Aortic Arch Vessels Research Articles

Prenatal Diagnosis of Fetal Interrupted Aortic Arch Type A by Two-Dimensional Echocardiography and Four-Dimensional Echocardiography with B-Flow Imaging and Spatiotemporal Image Correlation.

Fetal interrupted aortic arch (IAA) is a rare cardiac anomaly and its prenatal diagnosis is challenging. The purpose of our report is to evaluate the use of two-dimensional echocardiography (2DE) and 4D echocardiography with B-flow imaging and spatiotemporal image correlation (4D BF-STIC) in detecting IAA type A (IAA-A). Twenty-three cases of confirmed IAA-A identified by fetal echocardiography were involved in the study. The fetal echocardiography image data were reviewed to analyze the ratio of right ventricle to left ventricle (RV/LV) diameter, the ratio of main pulmonary artery to ascending aorta (MPA/AAO) diameter, and the correlation of RV/LV diameter ratio and size of ventricular septal defect (VSD). 4D BF-STIC was performed in 21 fetuses using the sagittal view (4D BF-STIC-sagittal) and the four-chamber view (4D BF-STIC-4CV) as initial planes of view. An additional 183 normal fetuses were also included in our study. RV/LV and MPA/AAO ratios were calculated and compared with that of IAA-A fetuses. Fetal 2DE, 4D BF-STIC-sagittal, and 4D BF-STIC-4CV were used to visualize the aortic arch and its associated neck vessels. Six subgroups were evaluated according to gestational age. Fetal 2DE, 4D BF-STIC-sagittal, and 4D BF-STIC-4CV made the correct prenatal diagnosis of IAA-A in 19/23 (82.6%), 14/21 (66.7%), and 19/21 (90.5%) of patients, respectively. A significantly enlarged MPA combined with symmetric ventricles was found in the IAA-A fetuses, while the size of the VSD was negatively correlated with RV/LV ratio. 4D BF-STIC-sagittal and 4D BF-STIC-4CV were better than traditional 2D ultrasound in detecting the aortic arch and neck vessels between 17 and 28 gestational weeks and 29 to 40 gestational weeks in normal fetuses. It is demonstrated that IAA-A could be diagnosed by traditional fetal echocardiography, while 4D technique could better display the anatomic structure and the spatial relationships of the great arteries. Use of volume reconstruction may promote its clinical usage and help prenatal diagnosis.

Radiofrequency In Situ Fenestration for Aortic Arch Vessels During Thoracic Endovascular Repair

Purpose: To report the first clinical application of a novel technique using radiofrequency puncture to create retrograde in situ fenestrations during thoracic endovascular aortic repair (TEVAR). Methods: Between June 2011 and December 2013, 40 TEVAR procedures were performed in our facility, including 10 cases in which in situ fenestration was planned. Two thoracic stent-graft models were deployed: the Valiant (n=5) and the Zenith TX2 (n=5). A 0.035-inch PowerWire radiofrequency guidewire delivered from a brachial approach was used to fenestrate the grafts covering a left subclavian artery (LSA) in 9 cases and a left common carotid artery in one. The fenestrations were serially dilated to 6 mm, and self-expanding Advanta V12 covered stents were positioned in the target arteries. Results: Technical success was achieved in 6 of the 10 planned cases. Of the remaining 4 cases, stent-grafts were deployed in zone 3 in 2 cases (one received a chimney to the LSA). Another stent-graft was deployed in zone 2 without endoleak after fenestration was abandoned (the LSA had good filling via the vertebral artery). In the last case, the fenestration was unsuccessful in double-layered (proximal extension overlap) stent-grafts; a carotid-axillary bypass was required. There were no fenestration-related complications, but overall surgical complications included a case of paraparesis that resolved following spinal drainage and a death from a preexisting aortoesophageal fistula. There were no postoperative strokes. All fenestrations remained patent, and there were no endoleaks at a mean 12-month follow-up (range 1–33). Conclusion: Radiofrequency puncture is a viable alternative to needle or laser punctures for in situ fenestration during TEVAR. Early clinical results suggest technical feasibility and acceptable early outcomes.

Preoperative Assessment of High-Risk Aortic Plaque by Magnetization-Prepared Rapid Acquisition with Gradient-Echo Imaging in a Patient with Total Arch Replacement.

