case report describes the usage of a percutaneous suture-mediated device (Perclose Proglide, Abbott Laboratories) to repair an iatrogenic subclavian artery arteriotomy., Results: Two patients had their injuries successfully repaired using a percutaneous closure device., Conclusions: The use of a percutaneous closure device to repair iatrogenic subclavian artery injuries is a safe and effective method of repair that precludes a more invasive exposure and repair.

Chronic type B aortic dissection with the right aortic arch was rare. We present the case of a 59-year-old man with a right aortic arch and chronic type B aortic dissection, with a maximum size of 80 mm. Graft replacement was successfully performed through right anterolateral thoracotomy with partial sternotomy through the fourth intercostal space. The patient's postoperative course was uneventful. He had no paralysis and was extubated on postoperative day 2 and discharged from the hospital on postoperative day 15. Anterolateral thoracotomy with partial sternotomy could be a suitable approach for right-sided aortic aneurysms.

A retroesophageal aberrant brachiocephalic artery is a very rare congenital aortic arch anomaly. We herein presented a 29-year-old man with right aortic arch, retroesophageal aberrant left brachiocephalic artery, left ligamentum arteriosus, and absent left internal carotid artery. Graft replacement of the descending aorta and anatomical reconstruction of left brachiocephalic artery was successfully performed using a midline sternotomy approach without blood transfusion. We discuss the surgical management for Kommerell's diverticulum.

Objectives: We present a case in which a 44-year-old female smoker with a complex medical and surgical history presented with acute upper limb ischemia., Methods: The patient was diagnosed with thoracic outlet syndrome causing symptomatic thrombosis of an aberrant right subclavian artery associated with diverticulum of Kommerell. The patient had history of extensive surgeries and radiation in the right chest with fibrotic changes, so surgical dissection in the area was associated with significant risk of nerve injury. Therefore, revascularization of the arm was performed via carotid to brachial artery bypass with reversed saphenous vein and the thoracic outlet was decompressed with segmental clavicular resection., Results: Patient has been symptom free for 3 years with patent bypass., Conclusions: This case demonstrates a unique presentation of distal thrombosis of a symptomatic aberrant right subclavian artery related to thoracic outlet syndrome. The combined claviculectomy-vein bypass is a safe and efficacious surgical approach that provides durable relief.

Tetralogy of Fallot is a cyanotic heart disease wherein aortopulmonary collaterals serve as source of pulmonary blood flow to maintain oxygenation. We report an incidentally detected isolated left subclavian artery supplying a compensatory ductus in a child with Tetralogy of Fallot that effectively contributed as a de novo palliative systemic to pulmonary artery shunt. Clinically, the entity could not be suspected, as the child did not have symptoms suggestive of arterial insufficiency of the left arm or weak pulses or neurological symptoms. The child underwent successful intracardiac repair with a reimplantation of left subclavian artery to left common carotid artery.

Introduction: Thoracic endovascular aortic repair (TEVAR) has become an accepted treatment for thoracic aortic disease. However, the principal complications relate to coverage of the thoracic aortic wall and deliberate occlusion of aortic branches over a potentially long segment. Complications include risk of stroke, spinal cord ischaemia (SCI) and arterial insufficiency to the left arm (left arm ischaemia (LAI)). This study specifically scrutinised the development of SCI and LAI after TEVAR for interventions for thoracic aortic disease from 1999 to 2020. In particular, those who underwent extra-anatomical bypass (both immediate and late) were compared to the length of thoracic aortic coverage by the stent graft., Materials and Methods: Ninety-eight patients underwent TEVAR. The presenting symptoms, pathology, procedural and follow-up data were collected prospectively with particular evidence of stroke, SCI and LAI both immediate onset and after 48 h of graft placement., Results: Fifty underwent TEVAR for an aneurysm (thoracoabdominal aortic aneurysm), 22 for dissection, 19 for acute transection and 7 for intramural haematoma/pseudoaneurysm of the thoracic aorta. Twenty-nine (30%) required a debranching procedure to increase the proximal landing zone (1 aorto-carotid subclavian bypass, 10 carotid/carotid subclavian bypass and 18 carotid/subclavian bypass). Ten patients (10%) died within 30 days of TEVAR. Twenty-four grafts covered the left subclavian artery origin without a carotid/subclavian bypass. Five required a delayed carotid/subclavian bypass for LAI (4) and SCI (1). Six developed immediate signs of SCI after TEVAR and these 11 (group i) had a mean (SD) length of coverage of the thoracic aorta of 30.2 (10.6) cm compared to 21.5 (11.2) cm (group g) in those who had no LAI or SCI post TEVAR, p  < 0.05., Conclusions: In this series, delayed carotid/subclavian bypass may be required for chronic arm ischaemia and less so for SCI. The length of coverage of thoracic aorta during TEVAR is a factor in the development of delayed SCI and LAI occurrence. Carotid subclavian bypass is required for certain patients undergoing TEVAR (particularly if greater than 20 cm of thoracic aorta is covered).

