Combined physician-modified fenestration and inner branch techniques for aortic pathology with aberrant subclavian artery

Hybrid Endovascular Treatment of an Anomalous Right Subclavian Artery Dissection in a Patient With Marfan Syndrome

Hybrid Treatment for Ruptured Diverticulum of Kommerell: A Minimally Invasive Option

The purpose of our study was to describe patterns of airway compression identified on cross-sectional imaging in infants and children with either right aortic arch and aberrant left subclavian artery or left aortic arch with aberrant right subclavian artery. Data from MR imaging and CT performed to evaluate pediatric patients for extrinsic airway compression were reviewed for cases that revealed an aberrant right or left subclavian artery. Clinical, endoscopic, and imaging findings in identified cases were reviewed. Recurrent patterns of extrinsic compression were reviewed among cases. Twelve patients with right aortic arch with aberrant left subclavian artery and nine patients with left aortic arch and aberrant right subclavian artery were identified. All 12 with right aortic arch with aberrant left subclavian artery had airway compression shown, with multiple sites or diffuse compression in six. Of these 12 patients, nine had compression at the level of the arch and aberrant subclavian artery (10 had Kommerell's diverticulum), and nine had compression of the distal airway in association with a midline descending aorta. Five of the nine patients with left aortic arch and aberrant right subclavian artery had airway compression shown, all at the level of the arch and aberrant subclavian artery. None of these compressions was associated with either Kommerell's diverticulum or midline descending aorta. Both right and left aberrant subclavian arteries can be associated with symptomatic airway compression, but the patterns of compression are different. The airway compression in right aortic arch with aberrant left subclavian artery is often associated with either Kommerell's diverticulum or midline descending aorta, whereas compression associated with left aortic arch and aberrant right subclavian artery is not.

Objective This retrospective study is to investigate the clinical features,treatment methods,and follow-up results of aberrant subclavian artery (ASA) combined with aortic dissection (AD). Methods Totally 17 patients with ASA combined with AD (ASA+AD) admitted to our hospital from August 2013 to February 2018,were included. Among these patients,there were 14 acute cases and 3 chronic cases; 13 males and 4 females; aged from 28 to 82 years,with the mean age of (54±14) years. All the ASAs in these 17 patients were located behind the esophagus. There were 15 cases of aberrant right subclavian artery (ARSA),including 13 cases of Stanford type B AD (TBAD) and 2 cases of Stanford type A AD (TAAD). The other 2 cases of aberrant left subclavian artery (ALSA) was combined with TBAD. In these 15 patients combined with TBAD,8 cases received the hybridization treatment,4 patients underwent the simple transluminal stent-graft placement,and 3 cases were subjected to the conservative treatment. All the other 2 patients combined with TAAD received the surgical treatment. Results Out of these 17 patients,16 cases were successfully followed up,while 1 patient was lost in the follow-up period (who received the conservative treatment). The follow-up period lasted from 5 to 58 months,with an average of (30±15) months. In the patients receiving the hybridization treatment,1 case reported perioperative death,and another 1 case suffered from severe endoleakage. In the patients receiving the simple transluminal stent-graft placement,1 case reported coldness in right upper extremity,combined with numbness. One case receiving the surgical treatment reported severe endoleakage within 3 months after operation. Moreover,2 cases reporting severe inner leakage underwent the secondary embolization treatment,obtaining satisfactory embolization effects. For the one case reporting coldness in right upper extremity,combined with numbness,after endovascular repairing treatment,the symptoms were significantly relived after drug treatment,without surgical treatment. No sever complications had been reported for the other patients during the follow-up period. Conclusion Patients with ASA+AD should be clearly diagnosed before surgery,and specific surgical plans should be determined according to specific conditions. Surgical treatment should be preferred for the patients of ASA combined with TAAD. For the patients of ASA combined with TBAD,the TEVAR or hybridization treatment or fenestration treatment could be considered,according to the condition of the arch branch vessels. Key words: Subclavian artery; Aorta; Aneurysm, dissecting; Radiology, interventional; Vascular surgical procedures

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). 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. 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. 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.

Repair of Kommerell's Diverticulum and Aberrant Subclavian Arteries: Classification of the Five Groups in Declining Frequency and Their Operative Approaches

