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We retrospectively analyzed patient records of all patients with a history of internal mammarian artery (IMA) coronary bypass undergoing coronary angiography at two cardiovascular centers between January 1st 1999 and December 31st 2019. A total of 11,929 coronary angiographies with or without percutaneous coronary intervention were carried out in 3921 patients. Our analysis revealed 82 (2%) patients with documented subclavian artery stenosis. Of these, 8 (10%) patients were classified as having mild, 18 (22%) moderate, and 56 (68%) severe subclavian artery stenosis. In 7 (9%) patients with subclavian artery stenosis, angiography revealed occlusion of the IMA graft. 26 (32%) patients with severe subclavian artery stenosis underwent endovascular or surgical revasculararization of the subclavian artery. In this retrospective multicenter study, subclavian artery stenosis was a relevant finding in patients with an internal mammarian artery coronary bypass graft undergoing coronary angiography. The development of dedicated algorithms for screening and ischemia evaluation in affected individuals may improve treatment of this potentially underdiagnosed and undertreated condition., (© 2022. The Author(s).)

Background: This study aimed to evaluate the safety and efficacy of physician-modified endovascular graft for preservation of left subclavian artery during thoracic endovascular aortic repair., Methods: From June 2019 to October 2022, 66 patients with a variety of thoracic aortic pathologies were treated with thoracic endovascular aortic repair using physician-modified endovascular graft left subclavian artery fenestration to achieve adequate proximal landing zone. The details of surgical techniques were described. The perioperative morbidity, mortality, and the outcomes of mid-term follow-up were analyzed., Results: Of the 66 patients (men: women, 53:13; age, 55.18 [55.18 ± 10.62] years), 53 (80.30%) presented with type B aortic dissection, 10 (15.15%) with thoracic penetrating aortic ulcer, 2 (3.03%) with thoracic aortic aneurysm, and 1 (1.52%) with left subclavian artery aneurysm. All of them underwent thoracic endovascular aortic repair using physician-modified endovascular graft left subclavian artery fenestration on the sterile back table. The technique success rate was 96.97% (n = 64). Total operation time was 92 min (interquartile range, 86-118), graft modification time was 19 min (interquartile range, 17-21), fluoroscopy time was 49 min (interquartile range, 41-62), and contrast agent dosage was 165 mL (interquartile range, 155-185). 30-day perioperative morbidities were 3 (4.55%) strokes, 1 (1.52%) retrograde type A aortic dissection, 1 (1.52%) aortic intimal intussusception, 1 (1.52%) left arm ischemia, and 3 (4.55%) type Ia endoleaks. Postoperative 30-day mortality and reintervention rates were 1.52% and 4.55%, respectively. Among the 63 patients included in the follow-up of 17 months (interquartile range, 7.75-18.25), the primary patency of left subclavian artery fenestration stents was 100%. Late complications were 1 (1.59%) distal stent graft-induced new entry and 1 (1.59%) death due to retrograde type A aortic dissection during the follow-up. The stent graft-induced new entry patient was observed with stable false lumen., Conclusions: Thoracic endovascular aortic repair with physician-modified endovascular graft for left subclavian artery revascularization is a safe, feasible, and efficacious technique associated with high success rate. Further study is needed for long-term outcome investigation., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Aberrant subclavian artery (ASA) with or without Kommerell's diverticulum (KD) is a rare anatomic aortic arch anomaly that can cause dysphagia and/or life-threatening rupture. The objective of this study is to compare outcomes of ASA/KD repair in patients with a left versus right aortic arch., Methods: Using the Vascular Low Frequency Disease Consortium methodology, a retrospective review was performed of patients ≥18 years old with surgical treatment of ASA/KD from 2000 to 2020 at 20 institutions., Results: 288 patients with ASA with or without KD were identified; 222 left-sided aortic arch (LAA), and 66 right-sided aortic arch (RAA). Mean age at repair was younger in LAA 54 vs. 58 years (P = 0.06). Patients in RAA were more likely to undergo repair due to symptoms (72.7% vs. 55.9%, P = 0.01), and more likely to present with dysphagia (57.6% vs. 39.1%, P < 0.01). The hybrid open/endovascular approach was the most common repair type in both groups. Rates of intraoperative complications, death within 30 days, return to the operating room, symptom relief and endoleaks were not significantly different. For patients with symptom status follow-up data, in LAA, 61.7% had complete relief, 34.0% had partial relief and 4.3% had no change. In RAA, 60.7% had complete relief, 34.4% had partial relief and 4.9% had no change., Conclusions: In patients with ASA/KD, RAA patients were less common than LAA, presented more frequently with dysphagia, had symptoms as an indication for intervention, and underwent treatment at a younger age. Open, endovascular and hybrid repair approaches appear equally effective, regardless of arch laterality., (Copyright © 2023 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: Vascular rings may cause tracheal and/or oesophageal compression. For many patients, symptoms/signs have been present for a long period before diagnosis. However, in the era of prenatal diagnosis, some units advocate universal early surgery. The risks and efficacy of surgery must be known to adequately counsel for the operation. This meta-analysis sought to define the morbidity and mortality associated with surgical correction, and persistent post-operative symptoms., Methods: PubMed, Cochrane Library and CINAHL databases were searched for studies that described the outcome of patients undergoing surgery for a double or right aortic arch (DAA or RAA). Non-comparative and random effects model-based meta-analyses were conducted to calculate the pooled rates of mortality, surgical complications, reintervention, and persistent follow-up symptoms., Results: Nineteen eligible studies were included comprising 18 studies describing outcomes for DAA surgery and 15 for RAA surgery. For DAA surgery, overall mortality rate was 0% [95% confidence interval (CI) 0.0-1.0], post-surgical complication rate 18% [95% CI: 12.0-23.0], prevalence of reintervention 3% [95% CI: 1.0-5.0] and prevalence of symptoms at last follow-up was 33% [95% CI: 17.0-52.0]. For RAA surgery, overall pooled mortality was 0% [95% CI: 0.0-0.0], prevalence of post-surgical complications was 15% [95% CI: 8.0-23.0], reintervention rate was 2% [95% CI: 0.0-4.0], prevalence of symptoms at last follow-up was 40% [95% CI: 26.0-55.0]., Conclusions: While surgery to correct a vascular ring is safe, the rate of persistent symptoms is high and further strategies must be sought to reduce this burden., Competing Interests: Conflicts of interest None declared., (Copyright © 2023 Elsevier Inc. All rights reserved.)

