Branchial Arteries Research Articles

The phylogeny of central chemoreception

Respiratory chemoreceptors responsive to changes in CO(2)/H(+) appear to be present in all vertebrates from fish to birds and mammals. They appear to have arisen first in the periphery sensitive to the external environment. Thus, in most fish CO(2)/H(+) chemoreceptors reside primarily in the gills and respond to changes in aquatic rather than arterial P(CO)₂ . In the air-breathing tetrapods (amphibians, mammals, reptiles and birds), the branchial arches regress developmentally and the derivatives of the branchial arteries are now exclusively internal. The receptors associated with these arteries now sense only arterial (not environmental) P(CO)₂/pH . Central CO(2)/H(+) chemoreception also appears to have arisen with the advent of air breathing, presumably as a second line of defense. These receptors may have arisen multiple times in association with several (but not all) of the independent origins of air breathing in fishes. There is strong evidence for multiple central sites of CO(2)/H(+) sensing, at least in amphibians and mammals, suggesting that it may not only have originated multiple times in different species but also multiple times within a single species.

PP-131 A CASE OF DIVERTICULUM OF KOMMERELL WITH ABERRANT RIGHT SUBCLAVIAN ARTERY, PATENT DUCTUS ARTERIOSUS, LIVER AND THREE PIECES SPLEEN REPLACING EACH OTHER ZONE

,Objective: Kommerell’s diverticulum is a rare condition, involving the left fourth aortic arch and the anomalous origin of the right subclavian artery (0.5%-2%). It is usually asymptomatic and is most often an incidental finding. In symptomatic patients symptoms usually arise from compressing of trachea and esophagus. Methods: A 38 year old male who was diagnosed chronic obstructive lung disease with his symptoms such as dyspnea and dysphagia presented to our department due to worsening of his symptoms. Three dimensional computerized tomography scans performed to him and kommerell’s diverticulum with aberrant right subclavian artery and patent ductus arteriosus has found. At the same CT, accidentally, there were left sided liver and right sided spleen in three pieces. As the scans showed, we confirmed that his symptoms occured due to that anomaly. Results: We report an unique case of Kommerell’s diverticula with patent ductus arteriosus, aberran right subclavian artery, persistant left superior vena cava, ascending aortic aneurysm, right sided liver and left sided three pieces spleen.

Internal Anatomy of Common Carp (Cyprinus carpio) as Revealed by Magnetic Resonance Imaging

Slices of T2-weighted and fat-suppressed images were obtained on a clinical scanner with the field strength of 1 T to identify various tissues, internal organs and structural details of a cyprinid fish (Cyprinus carpio). Different parts of pharyngeal and gastro-intestinal organs, liver and spleen were well distinguished. Kidneys were traced and the position of heart and its appendants such as bulbus arteriosus, ventral aorta and branchial arteries were identified. The images were confirmed by the corresponding slices of frozen fish.

Index of Suspicion

Index of Suspicion

Control of Branchial Artery Tone in Fish: Effects of Environmental Temperature and Phylogeny

Branchial artery vasoreactivity and nerve density were measured in teleosts of different phylogenetic relatedness from cold (-1.86 degrees to +1 degrees C) and temperate ( approximately 13 degrees C) environments. Polar Notothenia coriiceps and temperate Paranotothenia angustata are closely related Southern Hemisphere nototheniids, and polar Boreogadus saida and temperate Myoxocephalus scorpius are Northern Hemisphere species that are phylogenetically distant from each other and the nototheniids. Rainbow trout Oncorhynchus mykiss was used as a temperate comparison of different activity patterns. Cumulative dose-response curves for efferent branchial arteries (EBAs) revealed a lack of alpha-adrenergic (noradrenaline [NOR]) vasoactivity in M. scorpius and a lack of cholinergic (carbachol [CARB]) vasoactivity in B. saida, while responses in N. coriiceps and P. angustata were irregular. Oncorhynchus mykiss vessels were responsive to both constrictors, suggesting either receptor absence or spatial heterogeneity among species. The sensitivity (pEC(50)) of NOR or 5-hydroxytryptamine (5-HT) vasoconstriction showed little interspecific variation, while maximal tension varied among species for NOR but not 5-HT. Acute cooling did not affect agonist-independent vascular contraction induced by KCl or in response to NOR or 5-HT. The CARB sensitivity of EBAs increased with cooling in P. angustata alone. Each species possessed a unique pattern of innervation on both branchial arteries, distal and proximal to their respective aortas, that partially differentiated between nototheniids and nonnototheniids. We conclude there is little evidence for cold adaptation of branchial artery contractility, and mechanisms of vascular control likely reflect phylogeny rather than thermal history.

