The aberrant subclavian artery

The "full rectangle" sign: a novel method for ultrasonographic diagnosis of fetal aberrant right subclavian artery

OBJECTIVE

To evaluate the feasibility and accuracy of a novel ultrasonographic screening method for an aberrant right subclavian artery (ARSA) using the novel "full rectangle" method.

METHODS

This prospective study was conducted at a tertiary care center, September 2022 to February 2023. The study included unselected pregnant women at 14-38 weeks of gestation referred for routine or targeted anomaly scans. All participants underwent scanning by two experienced sonographers to ascertain the presence or absence of aberrant right subclavian artery (ARSA) using both conventional and novel "full rectangle sign" methods for validation purposes. This is a novel screening method for ARSA that demonstrates the retro-tracheal course at the level of the supra-aortic vessels, forming what we term the "full rectangle sign".

RESULTS

A cohort of 138 patients was enrolled. The "full rectangle" sign was discerned in 6 fetuses with ARSA (4.3%), while the typical three-sided figure of the right subclavian artery was demonstrated in the remaining 132 fetuses (95.7%). The novel method demonstrated 100% feasibility and complete concordance with the conventional method.

CONCLUSION

The study results indicate that the full rectangle sign serves as an effective and dependable screening tool for identifying ARSA. It offers the advantage of a clear, unobstructed view at a level unaffected by sternum shadowing and eliminates confusion with the azygous vein.

Fenestrated/Branched Physician-Modified Endovascular Grafts for Aortic Pathologies Involving the Aberrant Subclavian Artery

PURPOSE

The case series aim to explore the feasibility and effectiveness of using fenestrated/branched physician-modified endovascular grafts (PMEGs) to treat aortic pathologies involving the aberrant subclavian artery (ASA).

TECHNIQUE

We presented 3 cases with multiple anomalies and complications related to the ASA. Two patients had aberrant right subclavian arteries (ARSA) and developed aortic dissection spontaneously or iatrogenically after endovascular intervention for myocardial infarction. The third patient had an aberrant left subclavian artery (ALSA) together with a Kommerell's diverticulum (KD) arising from a right-sided aortic arch and developed an aortic dissection. In all 3 cases, an Ankura thoracic endograft (Lifetech, Shenzhen, China) was back-table modified by adding an inner branch and a fenestration for bilateral subclavian arteries, respectively. All procedures were successfully conducted, and all patients underwent 6-month follow-up courses, which were uneventful.

CONCLUSION

Our case series demonstrate a feasible and less invasive therapeutic approach, which produces promising results in treating the aortic pathologies involving the ASA. Further studies and long-term follow-up are required to refine this technical approach and to validate its durability.

CLINICAL IMPACT

The case series illustrate a total endovascular approach to treat aortic arch pathologies involving the ASA, which is one of the most frequent aortic arch anomalies. The use of PMEGs allows meticulous subclavian artery reconstruction without significant trauma brought by traditional open or hybrid approach. Our cases suggest that using PMEGs for total endovascular management of patients with ASA is feasible and effective, and it may help streamline the treatment of complex aortic pathologies.

Management of complex thoracic aortic diseases with aberrant right subclavian artery

BACKGROUND

We retrospectively evaluated early and intermediate outcomes of hybrid repair of complex thoracic aortic diseases involving an aberrant right subclavian artery. This paper aims to report features and available treatment options for this rare, hard-to-diagnose, and manage, aorta-related vascular condition.

METHODS

Between January 2012 and May 2019, 13 patients (mean age, 60.1 ± 9.3 years; nine men) underwent complex thoracic aorta repair surgery. Six patients had a thoracic aortic aneurysm, two had type A aortic dissection, and five had complicated type B aortic dissection. Hybrid repair strategies included de-branching in combination with single-stage aortic arch replacement with the frozen elephant trunk technique performed in four patients, thoracic endovascular aortic repair in six patients, and 2-stage hybrid repair consisting of a total arch replacement with a conventional/frozen elephant trunk (first stage) and subsequent endovascular repair (second stage) in three patients.

RESULTS

One early death occurred: a patient with acute type A aortic dissection, who underwent Bentall procedure and aortic arch replacement with the frozen elephant trunk technique, died in-hospital of multiorgan failure 41 days after the procedure. The remaining 12 patients were discharged in stable condition. The median follow-up duration was 36 months (2-71 months). Two late mortalities occurred: a patient with residual type A aortic dissection, who underwent arch replacement with the frozen elephant trunk technique, died of intracranial hemorrhage 3 months after the surgery. And 72 years old female patient died of acute exacerbation of chronic obstructive pulmonary disease 2 months after the surgery.

CONCLUSION

Our study indicates that various hybrid strategies can be used to treat complex thoracic aortic diseases involving an aberrant right subclavian artery. The approach of choice depends on the features of disease pathology, the aortic segments involved, and the operating surgeon's experience.

A stented elephant trunk procedure with retrograde cerebral perfusion for a rare type of pseudoaneurysm with an aberrant right subclavian artery

BACKGROUND

Aberrant right subclavian artery (ARSA) is a rare congenital vascular anomaly that increases the risk of aortic dissection (AD). Although several treatment options for cases of AD with ARSA have been proposed, such as traditional surgery, thoracic endovascular aortic repair, and a hybrid procedure, a consensus regarding the optimal treatment strategy has not yet been established. And there are no reported cases of pseudoaneurysm combined with ARSA.