A 64-year-old man was transferred to our hospital due to a diagnosis of Stanford type A acute aortic dissection complicated by cardiac tamponade. He was in shock status as well. Careful inspection of contrast- enhanced computed tomography revealed Kommerell's diverticulum with the aberrant right subclavian artery running behind the esophagus. The artery connected to the right axillary artery. The left vertebral artery was separately branched from the aortic arch. Primary entry was not detected on the preoperative computed tomography( CT). Left ventricular function was preserved by transthoracic echocardiography. At emergency surgery, total aortic arch replacement with reconstruction of the right axillary artery, both carotid arteries, and the left subclavian artery along with the left vertebral artery was successfully performed. The aberrant right subclavian artery was ligated at the origin. Kommerell' s diverticulum was completely excluded. Postoperative contrast-enhanced CT showed the patency of all reconstructed arteries. Although he suffered from acute cholecystitis and persistent bilateral pleural effusion, he was discharged in a good condition.

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.

A 59-year-old man was referred to our hospital for surgery for a dissecting aortic aneurysm with an aberrant right subclavian artery( ARSA). He had a history of surgery for atrial septal defect at the age of 3 and developed Stanford type B aortic dissection at the age of 53. The maximum diameter of the aortic aneurysm was 68 mm, and the entry was located close to the ARSA origin. We established cardiopulmonary bypass using the femoral artery and vein and performed a median re-sternotomy. We performed total arch replacement with the open stent-grafting technique. The ARSA was ligated from the right thoracic cavity. Three arch branches were reconstructed in situ, and the right axillary artery was bypassed with a 9 mm Dacron graft. Six months after that operation, reduction of the false lumen was observed. This strategy is considered to be effective for chronic aortic dissection with ARSA.

Background: We investigated the safety and feasibility of single branched endografts in the treatment of zone II thoracic endovascular aortic repair (TEVAR)., Methods: We performed a systematic research on Medline, Scopus and EMBASE for articles published up to February 2023. Primary end points included technical success, 30-day mortality, stroke and spinal cord injury (SCI) as well as unassisted left subclavian artery (LSA) branch patency by the end of follow-up. Secondary end points included early 30-day and persistent endoleaks, new onset dissection and reintervention by the end of follow-up., Results: Fourteen studies, three prospective case series and 11 retrospective case series comprised of 727 patients were finally included. The pooled technical success and 30-day mortality rates were 94.86 % (95% confidence interval (CI): 90.95-97.86) and 0.14% (95% CI: 0.00-0.87). The 30-day stroke and SCI rates were 0.45% (95% CI: 0.00-1.39) and 0.08% (95% CI: 0.00-0.99), respectively, while the unassisted LSA branch patency estimate was 99.12% (95% CI: 97.97-99.86). The early 30-day and persistent endoleak rates were 5.19% (95% CI: 2.45-8.65) and 2.57% (95% CI: 0.36-6.02), whereas new onset dissections and reinterventions estimates were 0.94% (95% CI: 0.17-2.11) and 2.40% (95% CI: 0.41-5.42)., Conclusions: While we have displayed the safety and feasibility of single branched endografts in the treatment of zone II thoracic aortic lesions, physicians should be aware of the persistency displayed by early type I endoleaks eventually requiring reintervention. The variations in device and lesion characteristics accompanied by the short-term follow-up presented in our review do not allow for definite conclusions to be drawn, necessitating further research through high-quality randomized controlled trials., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Subclavian artery aneurysms are rare lesions that usually require treatment for complications. Bidirectional stent-assisted coil embolization is the most effective treatment of complex wide-necked aneurysms. The stents provide a rigid scaffold that allows coil deposition with reduced risk of coil herniation into the parent vessel lumen. Bidirectional transradial and transfemoral approaches contribute to stable procedure. We report a successful bidirectional stent-assisted coil embolization of a saccular aneurysm of the subclavian artery as an alternative to stent graft implantation to diminish the risk of right vertebral artery occlusion. [ABSTRACT FROM AUTHOR]

Introduction: Percutaneous endovascular therapy is an accepted and preferred procedure for symptomatic subclavian artery disease. However, the technical feasibility and effectiveness of treating chronic total occlusion of the subclavian artery with this approach is uncertain. We aimed to evaluate the initial and mid-term results of endovascular therapy for patients with symptomatic chronic total occlusion of the left subclavian artery.Methods: Consecutive patients who underwent balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery between January 2010 and February 2014 were included.Results: Overall, 16 patients (10 male, 6 female; mean age 56 ± 13 years) underwent balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery. 6 (37.5%) had arm claudication, 8 (50.0%) had vertebrobasilar insufficiency and 2 (12.5%) had coronary steal. 18 balloon-expandable stents were implanted in 15 patients. Central luminal passage was not achieved in one patient because of the subintimal position of the guidewire (procedural success rate 93.8%). There were no procedure-related complications. Mean preprocedural and postprocedural systolic blood pressure differences between the upper extremities were 37 ± 13 (range 25-60) mmHg and 11 ± 9 (range 5-38) mmHg, respectively; the improvement was statistically significant. Outpatient follow-up revealed one asymptomatic restenosis at two years. The patency rate at two years was 93.3%.Conclusion: Balloon angioplasty and stenting for chronic total occlusion of the left subclavian artery is safe and effective, with good acute success rate and mid-term patency. Prospective randomised studies on larger patient populations would provide more precise results. [ABSTRACT FROM AUTHOR]