A new blood fluke of the genus Cardicola (Trematoda: Sanguinicolidae) from Pacific bluefin tuna Thunnus orientalis (Temminck & Schlegel, 1844) cultured in Japan

A new sanguinicolid blood fluke, Cardicola orientalis n. sp., is described from the afferent branchial artery and heart of Pacific bluefin tuna Thunnus orientalis (Temminck & Schlegel) cultured in Mie and Nagasaki Prefectures, Japan. The new species is most similar to C. ambrosioi Braicovich, Etchegoin, Timi et Sardella, 2006 from the Brazilian flathead, Percophis brasiliensis Quoy & Gaimard, but can be differentiated by the position of the female genital pore (in midline or slightly sinistral in C. orientalis vs. sinistral in C. ambrosioi) and much longer distance between male and female genital pore (101 μm vs. 27 μm). In wet mount preparations of infected fish, eggs were accumulated in great numbers in the gill lamellae and afferent filament arteries. Importance of this blood fluke infection of cultured Pacific bluefin tuna in Japan is discussed.

Absence of the right common carotid artery

In a 33-year-old male patient with multiple sclerosis, brain magnetic resonance imaging incidentally showed a narrow right intracranial internal carotid artery. Gadolinium-enhanced magnetic resonance angiography showed absence of the right common carotid artery. Right external and internal carotid arteries arose separately from the ipsilateral innominate artery and subclavian artery, respectively. Color-Doppler ultrasound confirmed this finding. Embriologically, the case could be interpreted as the disappearance of the third aortic arch with persistence of the carotid duct connecting the third and fourth aortic arches.

Abstract: P804 CONNECTION BETWEEN SERUM LEPTIN, ADIPONECTIN, ASYMMETRIC DIMETHYLARGININE LEVELS AND PARAOXONASE ACTIVITY IN RENAL TRANSPLANT PATIENTS

As a ubiquitous signaling molecule, nitric oxide (NO) exerts various important effects on the cardiovascular system and is involved in the regulation of vascular tone and myocardial metabolism in vertebrates. Lungfishes are closely related to tetrapods and provide an interesting possibility to understand the transition from water to land. Lungfishes are endowed with both systemic and pulmonary circulations, and their incompletely divided ventricle allows for blood to bypass either circuit. Lungfishes inhabit ephemeral waterbodies that may enforce prolonged aestivation during drought, throughout which nitric oxide synthase (NOS) expression is upregulated. To better understand the physiological relevance of NO on cardiovascular regulation in this transitory group, we measured vascular reactivity to muscarinic agonist acetylcholine, α- and β-adrenergic agonists (phenylephrine and isoproterenol, respectively), or the NO donor, sodium nitroprusside (SNP) on four vessel segments—efferent branchial arteries, gill artery, ductus arteriosus and pulmonary artery—from the African lungfish, Protopterus aethiopicus. In a simultaneous study, we measured oxygen consumption and twitch force in myocardial preparations in the presence and absence of an NOS inhibitor (asymmetric dimethylarginine; ADMA). Only the ductus arteriosus vasodilated in response to SNP. Isoproterenol caused vasodilation, whereas acetylcholine and phenylephrine vasoconstricted all vessel segments. NOS inhibition decreased myocardial force relative to oxygen consumption, indicating a lowered efficiency. We provide novel evidence that NO affects the vasculature of lungfish that may be derived from perivascular nitrergic nerves limited to the ductus arteriosus. Our data also suggests that NO exerts a tonic dampening of myocardial oxygen consumption which may be particularly important during aestivation.