Objective: Axillosubclavian vessel injury is rare, with most cases occurring after penetrating trauma. A prior database (2002-2006) analysis demonstrated an overall limb loss rate of 2.9%, with no difference between isolated arterial axillosubclavian vessel injury and combined artery/vein axillosubclavian vessel injury. Given increases in advanced vascular surgical techniques, as well as improved multidisciplinary care and expeditious diagnosis with computed tomography angiography, we hypothesized the national rate of limb loss in patients with arterial axillosubclavian vessel injury has decreased. In addition, we attempted to identify current predictors for limb loss in arterial axillosubclavian vessel injury. Finally, we hypothesized that combined artery/vein axillosubclavian vessel injury, as well as associated brachial plexus injury will have a higher risk for limb-loss and mortality compared to isolated arterial axillosubclavian vessel injury., Methods: A retrospective analysis of the National Trauma Data Bank was performed between 2007 and 2015. All patients ≥ 18 years of age with arterial axillosubclavian vessel injury were included. The primary outcome was limb loss. After a univariable logistic regression model identified significant covariates, we performed a multivariable logistic regression for analysis., Results: Of the total 5,494,609 trauma admissions, 3807 patients had arterial axillosubclavian vessel injury (<0.1%). Of these, 3137 (82.4%) had isolated arterial axillosubclavian vessel injury and 670 (17.6%) had combined artery/vein axillosubclavian vessel injury. The overall limb loss rate was 2.4% (from 2.9% in 2006, p = 0.47). After adjusting for covariates, independent risk factors for limb loss included a combined artery/vein axillosubclavian vessel injury (odds ratio = 3.54, confidence interval = 2.06-6.11, p < 0.001), blunt mechanism (odds ratio = 7.81, confidence interval = 4.21-14.48, p < 0.001), open repair (odds ratio = 2.37, confidence interval = 1.47-3.82, p < 0.001), and open proximal humerus fracture (odds ratio = 8.50, confidence interval = 4.97-14.54, p < 0.001). An associated brachial plexus injury was not associated with limb loss ( p = 0.37). Combined artery/vein axillosubclavian vessel injury was associated with higher risk for mortality compared to isolated arterial axillosubclavian vessel injury (odds ratio = 2.17, confidence interval = 1.73-2.71, p < 0.001)., Conclusions: The national rate of limb loss in trauma patients with arterial axillosubclavian vessel injury has not changed in the past decade. A combined artery/vein axillosubclavian vessel injury is an independent risk factor for limb loss, as well as open repair. However, the strongest risk factor is an open proximal humerus fracture. An associated brachial plexus injury is not associated with increased risk of limb loss. Patients with combined artery/vein axillosubclavian vessel injury have a twofold increased risk of death compared to patients with isolated arterial axillosubclavian vessel injury.