Background and purpose The thyrocervical trunk (TCT) is the second ascending branch of the subclavian artery. It is considered a 'border territory' between interventional vascular radiology and interventional neuroradiology because it gives rise to branches both cervical and to the upper limbs. We describe the TCT branches anatomy, the most frequent variants, and expose eight endovascular procedures performed through the thyrocervical trunk. Methods A retrospective review of all the interventional radiology procedures carried out through the TCT in our tertiary care center from August 2014 to January 2017 is presented. Results A total of eight endovascular procedures through the TCT including six preoperative embolizations: three paragangliomas, a cervical vertebral metastasis, a cervical vertebral aneurysmal bone cyst, and a very rare case of nerve root extradural cervical hemangioblastoma, as well as two emergency embolizations: a patient with a cervical traumatic active bleeding hematoma and a recurrent hemoptysis in a single ventricle patient. Conclusions A correct knowledge of the vascular anatomy, anatomical variants, and anastomosis (especially with the anterior spinal artery) of the TCT is essential for a safe embolization, both preoperatively and on an emergency basis. In cases of recurrent hemoptysis and severe lower-neck injuries, the TCT should always be reviewed. [ABSTRACT FROM AUTHOR]

Introduction: Mycotic pseudoaneurysm has traditionally been repaired surgically with excision of the infected artery and revascularization via extra-anatomical or in situ bypass. There have been reports of endovascular repair for high-risk patients for formal surgical repair. We present a case of a patient with 3 large pseudoaneurysms arising from the right subclavian artery, descending thoracic aorta, and right popliteal artery treated with endovascular and hybrid intervention. Case: A 74-year-old male with remote history of coronary artery bypass graft and recent sternoclavicular joint abscess developed 3 concurrent pseudoaneurysms arising from the right subclavian artery, distal descending thoracic aorta, and right popliteal artery. He underwent right axillary to common carotid bypass with endovascular stent graft placement in the distal innominate and proximal subclavian artery, and subsequently had thoracic endovascular aortic repair and right popliteal stent graft. Four months later, he presented with hemoptysis due to compression of the lung secondary to the pseudoaneurysm. He underwent right anterior thoracotomy and debridement of the pseudoaneurysm. Patient recovered from the procedure and discharged. Conclusion: Endovascular repair of mycotic pseudoaneurysm is an acceptable alternative for high-risk patients. Even when open approach became necessarily, endovascular stent graft decreased blood loss and morbidity. [ABSTRACT FROM AUTHOR]

A 58-year-old African American female, who had previously undergone a valve-sparing aortic root replacement for a type A dissection, represented 2 months later with a new focal dissection and aneurysm with intramural hematoma just distal to the origin of the left subclavian artery. Since no landing zone distal to the subclavian artery existed, the patient underwent thoracic endovascular aortic repair with laser fenestration-aided stent-graft placement in the left subclavian artery. The patient recovered without complication, and 52 months later, she is doing well with normal renal function and ambulatory status. [ABSTRACT FROM AUTHOR]

Aneurysms of the subclavian artery are rare phenomena that have the potential for limb and life-threatening complications. Delayed diagnosis increases the risk of life-threatening complications or at the very least may result in a detrimental effect to both functional capacity and quality of life; primary care offers a vital opportunity to screen for such rare vascular complications and should be a consideration in all patients with evolving peripheral nerve or vascular symptoms with a history of localized clavicular trauma. We present the case of a left subclavian artery aneurysm with radial artery thrombotic sequelae following an injury and screw-plate fixation of his left clavicle. This required a 2-stage surgical approach to treatment and provides useful learning considerations for identifying rare vascular anomalies early in a primary care setting. [ABSTRACT FROM AUTHOR]

Subclavian artery aneurysms (SAAs) are historically rare peripheral aneurysm. However, it can be associated with serious life-threatening complications including rupture, thrombosis, and embolism. The majority of such aneurysms are found incidentally. Historically, SAA have been repaired via an open approach. Increasing case reports demonstrate successful management of SAAs with endovascular repair. The present report describes a case of incidentally discovered large proximal saccular subclavian aneurysm with suspected remote traumatic etiology with a successful endovascular repair. [ABSTRACT FROM AUTHOR]

Purposes: To evaluate vertebral artery (VA) dominancy and the risk of brain infarction in T4 lung cancer patients with tumor invasion into the subclavian artery. Methods: We reconstructed the subclavian artery in 10 patients with T4 non-small cell lung cancer. The histological stages were IIIA in eight patients and IIIB in two patients. We evaluated the VA dominancy by performing a four-vessel study preoperatively and investigated the relationship between the methods of VA treatment and postoperative brain complications, retrospectively. Results: Seven patients had a superior sulcus tumor (SST) and three had direct invasion into the mediastinum. Based on the tumor location, a transmanublial approach was used in five patients and a posterolateral hook incision was used in the other five. All subclavian artery (SA) reconstructions were done using an artificial woven graft. Preoperative angiography of the VA revealed poor development of the contralateral side in two patients. One of these patients suffered a severe brain infarction on postoperative day 2, which proved fatal. In the other patient, the VA was connected to the left SA graft by a side-to-end anastomosis and there was no postoperative brain complication. Conclusions: Preoperative SA and VA angiography is mandatory for identifying the need for VA reconstruction in lung cancer patients with major arterial invasion. [ABSTRACT FROM AUTHOR]

Background: Within the trans-subclavian approach, procedural techniques can vary widely, and reported access generally refers to an infraclavicular axillary approach. We describe and report the use of a novel supraclavicular true subclavian approach for transcatheter aortic valve replacement (TAVR) exclusively for implantation of Sapien 3 valves.Case Presentation: We report our first five consecutive patients undergoing TAVR with a Sapien 3 valve using a standardized subclavian approach at a single center. In-hospital and 30-day complications were reported. The use of this approach resulted in successful implantation in 100% of patients in a safe manner with 0% mortality, stroke, and vascular injury during hospitalization and at 30 day follow-up. The in-hospital pacemaker implantation rate was 20%. The average length of stay was 3 days.Conclusions: TAVR with Sapien implant can be safely performed with a standardized supraclavicular subclavian approach in patients with unfavorable femoral access. [ABSTRACT FROM AUTHOR]