We present a case of a 70-year-old male who underwent surgical repair of an aortic arch aneurysm. Preoperative assessment of high-risk aortic plaque was performed using magnetization-prepared rapid acquisition with gradient-echo (MPRAGE) imaging. This preoperative image was compared with a histological analysis of plaque specimens from the aortic arch and neck vessels. A high signal intensity on MPRAGE images coincided with intraplaque hemorrhage. MPRAGE, which could detect a fragile plaque in the aorta, could be a powerful modality to prevent intraoperative stroke during cardiovascular surgery.

Aortic Arch Vessel Geometries and Deformations in Patients with Thoracic Aortic Aneurysms and Dissections

PurposeTo quantify aortic arch geometry and in vivo cardiac-induced and respiratory-induced arch translations and arch branch angulations using three-dimensional geometric modeling techniques. Materials and MethodsScanning with electrocardiogram-gated computed tomography angiography during inspiratory and expiratory breath holds was performed in 15 patients (age, 64 y ± 14) with thoracic aortic aneurysms or dissections. From the lumen models, centerlines of the thoracic aorta, brachiocephalic artery, left common carotid artery, and left subclavian artery and their branching ostia positions were quantified. Three-dimensional translation of vessel ostia, branching angles, and their changes secondary to cardiac pulsation and respiration were computed. ResultsDuring expiration, all ostia translated rightward from systole to diastole (P < .035). Regardless of cardiac phase, all ostia translated posteriorly and superiorly from inspiration to expiration (P < .05). Respiration induced greater posterior and superior translations than cardiac pulsation (P < .03). The left common carotid artery branch angled significantly more toward the aortic arch compared with the brachiocephalic artery and left subclavian artery (P < .03). No significant changes in branching angle were found from systole to diastole or inspiration to expiration. ConclusionsIn patients with thoracic aortic aneurysms or dissections, the thoracic aortic arch translated significantly secondary to inspiration and expiration and to a lesser extent secondary to cardiac pulsation. Insignificant branching angle changes suggest that the aortic arch and its branch origins move predominantly in unison.

PS22 Endovascular Repair of Ruptured Abdominal Aortic Aneurysm: Are Outcomes Improving?

aneurismal arch involvement (n 1⁄4 3 [21%]), residual arch dissections after ascending aortic repair (n 1⁄4 2 [14%]), post-traumatic aneurysm (n 1⁄4 1 [7%]), and type II thoracoabdominal aortic aneurysm with arch involvement (n 1⁄4 1 [7%]). A total of 22 aortic arch vessels (brachiocephalic trunk, 7; left common carotid artery, 11; bovine arch, 2; left subclavian artery [LSA], 2) were targeted. The left LSA was intentionally covered in 12 cases and preoperatively revascularized in nine. Successful endograft implantation was achieved in all cases. Two early postoperative deaths occurred (one retroperitoneal hematoma and stroke, and one unclear cause). Further major complications included a major stroke with significant early clinical improvement, one delayed transient paraplegia, and one Vascular Plug dislocation. The mean intensive care unit and hospital stays were 36 2 and 116 8 days, respectively. At 8 6 7 months of follow-up, the cumulative survival was 79%, with no aneurysm-related death or reinterventions. One type II endoleak is managed conservatively and one patient with persistant false lumen perfusion is planned to undergo endograft extension. Conclusions: FBSG present a feasible and safe therapeutic alternative for repair of aortic arch pathologies in high-risk patients.

Perioperative transesophageal echocardiography for aortic dissection

Aortic dissection is an infrequent but serious condition that often requires immediate operative intervention. We explore recent developments in the classification of aortic dissection and perioperative transesophageal echocardiography that assist with quantifying the severity of disease and facilitate its management. We describe the pivotal role of echocardiography in relation to key surgical considerations such as cannulation, aortic root surgery, perfusion in the aortic arch vessels, stenting in hybrid arch repair, and timing of preventative surgery. Developments in the classification of aortic dissection have improved our perspective and understanding of the key presenting features that affect mortality. Improvements in patient outcome may be achieved in part by appropriately timed echocardiography-guided surgery.

