Common brachiocephalic trunk: strategies for revascularization

Arch branch endografts for arch aneurysms associated with bovine anomaly

Bovine aortic arch is known to be associated with an increased rate of aortic arch expansion. The most frequently observed human variant of bovine aortic arch is a common origin of the innominate trunk and left common carotid artery. This is a report of two patients who had successful custom-made arch branch endograft treatment for an arch aneurysm associated with bovine arch anomaly. Modular endovascular repair of aortic arch aneurysms using an inner-branched device adds to the armamentarium of treatment options, and is a minimally invasive management modality without the need for sternotomy or intraoperative extracorporeal bypass.

A cadaveric study of aortic arch variation in an Irish population

AIM

The aim of this study is to investigate the incidence of variation in the branching pattern of aortic arch (AA) vessels in an Irish population.

METHOD

A cadaveric study of 24 subjects was conducted. The vessels of the AA were identified, their branching patterns were noted and photographed and the following measurements were recorded: the angle of the AA to the coronal plane, the distance from the midline to the brachiocephalic trunk (BCT); the left common carotid artery (LCC) ; the left subclavian artery (LSC), the distance between the BCT and the right subclavian artery (RSC); the RSC and the right vertebral artery (RVA), and between the LSC and left vertebral artery (LVA).

RESULTS

The 'normal' branching pattern (BCT, LCC, LSC) was observed in 79%. Thirteen percent had a two-branched AA (bovine variant), while the remainder had an aberrant left vertebral artery (LVA) originating from the AA. The mean distances from the midline to the BCT, LCC and LSC were 9.1, 10.8 and 21.4 mm, respectively. Mean distance from BCT to RSC was 34.09 mm. The mean distance from LSC to LVA was 39.79 mm, and the mean distance from RSC to RVA was 23.38 mm. The mean angle of the AA to the coronal plane was 59.02°.

CONCLUSION

This is the first study documenting the rates of variation of the AA in Ireland. Variation of AA branching is of radiological and surgical significance, particularly in the diagnosis and treatment of thoracic and head and neck diseases. Awareness of these variations is particularly relevant for interventionalists who access these vessels during endovascular surgery.

Variations in the Branching Pattern of the Aortic Arch Detected with Computerized Tomography Angiography

Objectives. The aim was to determine the prevalence of aortic arch variations in 881 patients who underwent neck CT angiography for various reasons. Material and Methods. 881 patients were included in the study who had undergone neck CT angiography between 2010 and 2013. Results. Of 881 patients, 770 (87.4%) patients with classic branching pattern of the aortic arch (AA) were observed. Variations in branching pattern were seen in 111 (12.6%) patients. The most common variation was the origination of the left common carotid artery (LCCA) from the brachiocephalic trunk (BCT). This pattern was observed in 64 (7.2%) cases. In 25 (2.8%) cases, the left vertebral artery (LVA) originated directly from the AA between the origin of the LCCA and left subclavian artery (SCA). 17 (1.9%) cases had aberrant right subclavian artery. Three (0.3%) cases showed right aortic arch. Two cases had right aortic arch with aberrant left subclavian artery. Conclusions. Variations in the branching pattern of the AA are not rare. Head and neck surgeons and interventional radiologists should be aware of aortic arch variations. CTA is a reliable imaging method for demonstrating anatomical features and variations of the AA.

Aortic development and anomalies

Development of the aorta takes place during the third week of gestation. It is a complex process that can lead to a variety of congenital variants and pathological anomalies. In diagnostic and interventional radiology, knowledge of aortic abnormalities and variant branching sequence is crucially important. This article gives a systematic overview of anatomical variability of the aorta.

Stenting for chronic total occlusion of the proximal subclavian artery

SUMMARY

We report the results of 26 patients who underwent stent deployment for chronic total occlusion of proximal subclavian artery. From January 1998 to October 2005, 26 patients (18 male; mean age, 62.7 years, range 22 to 83 years), 28 lesions, underwent 29 procedures of stenting for chronic total occlusion of the proximal subclavian artery.Twenty-three patients had symptoms of claudication in their arm, no patients had subclavian steal syndrome.A brachial approach was used in 21 procedures, a femoral approach was used in five procedures, and combined femoral-brachial approach was required in three procedures. Primary stent deployment was success in 24 lesions (85.7%), and secondary procedure was success in one patient, totally 25 lesions (89.3%) were successfully treated by stenting. Procedure related complication occurred in four cases, including stent migration without symptoms in two procedures, hemianopsia on next day in a case, and TIA on unclear reason in one case. Permanent morbidity rate is 3.4% in procedure. Target lesion re-treatment required in three lesions, caused by subacute thrombosis, in-stent-restenosis, and dissection of the vessel by stent edge. The cases of subacute thrombosis and in-stent-restenosis were treated by re-PTA, and the case of dissection was treated by additional stenting. Secondary patency was 100%. We conclude that stenting for chronic total occlusion of subclavian arteries appears feasible and safe.