Abstract: Introduction: We have used Oki stents for a number of different indications. After discovering that there are limited reports in the literature on these stents, we were motivated to share our experiences in Oki stenting. Objectives: While there is vast knowledge on double Y‐stents, the Oki stent is a relatively recent development in pulmonology. Here, we demonstrate that stenting of the right secondary carina using an Oki stent should be considered for obstructions in this region. Methods: We placed 13 mm × 10 mm × 9 mm Oki stents in six patients under general anesthesia via rigid bronchoscopy. Results: Three cases were post‐transplant patients with malacia, stenosis, and bronchopleural fistula. One case had an airway obstruction due to malignant disease, another case had a right aortic arc and aberrant left subclavian artery anomaly, and the final case had bronchopleural fistula. No serious complications were observed during stent placement. Conclusions: Oki stents can safely be used for many clinical conditions. Patients benefit greatly from stenting; however, two of our cases died due to infection, and one case died due to malignancy. [ABSTRACT FROM AUTHOR]

OBJECTIVES: The aim of our prospective randomized study was to compare modified reverse aortoplasty (MRA) and extended end-to-end anastomosis (EEA). METHODS: We have assessed the operative correction results in 54 infants with coarctation of the aorta and distal aortic arch hypoplasia who underwent primary repair in our institute between July 2013 and February 2014. All of the patients were < 12 months old when they had the operation. Patients were randomly assigned to 2 arms: modified reverse subclavian flap angioplasty (MRA group; n = 27) or extended end-to-end anastomosis (EEA group; n = 27). RESULTS: We found a significant difference in residual arterial hypertension between the groups: 2 (7.7%) patients in the MRA group and 8 (30.8%) patients in the EEA group, respectively (P = 0.03). Risk factors for arterial hypertension were precoarctation area rigidity and endocardial fibroelastosis. During the last follow-up visit, recoarctation was observed in 1 (3.8%) patient in the MRA group and in 2 (7.7%) patients in the EEA group, respectively (P = 0.50). Cox regression analysis showed that the only risk factor for recoarctation was the patient’s low weight before surgery [odds ratio (95% confidence interval) 0.016 (0.001–0.51), P = 0.047]. An aortic aneurysm developed in 2 (7.7%) patients in the MRA group; however, no significant difference was found between the groups (P = 0.15). CONCLUSIONS: The results of surgical repair of coarctation of the aorta using modified reverse subclavian flap angioplasty and extended anastomosis were comparable in mortality rates and early postoperative complications. Nevertheless, MRA may be beneficial in reducing residual arterial hypertension at the mid-term follow-up visit. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To report the early results of castor device, a kind of unibody single-branched stent graft, in the treatment of type B aortic dissection (TBAD) involving the LSA.Methods: From April 2013 to February 2014, 21 patients with TBADs underwent TEVAR with LSA revascularization by unibody single-branched stent grafts. Three patients with penetrating aortic ulcers in the aortic arch received additional reconstruction of left common carotid artery with chimney technique. Follow-up evaluations were conducted with computed tomography angiography (CTA) at 6, 12 months and annually after that.Results: All of the proximal entry tears were completely excluded. Good patency of the grafts was found in all cases. A small type I endoleak occurred in one patient during the procedure. Perioperative mortality is null, and there was no occurrence of serious complications. All patients completed the follow-up except one lost contact after discharge. One death occurred within 6 months after the operation, resulting from myocardial infarction, considered unrelated to the stent implantation. No endoleak occurred during follow-up. One compression of a chimney stent and one twist of side branch graft of castor were observed in 2 different patients, respectively. In other cases, CTA scans showed good patency of both the branched and chimney grafts. Two patients had partial thrombosis of the false lumen during follow-up. In other patients, complete thrombosis in the false lumen in thoracic aorta was revealed.Conclusion: The single-branched stent graft was safe and efficient in the 1-year follow-up. Further studies are required to determine its long-term outcomes. [ABSTRACT FROM AUTHOR]

The objective of this study is to describe the contemporary management of proximal upper extremity and neck arterial injuries by comparing open and endovascular repair at a single institution. This is a retrospective study of 22 patients that sustained subclavian, axillary, and carotid artery injuries from 2011 to 2016 that were managed with open or endovascular repair. There were nine subclavian, eight axillary, and five carotid artery injuries of which 10 (45.5%) underwent endovascular repair and 12 (54.5%) underwent open repair. There was no statistically significant difference between the groups including injury severity score or preoperative hypotension. There were no deaths in the endovascular group, and three (25.0%) deaths in the open group. All patients in the endovascular group were discharged home. In the open group, seven (58.3%) patients had at least one inpatient complication with a mean of 1.1 (standard deviation 1.4) complications per patient. In the endovascular group, there were three (30.0%) patients with inpatient complications and a mean of 0.4 (standard deviation 0.7) complications per patient (P = 0.18). Endovascular management of nonaortic cervicothoracic arterial injuries was successfully performed in hypotensive patients and patients with other life threatening traumatic injuries. Further studies are warranted to look at long-term patency of these repairs and to help develop a protocol to guide decision-making in the management of cervicothoracic injuries. [ABSTRACT FROM AUTHOR]

Background Left aberrant subclavian artery (LASA), is a type of right aortic arch (RAA) branching, which takes-off distally to the right subclavian artery and usually crosses behind the esophagus to the left upper limb. Taking into account the rarity of RAA, LASA is much more rarely seen than the right aberrant subclavian artery (RASA) originating from the left aortic arch. However, RAA may be associated with much more frequent presence of LASA, than left aortic arch with RASA. Anatomical LASA characteristics were not described up to date. Methods Individual patient records filed in the electronic database from a single high-volume tertiary cardiac center were retrospectively screened for the presence of RAA in the consecutive patients who underwent chest computed tomography from 2008 to 2016. Results 14 patients with LASA were identified. Only 3 were free of coexisting intra- or extra-cardiac anomalies. The most common defect was tetralogy of Fallot (3 patients). One patient had five congenital defects. Kommerell's diverticulum (KD) was present in 9 patients. In all patients the LASA course was retrotracheal and retroesophageal. In all but one patients esophageal modelling or compression by KD or LASA was present. Conclusions Knowledge of Kommerell's diverticulum presence and morphology as well as the LASA course during preinterventional work-up of patients with congenital heart defects is critical, since it may have surgical implications during corrective procedures. [ABSTRACT FROM AUTHOR]

