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Endovascular stent grafting is becoming more common in treating complex thoracic aortic aneurysms and dissections. When it becomes necessary to cover the supra-aortic vessels, maintaining blood supply through the supra-aortic branches can be achieved by performing in situ needle fenestration. We present a case of a 65-year-old man with a type B aortic dissection that extended from the origin of the left subclavian artery. A stent graft was inserted into the thoracic aorta distally of the origin of the left common carotid artery. Due to the stent graft moving distally and not adequately sealing the subclavian artery, a second stent graft was placed more proximally. Both stent grafts were successfully in situ fenestrated using a needle, and a stent graft was inserted into the subclavian artery. In conclusion, during thoracic endovascular aortic repair, in situ needle fenestration can be successfully carried out on two overlapping thoracic stent grafts., 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: To assess the safety and efficacy of the combination of brachial artery (BA) cutdown with purse-string suture (PSS) for BA preclosure during fenestrated thoracic endovascular aortic repair (f-TEVAR)., Methods: We reviewed the consecutive data in our center from January 2022 to May 2023. Clinical data were analyzed retrospectively, including the baseline characteristics, procedural details, complications, and outcomes. Dichotomous data were summarized as absolute values and percentages. Continuous variables were presented as median values and interquartile ranges (IQRs). All patients underwent arterial cutdown with the PSS technique for BA preclosure. The technique was considered successful when complete hemostasis was achieved and confirmed by ultrasonography 24 h postoperatively. The patients were followed up 30 days postoperatively for access-related complications., Results: Forty-eight patients who underwent f-TEVAR with 48 BA access sites were included [36 males and 12 females; median age: 62 (IQR: 30-78) years]. The median body mass index was 27.3 (IQR: 21.2-32.7) kg/m 2 . The median access establishing and closing times were 7.8 (IQR: 6-9.3) min and 3.7 (IQR: 2.5-5) min, respectively. The median operative time and length of stay were 75 (IQR: 63-87) min and 7 (IQR: 5-9) days, respectively. Although the success rate was 100%, partial numbness in the median nerve distribution was noted in 1 patient in the forearm. This resolved spontaneously and no permanent neurological problem was seen. No other access-related complications were noted, and the total complication rate was 2.1% (1/48)., Conclusions: BA preclosure with the PSS technique is safe and effective for left subclavian artery revascularization in Stanford B aortic dissection and can be another option for access closure during f-TEVAR., 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.

Purpose: Thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) revascularization has been used in patients with type B aortic dissection (TBAD), with inadequate proximal landing zone (PLZ). The outcomes of comparisons between TEVAR and hybrid procedure on patients with TBAD, with inadequate PLZ, are rarely reported. This study sought to compare and clarify the early and midterm outcomes between TEVAR and hybrid procedure in patients with TBAD, with inadequate PLZ., Materials and Methods: Between January 2019 and December 2021, 93 patients with TBAD, with inadequate PLZ, who underwent TEVAR or hybrid procedure, were retrospectively evaluated in Beijing Anzhen hospital. Demographics, comorbidities, preoperative imaging features, periprocedural details, and follow-up outcomes were analyzed. Survival was analyzed according to Kaplan-Meier method., Results: TEVAR procedures were performed on 41 patients (TEVAR group) and hybrid procedures on 52 patients (hybrid group). Early events, 30 day mortality, and all-cause mortality, were not significantly different between the 2 groups. However, patients receiving TEVAR had significantly shorter procedure time (p<0.001), hospital stay (p<0.001), and intensive care unit (ICU) stay (p=0.001) compared with those in the hybrid group. Patients receiving TEVAR had significantly lower midterm events (p=0.014) and re-intervention (p=0.015) compared with those in the hybrid group., Conclusion: The study indicated that TEVAR with LSA revascularization for TBAD with inadequate PLZ is associated with a trend toward lower rates of midterm events, while the early and midterm mortalities were comparable with those in hybrid procedure., Clinical Impact: This study is novel as it compared the outcomes between thoracic endovascular aortic repair (TEVAR) and hybrid procedure in patients with type B aortic dissection (TBAD), with inadequate proximal landing zone, which has been rarely reported previously. We believe that our study makes a significant contribution to the literature because it is clinically relevant as it demonstrated that TEVAR with left subclavian artery (LSA) revascularization for TBAD with inadequate proximal landing zone is associated with a trend toward lower rates of mid-term events, while the early and mid-term mortalities were comparable with those in the hybrid procedure., 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: Traumatic axillary and subclavian artery injuries are uncommon. Limited data are available regarding patient and injury characteristics, as well as management strategies and outcomes., Methods: Retrospective chart review was performed on patients presenting to University of Louisville Hospital, an urban Level One Trauma Center, with traumatic axillary and subclavian artery injuries from 2015-2021. Patients were identified using University of Louisville trauma, radiology, and billing database searches based on ICD9/10 codes for axillary and subclavian artery injuries. Descriptive statistics are expressed as frequencies and percentages. Comparisons were performed using Fisher's Exact and Chi-squared tests., Results: Forty-four patients with traumatic axillary-subclavian arterial injuries were identified for analysis. Blunt and penetrating trauma were equally represented (n = 22 for both). A variety of injury types were seen, including minimal/intimal injury, laceration, pseudoaneurysm, transection, occlusion, and arteriovenous fistula. Management strategies were also variable, including non-operative, endovascular, planned hybrid, open, and endovascular converted to open. In operative patients, revascularization technical success was high (n = 31, 97%) with low likelihood of thrombosis (n = 2, 6%) and no infections. Among all patients, amputation rate was 5% (n = 2) and mortality rate was 9% (n = 3). Regarding arterial involvement, blunt injury was more likely to affect the subclavian (n = 18) than the axillary artery (n = 6) ( P = .04). No significant difference was seen in brachial plexus injury based on artery involved (subclavian = 9 vs axillary = 11, P = .14) or mechanism (blunt = 6 vs penetrating = 11, P = .22). Non-operative management was more likely with subclavian artery injury (n = 11) vs axillary artery injury (n = 1) ( P = .008). There was no significant difference between decision for non-operative (blunt = 9, penetrating = 3) vs operative (blunt = 13, penetrating = 19) management based on mechanism ( P = .09). Transection injury was associated with an open repair strategy (endovascular/hybrid = 1, open/endovascular to open conversion = 11, P = .0003). Of the three patients requiring endovascular to open conversion, two required amputation, which were the only two patients in the study undergoing amputation., Conclusions: Both open and endovascular/hybrid strategies are useful when treating traumatic axillary and subclavian artery injuries and are associated with high likelihood of revascularization technical success, with low rates of thrombosis or infection, when treated promptly at a trauma center with vascular specialists available. Transection injuries were most often treated with open revascularization. Patients undergoing amputation had blunt transection injuries to the subclavian artery and underwent endovascular to open conversion after failed attempts at endovascular revascularization., 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.