Dependence of Aortic Arch Morphogenesis on Intracardiac Blood Flow in the Left Atrial Ligated Chick Embryo

Partial left atrial ligation before cardiac septation redistributes intracardiac blood flow and produces left ventricular hypoplasia in the chick. We hypothesized that redistributed intracardiac blood flow adversely alters aortic arch development. We ligated the left atrial appendage with a 10-0 nylon suture at stage 21 chick embryos, then reincubated up to stage 34. Sham embryos had a suture tied adjacent to the atrial wall, and normal controls were unoperated. We measured simultaneous atrioventricular (AV) and dorsal aortic (DAo) blood velocities from stage 24 embryos with an ultrasound pulsed-Doppler flow meter; and the left and right third and fourth aortic arch blood flow with a laser-Doppler flow meter. Ventricular and atrial cross-sectional areas were measured from sequential video fields for planimetry. Intracardiac flow patterns were imaged on video by injecting India ink into the vitelline vein. In separate embryos, radiopaque microfil was injected into the cardiovascular system for micro-CT scanning. We analyzed the morphologic characteristics of the heart at stage 34. Active AV and DAo stroke volume (mm(3)), right third and fourth aortic arch blood flow (mm(3)/s) were all decreased in ligated embryos (P < 0.05) when compared with normal and sham embryos. Ventricular end-diastolic volume versus normal and sham embryos decreased by 45% and 46%, respectively (P < 0.05). India ink injection revealed altered right aortic arch flow patterns in the ligated embryos compared with normal embryos. micro-CT imaging confirmed altered arch morphogenesis. Alterations in intracardiac blood flow disrupt both early cardiac morphogenesis and aortic arch selection.

How I became a biochemist

How I became a biochemist

Non-selective computed tomography angiography of a vascular ring anomaly in a dog

Non-selective computed tomography angiography (CTA) is an emerging imaging technique that will have continued application in veterinary medicine because of its short scan time, use of a single, peripheral venous injection and availability of more detailed anatomic information—including 3-dimensional reconstructions. The improved anatomic detail may facilitate veterinary students' learning of complex aortic arch malformations and details relative to the surgical approach. Herein we describe application of its use in a dog with a vascular ring anomaly due to a persistent right fourth aortic arch and left ligamentum arteriosum. Additionally, we compare images with a normal dog.

Vascular distribution of nitric oxide synthase and vasodilation in the Australian lungfish, Neoceratodus forsteri

The presence of nitric oxide synthase (NOS) and role of nitric oxide (NO) in vascular regulation was investigated in the Australian lungfish, Neoceratodus forsteri. No evidence was found for NOS in the endothelium of large and small blood vessels following processing for NADPH-diaphorase histochemistry. However, both NADPH-diaphorase histochemistry and neural NOS immunohistochemistry demonstrated a sparse network of nitrergic nerves in the dorsal aorta, hepatic artery, and branchial arteries, but there were no nitrergic nerves in small blood vessels in tissues. In contrast, nitrergic nerves were found in non-vascular tissues of the lung, gut and kidney. Dual-wire myography was used to determine if NO signalling occurred in the branchial artery of N. forsteri. Both SNP and SIN-1 had no effect on the pre-constricted branchial artery, but the particulate guanylyl cyclase (GC) activator, C-type natriuretic peptide, always caused vasodilation. Nicotine mediated a dilation that was not inhibited by the soluble GC inhibitor, ODQ, or the NOS inhibitor, L-NNA, but was blocked by the cyclooxygenase inhibitor, indomethacin. These data suggest that NO control of the branchial artery is lacking, but that prostaglandins could be endothelial relaxing factors in the vasculature of lungfish.

Oxygen dependency of hydrogen sulfide-mediated vasoconstriction in cyclostome aortas