Anatomical organization of aortic arch variations in the India: embryological basis and review

OBJECTIVES: To determine the percentage and type of aortic arch variations in Indian subjects and their clinical and surgical importance and embryological basis. PATIENTS AND METHOD: In our investigation, branching patterns of the aortic arch were studied in 62 formalin-fixed cadavers of both sexes of Indian origin, aged 45-79. The dissections were carried out in formalin-preserved cadavers and the aortic arch variations were observed after exposing the thoracic and cervical region during routine dissection of undergraduate students of Indian origin in Kasturba Medical College, Mangalore. RESULTS: The usual three-branched aortic arch was found in 56 cadavers (91.4%); variations were found in six cadavers (9.6%); 4.8% presented common origin of the carotid arteries; 1.6% had bi-innominate sequence, and the same specimen had left coronary artery arising from arch of aorta directly; 1.6% presented right subclavian artery arising directly from the aorta; 1.6% had left vertebral artery a branch of aortic arch. Five out of six cadavers with anomalous aortic arch branching pattern were females. One male cadaver presented anomalous origin of left vertebral artery directly from the arch. CONCLUSION: The wide spectrum of variations in the anatomical arrangements of the aortic arch branches in the Indian population was at par with other populations of the world. Although anomalous origins of the aortic arch branches are merely anatomic variants, accurate information about them is vital for vascular surgery in the thorax, head and neck region.

Complete percutaneous revascularization in Takayasu's disease

We described a case of a patient with Takayasu disease in whom percutaneous revascularization of left main coronary disease and right brachiocephalic trunk was performed.

Endovascular treatment of innominate artery stenosis in a bovine aortic arch--a case report

Recent reports have established the feasibility and safety of percutaneous transluminal angioplasty and stent placement in the treatment of innominate artery occlusive disease. Although the long-term durability of these endovascular approaches has not been clearly established, they are particularly attractive in patients who are not considered good candidates for surgical reconstruction. The authors present a case involving a morbidly obese Hispanic woman who had undergone previous coronary artery bypass and complained of right visual symptoms, dizziness, and right upper extremity claudication. Because of her unusual bovine anatomy and the desire to avoid reoperating in her chest, a unique approach with a left subclavian-to-carotid bypass and innominate artery angioplasty and stenting was used.

Occlusive thromboaortopathy (Takayasu disease): clinical and angiographic features and a brief review of literature

The aim of this study was to evaluate the diagnostic criteria and angiographic classifications of Takayasu arteritis by presenting the clinical, angiographic, and prognostic findings and a prospective follow-up of 78 patients. Occlusive thromboaortopathy or Takayasu arteritis is a large vessel vasculitis. The disease is systemic with an autoimmune and genetic etiology. The complete clinical and angiographic manifestations are reported for 78 cases based on diagnostic criteria of the American College of Rheumatology with a mean 6 +/- 3.2 years follow-up. The mean age was 34.7 and female:male ratio was 3.6:1. According to National Institute of Health criteria, 61.5% of patients were in the acute phase of disease with systemic symptoms such as fever, weight loss, malaise, and elevated C-reactive protein levels. Immunologic markers, such as antinuclear antibody and antineutrophil cytoplasmic antibodies, were negative. The tuberculin test result was positive in 47%. Vascular bruit was present in 89%. Almost all patients had stenoses, occlusions, or aneurysmatic changes of the aorta and its main branches. Hypertension was detected in 58% and left ventricular hypertrophy was initially present in 22 (28%) patients. The angiographic manifestations were classified as type I, cervicobrachial type with 20 cases (25.6%); type II, thoracoabdominal type with 13 cases (16.6%); type III, peripheral type with 10 cases (12.8%); and type IV, generalized type with 35 cases (44.8%). The coronary arteries were involved in 6 cases, pulmonary arteries in 11 initially 5 in follow-up (16 cases), and renal arteries in 28 cases, respectively. A good correlation of the clinical manifestations and the prognosis was observed. During follow-up, five patients suffered from myocardial infarction, six had cerebrovascular accident, seven patients underwent aortic valve replacement, and six patients died (mortality rate, 7.6%). The specificity and sensitivity of diagnostic criteria were 94% and 76%, respectively. In contrast to ours and Nasu's classification in the new classification of Numano, some angiographic types and subtypes of Takayasu arteritis are not present in our patients.