Congenital Cardiac, Aortic Arch, and Vascular Bed Anomalies in PHACE Syndrome (from the International PHACE Syndrome Registry)

PHACE syndrome represents the association of large infantile hemangiomas of the head and neck with brain, cerebrovascular, cardiac, ocular, and ventral or midline defects. Cardiac and cerebrovascular anomalies are the most common extracutaneous features of PHACE, and they also constitute the greatest source of potential morbidity. Congenital heart disease in PHACE is incompletely described, and this study was conducted to better characterize its features. This study of the International PHACE Syndrome Registry represents the largest central review of clinical, radiologic, and histopathologic data for cardiovascular anomalies in patients with PHACE to date. Sixty-two (41%) of 150 subjects had intracardiac, aortic arch, or brachiocephalic vessel anomalies. Aberrant origin of a subclavian artery was the most common cardiovascular anomaly (present in 31 (21%) of150 subjects). Coarctation was the second most common anomaly, identified in 28 (19%) of 150 subjects, and can be missed clinically in patients with PHACE because of the frequent association of arch obstruction with aberrant subclavian origin. Twenty-three (37%) of 62 subjects with cardiovascular anomalies required procedural intervention. A greater percentage of hemangiomas were located on the left side of the head and neck in patients with coarctation (46% vs 39%); however, hemangioma distribution did not predict the presence of cardiovascular anomalies overall. In conclusion, PHACE is associated with a high risk of congenital heart disease. Cardiac and aortic arch imaging with detailed assessment of arch patency and brachiocephalic origins is essential for any patient suspected of having PHACE. Longitudinal investigation is needed to determine the long-term outcomes of cardiovascular anomalies in PHACE.

Ataxia and vertigo due to anomalous origin of the left vertebral artery

The origin of anomalies of the left vertebral artery has been previously described. The vertebral artery is a collateral branch of subclavian artery and takes a posterior-vertical course to usually enter into the sixth cervical transverse foramen (88%).1Kubikova E. Osvaldova M. Mizerakova P. El Falougy H. Benuska J. A variable origin of the vertebral artery.Bratisl Lek Listy. 2008; 109: 28-30PubMed Google Scholar We report a case of a 64-year-old woman who presented with syncope and a 30-year history of vertigo during left head rotation. Physical examination showed bilateral vertical nystagmus and ataxia during deambulation with left head rotation. The duplex ultrasound showed the hemodynamically significant right carotid stenosis. The computed tomography angiography confirmed the carotid stenosis (A) with right vertebral artery hypoplasia (B) and left vertebral artery originated directly from the aortic arch between left carotid and subclavian arteries (A). There was additional abnormality of absence of the inferior thyroid branch of the thyrocervical trunk in the left side. The left vertebral artery in our case enters the forth transverse foramen (C; Video, online only). The patient underwent right carotid artery endarterectomy under plexus anesthesia. No complications were observed in the postoperative period. Her recovery was uneventful and she was discharged on postoperative day 3 with antiplatelet therapy. Six-month follow-up Doppler demonstrated carotid and vertebral arteries patency. The patient still complains of vertigo during left head rotation. The brachiocephalic trunk, left common carotid artery, and left subclavian artery are the typical three branches that arise from the aortic arch. However, the left vertebral artery arises from the arch of the aorta in approximately 6% of the population; in a few cases, it arises from the left common carotid artery or the root of the left subclavian artery.2Koenigsberg R.A. Pereira L. Nair B. McCormick D. Schwartzman R. Unusual vertebral artery origins: examples and related pathology.Catheter Cardiovasc Interv. 2003; 59: 244-250Crossref PubMed Scopus (42) Google Scholar The patients with left vertebral artery anomalies are usually asymptomatic. Rare cases have presented with dizziness, but this does not seem to be associated with the anomalous origin. In our cases, the left vertebral artery origin anomaly with its C4 entrance and contralateral hypoplasia could be causing the ataxia during head rotation. Accurate assessment of anatomic variations of vertebral arteries is mandatory before supra-aortic artery surgery and for planning aortic arch surgery or endovascular interventions. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiZTY2MTBlYzFhYTdkMGJjNmMzNzA3YzJiNDY0MjBkOCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NTYwNjg0fQ.AjK1K8aSSkxMWXvo9aKT4C7I6FJo338C8-sPdUd4BTA5ywkoNrWYZ6YaEQ8zkMu1J-5GjbGwMTPsHZrd2YMEBsdRC_eRqNLyp6BCG0IYkfV3rUcWVaSIrb7jXrN5N_WYVINA7fZrZ0YbPbr_JnwzWYEx2WsBsbMpfZl3FctOZysOlZ2glIt0UX7hb3jGzREPViBIkSl2Dse9noWW2273SDV4CfBpwOfdJA5RTcTu9PaKItHn4cc_3clH36qX4AGe59CKsVAuxxzTZSaX8CJ2TYO2vmDQp5Lci0KinF-pxYoJQvGPUmsPkqJ9chuE1LUul7jgM1CBt6sUBBoR5i4CoQ Download .mp4 (0.79 MB) Help with .mp4 files Video 1The video shows the 360° complete computed tomography volume rendering 3D-reconstruction of aortic arch and supra-aortic vessels.