We report in-vivo imaging of a constellation of arterial variants found incidentally on CT-angiography in a 23-year-old woman presenting with an ischaemic stroke. This extremely rare combination includes a common origin of both common carotid arteries, an abnormal origin of the right vertebral artery (VA) from the right common carotid artery and of the left VA from the aortic arch, associated with an aberrant right subclavian artery. This constellation, previously described in a female cadaver, has not been reported in-vivo. Awareness of this configuration is crucial for radiological diagnosis and when performing angiography and endovascular or surgical procedures in thorax, head and neck, to avoid complications., 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.

Subclavian artery injury during central venous line placement is a potentially life-threatening complication. Due to historically high mortality rates with attempted manual pressure for haemostasis, the current favoured method of repair is by open or endovascular means. This case describes the management of a central venous catheter placed through the internal jugular vein into the subclavian artery via a supraclavicular puncture. CT angiography revealed the arterial injury located 1 cm distal to the vertebral artery origin. Under fluoroscopic guidance in an endovascular hybrid theatre, a covered stent was deployed across the affected segment of the subclavian artery which resulted in occlusion of the vertebral artery origin to attain safe proximal seal. This was done during simultaneous removal of the catheter and manual pressure over the internal jugular vein. There were no complications and the patient recovered well post-procedure. This case highlights the importance of appropriate ultrasound techniques for central catheter insertion for precise visualisation to prevent inadvertent injury to distal structures. CT angiography is useful in planning endovascular management. Occlusion of the vertebral artery in this case did not result in any neurological complications., 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.

Coexistence of pulmonary embolism (PE) and arterial thrombosis in a single patient is rare. Management of such cases is challenging because there is no unified standard on how to treat this type of disease. We herein report a case involving a 73-year-old man who was admitted to the hospital because of a 2-day history of chest tightness. Pulmonary computed tomography angiography revealed a filling defect of the main pulmonary artery and bilateral branches as well as a left subclavian artery embolism. AngioJet mechanical thrombectomy (Boston Scientific, Marlborough, MA, USA) was used to treat the PE, and this was combined with left brachial artery incision and thrombectomy for treatment of the left subclavian artery embolism. The patient recovered well after the operation. The prognosis was good after 9 months of regular follow-up. AngioJet mechanical thrombectomy combined with left brachial artery incision thrombectomy may be a feasible treatment option for cases of PE combined with left subclavian artery embolism., Competing Interests: Declaration of conflicting interestsThe authors declare that there is no conflict of interest.

Right sided aortic arches with concomitant aberrant left subclavian arteries are exceedingly rare anatomical variants. We present a case of a 45 year old male that presented with symptoms consistent with dysphagia and known right sided aortic arch with an aberrant left subclavian artery. Though previous reports of repair have indeed been reported, we confirm that a hybrid approach to these anatomic variants remain feasible and with symptom resolution for patients., 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: Aberrant right subclavian artery (ARSA) is the most common of the aortic arch anomalies, occurring in .5% to 1% of the population. There is no standardized follow up protocol, especially in the asymptomatic cases. The purpose of the present study was to evaluate the natural history of ARSA and the role of serial CT scans. Methods: This is a single-center retrospective study of patients with ARSA depicted on chest computed tomography (CT) scans between February 2013 and July 2022. Data were collected from their medical records. Measurements of the aorta at different segments including the aortic diameter at the orifice of ARSA, and ARSA at ostium followed by 1 cm intervals were collected, as well as for follow-up CT scans. Results: 65 patients were diagnosed with ARSA, 70.8% of whom were women. The average age for the cohort was 58.569 ± 16.99 years. The median follow up time was 4 years (range 0-10 years), KM estimated survival after ARSA diagnosis at 1 and 5 years as 97% and 93%, respectively. Nineteen patients had a second CT scan and were included in the morphological CT dynamic analysis, on average of 29 ± 27 months apart (range 7-108). The mean ARSA diameter at origin was larger in the second scan 16.91 ± 4.31 mm compared to the initial scan 16.31 ± 4.96 mm, ( P = .04).The mean aortic arch diameter in the first and second CT were 28.54 ± 4.24 and 29.64 ± 5.14 ( P = .10), respectively. All other measurements did not disclose any significant enlargement over time. Conclusions: Our cohort demonstrate a benign natural history of ARSA with slow growth rates. However, due to our small sample size we can't draw a clinically sound recommendation on the need for imaging follow up, and further larger cohort with longer follow up interval are required., 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.

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., 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.