CASE PRESENTATION

A 44-year-old male was admitted with a 7-days history of chest pain. A physical examination was almost normal. Computed tomography angiography (CTA) showed an ARSA arose from the distal aortic arch and pseudoaneurysm located distal to the origin of the ARSA. The stented elephant trunk (SET) procedure with retrograde cerebral perfusion (RCP) was performed under moderate hypothermic circulatory arrest. The postoperative CTA demonstrated a well-perfused ARSA, left subclavian artery (LSA), left common carotid artery (LCCA), and right common carotid artery (RCCA), and occluded pseudoaneurysm with no endoleaks. He was discharged on postoperative day 9 and was doing well during his 6-months follow-up.

CONCLUSIONS

With a smaller incision, a simple cannulation method, shorter surgical and circulatory arrest times, fewer blood transfusion requirements, and effective brain protection, the SET procedure with RCP can be a safe and feasible treatment option for complicated aortic arch anomalies with ARSA.

Utilizing Single-Branched Stent in Combination With Fenestration or Chimney for Endovascular Repair of Aortic Arch Lesions With Aberrant Subclavian Artery

OBJECTIVE

The study was to figure out the feasibility, efficacy, and safety of a single-branched stent graft, namely Castor, in combination with fenestration or chimney in the context of aortic arch lesions presenting with aberrant subclavian artery (ASA) and/or Kommerell's diverticulum (KD).

METHODS

All consecutive patients with aortic arch lesions and ASA and/or KD receiving Castor from June 2018 to June 2023 were investigated.

RESULTS

Incorporating 18 patients, the study encompassed 11 cases with KD, 3 cases with dysphagia; 2 cases of right-sided aortic arch with left-sided aberrant left subclavian artery (ALSA), and 16 cases of left-sided aortic arch with right-sided aberrant right subclavian artery (ARSA). The mean operation time was 132±23 minutes. The mean measured proximal aortic diameter was 30.9±1.6 mm, and proximal diameter of Castor stent was 34 (32, 34.5) mm, with oversize of 9.1±1.6%; the mean measured branch diameter was 8.8±0.97 mm, and branch diameter of Castor stent was 10 (8, 10) mm, with oversize of 0.86±0.57 mm. Technical success rate was 100%, and no in-hospital mortality, no stroke, and no endoleak were identified. One (5.6%) case with spinal cord ischemia and one (5.6%) case with poor healing of operative site were identified. During the follow-up period, no aortic-related death or secondary intervention was recorded. The maximal aortic diameter was significantly reduced at the sixth postoperative month (padj=0.031); KD diameter was significantly reduced at the third (padj=0.001) and sixth (padj<0.001) postoperative month.

CONCLUSION

Totally endovascular repair of aortic arch lesions with ASA and KD via Castor stent in combination with fenestration or chimney is feasible, effective, and safe, which can achieve an encouraging medium-term outcome and provide excellent remodeling at the lesions.

CLINICAL IMPACT

Single branched stent in combination with fenestration or chimney achieved a sufficient proximal landing zone and provided an encouraging medium-term outcome in this retrospective review of 18 patients receiving endovascular treatment of pathological aortic arch with aberrant subclavian artery and/or Kommerell's diverticulum. The authors suggest this time-saving and efficient technique to establish systematic experience for the treatment in this kind of patients.

Transarterial embolization of radicular arteriovenous fistula at the craniocervical junction

Craniocervical junction arteriovenous fistula (CCJ AVF) is a rare vascular disorder. Direct surgery for CCJ AVF is generally reported to have better outcome compared to endovascular treatment. However, no certain consensus has been obtained so far. We report a case of radicular CCJ AVF treated by transarterial embolization that resulted in a good outcome. A 69-year-old man presented with subarachnoid hemorrhage primarily in the posterior cranial fossa. Based on digital subtraction angiography showed radicular CCJ AVF with varix. Transarterial embolization was performed with n-butyl-2-cyanoacrylate on day 17 after onset and successfully cured. The neurovascular anatomy of CCJ AVF is complicated, but endovascular treatment may be a treatment option with detailed understanding of angioarchitecture and selective endovascular procedure.

Characterization and surgical management of aberrant subclavian arteries

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.

Acute aortic dissection with an aberrant right subclavian artery resulting in rapid false lumen enlargement: a case report

BACKGROUND

An aberrant right subclavian artery complicated by acute aortic dissection has been reported. Aneurysmal degeneration in the descending aorta adjacent to the Kommerell diverticulum in older patients has also been reported. There are concerns regarding the anatomic and pathological aspects of an aberrant right subclavian artery accompanying the Kommerell diverticulum with respect the surgical strategy for acute aortic dissection.

CASE PRESENTATION

We report the case of a 79-year-old man with an aberrant right subclavian artery who developed acute aortic dissection (DeBakey IIIa) and rapid enlargement of the false lumen with deteriorating dysphagia and back pain. Total arch replacement with the frozen elephant trunk technique was performed. The aberrant right subclavian artery was closed using a stent graft proximally and was ligated distally at the right side of the posterior mediastinum. To prevent injury to the esophagus, the aberrant right subclavian artery was identified by lifting the right side of the thoracic wall using a thoracotomy device for internal thoracic artery harvest to expose the dorsal circumference of the superior vena cava. Additionally, the right subclavian artery was reconstructed using an extra-anatomical bypass.