Introduction: Vertebrobasilar territory ischemia leads to disabling neurological symptoms and may be caused both by vertebral artery (VA) and subclavian artery (SA) stenosis. The coexisting symptomatic ipsilateral VA and proximal SA stenosis should be considered as a true bifurcation lesion for percutaneous treatment. Aim: To evaluate the safety and efficacy of simultaneous angioplasty of vertebral and subclavian stenosis. Material and methods: Fifteen patients (age 69.5 years, 46.7% men, all symptomatic from posterior circulation (history of stroke, transient ischemic attack, chronic ischemia symptoms)) were scheduled for simultaneous SA/VA angioplasty. Clinical and duplex ultrasound follow-up was conducted 1, 6 and 12 months after the procedure. Results: The technical success rate was 100%. Single balloon-mounted stent angioplasty was performed for all VAs and for 13 (86.7%) SAs. In 4 cases a simultaneous radial and femoral approach was required. The mean North American Symptomatic Carotid Endarterectomy Trial (NASCET) VA stenosis was reduced from 88.7 ±9.7% to 5.7 ±6.8% and SA stenosis from 80 ±12.2% to 11 ±12.3% (p < 0.01). No periprocedural death, stroke, myocardial infarction or transient ischemic attack occurred. During follow-up (range: 6-107 months) in 10 of 15 (66.7%) patients relief of chronic ischemic symptoms was observed. No stroke/TIA occurred. One cardiovascular and 2 non-cardiovascular deaths were recorded. There was 1 symptomatic vertebral and 1 subclavian in-stent restenosis, and 2 cases of asymptomatic VA in-stent occlusion occurred. Conclusions: Simultaneous vertebral and subclavian artery stenting is safe and effective. The restenosis rate remains at an acceptable level and it may be treated successfully with drug-eluting balloon angioplasty. In selected patients a dual radial and femoral approach may facilitate the procedure. [ABSTRACT FROM AUTHOR]

Background Optimal management of complicated chronic type B dissection with involvement of the distal aortic arch is controversial. Late complications related to thoracic endovascular aortic repair (TEVAR) are much more common than those using open aortic surgery. We reviewed our experience of left subclavian artery (LSCA) transposition with implantation of a stented elephant trunk for complicated chronic type B dissection with involvement of the distal aortic arch. Materials and Methods From January 2011 to June 2015, 20 patients with complicated chronic type B dissection with involvement of the distal aortic arch underwent LSCA transposition with implantation of a stented elephant trunk via a median sternotomy under hypothermic cardiopulmonary bypass with selective antegrade cerebral perfusion (SACP). Preoperative renal dysfunction was observed in three patients, left heart failure in one patient, and spinal cord ischemia in one patient. Results There was one (5.0%, 1/20) in-hospital death. All but one patient required mechanical ventilation for < 24 hours. Mean duration of mechanical ventilation and mean duration of stay in the intensive care unit was 16 ± 4 and 35 ± 16 hours, respectively. No severe complications occurred. There was one death because of unknown cause during follow-up. One case received thoracoabdominal aortic replacement 9 months after surgery. Conclusion Acceptable surgical outcomes were obtained using LSCA transposition with implantation of a stented elephant trunk. This method is an alternative to TEVAR for complicated chronic type B dissection with involvement of the distal aortic arch. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Vertebral artery variations are common in thoracic aortic patients. If patients have the aberrant left vertebral artery, the more difficult to determine the treatment modality.Case Presentation: We report the case of a 63-year-old man with an aberrant left vertebral artery originating from an aneurysmal aortic arch. The patient underwent a successful hybrid thoracic endovascular aortic repair after aortic arch debranching and transposition of the aberrant left vertebral artery to the left common carotid artery through a supraclavicular incision without sternotomy.Conclusions: The aberrant left vertebral artery originating from the aortic arch can be safely transposed to the left common carotid artery through a supraclavicular approach. [ABSTRACT FROM AUTHOR]

We present an unusual case of ruptured subclavian artery pseudoaneurysm following hydrotherapy and shoulder massage session on a background of clavicle non-union.Following a clavicle fracture 16 years ago, which was managed conservatively, a woman in her 30s presents over a decade later with a ruptured subclavian artery pseudoaneurysm.The original midshaft clavicle fracture was sustained 16 years ago. Conservative management was agreed, and she was discharged. Six years ago, she developed a small subclavian artery pseudoaneurysm which was kept under surveillance for 12 months with no active intervention required.Over the following years, she continued to have intermittent shoulder girdle discomfort and neuropathic symptoms. On this presentation, after a sports massage, she presented with rapid-onset supraclavicular and axillary swelling. This was diagnosed as a ruptured subclavian artery pseudoaneurysm and was treated with emergency radiological-guided stenting and subsequent internal fixation of the clavicle non-union.The patient then attended regular orthopaedic and vascular follow-up to ensure her clavicle fracture unites and the graft remains patent.We discuss the case presentation and management of this unusual injury., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Various surgical treatments are available for occlusive subclavian and common carotid artery diseases. Nevertheless, to date, when cerebral endovascular treatment is utilized, revascularization via direct surgery may be required. This study reported five symptomatic cases of revascularization for CCA and SCA occlusive and stenotic lesions that were expected to be challenging to treat with endovascular treatment. We performed subclavian artery-common carotid artery or internal carotid artery bypass using artificial blood vessels or saphenous vein grafts in five patients with subclavian steal syndrome, symptomatic common carotid artery occlusion, and severe proximal common carotid artery stenosis. In this study, good bypass patency was achieved in all five cases. Although there were no intraoperative complications, one patient had a postoperative lymphatic leak. Moreover, there was no recurrence of stroke during postoperative follow-up for an average of 2 years. Conclusively, subclavian artery-common carotid artery bypass can be an effective surgical treatment for common carotid artery occlusion, proximal common carotid artery stenosis, and subclavian artery occlusion.

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.