Purpose: The purpose of this study was to evaluate the efficacy and safety of zone 2 thoracic endovascular aortic repair assisted by the chimney technique or single-branched stent graft for the preservation of the left subclavian artery, and summarize our single-center experience with the techniques., Materials and Methods: From February 2017 to June 2020, 137 patients who underwent left subclavian artery revascularization during zone 2 thoracic endovascular aortic repair were enrolled. Patients had acute type B aortic dissection and penetrating aortic ulcer associated with intramural hematoma. The chimney technique was performed in 68 patients (group A), and single-branched stent graft was deployed in 69 patients (group B). All procedures were performed during the acute phase. Primary technical success, immediate postoperative endoleak, neurologic complications (stroke or spinal cord ischemia), 30-day mortality, 1-year technical success, all-cause mortality, patency of the left subclavian artery, and reintervention were analyzed. Comparing the occurrence of the Bird-Beak Configuration, defined as a gap between the aortic wall and the sent graft with stent protrusion into the aortic lumen more than 5 mm, was also performed., Results: Primary technique success was achieved in 66 and 67 patients in groups A and B, respectively. The incidence of immediate postoperative endoleak, neurologic complications (stroke or spinal cord ischemia), and 30-day mortality were 5.9%, 1.5%, and 4.4% in group A, and 2.9%, 2.9%, and 2.9% in group B, respectively. During follow-up, the 1-year technical success rate was similar in both groups. All-cause mortality was similar in both groups (3.1% in group A and 4.5% in group B). The patency of the left subclavian artery was not significantly different between the 2 groups with 2 and 3 occlusions in groups A and B, respectively. The rate of reintervention was higher in group B (3.1% vs 1.6%, p=0.536), with a non-significant difference. Bird-Beak Configuration was more prominent in group B with the incidence of 59.42%., Conclusions: Acting as minimally invasive alternatives, both techniques are feasible for left subclavian artery preservation during zone 2 thoracic endovascular aortic repair for type B acute aortic syndromes with encouraging mid-term outcomes. Long-term follow-up is required to confirm these findings., 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: Kommerell's diverticulum (KD) with a right aortic arch (RAA) and aberrant left subclavian artery (aLSCA) is a rare congenital anomaly of the aortic arch. Treatment is not well defined due to its uncommon presentation, with rupture and dissection risk rates of up to 53%., Case Summary: A 54-year-old male with a history of chronic obstructive pulmonary disease (COPD) and hypertension presented with difficulty breathing during exercise without dysphagia. Follow-up computerized tomography angiogram (CTA) revealed the presence of a RAA and aLSCA arising from the descending thoracic aorta with an adjacent 58 × 41-mm KD and tracheal and esophageal displacement. Due to the size of the KD, risk of rupture, unsuitable anatomy for total endovascular aortic repair (EVAR), and high COPD burden, the patient was planned to undergo a hybrid surgical repair. Left common carotid (LCCA) artery to LSCA bypass, full aortic debranching, LSCA embolization and percutaneous thoracic endovascular aortic repair (TEVAR) were performed. Successful device position and exclusion of the diverticulum and aneurysmal aorta were observed after completion thoracic aortogram. 18-month follow-up CTA demonstrated patency of the LSCA to LCCA bypass graft and arch vessel branches, as well as stable exclusion of the KD. Persistence of a type II endoleak originated at the right first posterior intercostal artery has been noted and is being followed conservatively since no sac growth has occurred., Conclusion: We highlight the presence of a KD with RAA and aberrant subclavian artery, a rare congenital anatomic variation of the aortic arch with complex anatomy. Surgical planning must be individualized according to comorbidities and anatomical variations identified on imaging and 3D reconstructions.

Parathyroid adenomas are responsible for 80% to 85% of cases of primary hyperparathyroidism. Giant parathyroid adenomas are a rare type of parathyroid adenoma defined as weighing >3.5 grams. Although giant parathyroid adenomas are rare entities whose clinical presentation may not be atypical, their surgical management can be challenging, especially in the setting of anatomical variants. We present here a case of a 29-year-old female with a 37-gram giant adenoma which was diagnosed after presentation with recurrent severe headaches. The presentation was also unique in that it was associated with a right aberrant subclavian artery and nonrecurrent laryngeal nerve.

Introduction: The management of Kommerell's Diverticulum (KD) has evolved from open surgical resection and graft replacement of the aorta, to endovascular repair in asymptomatic patients due to its recognized possible sequelae - aortic rupture and dissection. Despite these technical advances, standard indications for intervention and treatment algorithms remain unclear. We will present our single-center experience in the treatment of KD, supporting a multidisciplinary endovascular-first approach., Methods: All patients who underwent thoracic endovascular aortic repair (TEVAR) for KD between 2017 and 2020 were retrospectively identified from a prospectively maintained institutional surgery database. Chart review was used to characterize presenting symptoms, interventions, technical results, and complications. Revascularization was performed using carotid-axillary bypass. Routine endovascular subclavian artery occlusion was employed to eliminate retrograde diverticulum perfusion and avoid open ligation., Results: 8 patients were identified, including 6 females and 2 males between the ages of 44-76. Patients presented with dysphagia (n = 3), acute embolic stroke (n = 1), transient ischemic attack (TIA) (n = 1), upper extremity embolization (n = 1), and acute type B aortic dissection (n = 1). One patient had a prior incomplete open repair that was successfully treated endovascularly. Another patient had a mediastinal neoplasm infiltrating an incidental aberrant subclavian artery and KD. All cases had symptomatic improvement and successful endovascular repair as demonstrated on post-operative imaging. Perioperative complications included percutaneous access site pseudoaneurysm (n = 2), stroke (n = 1), and subclavian artery rupture immediately recognized and treated (n = 1). There was no perioperative mortality., Conclusion: Endovascular techniques have resulted in technical success and symptomatic improvement for KD without open thoracotomy or sternotomy. Significant rates of endovascular complications and paucity of long-term durability data should be considered. Until formal criteria for repair are established, early application of TEVAR using a consistent multi-specialty approach may mitigate the risk of unpredictable aortic complications in these patients while avoiding the accepted morbidity and mortality of open surgery.