CONCLUSIONS

This surgical strategy could be useful in patients with an aberrant right subclavian artery and the Kommerell diverticulum who require total arch replacement.

Alterations of Arterial Morphology in Aberrant Subclavian Artery Patients with Type B Dissection and its Association with Dissection

OBJECTIVE

The arterial morphology in aberrant subclavian artery (ASA) patients and its association with type B aortic dissection are important for treatment and prevention. This study examined the arterial morphology of ASA patients with type B dissection and evaluated its association with type B dissection in vivo.

METHODS

The presence of ASA and type B dissection was screened from patients with aortic dissection receiving computed tomography angiography (CTA) from January 2011 to May 2021. ASA patients with type B dissection (Group 1, n=16), clinically-matched counterparts without type B dissection (Group 2, n=32) and clinically-matched type B dissection subjects without ASA (Group 3, n=32) were measured for the angles of ascending aorta, aortic arch, aortic deviation, and the diameters of ascending aorta, aortic arch, ASA ostium and middle ASA segment. The correlation between ASA morphology and type B dissection was analyzed by variance analysis or Wallies H test.

RESULTS

Compared with Group 2, Group 1 reported a sharper ascending aortic angle (131.5^o±13.7^o vs. 148.1^o±7.8^o, P=0.001), larger aortic deviation angle in plane 2 (28.2^o±6.0^o vs. 22.1^o±7.2^o, P=0.005) and plane 3 (26.4 ^o±7.3^o vs. 21.8^o±6.3^o, P=0.028). Similarly, Group 1 displayed a greater diameter in the ascending aorta, aortic arch, and the ostium and middle of ASA (38.3±4.1mm vs. 33.6±4.5mm, P=0.001; 34.0±9.3mm vs. 26.2±2.9mm, P=0.004; 20.3±9.3mm vs. 14.0±3.2mm, P=0.018; 10.8±2.3mm vs. 9.0±1.5mm, P=0.002, respectively), without a significant difference in the aortic arch angle. Compared with Group 3, Group 1 showed a sharper ascending aortic angle (131.5^o±13.7^o vs. 142.5^o±11.7^o, P=0.026) and smaller aortic deviation angle in plane 1 (21.7^o±6.2^o vs. 28.9^o±6.2^o, P=0.04) and plane 3 (26.4^o±7.3^o vs. 21.8^o±6.3^o, P=0.007), though with no significant difference in the aortic arch angle, aortic deviation angle in plane 2, and ascending aortic diameter.

CONCLUSIONS

The diameters of the ostium and middle segment of ASA and ascending aorta and the angles of ascending aorta and aortic deviation are potential risk factors for type B dissection in ASA patients, which may provide new insights into the mechanism of type B dissection in patients with ASA.

Hybrid repair of a distal aortic arch aneurysm with aberrant right subclavian artery and Kommerell's diverticulum: A case report

Introduction and importance

Aberrant right subclavian artery (ARSA) and Kommerell's diverticulum (KD) are common vascular anomalies of the aortic arch. Anatomic reconstruction of ARSA is difficult with only the median sternotomy approach.

Case presentation

A 55-year-old woman was referred to our hospital for a thoracic aneurysm. CT showed 46 mm diameter of distal aortic arch aneurysm with ARSA and KD. ARSA branched from the distal aortic arch and crossed behind the esophagus. It was difficult to reconstruct ARSA anatomically via the median sternotomy approach. We performed coil embolization of ARSA and total aortic arch replacement (TAR) and extra-anatomic right subclavian artery reconstruction for the distal aortic arch aneurysm with ARSA and KD. The patient was discharged home with no complications.

Clinical discussion

There were differences in blood pressure of the upper extremities after coil embolization of ARSA; however, subclavian steal syndrome or cerebral complications did not occur. If there is no abnormal finding in head and neck arteries before surgery, coil embolization of ARSA is safe and open distal anastomosis of the distal aortic arch can be performed in a bloodless field.

Conclusion

Hybrid repair by coil embolization and TAR for the distal aortic arch aneurysm with ARSA and KD were considered to be a useful in the absence of cerebral vascular stenosis or obstruction.

•

Anatomic reconstruction of aortic arch anomaly with aortic aneurysm is difficult.

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Hybrid repair by coil embolization and open surgery is useful and safe.

Hybrid Single-Stage Repair of Kommerell's Diverticulum in a Right Aortic Arch in a Patient With 22q11.2 Deletion Syndrome

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.