We determined the relationship between aortic arch anatomy in tetralogy of Fallot with pulmonary stenosis and chromosomal or genetic abnormality, by performing analysis of 257 consecutive patients undergoing surgical repair from January, 2003 to March, 2011. Chromosomal or genetic abnormality was identified in 49 of the 257 (19%) patients. These included trisomy 21 (n = 14); chromosome 22q11.2 deletion (n = 16); other chromosomal abnormalities (n = 9); CHARGE (n = 2); Pierre Robin (n = 2); and Kabuki, Alagille, Holt-Oram, Kaufman McKusick, Goldenhar, and PHACE (n = 1 each). Aortic anatomy was classified as left arch with normal branching, right arch with mirror image branching, left arch with aberrant right subclavian artery, or right arch with aberrant left subclavian artery. Associated syndromes occurred in 33 of 203 (16%) patients with left arch and normal branching (odds ratio 1); three of 36 (8%) patients with right arch and mirror image branching (odds ratio 0.4, 95% confidence interval 0.1-1.6); seven of eight (88%) patients with left arch and aberrant right subclavian artery (odds ratio 36, 95% confidence interval 4-302); and six of 10 (60%) patients with right arch and aberrant left subclavian artery (odds ratio 8, 95% confidence interval 2-26). Syndromes were present in 13 of 18 (72%) patients with either right or left aberrant subclavian artery (odds ratio 15, 95% confidence interval 4-45). Syndromes in patients with an aberrant subclavian artery included trisomy 21 (n = 4); chromosome 22q11.2 deletion (n = 5); and Holt-Oram, PHACE, CHARGE, and chromosome 18p deletion (n = 1 each). Aberrant right or left subclavian artery in tetralogy of Fallot with pulmonary stenosis is associated with an increased incidence of chromosomal or genetic abnormality, whereas right aortic arch with mirror image branching is not. The assessment of aortic arch anatomy at prenatal diagnosis can assist counselling.

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

Stent Graft-Induced Aortic Wall Injury—Anesthesia Pitfalls and Pearls for the Thoracic Endovascular Aortic Repair Procedure

Early outcomes of robotic management of aberrant subclavian artery.

ObjectivesTo evaluate the in-hospital and later outcomes of thoracic endovascular aortic repair (TEVAR) for type B intramural hematoma (TBIMH) combined with an aberrant subclavian artery (aSCA).MethodsIn the period from January 2014 to December 2020, 12 patients diagnosed with TBIMH combined with aSCA and treated by TEVAR were enrolled in this retrospective cohort study, including 11 patients with the aberrant right subclavian artery (ARSA) and 1 with an aberrant left subclavian artery (ALSA). A handmade fenestrated stent-graft or chimney stent or hybrid repair was performed when the proximal landing zone was not enough.ResultsThe mean age of all the patients was 59.2 ± 7.6 years, and 66.7% of patients were men. There were 4 patients with Kommerell's diverticulum (KD). The procedures in all 12 patients were technically successful. There was one case each of postoperative delirium, renal impairment, and type IV endoleak after TEVAR. During follow-up, 1 patient died of acute pancreatitis 7 months after TEVAR. The overall survival at 1, 3, and 5 years for the patients was 90.9, 90.9, and 90.9%, respectively. KD was excluded in 2 patients, and the handmade fenestrated stent-graft was applied in the other 2 patients to preserve the blood flow of the aSCA. No neurological complications developed and no progression of KD was observed during the follow-up.ConclusionThoracic endovascular aortic repair for patients with aSCA and TBIMH is promising. When KD was combined, we could exclude KD or preserve the blood flow of aSCA with regular follow-up for the diverticulum according to the size of the KD.

The purpose of this study was to evaluate the utility of 16-slice multidetector computed tomographic (MDCT) angiography for identifying anatomic features of aberrant subclavian arteries. Seventeen patients with aberrant subclavian arteries were assessed by MDCT angiography. The aortic arch position, the presence of a Kommerell's diverticulum, aneurysm, vascular compression of trachea and oesophagus and associated cardiovascular abnormalities were evaluated. MDCT findings were confirmed by surgery in eight patients but in the other nine patients no further evaluation or management was warranted as the aberrant subclavian artery had no significant clinical consequence. Eleven patients had an aberrant right subclavian artery arising from the left aortic arch and six patients had an aberrant left subclavian artery arising from the right aortic arch. Kommerell's diverticulum was identified in three patients with an aberrant right subclavian artery and in five patients with an aberrant left subclavian artery. In two patients it was aneurysmal. Oesophageal compression was detected in eight patients, and tracheal compression was identified in only one paediatric patient. An aberrant subclavian artery was associated with complex congenital heart disease in one patient, intracardiac defects in two patients, aortic coarctation in two patients, patent ductus arteriosus in two patients and an aberrant vertebral artery in one patient. In conclusion, MDCT angiography is superior to digital subtraction angiography for the assessment of aberrant subclavian arteries since digital subtraction angiography has only a poor ability to visualize adjacent structures completely and is invasive in nature. MDCT angiography or magnetic resonance angiography are the current standard in the initial evaluation of thoracic vascular anomalies.

Midterm Morphological Change of Kommerell's Diverticulum after Hybrid Thoracic Endovascular Aortic Repair

Endoleak Type II: Deceitful Predictor of Delayed Paraplegia

Complicated acute type B aortic dissection with involvement of an aberrant right subclavian artery and rupture of a thoracoabdominal aortic aneurysm, Crawford type I: Successful emergency endovascular treatment