Anomalous origin of the left subclavian artery from the pulmonary artery is a rare congenital cardiac malformation. We describe a case of anomalous origin of the left subclavian artery from the pulmonary artery in a patient who presented with symptoms of vertebrobasilar insufficiency and underwent reimplantation of the left subclavian artery into the left common carotid artery from the supraclavicular approach.

A newborn presented with tetralogy of Fallot (TOF), right aortic arch (RAA), and isolated left brachiocephalic artery. The RAA supplied the right common carotid artery, right vertebral artery, and right subclavian artery, in that order. The left common carotid and left subclavian arteries were in continuity with no aortic origin. Ultrasound demonstrated retrograde flow in the left vertebral artery supplying antegrade flow to the diminutive left subclavian artery (ie, "steal phenomenon"). The patient underwent repair of TOF without intervention on the left common carotid or left subclavian arteries and is being followed conservatively.

While unusual, aberrant right subclavian artery (ARSCA) can occasionally be a source of significant dysphagia in children. We present a case of a 13-year-old female who reported a three-year history of dysphagia to solid foods and was found to have ARSCA on a barium swallow study and computed tomography scan of the chest. We reimplanted the ARSCA into the right carotid artery in end-to-side fashion using a partial median sternotomy approach. At six months follow-up, her symptoms had completely resolved, and her postoperative echocardiogram showed an unobstructed reimplanted ARSCA. Meeting presentation: AATS 102nd Annual Meeting; May 14, 2022; Boston, MA.

This manuscript describes an endovascular repair of a symptomatic, large proximal left subclavian artery aneurysm in a patient with dextrocardia and right-sided aortic arch and absent bilateral internal carotid arteries. The patient had surgical reconstruction as an infant for congenital heart disease with Ventricular Septal Defect, bifid sternum . Given her previous surgical history, we declined an open operation and performed an endovascular repair with stent grafts to successfully repair the subclavian artery aneurysm. The patient had an uneventful postoperative course and follow-up ultrasonography demonstrated successful repair with preservation of flow through the left subclavian and vertebral arteries with resolution of her symptoms.

Purpose: To describe a technique of vascular plug penetration by a guidewire with a heavy tip load for additional embolization of a type 2 endoleak after endovascular aortic aneurysm repair (EVAR)., Technique: The technique of vascular plug penetration is effective for additional embolization of a type 2 endoleak, when large arteries such as left subclavian artery (LSA) or hypogastric artery remain patent even after the embolization of the vessel has been performed using a vascular plug and are responsible for the endoleak. A tapered guidewire with a heavy tip load enables the penetration of the disk of the plug, followed by introduction of a microcatheter into the endoleak nidus. In the presented case, the technique successfully eliminated a type 2 endoleak in a thoracic aortic aneurysm for which a patent LSA despite the embolization by a vascular plug was responsible., Conclusion: The technique of vascular plug penetration allows an access to an endoleak cavity via a vascular plug placed in an aortic side branch for additional embolization of a type 2 endoleak after EVAR.

Purpose: A hybrid aortic repair using the frozen elephant trunk (FET) technique with an open distal anastomosis in zone 2 and debranching of the left subclavian artery (LSA) has been demonstrated to be favorable and safe. Although a transposition of the LSA reduces the risk of cerebellar or medullar ischemia, this may be challenging in difficult LSA anatomies., Case Report: We present the case of a 61-year old patient with DeBakey I aortic dissection, treated with FET in moderate hypothermic circulatory arrest (26°C) and selective cerebral perfusion using a Thoraflex-Hybrid (Vascutek Terumo) prosthesis anchored in zone 2, with overstenting of the LSA orifice and no additional LSA debranching. Sufficient perfusion of the LSA was proved intraoperatively using LSA backflow analysis during selective cerebral perfusion in combination with on-site digital subtraction angiography (ARTIS Pheno syngo software). No neurologic dysfunction or ischemia occurred in the postoperative course. An angiographic computed tomography revealed physiologic LSA perfusion, with subsequent thrombotic occlusion of the false lumen in the proximal descending aorta after 7 days., Conclusion: Using an angiography-guided management in patients with complex DeBakey I dissection and difficult anatomy may simplify a proximalization of the distal anastomosis in zone 2 for FET, even without an additional LSA debranching.

Background: Upper extremity arterial aneurysms are a rare, potentially limb-threatening disorder. Due to its rarity, the best treatment modality and outcomes are not entirely established; however, there is a consensus that open surgery is the first-line treatment. We present a complex case of an arterial aneurysm of the subclavian-axillary-brachial axis adequately treated using a hybrid surgical and endovascular treatment., Case Presentation: A 59-year-old man presented to the emergency department with acute ischemia of the right upper limb. An extensive thrombosed aneurysm of the subclavian-axillary-brachial axis was identified. The treatment was carried out in two stages. In the first phase, urgent limb revascularization was performed using the great saphenous vein to perform a subclavian-brachial artery bypass. Later, the aneurysm was excluded using a vascular plug and multiple coils. Successful treatment was achieved with no morbidity for the patient., Conclusions: Although the gold standard for treating upper limb aneurysms is open surgery, endovascular techniques can be a significant adjunct, reducing treatment morbidity and even mortality.