Introduction: Endovascular intervention involving the aortic arch, particularly in thoracic aortic dissection, remains challenging and controversial at current time when there is no commercially suitable grafts on most of the international markets. This study compared two endovascular treatments that maintain left subclavian artery perfusion using two modified techniques for type-B aortic dissection patients., Methods: Consecutive cases utilizing chimney or in situ fenestration techniques to preserve left subclavian artery in type B AD from 2006 to 2015 in our single institution were retrospectively reviewed. Statistical analyses were performed with Student t-test, Wilcoxon rank sum, and Fisher exact tests when appropriate. Significant statistical differences were determined with p < 0.05., Results: A total of 85 cases, including 67 (79.8%) with chimney and 18 (21.2%) with in situ fenestration techniques were identified in this retrospective study. In chimney group, there were 18 (26.9%) acute, 29 (43.3%) sub-acute, and 20 (29.9%) chronic aortic dissections. We implanted 24 Zenith and 43 Talent aortic endografts along with 55 balloon-expandable bare stents and 12 self-expanding covered stents in chimney group. Whereas in in situ fenestration group, there were four (22.2%) acute, six (33.3%) subacute, and eight (44.5%) chronic aortic dissections, all of which received Zenith endografts with 11 balloon-expandable covered and seven self-expanding covered stents, respectively. Demographic variables were similarly distributed with 100% intraoperative technical overall success in both groups. Comparing to in situ fenestration group, chimney group has shorter procedural and fluoroscopy time, less blood loss, and contrast volume used. All patients were followed-up to 52 months (median 38, range 24-52). Overall group mortality is 3.6% (3/84). All deaths were from chimney group. There was no procedure-related stroke observed within the study series. Primary patency was maintained while aortic remodeling with complete false lumen was achieved in all patients except that there were three (4.55%) Type-I endoleak cases in early post-operative period and one (1.5%) stent compression at 3-months follow-up in chimney group. There were no stent-related complications observed in in situ fenestration group., Conclusion: Although there were previous studies describing the similar techniques, this study appears to be the first study to compare in situ fenestration and chimney techniques for aortic dissection involving the left subclavian artery according to the MEDLINE search. Although we are unable to establish the superiority between two approaches due to small sample size and relative short period of follow-up, in situ fenestration may represent a more favorable option, especially among aortic dissections with short proximal landing zones in the study.

Kommerell's diverticulum with a right aortic arch and aberrant left subclavian artery is a rare anomaly, and the optimal operative strategy has not yet been established. In particular, the approach to the diverticulum is controversial, with the greatest concern being whether or not to add a right thoracotomy to the median sternotomy for distal anastomosis. We successfully performed total arch replacement through a median sternotomy only, by referring to preoperative computed tomography. We think that if the aneurysm is in a shallow position from the tracheal bifurcation, total arch replacement is possible with a midline incision only.

An 83-year-old woman with a Kommerell diverticulum was treated by anatomical endovascular repair with a deep site in-situ fenestration instead of complex debranching techniques. The main component of the thoracic stent-graft was deployed just distal to the third cervical branch to completely exclude the Kommerell diverticulum. A deep site in-situ fenestration was made on the main component using a radiofrequency needle through the left subclavian artery, and a stent-graft was deployed to bridge the main component to the left subclavian artery. Six months postoperatively, the Kommerell diverticulum was completely excluded with excellent left subclavian artery patency.

The presence of an isolated left subclavian artery arising from the pulmonary artery in a patient with d-transposition of the great arteries is exceedingly rare. Prior to undertaking repair of this congenital cardiac anomaly, identification of an isolated left subclavian artery originating from the pulmonary artery is imperative in order to plan the appropriate intervention to prevent the development of subclavian artery steal or vertebrobasilar insufficiency. We describe the case of a 5 day-old girl in whom an isolated left subclavian artery arising from the pulmonary artery was detected after surgical entry for repair of transposition of the great arteries.