Thoracic endovascular aortic repair for chronic aortic dissection after total arch replacement for aberrant right subclavian artery: A case report

An aberrant right subclavian artery (ARSA) is an extremely rare congenital anomaly that forms during aortic arch development. Most reports of thoracic endovascular aortic repair (TEVAR) described an ARSA in the right aortic arch, but it is rare in the left aortic arch. We present the case of a 66-year-old man who underwent total arch replacement because of acute type A aortic dissection. An outpatient follow-up examination revealed that the aortic diameter enlargement exceeded 60 mm because of false lumen entry from the ARSA. Therefore, surgical intervention was planned. TEVAR, ARSA embolization, and bilateral axillary bypass surgery were successfully performed for a chronic dissecting aortic aneurysm for which the ARSA was the inflow route. He was discharged 12 days after surgery. Four years later, no enlargement of the aneurysm diameter was observed. TEVAR is a minimally invasive and useful treatment option for chronic type B dissections with an ARSA associated with the left aortic arch; however, patients with an ARSA have fragile blood vessels and require careful follow-up.

Pleural Approach to Aberrant Right Subclavian Artery in Aortic Surgery

An aberrant right subclavian artery usually arises from the aortic arch just distal to the left subclavian artery and crosses behind the esophagus on its way to the right axillary artery. Several reconstructive techniques of this artery in aortic surgery have been reported but mostly resulted in troublesome procedures. Here, we describe an alternative strategy presenting the occlusion of the aberrant right subclavian artery through the right pleural approach followed via extraanatomical axillary artery bypass. This surgical approach might be a simple and safe option for the aberrant right subclavian artery.

Total endovascular repair of a mycotic thoracic aortic aneurysm in a patient with an aberrant right subclavian artery

An aberrant right subclavian artery (ARSA) is a rare arterial anomaly. Although a few cases of total endovascular repair for the ARSA aneurysm have been previously reported, anatomical limitations and the possibility of endoleaks remained. In this case, we created 4 holes on the stent graft for each cervical branch, with reference to the preoperative computed tomography findings. This approach might enable us to repair all types of thoracic aortic aneurysms with ARSA with each anatomical feature.

Femoral artery cannulation as a safe alternative for aortic dissection arch repair in the era of axillary artery cannulation

BACKGROUND

To evaluate the safety and efficacy of femoral artery cannulation as an alternative to axillary artery cannulation, we retrospectively compared outcomes between patients with axillary or femoral artery cannulation during open aortic arch repair for type A aortic dissection (TAAD).

METHODS

Between January 2014 and January 2019, 646 patients underwent open aortic arch repair with circulatory arrest for TAAD using antegrade selective cerebral perfusion (SACP) and were divided into two groups according to the site of arterial cannulation: an axillary artery group (axillary group, n=558) or a femoral artery group (femoral group, n=88). The axillary artery was considered as the primary cannulation site, and the femoral artery was used as an alternative when axillary artery cannulation was deemed unsuitable or had failed. Propensity score matching was performed to correct baseline differences.

RESULTS

After propensity score matching, the patients' characteristics were comparable between groups (n=85 in each). The incidence of in-hospital mortality (10.6% vs. 14.1%; P=0.642) and stroke (3.5% vs. 5.9%; P=0.720) were comparable between the axillary and femoral groups. The incidence of newly required dialysis was lower in the femoral group, but the difference was not statistically significant (34.1% vs. 20.0%; P=0.050). Other outcomes and major adverse events were comparable.

CONCLUSIONS

Femoral artery cannulation produced similar perioperative outcomes to axillary cannulation after open arch repair for TAAD. The femoral artery can be used as a safe and effective alternative to the axillary artery for arterial cannulation in TAAD patients undergoing open arch repair.

Different therapeutic modalities for aortic arch disease combined with Kommerell's diverticulum: single-center experience with nine cases

Background

Aortic arch disease with Kommerell’s diverticulum is an uncommon but troublesome condition, and there are a variety of therapeutic modalities for treating this. We retrospectively analyzed cases who underwent open surgery to summarize different situations and approaches.

Methods

From November 2015 to January 2019, nine patients underwent operation for the mentioned disorder. Four patients with aortic dissection received total arch replacement. Two patients suffering from type B aortic dissection (TBAD) have accepted graft replacement from ascending aorta (aAO) to descending aorta. Two patients with true aneurysm and congenital malformation underwent graft bypass from aAO to descending aorta. One patient had graft replacement of descending aorta.

Results

There were nine (eight males and one female) patients with median age of 45 (from 14 to 54) years. The 30-day mortality was 11.1% (1 patient) due to refractory respiratory failure caused by compression of bronchus. One patient had complication of peripheral neuropathy and recovered eventually. Eight patients were followed-up for a median period of 20 [9–46] months. All patients were alive and had no long-term complications except one patient who received re-intervention due to delayed dilation of downstream aorta.

Conclusions

Treatment for different arch lesions with Kommerell’s diverticulum should follow corresponding indications. Open surgery is the preferred choice and detailed therapeutic strategy depends on the extension of aneurysm, classification and phase of dissection. Stenting might cause airway compression when right-sided arch and vascular ring exist.