Vascular complications are relatively rare following surgical fixation of midshaft clavicle fractures. Here, we report a case of a woman in her 30s presenting 10 years after right clavicular open reduction and internal fixation with revision 6 years prior with sudden and rapidly progressive neck swelling. Physical examination revealed a soft pulsating mass in her right supraclavicular fossa. Ultrasound and CT angiography of the head and neck showed a pseudoaneurysm of her right subclavian artery with a surrounding haematoma. She was admitted to the vascular surgery team for endovascular repair with stenting. Postoperatively, she developed arterial thrombi requiring thrombectomy (twice) and is now on lifelong anticoagulation. It is crucial to be aware of complications that can develop in patients with a history of clavicular fracture managed non-operatively or operatively even years later and highlights the importance of risk and benefit discussions and counselling., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Aberrant subclavian artery (ASA) and Kommerell's diverticulum (KD) are rare vascular anomalies that may be associated with lifestyle-limiting and life-threatening complications. The aim of this study is to report contemporary outcomes after invasive treatment of ASA/KD using a large international dataset., Methods: Patients who underwent treatment for ASA/KD (2000-2020) were identified through the Vascular Low Frequency Disease Consortium, a multi-institutional collaboration to investigate uncommon vascular disorders. We report the early and mid-term clinical outcomes including stroke and mortality, technical success, and other operative outcomes including reintervention rates, patency, and endoleak., Results: Overall, 285 patients were identified during the study period. The mean patient age was 57 years; 47% were female and 68% presented with symptoms. A right-sided arch was present in 23%. The mean KD diameter was 47.4 mm (range, 13.0-108.0 mm). The most common indication for treatment was symptoms (59%), followed by aneurysm size (38%). The most common symptom reported was dysphagia (44%). A ruptured KD was treated in 4.2% of cases, with a mean diameter of 43.9 mm (range, 18.0-100.0 mm). An open procedure was performed in 101 cases (36%); the most common approach was ASA ligation with subclavian transposition. An endovascular or hybrid approach was performed in 184 patients (64%); the most common approach was thoracic endograft and carotid-subclavian bypass. A staged operative strategy was employed more often than single setting repair (55% vs 45%). Compared with endovascular or hybrid approach, those in the open procedure group were more likely to be younger (49 years vs 61 years; P < .0001), female (64% vs 36%; P < .0001), and symptomatic (85% vs 59%; P < .0001). Complete or partial symptomatic relief at 1 year after intervention was 82.6%. There was no association between modality of treatment and symptom relief (open 87.2% vs endovascular or hybrid approach 78.9%; P = .13). After the intervention, 11 subclavian occlusions (4.5%) occurred; 3 were successfully thrombectomized resulting in a primary and secondary patency of 95% and 96%, respectively, at a median follow-up of 39 months. Among the 33 reinterventions (12%), the majority were performed for endoleak (36%), and more reinterventions occurred in the endovascular or hybrid approach than open procedure group (15% vs 6%; P = .02). The overall survival rate was 87.3% at a median follow-up of 41 months. The 30-day stroke and death rates were 4.2% and 4.9%, respectively. Urgent or emergent presentation was independently associated with increased risk of 30-day mortality (odds ratio [OR], 19.8; 95% confidence interval [CI], 3.3-116.6), overall mortality (OR, 3.6; 95% CI, 1.2-11.2) and intraoperative complications (OR, 8.3; 95% CI, 2.8-25.1). Females had a higher risk of reintervention (OR, 2.6; 95% CI, 1.0-6.5). At an aneurysm size of 44.4 mm, receiver operator characteristic curve analysis suggested that 60% of patients would have symptoms., Conclusions: Treatment of ASA/KD can be performed safely with low rates of mortality, stroke and reintervention and high rates of symptomatic relief, regardless of the repair strategy. Symptomatic and urgent operations were associated with worse outcomes in general, and female gender was associated with a higher likelihood of reintervention. Given the worse overall outcomes when symptomatic and the inherent risk of rupture, consideration of repair at 40 mm is reasonable in most patients. ASA/KD can be repaired in asymptomatic patients with excellent outcomes and young healthy patients may be considered better candidates for open approaches versus endovascular or hybrid modalities, given the lower likelihood of reintervention and lower early mortality rate., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

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 45-year-old man complaining of chest and back pain due to acute aortic dissection was referred to our department. A contrast enhanced computed tomography( CT) scan showed Stanford type B aortic dissection with Kommerell diverticulum and aberrant right subclavian artery. The patient underwent antihypertensive treatment for one month. Despite the successful treatment, CT scan revealed a 5 mm false lumen dilatation in this period. We decided to close the primary entry. The operation was performed through median sternotomy;after establishing cardio-pulmonary bypass, the ostium of the aberrant right subclavian artery( ARSA) was sutured closed and anastomosed the ARSA and right common carotid artery. Total arch replacement was performed using frozen elephant trunk technique. His postoperative course was uneventful.

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.

Rationale and Objectives: Noninvasive diagnostic imaging of subclavian artery (SCA) and internal thoracic artery (ITA) is crucial to the patients planning to use ITA for coronary artery bypass grafting (CABG). The guidelines have not yet provided guidance on screening high-risk groups. The present study aimed to evaluate the contribution of ultrasonography in the assessment of SCA and ITA, especially for the patients referred for CABG who planned to use ITA graft., Materials and Methods: Patients diagnosed with multivessel coronary heart disease were enrolled and some of them planned CABG. Bilateral SCAs and ITAs were routinely evaluated by color Doppler ultrasound (CDUS) before operation. The luminal diameter and the peak systolic velocity of the proximal and distal parts of SCA and ITA were measured. Depending on the Doppler waveform, the lumen narrowing rate was calculated., Results: The final analysis was carried out in 572 patients. Thirty-five patients had moderate (50%-69%), severe (70%-99%) stenosis or occlusion in the SCA (left-sided in 21 and right-sided in 14). One patient had severe proximal stenosis in left ITA and one patient had no flow in left ITA due to the occlusion in left SCA. One patient had anatomic variation of isolated right aortic arch with aberrant left SCA. All of those cases were confirmed with multidetector computed tomography angiography., Conclusion: CDUS could be used for the evaluation of SCA and ITA before CABG as part of presurgical vascular assessment and provide an import basis for the imaging diagnosis and surgical plan., (Copyright © 2022 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved.)