Objectives Investigate the impact of left subclavian artery coverage without revascularization on spinal cord ischemia development in patients undergoing thoracic endovascular aortic repair. Methods The Vascular Quality Initiative thoracic endovascular aortic repair module (April 2011-July 2014) was analyzed. Patients undergoing left subclavian artery coverage were divided into two groups according to revascularization status. The association between left subclavian artery revascularization with the primary outcome of spinal cord ischemia and the secondary outcome of stroke was assessed with multivariable analysis adjusting for between-group baseline differences. Results The left subclavian artery was covered in 508 (24.6%) of the 2063 thoracic endovascular aortic repairs performed. Among patients with left subclavian artery coverage, 58.9% underwent revascularization. Spinal cord ischemia incidence was 12.1% in the group without revascularization compared to 8.5% in the group undergoing left subclavian artery revascularization (odds ratio (95%CI): 1.48(0.82-2.68), P = 0.189). Multivariable analysis adjustment identified an independent association between left subclavian artery coverage without revascularization and the incidence of spinal cord ischemia (adjusted odds ratio (95%CI): 2.29(1.03-5.14), P = 0.043). Although the incidence of stroke was also higher for the group with a covered and nonrevascularized left subclavian artery (12.1% versus 8.5%), this difference was not statistically significant after multivariable analysis (adjusted odds ratio (95%CI): 1.55(0.74-3.26), P = 0.244). Conclusion For patients undergoing left subclavian artery coverage during thoracic endovascular aortic repair, the addition of a revascularization procedure was associated with a significantly lower incidence of spinal cord ischemia.

Approximately 40-50% of patients undergoing thoracic endovascular aortic repair require left subclavian artery coverage for adequate proximal landing zone. Many of these patients undergo left subclavian artery revascularisation. However, outcomes data for left subclavian artery revascularisation in the context of thoracic endovascular aortic repair remain limited. In this study, 70 left subclavian artery revascularisation procedures, performed on thoracic endovascular aortic repair patients at a tertiary hospital, were retrospectively reviewed. Particular emphasis was placed on revascularisation-related outcomes during staging interval between revascularisation and thoracic endovascular aortic repair. Forty-six (66%) carotid-subclavian bypass, 17 (24%) carotid-carotid-subclavian bypass and 7 (10%) aorto-inominate-carotid-subclavian bypass procedures were performed. There were no strokes or mortalities following left subclavian artery revascularisation procedures alone. Three (10%) minor complications occurred including a seroma, a haematoma and a temporary neuropraxia. Separation of complications following left subclavian artery revascularisation from those of the associated thoracic endovascular aortic repair can be difficult. Early outcomes data from patients who underwent left subclavian artery revascularisation in isolation indicate that the procedure is safe with low complication rates.

Introduction: Subclavian stenosis has a prevalence of approximately 2% in the community, and 7% within a clinical population. It is closely linked with hypertension and smoking. There is a relative paucity of published data to inform clinicians on the optimal mode of treatment for subclavian artery stenosis., Objectives: To compare clinical outcomes of subclavian bypass surgery with that of subclavian endovascular re-vascularisation. Endpoints were survival time, re-intervention-free survival, and symptom-free survival., Method: In all, 21 subclavian interventions were performed from 2000 to 2010. We compared angioplasty vs angioplasty with stenting vs bypass., Results: Technical success was 100% in all groups. Symptom-free survival, at 70 months, was 60% in the angioplasty group, 100% in the angioplasty and stenting group and 75% in the bypass group. Re-intervention rate was 40% in the angioplasty group, 0% in the angioplasty and stenting group and 25% in the bypass group. Median time for re-intervention was 9.5 months in angioplasty patients and 36 months in bypass patients (p = 0.102). Target lesion revascularisation was 20.0% for angioplasty procedures, 16.67% for angioplasty and stenting and 25% for bypass procedures., Conclusion: Angioplasty with stenting provides improved symptom-free survival and freedom from re-intervention in patients with symptomatic subclavian artery stenosis., (© The Author(s) 2015.)

We describe our experience of surgical treatment in a 28-year-old woman with vascular Ehlers-Danlos syndrome. A right subclavian artery aneurysm was detected. The right vertebral artery arose from the aneurysm. Digital subtraction angiography showed interruption of the left vertebral artery. The aneurysm was excised and the right vertebral artery was anastomosed end-to-side to the right common carotid artery under deep hypothermia and circulatory arrest. The patient remained very well 4 years after surgery, with no late vascular complication., (© The Author(s) 2014.)