The “No ARSA” Sign: A Novel Method of Prenatal Screening for Aberrant Right Subclavian Artery

An aberrant right subclavian artery (ARSA) can be overlooked by the conventional method as described by Chaoui et al., due to acoustic shadowing. The aim of this study was to evaluate the feasibility and accuracy of a novel screening method for ARSA by demonstrating the brachiocephalic artery bifurcation, referred to as the “No ARSA” sign. A prospective study conducted at a tertiary care center between 2018 and 2019 included unselected pregnant patients at a median gestational age of 15.1 (14.2–22.1; IQR (inter-quartile range)) weeks, who had been referred for a routine or targeted anomaly scan. All participants were scanned for the presence or absence of ARSA using both the conventional and the novel “No ARSA” methods for validation purposes. A total of 226 unselected patients were enrolled in the study. The “No ARSA” sign was visualized in 218 fetuses (96.5%). In the remaining 8 cases (3.5%), the “No ARSA” sign was not demonstrated. In these fetuses, an ARSA was visualized by the conventional method. The new method exhibited 100% feasibility and was in complete agreement with the conventional method. Intra- and inter-observer agreement was excellent (κ = 1). The results of the study suggest that the “No ARSA” sign is an efficient and reliable screening tool for ARSA.

Surgical treatment for Kommerell's diverticulum associated with aortic dissection involving aortic arch

OBJECTIVE

Kommerell diverticulum with aortic dissection involving aortic arch is a rare but troublesome condition. The purpose of this study is to summarize the experience and strategy of surgical treatment.

METHOD

From November 2015 to January 2018, seven consecutive patients underwent surgical treatment in our institution. Three patients with acute type A aortic dissection and one patient with acute type B aortic dissection received total arch replacement and frozen elephant trunk (FET) implantation through median sternotomy. Three patients with chronic type B aortic dissection underwent total aortic arch and descending aorta replacement through median sternotomy and lateral thoracotomy.

RESULT

There were seven male patients whose median age was 42.3 ± 11.7 (from 14 to 54) years old. There was no perioperative death in this study. One patient had postoperative critical illness polyneuropathy and required prolonged mechanical ventilation (485 hours) and recovered finally. Follow up was completed for all seven patients with a median follow-up time of 7 (3-46) months. One patient with type A dissection developed aneurysm of the descending aorta distal to the FET and received reintervention. No clinical events and abnormal computed tomography manifestations were found in the other seven patients.

CONCLUSION

Total arch replacement and FET through single median incision is a reliable method for Kommerell diverticulum associated with acute dissection involving arch. For Kommerell diverticulum associated with chronic type A or B aortic dissection involving aortic arch, graft replacement by double or single incision is safe and appropriate.

Vascular anomaly: Cause of infant respiratory distress and dysphagia

Aberrant right subclavian artery with a left aortic arch is rare, but it is the most common congenital aortic arch anomaly. It can present as an incidental finding later in life or be symptomatic at a young age. Here, we describe a case of an aberrant right subclavian artery discovered in a 4 month old with respiratory distress and feeding difficulties. She underwent an extensive aerodigestive evaluation including bronchoscopy, both flexible and rigid, upper GI endoscopy, modified barium swallow with esophageal sweep, chest imaging, CT thorax and echocardiogram. The final decision per the management team was to observe the patient in order to allow more growth. She ultimately improved with age and remains asymptomatic.

CT evaluation of aberrant right subclavian artery: anatomy and clinical implications

PurposeThe aim of the study was to perform CT angiography-based evaluation of aberrant right subclavian artery prevalence, anatomy, and its influence on clinical symptoms.

METHODS

A total of 6833 patients who underwent 64-slice or dual-source CT angiography and those who revealed aberrant right subclavian artery underwent evaluation of its anatomy and were interviewed for the presence of clinical symptoms.

RESULTS

Aberrant right subclavian artery was found in 32 (0.47%) patients consisting of 13 males and 19 females, with mean age of 60.8±13.4 years. Among the interviewed 30 (94%) patients, oesophageal compression was observed in 14 cases (47%) and tracheal compression in three cases (10%). None of the patients underwent surgery related to aberrant right subclavian artery. Dysphagia was the most common clinical symptom in nine cases (30%), and in those patients the median distance between aberrant right subclavian artery and trachea was lower (4 mm) than in individuals without dysphagia (7.5 mm) (p = 0.009). The median lumen area of the aberrant right subclavian artery at the level of oesophagus was higher in patients with dysphagia (208 mm2) compared with individuals without dysphagia (108 mm2) (p = 0.01).

CONCLUSIONS

Aberrant right subclavian artery is a rare occurring abnormality in CT angiography. In the evaluated adult population, the most common symptom was dysphagia, which occurred in patients with decreased distance between aberrant right subclavian artery and trachea and increased lumen area of the aberrant artery at the level of compressed oesophagus.

Prenatal diagnosis of aberrant right subclavian artery in an unselected population

Purpose

The purpose of this study was to determine the frequency of aberrant right subclavian artery (ARSA) among unselected fetuses and to evaluate its association with chromosomal abnormalities and other congenital anomalies.

Methods

In all, 7,547 fetuses (gestational age, 20 to 34 weeks) were examined using routine antenatal sonography at our institution between April 2014 and September 2015. The right subclavian artery was assessed using grayscale and color Doppler ultrasonography in the transverse 3-vessel and tracheal view, and confirmed in the coronal plane.

Results

ARSA was found in 28 fetuses (0.4%). Further, 27 of these 28 fetuses were euploid (96.4%). Trisomy 18 was the only chromosomal anomaly (3.6%) found in the study sample. ARSA was an isolated finding in 23 of the 28 cases (82.1%). In the remaining three cases (10.7%), ARSA was accompanied with extracardiac anomalies. Other cardiac defects were present in three cases (10.7%).