Hydrogen sulfide (H(2)S) has been proposed to mediate hypoxic vasoconstriction (HVC), however, other studies suggest the vasoconstrictory effect indirectly results from an oxidation product of H(2)S. Here we examined the relationship between H(2)S and O(2) in isolated hagfish and lamprey vessels that exhibit profound hypoxic vasoconstriction. In myographic studies, H(2)S (Na(2)S) dose-dependently constricted dorsal aortas (DA) and efferent branchial arteries (EBA) but did not affect ventral aortas or afferent branchial arteries; effects similar to those produced by hypoxia. Sensitivity of H(2)S-mediated contraction in hagfish and lamprey DA was enhanced by hypoxia. HVC in hagfish DA was enhanced by the H(2)S precursor cysteine and inhibited by amino-oxyacetate, an inhibitor of the H(2)S-synthesizing enzyme, cystathionine beta-synthase. HVC was unaffected by propargyl glycine, an inhibitor of cystathionine lambda-lyase. Oxygen consumption (M(O(2))) of hagfish DA was constant between 15 and 115 mmHg P(O(2)) (1 mmHg=0.133 kPa), decreased when P(O(2)) <15 mmHg, and increased after P(O(2)) exceeded 115 mmHg. 10 micromol l(-1) H(2)S increased and > or =100 micromol l(-1) H(2)S decreased M(O(2)). Consistent with the effects on HVC, cysteine increased and amino-oxyacetate decreased M(O(2)). These results show that H(2)S is a monophasic vasoconstrictor of specific cyclostome vessels and because hagfish lack vascular NO, and vascular sensitivity to H(2)S was enhanced at low P(O(2)), it is unlikely that H(2)S contractions are mediated by either H(2)S-NO interaction or an oxidation product of H(2)S. These experiments also provide additional support for the hypothesis that the metabolism of H(2)S is involved in oxygen sensing/signal transduction in vertebrate vascular smooth muscle.

Recurrent sarcoma originating from the pulmonary artery 6 years after extensive thoracic resection

sided aortic arch and Kommerell diverticulum. Kommerell diverticulum (Figure 2) is a saccular aneurysmal dilation at the origin of an aberrant right or left subclavian artery. It is a rare anomaly that occurs in association with a double or left aortic arch and an aberrant right subclavian artery (0.5% of the population) or with a right aortic arch and an aberrant left subclavian artery (0.1%). Embryologically, it represents the persistent distal end of the interrupted fourth aortic arch, between the carotid and subclavian arteries. The question arises as to whether this congenital anomaly increases the likelihood of development of an AEF in response to disease or disruption. Kommerell diverticulum represents a likely area of weakening in the aortic wall that can also compress the esophagus and, in theory, could cause erosion of the structure into each other, especially when disruption of adventitial layers has occurred, such as with trauma. In summary, long-term survival can be achieved with early diagnosis and prompt surgical management of AEF. Because this condition presents in a catastrophic manner, younger and healthier patients are more likely to have better outcomes. In our case, the patient’s young age and the relatively small size of his AEF, as well as prompt diagnosis and surgical treatment, proved the ultimate determinants of success and are why he remains alive to this day.

Oxygen Dependency of Hydrogen Sulfide‐mediated Vasoconstriction in Cyclostome Aortas

Hydrogen sulfide (H2S) is a vasoregulatory molecule and recent evidence suggests it may be an O2 sensor for hypoxic vasoconstriction (HVC). Here we examined H2S ‐ O2 interactions in hagfish vessels. In myographic studies, H2S (Na2S) dose‐dependently constricted dorsal aortas (DA) and efferent branchial arteries (EBA) but did affect ventral aorta or afferent branchial arteries; hypoxia produces similar responses. Hypoxia enhanced DA sensitivity to H2S. HVC in DA was augmented by the H2S precursor cysteine and inhibited by aminooxy acetate (AOA), an inhibitor of the H2S‐synthesizing enzyme, CBS. HVC was unaffected by propargyl glycine, the CSE inhibitor. DA O2 consumption (MO2) was constant between PO2 15–115 mmHg, but decreased when PO2 &lt;15 mmHg and increased after PO2 exceeded 115 mmHg. 10 uM H2S increased MO2, whereas MO2 fell when [H2S] &gt;100 uM. Consistent with the effects on HVC, cysteine increased and AOA decreased MO2. These results show that H2S is a monophasic vasoconstrictor of specific cyclostome vessels and because hagfish lack vascular NO, and vascular sensitivity was enhanced at low PO2, it is unlikely that H2S contractions are mediated by either H2S‐NO interaction or an oxidation product of H2S. They also support the hypothesis that H2S metabolism is an O2 sensor in vertebrate vascular smooth muscle. Support: NSF IBN 0235223, IOS 0641436 and Erskin Fellowship (KRO)