A 16-year-old boy suffered a subarachnoid hemorrhage and underwent open head surgery. He was subsequently diagnosed with coarctation of the aorta and referred to our hospital. The coarctation was at the distal transverse arch, just at the site of branching of the subclavian artery. Total arch replacement with selective cerebral perfusion was selected because of the short hypoplastic arch. The patient had an uneventful postoperative course, and was doing well 3 years after the surgery., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: Kommerell's diverticulum is an extremely rare congenital aortic anomaly. Because of its rarity, the optimal surgical strategy for Kommerell's diverticulum has not been established. In this study, we reviewed our experience of surgical correction of this anomaly., Methods: Between 2007 and 2013, we managed 9 surgical cases of Kommerell's diverticulum; 7 had a right aortic arch with an aberrant left subclavian artery, and 2 had a left aortic arch with an aberrant right subclavian artery. None of these patients had any symptom resulting from structural compression between the aneurysm and the aberrant subclavian artery. All patients underwent surgical treatment to prevent aneurysmal rupture. Six patients had replacement of the thoracic descending aorta and in-situ reconstruction of the aberrant subclavian artery through a right thoracotomy, and 3 underwent the same procedures through a left thoracotomy. Three different methods of extracorporeal circulation were applied, according to the anatomical features of each case., Results: There was one hospital death. This patient developed severe cerebral infarction and died of multiple organ failure on the 65th postoperative day. There were no other major complications nor any need for rehospitalization., Conclusion: Kommerell's diverticulum should be treated using an optimal strategy based on each patient's anatomical features and other characteristics., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Central line placement is an integral part of our daily routine and although it is necessary in a select group of patients, serious complications may occur in up to 10% of cases. Inadvertent placement in the subclavian artery is considered to be one of the most challenging complications to the vascular specialist, which is mainly due to its deep anatomical location. Several endovascular options are available and should be tailored to fit each scenario. Herein, we present different approaches for the management of three cases of inadvertent subclavian artery cannulation. The first patient was treated with a covered stent, the second with prolonged balloon inflation, and the third with a closure device., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Aberrant right subclavian artery is a rare anatomical finding of abnormal embryologic development of the dorsal aorta and right subclavian artery. An associated aortic outpouching, or Kommerell diverticulum, may develop at the origin of the aberrant right subclavian artery. Given historically high rates of aneurysm rupture and mortality, early repair is indicated. Successful aneurysm exclusion can be accomplished with thoracic endovascular stent grafting following open carotid-subclavian bypass, maintaining upper extremities perfusion. Such hybrid techniques offer a decrease in mortality and complication rates. Herein, we describe a successful repair of a symptomatic (dysphagia, weight loss) aberrant right subclavian artery with Kommerell diverticulum using this hybrid open-endovascular approach., (© The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Objective: We aimed to evaluate outcomes of thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) coverage without bypass (TEVAR + SUB) to TEVAR with coverage of the LSA with a bypass at the time of the initial procedure or later at a separate procedure (TEVAR + SUB + BYPASS)., Methods: The Centers for Medicare & Medicaid Services inpatient claims for 2006-2007 were queried using Current Procedural Terminology codes for TEVAR, TEVAR + SUB, TEVAR + SUB + BYPASS or later as a separate procedure., Results: A total of 2676 patients underwent TEVAR; 869 (32.5%) underwent TEVAR + SUB and 49 (5.6%) TEVAR + SUB + BYPASS. At the time of the initial procedure, TEVAR + SUB + BYPASS was associated with a higher incidence of stroke compared to TEVAR + SUB (12.8% vs. 3.8 %; p = 0.0033). Among TEVAR + SUB, only 1.93% (50 patients) had a subsequent bypass performed during a one-year follow-up. Overall rates of morbidity (p = 0.004) and mortality (p = 0.011) trended towards significance in favor of TEVAR + SUB., Conclusions: TEVAR + SUB were associated with lower rates of mortality and complications. Only a small percentage of TEVAR + SUB required a bypass at one year after procedure. Our data suggest that routine LSA bypass during TEVAR is unnecessary and associated with increase morbidity and mortality., (© The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