Conclusion

Isolated ARSA does not seem to be associated with a significantly increased risk of aneuploidy. However, the possibility of fetal karyotyping, which is a more invasive procedure, should be discussed in the light of the overall risk of the fetus.

Axillary Artery Cannulation in Acute Aortic Dissection: A Word of Caution

Arterial cannulation into the right axillary artery is a commonly adopted perfusion strategy in the treatment of acute aortic dissection. Here we describe our experience of accidentally cannulating the axillary artery in a case of acute aortic dissection with an aberrant right subclavian artery, which was missed preoperatively because its proximal segment was malperfused by the dissection and thereby not enhanced. The rapid hemodynamics collapse at the start of the bypass was reversed by prompt switching to femoral perfusion. Postoperative follow-up computed tomographic angiography revealed a well-perfused right aberrant subclavian artery. Surgeons should be aware of an aortic arch anomaly whenever performing an axillary artery cannulation.

Two-stage operation for Stanford type A acute aortic dissection originating from Kommerell's diverticulum

We report a rare case of Stanford type A acute aortic dissection involving an aberrant right subclavian artery and originating from Kommerell's diverticulum in a 52-year old man. Initially, as an emergency measure, total arch replacement and right axillary artery reconstruction were performed. However, due to the subsequent enlargement of the false lumen, thoracic endovascular aortic repair and right subclavian artery coiling were performed successfully 5 months after the first operation. Herein, we describe surgical management approaches for the treatment of a Stanford type A acute aortic dissection with aberrant right subclavian artery.

Incidence of branching patterns variations of the arch in aortic dissection in Chinese patients

Several authors have described anatomic variations of the aortic arch in 13% to 20% of the patients who do not have aortic disease. However, few studies have evaluated these patterns in the thoracic aortic dissection (TAD). In the authors' knowledge, this is the first survey that specifically investigates the frequency of these variations in a broad, nonselected group of Chinese patients with aortic dissection. Furthermore, it compares this group with a group of patients without aortic disease.The objective of this study was to define the variation frequency of the aortic arch branches pattern using the tomographic studies of 525 Chinese patients with a diagnosis of TAD. The Stanford classification was used to set the site of the initial tear of the dissection. In addition, we performed an epidemiological analysis of the aortic arch anatomic variations in TAD, and its possible implications for surgical or endovascular treatment. The general hypothesis proposal asserted that Chinese patients with dissection of the aorta have a similar incidence of variations of the aortic arch to the patients without aortic disease.A retrospective study of cases and controls was carried out using the tomographic studies (CT) of all patients admitted to the First Affiliated Hospital of Zhengzhou University, located at Henan-China, with a confirmed diagnosis of aortic dissection from January 2012 until December 2014. The group of cases consisted of 525 patients: 374 men and 151 women, with a mean age of 52.27 years (range, 20-89). The average age of the patients with Stanford A and B aortic dissection was 49.46 and 53.67, respectively. The control group consisted of 525 unselected patients without TAD who underwent a CT scan of the chest due to other indications. This group consisted of 286 men and 239 women, with a mean age of 53.60 years (range, 18-89). All the patients with aneurysm or dissection were excluded from the control group. We performed a statistical analysis of demographic data.The study found 7 different patterns of the aortic arch on both groups of cases and controls. Within the 525 patients with TAD were observed 85 (16.19%) anatomical variations, while the control group showed 112 variations (21.33%); P = 0.033. The most common anatomical variant was the bovine arch, found in 62 (11.80%) cases of TAD compared with 77 (14.66%) in the control group; P = 0.172. Anatomical variations were observed in 14.32% of the patients with Stanford A dissection and 17.09% of the patients with Stanford B dissection; P = 0.425. Patients with Stanford A dissection showed the pattern of bovine arch in 23 (13.21%) of 174 cases. In contrast, the patients with Stanford B dissection showed it in 39 (11.11%) of 351 cases; P = 0.481. The anatomical variant defined as vertebral artery of direct origin of the aortic arch was more frequent in the patients with Stanford B dissection (5.12%). The patients with Stanford A dissection presented this pattern in 1.14% of the cases; P = 0.025. This study observed an increased frequency of aortic dissection in the subgroup from 41 to 60 years old. In the subgroup from 41 to 60 years old without TAD, a greater frequency of anatomical variations were found than in the patients with TAD (20.81% vs 14.23%; P = 0.050). The same fashion was seen in patients older than 80 years (27.27% vs 0%; P = 0.030). The anatomical variations of the aortic arch with TAD occurred in 14.97% of the male patients and 19.20% of the female patients compared to 21.67% to 20.92% in the control group; P = 0.026 and P = 0.681, respectively.The aortic arch variations were found less frequently in the TAD group than in the control group in the present Chinese series. The bovine arch was considered the variant pattern of the major frequency in the patients with TAD and the control group. The anatomical variant of 4 branches, defined as vertebral artery of direct origin of the aortic arch, was more frequent in patients with Stanford B aortic dissection than in the patients with Stanford A.This finding might show an association between the geometry of the aortic arch and the site of onset of first intimal tear of dissection.