Background: Retrospective evaluation of the safety and efficacy of the retrieval of misplaced central venous catheters (CVCs) in subclavian arteries using the femoral closure device Angio-Seal™., Methods: The clinical data of five patients (female, n  = 2; mean age, 55.0 years ± 11.9) in whom a misplaced CVC within a subclavian artery was removed followed by closure of the vessel entry site with 8-French (F) Angio-Seal™ was analyzed., Results: In 4/5 patients (80%; CVC diameter, 7-8F) the procedure was technically successful without complications. In 1/5 patients (20%; CVC diameter, 11.5F) the procedure failed and an additional covered stent was placed for successful closure of the vessel entry site. There were no complications associated with the Angio-Seal™ or stent implantation during follow-up., Conclusion: Retrieval of a misplaced CVC within a subclavian artery using the percutaneous closure device Angio-Seal™ is quite safe and effective; however, caution is required if there is a mismatch in the diameter of the Angio-Seal™ and CVC. In the case of procedure failure, successful closure of the vessel entry site can be achieved by covered stent placement.

Hybrid single-stage repair of Kommerell's diverticulum in a right aortic arch.Aortic arch anomalies, isolated or associated with congenital heart defects, are cardiovascular manifestations frequently associated with 22q11.2 deletion syndrome. Kommerell's diverticulum in the context of a right aortic arch is an exceedingly rare congenital anomaly, consisting in aneurysmal degeneration of the origin of an aberrant left subclavian artery. Open surgical repair has been the treatment paradigm, but in recent years, hybrid and endovascular procedures have also been proposed. In this report we present the case of a patient affected by 22q11.2 deletion syndrome successfully treated for Kommerell's diverticulum associated with a right-sided aortic arch through a single-stage hybrid procedure, consisting of bilateral carotid-subclavian bypass, exclusion of the diverticulum by an endovascular thoracic stent graft, and aberrant left subclavian artery plug occlusion. This type of hybrid technique can be an excellent alternative to extensive open surgical repairs or when total endovascular repair is deemed unachievable, also in the context of a complex genetic syndrome.

Mycotic subclavian aneurysms are rare, and their presence typically mandates urgent repair due to the associated high risk of rupture and mortality. A multi-disciplinary team effort is of utmost importance in ensuring favorable results. In this case report, we present a 79-year-old male with a rapidly enlarging mycotic left subclavian artery aneurysm secondary to a retrosternal abscess and left sternoclavicular septic arthritis, who underwent aneurysmal exclusion, a left carotid-left axillary bypass and pectoralis muscle flap coverage with a good outcome.

Background: Coarctation of the aorta (CoA) can either present alone as an isolated condition or in association with other aortic arch or cardiac anomalies. One percent of patients with CoA have concomitant an aberrant right subclavian artery (ARSA). Purpose: We report the case of a 35-year-old woman with uncontrolled hypertension who was found to have CoA and ARSA. Results: The patient was treated successfully using a hybrid procedure comprising ARSA ligation and subclavian to carotid transposition, followed by thoracic endovascular aortic repair. Conclusions: Patients with CoA should be carefully studied, considering the possible coexistence of other congenital aortic arch defects, such as ARSA. Hybrid repair is a safe and effective approach for this condition.

Purpose: The purpose of this study was to evaluate the association between the distance from the primary intimal tear (PIT) to the left subclavian artery (LSA) (PIT-LSA distance) and the risk of aortic enlargement after thoracic endovascular aortic repair (TEVAR)., Methods: This is a retrospective cohort study. A total of 228 patients were reviewed from the database of the Registry Of type B aortic dissection with the Utility of STent graft (ROBUST) study performed from January 1, 2011, to December 31, 2016. Of them, 196 patients were eligible for analysis. The PIT-LSA distance was defined as the length from the distal edge of the LSA orifice to the proximal edge of the PIT along the centerline of the true lumen. According to the border between zone 3 and zone 4 of the Ishimaru classification, patients were divided into group A (n = 117, PIT-LSA distance ≤ 2 cm) and group B (n = 79, PIT-LSA distance > 2 cm). Thoracic aortic enlargement (TAE) was defined as a thoracic aortic volume increase of ≥20%. Multivariate Cox regression was used to estimate the association between the PIT-LSA distance and risk of TAE after TEVAR., Results: The mean age was 52.3 ± 11.6 years, and 88.8% of patients were male. There were no significant differences between groups in demographic and baseline characteristics. The PIT-LSA distance was 1.1 cm (range, -1.6 to 2.0 cm) in group A, and 2.9 cm (range, 2.1-12.6 cm) in group B. TAE occurred in 27 patients in group A, and 6 in group B. The mean follow-up was 12.4 months (range, 0.10-83.1 months) in group A, and 12.63 months (range, 0.10-82.77 months) in group B. The cumulative 12- and 24-month rates of freedom from TAE were 79.0% and 71.3% in group A, versus 92.5% and 92.5% in group B, respectively. Multivariate Cox regression analysis revealed that the PIT-LSA distance was an independent predictor of TAE after TEVAR (adjusted hazard ratio, 0.66; 95% confidence interval, 0.48-0.90; p = 0.009)., Conclusion: Patients with a more proximal PIT location have a higher incidence of thoracic aortic enlargement after TEVAR. The location of the PIT in relation to the LSA can be used to identify patients who need closed surveillance after TEVAR or early preemptive intervention.

Here we present a 47-year-old male diagnosed with a pseudocoarctation of the aorta and a funnel-like subclavian artery aneurysm with a large orifice and severe aortic valve insufficiency. The patient underwent a two-stage repair for both pathologies. After an aortic valve replacement, postcardiotomy pericardial effusion occurred and was medically managed. Six months later, the patient underwent a distal arcus aorta and subclavian artery replacement with a left posterolateral thoracotomy as the second stage. Due to the strict adhesions, pulmonary veins were not cannulated and an extracorporeal bypass between the pulmonary artery and femoral artery was used for distal body perfusion. The coincidence of subclavian aneurysms and a pseudocoarctation of the aorta is rare and a literature review was performed to identify treatment options for this pathology.