We describe the case of a 74-year-old man who underwent a hybrid open and endovascular approach for repair of dissecting thoracic aortic aneurysm of a right aortic arch with aberrant left subclavian artery arising from a Kommerell's diverticulum. Total debranching using a tailored quadrifurcated graft and thoracic endovascular aneurysm repair for the transverse aortic lesion were performed. The procedures were successfully accomplished with complete exclusion of the aneurysm. This hybrid procedure for complex aortic arch disease may reduce perioperative complications compared to challenging conventional open approaches., (© The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Percutaneous transluminal angioplasty and stenting is being employed with increasing frequency for stenosis involving the brachiocephalic circulation. However, the efficacy of these procedures is limited by intimal hyperplasia and subsequent re-stenosis. Long-term results for treating lesions of the subclavian or innominate artery have shown significant re-stenotic rate. Accordingly, carotid-subclavian bypass remains as an important procedure. Alternative methods may still be required, particularly after failure of open re-vascularization and percutaneous techniques. This report describes an underused technique that enables upper extremity revascularization following prior attempts at endovascular and standard open techniques.

Subclavian artery aneurysm is a rare but serious disease due to the risk of thrombosis, embolization, rupture and compression of adjacent structures. Treatment consists of surgical and endovascular techniques. Up to now few long-term follow-up results have been reported. In our study the results from 15 patients treated for subclavian artery aneurysms were evaluated. Eleven patients underwent open surgical reconstruction, four patients were treated endovascularly. After a mean follow-up period of 77 months (83 months for the open surgical group, 38 months for the endovascular group), 10 of 11 open surgical reconstructions and all primarily implanted stent grafts were patent. Secondary intervention was necessary in two patients. Thirty-day mortality for both treatment groups was 0%. Subclavian artery aneurysm-related symptoms disappeared in six out of 10 patients after the treatment. Long-term outcomes with good technical results, patency rates and low periprocedural morbidity could be shown in both treatment groups.

Experience with and acceptance of endovascular repair of arch vessel injuries continues to increase. This manuscript reports the case of a 65-year-oldman with a gunshot wound to the right supraclavicular area with a hematoma, pulsating mass and loss of neurological function of the right upper extremity. As he was hemodynamically stable, a computed tomography angiogram was performed and it demonstrated a 6 cm right subclavian/axillary artery pseudoaneurysm. The patient was taken to the angiogram/ hybrid room and an arch angiogram was performed. A selective right subclavian angiogram was performed and a covered stent was deployed across the pseudoaneurysm and a completion angiogram showed complete exclusion with normal runoff to the upper extremity. In conclusion, penetrating subclavian/axillary artery trauma can be successfully managed with minimal morbidity via early utilization of endovascular covered stent therapy. A literature review suggests that the endovascular approach will soon be the standard of care for traumatic disruption of subclavian arteries.

Kommerell's diverticulum causes compression of the esophagus between the aberrant origin of the left subclavian artery and ascending aorta, leading to dysphagia or dyspnea. We describe 3 cases of successful surgical treatment of right aortic arch with Kommerell's diverticulum and aberrant origin of the left subclavian artery, using a right anterolateral partial sternotomy. This allows both resection of the Kommerell's diverticulum as well as reconstruction of the aberrant origin of the left subclavian artery anatomically.

Background: A bypass between the left common carotid artery and the left subclavian artery has been made in some patients undergoing thoracic endovascular aortic repair that covers the orifice of the left subclavian artery. However, complications associated with temporary occlusion of the left common carotid artery are reportedly not uncommon., Methods: Between January 2009 and September 2011, left external carotid-to-left subclavian artery bypass was made using a polytetrafluoroethylene graft in 15 patients undergoing a thoracic endovascular aortic repair that covered the orifice of the left subclavian artery. Adverse effects associated with the procedure were assessed, and patency of the bypass graft was determined by contrast-enhanced computed tomography before discharge and at least once during follow-up., Results: All patients were discharged without any brain complications. All 15 bypass grafts were patent prior to discharge and during the follow-up period. One patient suffered temporary left recurrent laryngeal nerve palsy postoperatively. No other sequelae were associated with left external carotid-to-left subclavian artery bypass., Conclusion: Left external carotid-to-left subclavian artery bypass is a promising procedure in patients undergoing thoracic endovascular aortic repair that covers the orifice of the left subclavian artery.

This is one of the first reports of a left subclavian pseudoaneurysm in a patient presenting with massive hemoptysis. We present a challenging case of a patient who consulted for hemoptysis. Imaging revealed a left subclavian artery pseudoaneurysm that caused a pulmonary parenchymal lesion. Treatment with a self-expanding thoracic stent-graft and a subclavian occluder was successful.