Hybrid endovascular repair for an arch aneurysm combined with aberrant right subclavian artery

This report describes a hybrid endovascular approach to a 9.3-cm saccular aneurysm of the left sided aortic arch combined with an aberrant right subclavian artery. The two-step procedure consisted of a bilateral carotid-subclavian bypass, followed by an ascending aorta-bicarotid bypass and completed by an endovascular exclusion of the aneurysm by covering the whole aortic arch and its branches. The patient had no postoperative complications and was discharged 10 postoperative day. Hybrid procedures may be useful in complex aortic arch pathologies and may reduce postoperative complications in comparison with conventional open surgery.

Kommerell's diverticulum in the current era: a comprehensive review

Kommerell's diverticulum is a developmental error with a remnant of fourth dorsal aortic arch, named after Dr. Kommerell, a radiologist, who made the first diagnosis in a living individual. The diverticulum can occur in both the left and right aortic arch, from which an aberrant subclavian artery rises to the contralateral side. Pediatric patients often present with airway symptoms whereas dysphagia and chest discomfort are more common in the adult patients. Computed tomography or magnetic resonance imaging can provide details of the diverticulum, associated arch anomalies, and its relationship with surrounding organs. Recent histological studies indicated the presence of cystic medial necrosis in the diverticulum wall, which would explain the reported high rates of aortic dissection and rupture associated with the diverticulum. Accumulated knowledge on this entity and the recent advancement of imaging techniques, surgical/endovascular strategies, and perioperative management, have led to more aggressive intervention to the diverticulum in the early phase. While still under debate it is generally accepted to consider surgical intervention when the diameter of the diverticulum orifice exceeds over 30 mm, and/or the diameter of the descending aorta adjacent to the diverticulum exceeds over 50 mm. Treatment options include open surgical repair, hybrid endovascular repair, and total endovascular repair. The selection of treatment strategy for Kommerell's diverticulum should be based on the anatomy, comorbidities of the patient, and surgical expertise available. The summaries of open and endovascular repairs of over 210 cases from literature search from 2004 to 2014 are also provided in this review.

Simultaneous hybrid treatment of aneurysmal aberrant right subclavian artery

We review the literature and report our experience on the simultaneous hybrid treatment (open and endovascular) of two symptomatic aneurysms of an aberrant right subclavian artery (ARSA). At follow-up (four years and one year, respectively) both patients were alive and free of symptoms. Hybrid treatment of an aneurysmal ARSA is a safe and effective procedure. However, a larger series of patients with long-term follow-up is necessary to determine the role of this technique.

Surgical strategy for Kommerell’s diverticulum with aberrant subclavian artery

Background

Kommerell’s diverticulum is an extremely rare congenital aortic anomaly. Because of its rarity, the optimal surgical strategy for Kommerell’s diverticulum has not been established. In this study, we reviewed our experience of surgical correction of this anomaly.

Methods

Between 2007 and 2013, we managed 9 surgical cases of Kommerell’s diverticulum; 7 had a right aortic arch with an aberrant left subclavian artery, and 2 had a left aortic arch with an aberrant right subclavian artery. None of these patients had any symptom resulting from structural compression between the aneurysm and the aberrant subclavian artery. All patients underwent surgical treatment to prevent aneurysmal rupture. Six patients had replacement of the thoracic descending aorta and in-situ reconstruction of the aberrant subclavian artery through a right thoracotomy, and 3 underwent the same procedures through a left thoracotomy. Three different methods of extracorporeal circulation were applied, according to the anatomical features of each case.

Results

There was one hospital death. This patient developed severe cerebral infarction and died of multiple organ failure on the 65th postoperative day. There were no other major complications nor any need for rehospitalization.

Conclusion

Kommerell’s diverticulum should be treated using an optimal strategy based on each patient’s anatomical features and other characteristics.

Hybrid repair of a ruptured right-sided aortic arch with an aberrant left subclavian artery arising from a diverticulum of Kommerell: a case report

Right-sided aortic arch with an aberrant left subclavian artery is a rare aortic arch anomaly. Although usually asymptomatic, aneurysm formation, dissection, and rupture can occur due to the aberrant vasculature and can be life-threatening. Hybrid, endovascular techniques have been implemented in instances of elective repair of aneurysmal diverticula of Kommerell in similar anatomical settings, but little has been written regarding urgent cases of rupture. We report a case of ruptured right-sided aortic arch with an aberrant left subclavian artery arising from a diverticulum of Kommerell successfully treated with hybrid aortic debranching and thoracic endovascular aortic stenting.

Successful surgical exclusion of rapidly expanding kommerell diverticulum following a total arch replacement for an acute type a aortic dissection

A 50-year-old man presented with an acute type A aortic dissection with an aberrant right subclavian artery. Emergent total arch replacement with an elephant trunk was performed. Intraoperatively, the origin of the aberrant right subclavian artery could not be resected because it was located too far from the distal arch. After two weeks, the patient became aware of dysphagia. Postoperative computed tomography showed the esophagus was compressed anteriorly by the aneurismal origin of this aberrant vessel (Kommerell diverticulum) with a patent false lumen. Additional replacement of the descending aorta via left thoracotomy was performed immediately to exclude a Kommerell diverticulum.