Objective: Thoracic endovascular aortic repair (TEVAR) has been the favored approach for the treatment of type B aortic dissection (TBAD). To obtain an adequate proximal landing zone, coverage of the left subclavian artery (LSA) will often be necessary. The occurrence of possible neurologic complications has continued to be debated. We investigated the management of the LSA in patients with TBAD undergoing endovascular repair., Methods: We searched the PubMed and MEDLINE databases to October 2020 for studies of TEVAR for TBAD. Data on the study design, demographics, endograft details, LSA coverage and revascularization, mortality, complications, and follow-up were extracted and analyzed. The effects of LSA coverage and revascularization on neurologic complications and outcomes were investigated., Results: A total of 26 reports (24 retrospective and 2 prospective) were deemed eligible for our study. A total of 1483 patients (mean age, 56.9 ± 6.2 years) had undergone TEVAR for acute (n = 932; 62.9%), subacute (n = 36; 2.4%), or chronic (n = 515; 34.7%) TBAD, with a success rate of 97.8% and hospital mortality of 4.9%. The LSA origin had been covered for 707 patients (47.7%), and 326 had undergone LSA revascularization (surgical, n = 96; endovascular, n = 170; unspecified or not reported, n = 60). LSA revascularization was concomitant for 68.1% of cases, after TEVAR for 1.8%, and not reported for 30.1%. Of 1146 patients, 10 (0.9%) had experienced left arm claudication, and the overall stroke rate was 3.3% (2.7% for the LSA group and 1% for the uncovered LSA group; P = .0815). Of the patients with stroke and a covered LSA, 1% (2 of 203) had undergone LSA revascularization and 4.8% (5 of 105) had not (P = .0478). Twenty-six patients (1.9%) had developed paraplegia: 0.7% (3 of 433) with a covered LSA, 1.4% (7 of 491) with an uncovered LSA (P = .3508), and not reported for 16 patients. Endoleak was present in 138 patients (13.4%) at a mean follow-up of 32.1 ± 25.6 months., Conclusions: Our review has shown that LSA coverage during endovascular repair for complicated TBAD will does not significantly increase the risk of neurologic complications; however, revascularization of the LSA should be always recommended., (Copyright © 2022. Published by Elsevier Inc.)

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

Kommerell diverticulum (KD) with aberrant left subclavian artery (ALSA) is a rare congenital variation of vascular structure. We reported a case of 3‐year‐old boy with KD and ALSA, which was preliminarily diagnosed by transthoracic echocardiography and verified by computed tomography angiography (CTA). The patient was treated successfully with KD resection and anastomosed the left subclavian artery directly to the left carotid artery under cardiopulmonary bypass. Our case illustrates that echocardiography and CTA should be used to comprehensively assess all the internal and external cardiac structures in order to determine the appropriate surgical plan. [ABSTRACT FROM AUTHOR]

Purpose: Whether to proceed left subclavian artery (LSA) revascularization in patients with LSA coverage due to insufficient proximal landing zone (PLZ) during thoracic endovascular aortic repair (TEVAR) remains controversial., Methods: A total of 903 patients who received TEVAR were retrospectively analyzed. LSA could be covered if the PLZ was less than 15 mm accompanied with 1) a dominant or balanced right vertebral artery, 2) a complete circle of Willis, and 3) a left vertebral artery with a diameter ≥3 mm and without severe stenosis., Results: LSA selective coverage was necessary for 35.0% (316/903) of the patients to extend the PLZ. Patients presented with weakness, pain, cooling and discoloration of the left upper extremity (LUE), and pulselessness of the left brachial artery were more in the LSA-covered group. The ischemia of LUE occurred more often in patients with LSA covered completely than in those with LSA covered partially. Functional arm status showed no significant difference in the arm, shoulder, and hand questionnaire scores at 12 months postoperative between the LSA-covered group and LSA-uncovered group, or between the LSA-covered completely group and LSA-covered partially group., Conclusion: It was safe to cover the LSA origin without revascularization if the PLZ was less than 15 mm accompanied with careful evaluation (description in method).