Regression of takayasu retinopathy after revascularization of occluded branches of the aortic arch by percutaneous angioplasty.

To present a patient with decreased vision because of Takayasu retinopathy who had improvement in vision and regression of retinopathy after percutaneous angioplasty of occluded aortic arch vessels. Interventional case report. A 37-year-old woman with multiple cerebral infarcts and recurrent seizures was referred with painless progressive reduction in vision in the right eye of few months' duration and left eye for 2 years. Vision was 20/120 in the right eye and perception of light in the left eye. There was mild disk pallor in the right eye, optic atrophy in the left eye, and microaneursyms in both eyes. Angiographic findings were consistent with type I Takayasu arteritis. Angioplasty and stenting was performed initially to the right subclavian and common carotid arteries and to the left subclavian, and left internal carotid arteries 6 weeks later. There was improvement in vision to 20/80 and regression of Takayasu retinopathy in the right eye at 3 months post procedure that improved further to 20/50, 6 months post procedure. Vision, as expected, remained poor in the left eye despite revascularization. Restoration of flow in the aortic arch vessels may result in reversal of ischemic retinal changes in patients with Takayasu retinopathy.

Type I and Type II hybrid aortic arch replacement: postoperative and mid-term outcome analysis.

Hybrid aortic arch replacement has emerged as a safe treatment modality for arch aneurysms, especially in patients of old age and with greater comorbid burden. We assessed our institutional outcomes in patients undergoing Types I and II hybrid aortic arch replacement. From 2005 to 2012, 685 patients underwent thoracic endovascular repair (TEVAR), of whom 104 had hybrid arch repair (open + endovascular approach). 47 of these patients had treatment for aortic arch aneurysm ± proximal ascending aortic aneurysm. The hybrid repair entailed aortic arch vessel debranching and concomitant/delayed antegrade ± retrograde TEVAR stent grafting of the arch. Type III patients were excluded from the analysis. Data was prospectively maintained. 28 patients had Type I repair, 8 had Type II repair, and 11 had Type III repair. Mean age was 71±8 years. Primary aortic pathology was aneurysm (81%), followed by chronic arch dissection (11%). 14% of patients required reoperative cardiac surgery. Stent graft deployment rate was 100% after arch vessel debranching. Postoperative endoleak rate was zero. Average cardiopulmonary bypass time was 215±64 minutes, with crossclamp time of 70±55 minutes, and circulatory arrest time of 50±17 minutes. Paraplegia rate was 5.5% (n=2), with stroke rate of 8% (n=3) and renal failure rate of 3% (n=1) requiring hemodialysis. In-hospital mortality was 8% (n=3). Mean length of stay was 17.2±14 days. Median follow-up was 30±21 months. Freedom from all-cause mortality was 71%, 60%, and 48% at 1, 3, and 5 years respectively. Aortic reoperation rate was 2.7% (n=1). No patient had Type I or III endoleak at follow-up. Freedom from mortality was improved in cases performed more recently (July 2008 to 2012) than during our early experience (2005 to June 2008) (81% versus 44% at 3 years, P=0.05). Hybrid aortic arch replacement can be performed with good postoperative and midterm results in a cohort of old patients with significant comorbidity. With greater experience, early and midterm outcomes continue to improve. The hybrid arch technique may represent a technical advancement in the field of aortic arch surgery.

Hemodynamics of the transitional aortic arch patterning at a key embryonic stage

Purpose: This study examines the morphologic and hemodynamic changes occurring in the early embryonic aortic arch (AA) vessels. Methods: We applied fluorescent dye microinjection and optical coherence tomography to measure the diameters of the bilateral embryonic chick AAs at stages 18, 21, and 24 (3, 3.5, and 4 days, respectively). Polymeric casts were used to generate 3D models of the AAs at each stage, reconstructed from micro-computed tomography scans. Pulsatile blood flow was simulated using computational fluid dynamics (CFD), with stage-specific inlet flow based on Doppler ultrasound. Results:We found that the AAs present at stages 18 and 24did not vary from embryo to embryo while the intermediate stage 21 presented with four possible configurations. This variability was associated with increasedwall shear stress (WSS) levels at stage 21 compared to stages 18 and 24, as computed from CFD results. Diameter measurements showed asymmetric growth of AA pair IV, where both laterals increased from stage 18 to 21 while only the right lateral increased from stage 21 to 24 (Pb.05). CFD revealed that the right lateral flow of AA pair IV was more than 1.8 times that of the left lateral at all stages. Regression analysis revealed a quadratic relationship between a change in WSS and a change in AA diameter (P=.002). Conclusions: Our study provides the first comparison between quantitative in vivo data and CFD-predicted hemodynamics of the early embryonic AA. Changes in flow distribution and WSS were associated with increased morphogenetic activity of the stage 21 AAs.