Subclavian artery (SA) aneurysms (SCAA) are relatively uncommon but carry a significant risk of rupture, thrombosis and embolism if left untreated. We describe the etiology, mode of presentation and outcome of surgical management of 10 patients presenting with SCAA between January 1990 and December 2010. The mean age was 43.7 years. There were seven men and three women. Five patients had aneurysms due to trauma, four had it due to thoracic outlet syndrome and one had it secondary to atherosclerosis. Five patients presented with ischemic symptoms of the distal upper extremity, while the rest presented with a pulsatile neck mass. All patients were treated surgically. Six patients were approached with combined supra- and infraclavicular incisions. Aneurysm resection with reconstruction using saphenous vein or synthetic grafts was done in eight patients. There was no perioperative mortality. The early patency rate was 100%. Surgical treatment is effective and recommended for most patients with SCAA.

A right-sided aortic arch associated with an aberrant subclavian artery is a rare anomaly. Regardless, this condition is clinically relevant because mortality is associated with rupture, morbidity results from compression of mediastinal structures, and the surgery is complex. We describe the successful surgical repair of this vascular anomaly by totally debranching the neck vessels and placing an endovascular stent-graft to exclude the ruptured Kommerell's diverticulum.

We describe the case of a 45-year-old man with a unique constellation of supra-aortic artery aneurysms detected by chest X-ray during work-up for chronic cough. During his diagnostic work-up, the patient suffered an embolic stroke likely secondary to disrupted plaque originating in an aneurysmal right vertebral artery. Endovascular repair was not a viable option due to the diffuse and bilateral nature of aneurysmal disease, including involvement of the innominate and right carotid and vertebral arteries. The patient was successfully treated with a two-stage open surgical approach involving an initial right carotid artery to vertebral artery bypass and subsequent in situ reconstruction utilizing a bifurcated Dacron graft sewn to the proximal aortic arch with distal extension to the right common carotid and axillary arteries.

The purpose of this study is to report the results of axillo-axillary bypass (AAB) for coronary subclavian steal syndrome due to proximal subclavian artery occlusion. From 2003 to 2010, AAB using a polytetrafluoroethylene (PTFE) graft was performed in 11 patients with coronary subclavian steal syndrome. There was no perioperative mortality, stroke or cardiac complications. Over a mean follow-up of 36 months (range: 6-81 months), all bypass grafts have remained patent. No patient developed recurrent symptoms of myocardial ischemia. One patient died from hemorrhagic stroke at 31 months. Our results showed that AAB using a PTFE graft provides an effective and durable treatment option for coronary subclavian steal syndrome when attempted endovascular therapy of the occluded proximal subclavian artery is unsuccessful.

Left subclavian artery aneurysm with an aneurysm of the aberrant right subclavian artery is a rare condition with a reported incidence of 0.13% to 1%. We report the successful surgical correction of both conditions in a 34-year-old man.

Acute hemoptysis might be caused by aneurysms of the subclavian artery. We report a 75-year-old female patient presenting with recurrent hemoptysis, dyspnea, fever, and episodes of unclear pneumonia. Further examination revealed a large intrathoracic aneurysm of the right subclavian artery. After an initial transfemoral interventional attempt to occlude the entry of the aneurysm, the patient developed persistent thoracic pain. The patient was then treated by a combined extrathoracic hybrid procedure with a left to right carotid-carotid-axillary artery bypass and an endovascular aneurysm exclusion by insertion of two iliac artery occluder stent grafts in the proximal brachiocephalic trunk and the distal right subclavian artery. After this combined intervention, hemoptysis disappeared, and the patient recovered remarkably during a follow-up of 24 months.

The combination of right cervical aortic arch, aberrant retroesophageal left subclavian artery originating from a Kommerell's diverticulum, and a ligamentum arteriosum, constitutes a rare form of vascular ring. Two patients aged 21 days and 54 years, who were diagnosed by multislice 3-dimensional computed tomography and magnetic resonance imaging, underwent surgical division of a vascular ring. The adult required resection of a Kommerell's aneurysm and subclavian artery reimplantation.