In situ laser fenestration (ISLF) is currently used to reconstruct the aortic major branches during thoracic endovascular aortic repair (TEVAR). To our knowledge, there have been no reports on the application of ISLF for delayed revascularization of the LSA previously sealed in TEVAR. This report describes 5 patients who underwent ISLF for delayed LSA revascularization, with a technical success rate of 80%. No endoleakage occurred, and stents remained patent during more than 6-month follow-up. ISLF is an effective, safe and minimally invasive method for delayed revascularization of the LSA following TEVAR for type B aortic dissection (TBAD) when patients are selected appropriately.

The effects of increasing blood flow on the pathogenic wall shear stress (pWSS) of subclavian arteries (SAs) are currently unclear. Patient-specific models of the SA were constructed based on computed tomographic images from two patients. Using the Ansys Fluent 19.0 transient laminar flow solver, the finite volume method was chosen to solve the Navier-Stokes equation governing fluid behavior. The time-averaged wall shear stress, ratio of risk area, cumulative ratio of risk area ( P ¯ ), ratio of risk time, and ratio contour of risk time were calculated to describe the temporal and spatial distributions of pWSS. Virtually all pWSS occurred during the diastolic phase. The P ¯   was 2.3 and 1.29 times higher on the left than on the right in Patients 1 (P1) and 2 (P2), respectively. Increasing the blood flow volume of the left SA by 20%, 40%, and 60% led to a 9.27%, 15.10%, and 20.99% decrease in   P ¯ for P1 and a 5.74%, 11.55%, and 17.14% decrease in P ¯ for P2, respectively, compared with baseline values. In conclusion, the left SA showed greater diastolic pWSS than the right SA, and increasing the blood flow volume reduced the pWSS in the left SA.

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.

Purpose: Aberrant right subclavian artery (ARSA) associated with Kommerell's diverticulum (KD) is a common congenital arch anomaly. It can be complicated by type B aortic dissection (TBAD) or aneurysmal formation at its ostium. Recently, hybrid repair with thoracic endovascular aortic repair (TEVAR) has appeared to be more favorable. Due to the normal anatomic proximity of the ARSA to the left subclavian artery (LSA) orifice in KD, coverage of the bilateral subclavian arteries (SCAs) to obtain an adequate proximal landing zone (PLZ) is usually required, and double cervicotomy for SCA revascularization potentially increases the risk of complications., Technique: This technique was demonstrated on a 50-year-old man presenting with progressive aneurysmal formation of KD with ARSA after chronic TBAD. A 3-step technique, namely left cervical debranching with a left common carotid artery to LSA bypass graft, TEVAR, and an LSA-to-ARSA endovascular debranching with a self-expanding covered stent by a through-and-through wire from the right brachial artery to the bypass graft, was performed in a 1-stage repair to cover the primary tear of TBAD and preserve the bilateral SCAs. The postoperative course was uneventful., Conclusion: This technique can prevent complications from double cervicotomy and achieve an adequate PLZ with preservation of the bilateral SCAs for TEVAR.

Pseudocoarctation of the aorta is an uncommon congenital entity characterized by juxtaductal elongation and tortuosity of the aortic arch. It is known to be associated with aneurysm formation. Our patient is a 7.7-month-female infant followed prenatally by magnetic resonance imaging that detected this anomaly. Subsequently, postnatal preoperative computed tomography angiography was confirmatory. The operation comprised resection of the aneurysmal portion of the aorta and extended end-to-end reconstruction, without prosthesis usage. The left subclavian artery was reimplanted into the left carotid artery. The postoperative course was uneventful. Computed tomography aortography and transthoracic echocardiography demonstrated no residual stenosis at six months of follow-up.

Anomalous origin of the subclavian artery from the pulmonary artery is a rare but well-described entity. We report a case of anomalous origin of the left subclavian artery from the left pulmonary artery in a patient with transposition of the great arteries. We discuss the safe intraoperative management of this anomaly in a patient in whom the diagnosis was made intraoperatively.

Background: Adequate seal for thoracic endovascular aortic repair (TEVAR) commonly requires landing in zone 2, but can prove to be challenging due to the tortuous and angulated anatomy of the region., Objectives: Our objective was to determine the proximal landing accuracy of zone 2-targeted TEVARs following carotid-subclavian revascularization (CSR) and its impact on clinical outcomes., Methods: Retrospective review of patients that underwent CSR for zone 2 endograft delivery at a tertiary institute between January 2008 and March 2018 was conducted. Technical outcomes were assessed by examining the incidence of intraoperative corrective maneuvers, 1a endoleaks and reinterventions. Distance to target and incidence of LSA stump filling were examined as radiographic markers of landing accuracy., Results: Zone 2-targeted TEVAR with CSR was performed in 53 patients for treatment of dissections (49%), aneurysms (30%) or trauma (21%). Nine (17%) cases required intraoperative corrective procedures: 5 (9%) proximal cuffs due to type 1a endoleak and 4 (8%) left common carotid artery (LCCA) stenting due to inadvertent coverage. Cases performed using higher resolution hybrid fluoroscopy machine compared to mobile C-arm were associated with increased proximal cuff use (OR 8.8; 95% CI 1.2-62.4). Average distance between the proximal edge of the covered graft to LCCA was 8 ± 1 mm and larger distances were not associated with higher rates of 1a endoleak. Twenty-eight (53%) cases of antegrade LSA stump filling were noted on follow-up imaging, but were not associated with higher rates of reinterventions (OR 0.8, 95% CI [0.2-4.6]). Three (6%) patients had a stroke within 30 days and 4 (8%) patients expired within 1 month. Intraoperative corrective maneuvers, post-operative 1a endoleak and reinterventions were not associated with higher rates of stroke or mortality., Conclusion: Using current endografts and imaging modalities, zone 2-targeted TEVARs have suboptimal technical accuracy.