Objective: Aberrant subclavian arteries (aSCAs), with or without aortic pathology, are uncommon. The purpose of the present study was to review our experience with the surgical management of aSCA., Methods: We performed a retrospective review of patients who had undergone surgery for an aSCA between 1996 and 2020. Symptomatic and asymptomatic patients were included. The primary end points were ≤30-day and late mortality. The secondary end points were ≤30-day complications, graft patency, and reinterventions., Results: A total of 46 symptomatic and 3 asymptomatic patients with aSCA had undergone surgery (31 females [62%]; median age, 45 years). An aberrant right subclavian artery was present in 38 (78%) and an aberrant left subclavian artery in 11 patients (22%). Of the 49 patients, 41 (84%) had had a Kommerell diverticulum (KD) and 11 (22%) had had a concomitant distal arch or proximal descending thoracic aortic aneurysm. Symptoms included dysphagia (56%), dyspnea (27%), odynophagia (20%), and upper extremity exertional fatigue (16%). Five patients (10%) had required emergency surgery. The aSCA had been treated by transposition in 32, a carotid to subclavian bypass in 11, and an ascending aorta to subclavian bypass in 6. The KD was treated by resection and oversewing in 19 patients (39%). Fifteen patients (31%) had required distal arch or proximal descending thoracic aortic replacement for concomitant aortic disease and/or KD treatment. Thoracic endovascular aortic repair was used to exclude the KD in six patients (12%). Seven patients (14%) had undergone only bypass or transposition. The 30-day complications included one death from pulseless electrical activity arrest secondary to massive pulmonary embolism. The 30-day major complications (14%) included acute respiratory failure in three, early mortality in one, stroke in one, non-ST-elevation myocardial infarction in one, and temporary dialysis in one patient. The other complications included chylothorax/lymphocele (n = 5; 10%), acute kidney injury (n = 2; 4%), pneumonia (n = 2; 4%), wound infection (n = 2; 4%), atrial fibrillation (n = 2; 4%), Horner syndrome (n = 2; 4%), lower extremity acute limb ischemia (n = 1; 2%), and left recurrent laryngeal nerve injury (n = 1; 2%). At a median follow-up of 53 months (range, 1-230 months), 40 patients (82%) had had complete symptom relief and 9 (18%) had experienced improvement. Six patients had died at a median of 157 months; the deaths were not procedure or aortic related. The primary patency was 98%. Reintervention at ≤30 days had been required for two patients (4%) for ligation of lymphatic vessels and bilateral lower extremity fasciotomy after proximal descending thoracic aorta replacement. One patient had required late explantation of an infected and occluded carotid to subclavian bypass graft, which was treated by cryopreserved allograft replacement., Conclusions: Surgical treatment of the aSCA can be accomplished with low major morbidity and mortality with excellent primary patency and symptom relief., (Copyright © 2022 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Children born with congenital heart defects typically undergo staged palliative surgeries to reconstruct the circulation to improve transport of deoxygenated blood to the lungs. As part of the first surgery, a temporary shunt (Blalock-Thomas-Taussig) is often created in neonates to connect a systemic and a pulmonary artery. Standard-of-care shunts are synthetic, which can lead to thrombosis, and much stiffer than the two host vessels, which can cause adverse mechanobiological responses. Moreover, the neonatal vasculature can undergo significant changes in size and structure over a short period, thus constraining the use of a non-growing synthetic shunt. Recent studies suggest that autologous umbilical vessels could serve as improved shunts, but there has not been a detailed biomechanical characterization of the four primary vessels - subclavian artery, pulmonary artery, umbilical vein, and umbilical artery. Herein, we biomechanically phenotype umbilical veins and arteries from prenatal mice (E18.5) and compare them to subclavian and pulmonary arteries harvested at two critical postnatal developmental ages (P10, P21). Comparisons include age-specific physiological conditions and simulated 'surgical-like' shunt conditions. Results suggest that the intact umbilical vein is a better choice as a shunt than the umbilical artery due to concerns with lumen closure and constriction related intramural damage in the latter. Yet, decellularization of umbilical arteries may be a viable alternative, with the possibility of host cellular infiltration and subsequent remodeling. Given recent efforts using autologous umbilical vessels as Blalock-Thomas-Taussig shunts in a clinical trial, our findings highlight aspects of the associated biomechanics that deserve further investigation., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: For descending thoracic aortic aneurysms (TAA) in proximity of the aortic arch, debranching of the left subclavian artery (LSA) may be necessary to extend proximal sealing in zone 2. The aim of this study was to determine the added proximal apposition length gained from LSA debranching during thoracic endovascular aortic repair (TEVAR)., Methods: This multicenter retrospective study (2010-2020) included patients who underwent elective TEVAR in zone 2 for a degenerative TAA where the LSA was surgically debranched. The endograft position on the first postoperative computed tomography angiography (CTA) scan was assessed using post-processing software. The analysis included the shortest apposition length (SAL), the tilt of the proximal edge of the endograft, and the distance between the endograft and the left common carotid artery. Clinical endpoints (neurological complications and endoleaks) at 30 days were also reported., Results: Twenty-two patients were included. The median interval between TEVAR and the first postoperative CTA was 3 days (2-10 days). Median SAL was 9.2 mm (1.3-26.4 mm), of which 8.6 mm (1.3-16.2 mm) was gained proximal of the LSA, including the LSA orifice. In 12 patients (55.5%) the SAL was <10 mm. The median tilt was 18.3° (13.9°-22.2°). Seven endoleaks were reported on the first CTA: 1 type Ia, 2 type Ib, 3 type II, and 1 type III., Conclusions: Debranching the LSA adds valuable sealing length in zone 2, but the SAL was still relatively short in many patients, putting these patients at risk for a future type Ia endoleak. Accurate assessment of the circumferential apposition on postoperative CTA follow-up in these high-risk patients with short, complex landing zones seems mandatory. Evaluation of apposition in a larger population with longer follow-up is advised.

The management of a rare midclavicular crossbow bolt injury to the subclavian artery is discussed. Important concepts include the initial clinical diagnosis, operative planning, the surgical approach to the retro-clavicular great vessels, the technical aspects of repair, and postoperative course. A discussion of the reasoning behind an operative vs. endovascular approach is also discussed.

Background: Kommerell's aneurysm is a saccular or fusiform dilatation found in 3-8% of Kommerell's diverticulum cases. A non-dissecting rupture rate of 6% has been reported. If ruptured, emergent surgical correction is usually granted. However, evidence regarding the optimal surgical approach in this acute setting is scarce. In this case report series, we aim to describe our experience managing type-1 non-dissecting ruptured Kommerell's aneurysm with hybrid emergent surgical approaches., Cases Presentation: From January 2005 to December 2020, three cases of type-1 non-dissecting ruptured Kommerell's aneurysm requiring emergent surgical repair were identified. The mean age was 66.67 ± 7.76 years, and 3/3 were male. The most common symptoms were atypical chest pain, dyspnoea, and headache (2/3). The mean aneurysm's diameter was 63.67 ± 5.69 mm. Frozen Elephant Trunk was the preferred surgical approach (2/3). The Non-Frozen Elephant Trunk patient underwent a hybrid procedure consisting of a supra-aortic debranching and a zone-2 stent-graft deployment. We found a mean clamp time of 140 ± 60.75 min, cardiac arrest time of 51.33 ± 3.06 min, and a hospital stay of 13.67 ± 5.51 days. The most common complications were surgical-site infection and shock (2/3). Only one patient died (1/3)., Conclusion: Evidence of management for non-dissecting ruptured Kommerell's aneurysms is scarce. Additional, robust, and more extensive studies are required. The selection of the appropriate surgical approach is challenging, and each patient should be individualized. Frozen Elephant Trunk was feasible for patients requiring emergent surgical repair in our centre. However, other hybrid or open procedures can be performed., (© 2023. The Author(s).)

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.

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.