Computed tomography angiography of hybrid thoracic endovascular aortic repair of the aortic arch

Endovascular repair of the aorta has traditionally been limited to the abdominal aorta and, more recently, the descending thoracic aorta. However, recently hybrid repairs (a combination of open surgical and endovascular repair) have made endovascular repair of the aortic arch possible. Hybrid repair of the aortic arch typically involves an open surgical debranching procedure that allows for revascularization of the aortic arch vessels and subsequent endovascular stent placement. These approaches avoid the deep hypothermic circulatory arrest required for full, open surgical repair of the aortic arch. In hybrid repairs, the stent landing zone determines which branch vessels will be covered and therefore need revascularization. This article will review the preprocedure assessment with computed tomography angiography, techniques for revascularization and postprocedure complications.

Modified Perfusion Strategy and Aortic Arch Debranching in Complicated Acute Aortic Dissection Type A: A Bridge to Definitive Endovascular Therapy

Patients with acute aortic dissection type A (AADA) with aortic arch and supra-aortic vessel involvement have a higher postoperative stroke prevalence and risk of later aortic arch aneurysm development. We report a case of AADA with involvement of supraaortic arteries, complicated by cerebral malperfusion. The ascending aorta was replaced using bilateral antegrade cerebral perfusion through side-grafts attached to both carotid arteries, which were subsequently used as aorto-bi-carotid bypass. One year later, the diameter of aortic arch increased to 5 cm. The endovascular treatment of aortic arch was easily performed since debranching was already almost complete. Immediate bilateral carotid artery inflow and subsequent aorto-bi-carotid bypass is a safe way to prevent cerebral malperfusion in the setting of complicated AADA.A potential benefit of this technique is almost complete debranching that facilitates an endovascular arch replacement.

Abstract TP124: Mediators of the Age Effect among Patients Treated with Carotid Artery Stenting: The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST)

Background An increased risk of periprocedural stroke and death has been reported for older patients treated with carotid stenting (CAS). Selection of patients for CAS could be improved if patient or artery characteristics responsible for this higher risk could be identified. Methods The 1123 CREST patients randomized to CAS who received CAS within 30-days were analyzed. From the CREST sites, risk factors for atherosclerosis (hypertension, diabetes, and dyslipidemia) and arterial characteristics by angiography (lesion length, eccentric lesions, ulcerated lesions, and percent stenosis) were assessed. From the CREST core labs, potential mediators of the age effect included peak systolic velocity (ultrasound core, available on 853 patients) and arterial characteristics (angiographic core, available on 1042 patients, narrow/no ulcer or wide mouth, lesion location, and distal tortuosity). Mediation analysis assessed impact of adjustment for these factors on the magnitude of the estimated increased risk for CAS at older ages. Results After adjustment for sex and symptomatic status, there was a 1.72-times (95% CI: 1.26 - 2.37) increased risk of periprocedural stroke and death associated with each decade of patient age. Adjustment for lesion length as assessed in the clinical center significantly attenuated this increased risk at older ages to 1.66 (95% CI: 1.20 - 2.29, p = 0.039), an 8.3% attenuation. No other factor showed evidence as a contributor to the periprocedural increased risk of stroke and death in older patients (p &gt; 0.10). Conclusion These data suggest that a longer carotid artery lesion length is a significant contributor to the increased risk of CAS in the elderly. However, attenuation of the age effect was modest, less than a 10% change in the hazard ratios. Other potential mediators such as tortuosity and atherosclerosis of the aortic arch and great vessels were not assessed. Non-anatomic factors that are more common with advancing age such as cerebral white matter disease and subclinical dementia were also not assessed and may play a role in how elderly patients respond to ischemic insults.