Introduction: Thoracic Endovascular Aortic Repair (TEVAR) has become the procedure of choice for pathology involving the descending thoracic aorta since its approval by the FDA in 2005. Left subclavian artery (LSA) coverage is commonly required to facilitate an adequate proximal landing zone for the endograft. The traditional revascularization procedure of choice is carotid-subclavian bypass, however recent studies report complication rates as high as 29%-specifically phrenic nerve palsy in 25% of patients undergoing this procedure. Our aim is to present our experience using carotid-axillary bypass as a safe alternative to carotid-subclavian bypass., Methods: All patients undergoing carotid-axillary bypass for TEVAR with LSA coverage between June 2016 and September 2019 at a tertiary medical center were retrospectively identified. Short-term and long-term complications were identified and analyzed including: phrenic nerve, recurrent laryngeal nerve, and axillary nerve injuries, as well as local vascular complications requiring re-intervention. All perioperative chest radiographs were reviewed for new hemidiaphragm elevation to assess for phrenic nerve injuries., Results: 35 patients underwent carotid-axillary bypass in conjunction with TEVAR during this time period. The majority of bypasses were performed concurrently with TEVAR (80.0%, 28/35) utilizing GORE PROPATEN 8 mm externally supported vascular graft (91.4%, 32/35). The complication rate specific to carotid-axillary bypass was 14.3% (5/35). We observed a significantly lower (0%, 0/35, P < 0.01) rate of phrenic nerve palsy for carotid-axillary bypass compared to the previously reported 25% (27/107) for carotid-subclavian bypass. For patients with available follow-up imaging (85.7%, 30/35), there was a 100% patency rate at time intervals ranging from 0-1066 days (IQR = 3-37.8)., Conclusion: Carotid-axillary bypass can be performed as a safe alternative to carotid-subclavian bypass for LSA coverage during TEVAR involving a more superficial anatomic course of dissection. Phrenic nerve palsy, a well-described complication of the traditional carotid-subclavian bypass, was not observed in this retrospective series.

The right subclavian artery (RSA) approach is an infrequently used alternative-access method for transcatheter aortic valve replacement (TAVR), which may be considered when transfemoral and left subclavian artery (LSA) access routes are contraindicated. The double arterial bend encountered along the course of the RSA to the aortic root makes advancement of the TAVR delivery system more challenging, but can be overcome using a steerable delivery system over an ultra-stiff guidewire. We report 5 cases from our institution of TAVRs performed via the RSA approach in patients with severe aortic stenosis that were unsuitable for transfemoral or LSA access. The procedures were performed under general anesthesia, using a 5-cm infraclavicular incision. In each case, an Edwards Commander Delivery System was advanced through an eSheath over an Innowi guidewire, and an Edwards SAPIEN 3 valve was successfully deployed. The mean fluoroscopy time was 19.5 ± 3.8 minutes. No aortic regurgitation (AR) was present postprocedure for 4 out of 5 cases, and 1 had mild to moderate AR. The length of hospital stay was 2 to 3 days for 4 patients. All patients had an excellent outcome at 12 months post-procedure. The RSA approach is a safe and feasible access method for TAVR, and we recommend that it be considered as the next best access method if transfemoral and LSA approaches are unsuitable.

Purpose: To evaluate the safety and feasibility of the in situ needle fenestration (ISNF) technique for reconstruction of the left subclavian artery (LSA) during thoracic endovascular aortic repair (TEVAR) of complicated aortic arch pathologies., Materials and Methods: A retrospective review was conducted from January 2014 to December 2019 of 50 patients (mean age 60.2±11.1; 45 men) who underwent ISNF to revascularize the LSA during TEVAR. Twenty-one of the patients also required revascularization of the left common carotid artery (LCCA; n=19) and innominate artery (IA; n=2) using physician-modified in vitro fenestration. Overall, 73 supra-aortic branches were targeted for revascularization., Results: ISNF was successful in 48 patients (96%); one LSA could not be stented and a tortuous LSA prevented the needle from fenestrating the graft. No perioperative major adverse event occurred. There were no type I and 4 type III endoleaks (8%), 3 of which occurred among the first 20 cases. Types II and IV endoleaks were found in 3 (6%) and 6 (12%) cases, respectively; all disappeared during a median follow-up of 15 months (range 3-66). One death (2%) occurred within 12 months due to cerebral hemorrhage. Two patients (4%) required open reinterventions at 6 and 62 months., Conclusion: ISNF for revascularization of the LSA during TEVAR seems to be feasible with acceptable midterm outcomes. The learning curve and evolving patient selection criteria affected technical success, complications, and the need for reinterventions. Long-term durability requires further evaluation.

The proximal segment of the vertebral artery most often consists of a persistent sixth cervical intersegmental artery that originates from the subclavian artery, but it may also derive from a fifth, fourth, or third cervical intersegmental artery (in decreasing order of frequency), or from a first thoracic intersegmental artery. The involvement of more cranial cervical branches is exceptional, with no known persistent first cervical intersegmental artery and possibly five cases of persistent second cervical intersegmental arteries reported so far. This report describes a patient with multiple arterial variations including right persistent second cervical intersegmental artery of common carotid origin, distal VA duplication, circumflex aortic arch, and segmental internal carotid agenesis in a context of possible PHACE syndrome.