Characteristic travelling patterns of non-recurrent laryngeal nerves

Background:

The non-recurrent laryngeal nerve is subject to potential injury during thyroid surgery. Intra-operative identification and preservation of this nerve can be challenging. Its presence is associated with an aberrant subclavian artery and the developmental absence of the brachiocephalic trunk. This study aimed to evaluate the incidence of non-recurrent laryngeal nerves and present a new classification system for the course of these nerves.

Methods:

Non-recurrent laryngeal nerves were identified on the right side in 15 patients who underwent thyroidectomy. The incidence of non-recurrent laryngeal nerves (during thyroidectomy) and aberrant subclavian arteries (using neck computed tomography) was evaluated, and the course of the nerves was classified according to their travelling patterns.

Results:

The overall incidence of non-recurrent laryngeal nerves was 0.68 per cent. The travelling patterns of the nerves could be classified as: descending (33 per cent), vertical (27 per cent), ascending (20 per cent) or V-shaped (20 per cent).

Conclusion:

Clinicians need to be aware of these variations to avoid non-recurrent laryngeal nerve damage. A retroesophageal subclavian artery (on neck computed tomography) virtually assures a non-recurrent laryngeal nerve. This information is important for preventing vocal fold paralysis. Following a review of non-recurrent laryngeal nerve travelling patterns, a new classification was devised.

Hybrid endovascular treatment of an aberrant right subclavian artery with Kommerell aneurysm

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

Embolization of an Aberrant Right Subclavian Artery Aneurysm with Amplatzer Vascular Plug without Bypass

Aberrant right subclavian artery (ARSA) aneurysms are rare, but the risk of rupture and thromboembolism is high, with a postrupture mortality rate of 50%. Open surgical repair of ARSA aneurysms usually requires thoracotomy and aortic grafting, which can be contraindicated in high-risk patients with multiple comorbidities. Endovascular repair of ARSA aneurysms has been reported, with or without adjunctive surgical bypass. We report a case of an 80-year-old woman resenting with an asymptomatic 4 cm ARSA aneurysm who underwent a completely endovascular treatment of the aneurysm using an Amplatzer vascular plug II (St. Jude Medical Inc., St. Paul, MN).

Hybrid treatment in a patient with acute aortic syndrome and an aberrant right subclavian artery

A 57-year-old man was admitted to our department with recent onset of chest pain. Computed tomography (CT) scans revealed an acute aortic syndrome manifested by a penetrating atherosclerotic ulcer and contained rupture at the level of origin of an aberrant right subclavian artery. A combined vascular and endovascular approach was selected. The entire arch was rerouted, a reversed bifurcated Dacron prosthesis was placed, and a bypass was created between the right common carotid artery and the lusorian artery, followed by thoracic endovascular aortic repair. The clinical course was uneventful. The CT scan obtained after the procedure revealed regular supra-aortic perfusion and complete exclusion of the complex lesion.

Open triple-branched stent graft applied to patient of acute type A aortic dissection with aberrant right subclavian artery

A 57-year-old Chinese male patient presented with Standford type A aortic dissection with an aberrant right subclavian artery (ARSA). At operation, the ascending aorta was replaced by a mono-branch vascular prosthesis with the branch bypassing to the ARSA; the triple-branched stent graft was inserted into the true lumen of the arch and proximal descending aorta (covering the origin of the ARSA) with each sidearm graft being positioned into the aortic branches; and then its proximal end was sutured to mono-branched vascular prosthesis. Follow-up computed tomography angiography showed false lumen of the dissection disappeared with satisfactory position of the triple-branched stent graft.

Cardiovascular pathology in males and females with 45,X/46,XY mosaicism

CONTEXT

The phenotype of 45,X/46,XY mosaicism is heterogeneous ranging from females with Turner syndrome (TS) to apparently normal males. Males with 45,X/46,XY frequently show stigmata typically associated with TS. We hypothesised that males with 45,X/46,XY have similar cardiovascular pathology as females with 45,X/46,XY.

OBJECTIVE

To investigate cardiovascular abnormalities in 45,X/46,XY males and to compare them with 45,X/46,XY females.

DESIGN

Patients with 45,X/46,XY mosaicism were selected from the Belgian Registry for Growth and Puberty problems and via the multidisciplinary clinic for disorders of sexual development.

PATIENTS

EIGHTEEN PATIENTS WERE INCLUDED: 8 raised as females (F) and 10 as males (M).

INTERVENTION

Complete cardiac examination with blood pressure measurement, ECG, echocardiography and MRI.

MAIN OUTCOME MEASUREMENT

Cardiac parameters were registered for both groups. In a second phase, clinical features and external masculinisation score (EMS) were retrospectively collected from the medical files.

RESULTS

A structural heart defect was diagnosed before inclusion in 1 F with coarctation and 1 M with spontaneously closed VSD. A bicuspid aortic valve was found in 8 (3 F, 5 M). Dilation of the ascending aorta was present in 4 M and was severe in 2 young boys. QTc was prolonged in 3 F and 2 M.

CONCLUSION

Males with 45,X/46,XY mosaicism have similar cardiovascular pathology as 45,X/46,XY females. Dilation of the ascending aorta can be important, also in males. We advise cardiac screening and life-long monitoring in all males with 45,X/46,XY mosaicism according to the existing guidelines for Turner syndrome.