Supravalvular aortic stenosis in adult with anomalies of aortic arch vessels and aortic regurgitation

The supravalvular aortic stenosis is a rare congenital heart defect being very uncommon in adults. We present a case of supravalvular aortic stenosis in adult associated with anomalies of the aortic arch vessels and aortic regurgitation, which was submitted to aortic valve replacement and arterioplasty of the ascending aorta with a good postoperative course.

Five-vessel aortic arch associated with a bicuspid aortic valve

Little information exists regarding the prevalence of aberrant or ectopic aortic arch vessels in patients with different cardiovascular anomalies. We present a young patient with an aberrant right subclavian artery associated with an ectopic left vertebral artery and a bicuspid aortic valve.

Radiopacity of Self-Adhesive Resin Cements using a Digital X-ray System

As mediastinal sarcomas commonly present as large tumors invading adjacent vital structures, complete resection is frequently challenging. For such tumors, aggressive surgical strategies, such as the resection and reconstruction of the invaded vital structures under cardiopulmonary bypass, may be required to achieve complete resection and to improve survival. Herein, we report a case of recurrent mediastinal sarcoma invading the aortic arch and arch vessels that was successfully removed by total arch replacement.

Total aortic arch replacement with a novel four-branched frozen elephant trunk graft: first-in-man results†

The combined disease of the aortic arch and the proximal descending aorta remains a surgical challenge. With the 'frozen elephant technique', the ascending aorta, along with the aortic arch, is replaced conventionally and an endovascular stent graft is placed into the descending aorta in the antegrade manner through the open aortic arch, thereby potentially allowing for a 'single-stage' operation. The purpose of this study was to assess the feasibility of a novel four-branched hybrid graft (Vascutek, Scotland). From April 2010 to August 2011, 34 patients (25 males, age 60 ± 14 years) were operated on [14 aneurysms, 20 dissections (18 acute)]. Ten of these patients had undergone previous cardiac operations. The collapsed endoprosthesis was deployed in the descending aorta through the opened aortic arch. A sewing collar between the graft segments simplified the 'distal' anastomosis. The four-branched graft segment allowed the replacement of the aortic arch and supra-aortic vessels individually. Concomitant procedures were performed if necessary. There were three deaths within the 30 postoperative days. All of them were of AADA patients. The mean cardiopulmonary bypass time was 254 ± 53 min, aortic cross clamp time was 148 ± 48 min and circulatory arrest time was 48 ± 22 min. Aortic valve-sparing root surgery was performed in 12 patients, Bentall procedure in four, CABG in three and mitral valve repair in two. In one patient, a secondary endovascular extension of the stent graft was necessary to reach the landing zone. In all others, postoperative CT-Scans confirmed the desired results. The graft adds to the 'frozen elephant trunk' concept for treating the arch and proximal descending aorta. Early experience demonstrates an excellent 30-day survival. Combining the frozen elephant with a four-branched arch graft increases the armament of the surgeon in the treatment of complex and diverse aortic arch pathology.

Subclavian artery injury following blunt trauma: A report of three cases

Subclavian artery injuries are rare in blunt chest trauma, constituting just 1–2 percent of all acute vascular injuries. The diagnosis of injury to the subclavian artery is challenging as a good percentage of patients with such vascular injuries have palpable distal pulses, no signs of any external local trauma and associated injuries often divert the attention of treating physicians. Subclavian artery injuries are the second most common injuries to occur to the aortic arch vessels. The mechanism of injury to these vessels varies from deceleration to traction on upper extremity and neck. Angiography is vital in diagnosis and surgical planning of these patients depends on the site and side of the vascular injuries. Early surgical treatment is an important part of management of these patients. Endovascular treatment is of value in a selected subgroup of subclavian artery injury patients. Reported mortality of subclavian artery injuries varies according to haemodynamic status of patient, time of presentation and other associated injuries. A high degree of suspicion is key to diagnosing these vascular injuries. Early appropriate surgical repair of vascular injury, in combination with aggressive treatment of associated injuries, is important for the optimal outcome of these cases. Here we report three cases of subclavian artery injury, which were successfully treated in Hamad General Hospital by vascular surgery and intensive care teams.

Aortic arch vessel anomalies associated with persistent trigeminal artery

Developmental anomalies of the aortic arch vessels and persistent trigeminal artery that is the most common of the four anomalous carotid–basilar anastomoses are repeatedly reported in the literature as separate entities. Herein we report a previously undescribed variant including the coexistence of persistent trigeminal artery, truncus bicaroticus and direct origin of left vertebral artery from aortic arch.