Purpose: To evaluate the perioperative stroke incidence following thoracic endovascular aortic repair (TEVAR) with differing left subclavian artery (LSA) coverage and revascularization approaches in a real-world setting of a nationwide clinical registry. Materials and Methods: The National Surgical Quality Improvement Program registry was interrogated from 2005 to 2017 to identify all nonemergent TEVAR and/or open LSA revascularization procedures. In this time frame, 2346 TEVAR cases met the selection criteria for analysis. The 30-day stroke incidence was compared between patients undergoing TEVAR with (n=888) vs without (n=1458) LSA coverage, for those with (n=228) vs without (n=660) concomitant LSA revascularization among those with coverage, and following isolated LSA revascularization for occlusive disease (n=768). Multivariable logistic regression was employed for risk-adjusted analyses and to identify factors associated with stroke following TEVAR. Results of the regression analyses are presented as the adjusted odds ratio (OR) with 95% confidence interval (CI). Results: The stroke incidence was 2.3% following TEVAR without vs 5.2% with LSA coverage (p<0.001). In TEVARs with LSA coverage, the stroke incidence was 7.5% when the LSA was concomitantly revascularized and 4.4% without concomitant revascularization, while stroke occurred in 0.5% of isolated LSA revascularizations. Of 33 TEVAR patients experiencing a perioperative stroke, 8 (24%) died within 30 days. LSA coverage was associated with stroke both with concomitant revascularization (OR 4.0, 95% CI 2.2 to 7.5, p<0.001) and without concomitant revascularization (OR 2.2, 95% CI 1.3 to 3.8, p=0.002). Other preoperative factors associated with stroke were dyspnea (OR 1.8, 95% CI 1.1 to 3.0, p=0.014), renal dysfunction (OR 2.2, 95% CI 1.0 to 3.8, p=0.049), and international normalized ratio ≥2.0 (OR 3.6, 95% CI 1.0 to 13, p=0.045). Conclusion: Stroke following TEVAR with LSA coverage occurs frequently in the real-world setting, and concurrent LSA revascularization was not associated with a lower stroke incidence.

Objectives: Left subclavian artery (LSA) revascularization in thoracic endovascular aortic repair (TEVAR) remains controversial. Left subclavian artery coverage without revascularization can cause stroke and death. TEVAR has gained popularity for the treatment of chronic type B aortic dissection (cTBD). Using the Vascular Quality Initiative (VQI) database, we reviewed outcomes of LSA revascularization in TEVAR for cTBD., Methods: The VQI registry identified 5683 patients treated with TEVAR from July 2010 to July 2016, including 208 repairs for cTBD. We analyzed outcomes per the Society for Vascular Surgery reporting standards., Results: Of the 208 patients, 150 (72.1%) were male with a median age of 65.0 years (interquartile range [IQR], 55.0-72.0). Median aneurysm diameter was 5.7 cm (IQR, 5.0-6.5 cm). Data on the patency of the LSA was available in 131 (63.0%) patients. Twenty-five (19.1%) had occlusion of the LSA without revascularization, while 106 (80.9%) maintained patency or had revascularization. Successful device delivery occurred in all 131 (100%) patients. Maintaining LSA patency did not affect the rate of cerebrovascular accident ( P = .16), spinal cord ischemia ( P = 1.00), or death ( P = 1.00). This was also nonsignificant when analyzing the subgroup of 98 elective cases. There was no difference in the rates of endoleak. Any intervention for the LSA (revascularization or occlusion) led to a longer procedure time (203.6 minutes vs 163.7 minutes, P = .04)., Conclusions: Maintaining LSA patency during TEVAR for cTBD offers no advantage in perioperative morbidity or endoleak. Occlusion of LSA may be performed safely in this cohort and revascularization reserved for those who have anatomy that compromises perfusion to critical organs.

An aberrant right subclavian artery is a congenital aortic arch anomaly in which the right subclavian artery originates from the proximal descending aorta. The presence of an aberrant right subclavian artery can make right transradial coronary interventions more difficult and even lead to complications. Iatrogenic intramural hematomas and dissection of aberrant right subclavian arteries during transradial coronary angiography have been previously reported. We herein report a case of iatrogenic aortic dissection following attempts to perform right transradial coronary angiography in a patient with an aberrant right subclavian artery. Clinicians should be vigilant for the presence of an aberrant right subclavian artery during right transradial coronary angiography and ensure gentle manipulation of wires and catheters to avoid complications.

We present a rare case of a 10-cm right subclavian artery pseudoaneurysm, with slow growth over 4 years after a traumatic fracture of the right clavicle. The patient had multiple prior endovascular attempts of embolization and stenting at other hospitals; despite this the pseudoaneurysm continued to grow and caused mass effect and neurologic symptoms. We present our open approach for the repair and a review of literature.

A 24-year-old woman with a history of coarctation repair by subclavian flap aortoplasty presented at 15 weeks' gestation with transient episodes of vision loss. She was diagnosed with subclavian steal syndrome and underwent left carotid artery to subclavian artery bypass at 17 weeks' gestation. She has had no recurrence of symptoms at ten months of postoperative follow-up. Despite the anatomic substrate for subclavian steal in patients with this type of surgical repair, neurologic symptoms are uncommon. It is possible that the pregnancy-induced fall in systemic vascular resistance triggered symptoms in this previously asymptomatic patient.

A 57-year-old man, with a history of coarctation patch repair at three years of age, presented with left ventricular dilatation and moderate to severe dysfunction. A computed tomographic angiogram of the chest revealed moderate residual stenosis of the distal arch and proximal descending aorta and a large aneurysm adjacent to the origin of the left subclavian artery. Due to high surgical risk, a hybrid approach was undertaken with temporary balloon occlusion of the left subclavian artery, followed by surgical left common carotid to left subclavian artery graft and percutaneous covered stent implantation to relieve the obstruction and exclude the aneurysm.