Effects of hypoxia on vertebrate blood vessels

Hypoxia contracts mammalian respiratory vessels and increases vascular resistance in respiratory tissues of many vertebrates. In systemic vessels these responses vary, hypoxia relaxes mammalian vessels and contracts systemic arteries from cyclostomes. It has been proposed that hypoxic vasoconstriction in cyclostome systemic arteries is the antecedent to mammalian hypoxic pulmonary vasoconstriction, however, phylogenetic characterization of hypoxic responses is lacking. In this study, we characterized the hypoxic response of isolated systemic and respiratory vessels from a variety of vertebrates using standard myography. Pre-gill/respiratory (ventral aorta, afferent branchial artery, pulmonary artery) and post-gill/systemic (dorsal and thoracic aortas, efferent branchial artery) from lamprey (Petromyzon marinus), sandbar shark (Carcharhinus plumbeus), yellowfin tuna (Thunnus albacares), American bullfrog (Rana catesbeiana), American alligator (Alligator mississippiensis), Pekin duck (Anas platyrhynchos domesticus), chicken (Gallus domesticus) and rat (Rattus norvegicus) were exposed to hypoxia at rest or during pre-stimulation (elevated extracellular potassium, epinephrine or norepinephrine). Hypoxia produced a relaxation or transient contraction followed by relaxation in all pre-gill vessels, except for contraction in lamprey, and vasoconstriction or tri-phasic constriction-dilation-constriction in all pulmonary vessels. Hypoxia contracted systemic vessels from all animals except shark and rat and in pre-contracted rat aortas it produced a transient contraction followed by relaxation. These results show that while the classic "systemic hypoxic vasodilation and pulmonary hypoxic vasoconstriction" may occur in the microcirculation, the hypoxic response of the vertebrate macrocirculation is quite variable. These findings also suggest that hypoxic vasoconstriction is a phylogenetically ancient response.

First record of a fish parasite &lt;I&gt;Aporocotyle simplex&lt;/I&gt; (Digenea) from the Polish Exclusive Economic Zone of the Baltic Sea

Background. One specimen of Aporocotyle simplex Odhner, 1900 (Digenea: Sanguinicolidae) was confirmed in 2004 from the branchial artery of a dab, Limanda limanda (Linnaeus, 1758), from the Gulf of Gdańsk. This work provides a partial description and a few morphological measurements of that specimen. This is the first record of A. simplex from Poland.

Flow-Induced Asymmetry

Mammalian embryos initially develop symmetrically; then, in response to Nodal signaling and the action of the transcription factor Pitx2, organ asymmetry occurs. For example, during embryonic development, two blood vessels on the right side--the right sixth branchial arch artery and the dorsal aorta--undergo complete regression, resulting in the formation of the asymmetrical aortic arch and the pulmonary trunk (see Snider and Conway). Yashiro et al . determined that although Pitx2 activity was required for regression of the sixth branchial arch artery, which is the first vessel to regress, expression of this gene was not required in the artery itself. Instead, Pitx2 was required for a morphological change, the formation of a spiral structure of the myocardial left outflow tract, a structure through which blood leaves the heart. In animals in which the outflow tract did not spiral, regression of neither the right sixth branchial arch artery nor the right dorsal aorta occurred. Echocardiography showed that after the formation of the spiral structure, the blood flow to the right side vessels destined for regression was reduced, whereas blood flow to the left side vessels was greater than before the morphological change. Furthermore, this change in blood flow was lost in embryos with a promoter-mutated Pitx2 (Pitx ΔASE/ΔASE ), which also lacked a spiral form to the outflow tract and had persistent right vessels. To confirm that decreased blood flow was the signal for regression, the authors ligated the left sixth branchial arch artery prior to the formation of the spiral structure by the outflow tract and found that the left-side vessels (sixth branchial arch artery and dorsal aorta) regressed and the right, unligated vessels persisted. In the persistent left vessels in wild-type animals, there was increased expression of the gene encoding platelet-derived growth factor-A (PDGF-A) and increased phosphorylation of vascular endothelial growth factor receptor 2 (VEGFR2) compared with that in the right vessels after the morphological change. Again, this difference was lost in the Pitx ΔASE/ΔASE embryos. Simultaneous pharmacological inhibition of PDGFR and VEGFR triggered bilateral loss of the sixth branchial arch arteries. Thus, the authors suggest that the Nodal-Pitx2 pathway triggers a morphological change that increases blood flow on the left side and decreases blood flow on the right side, producing an asymmetric signal of growth factor signaling, allowing the side with the higher blood flow to survive and the side with less to regress. P. Snider, S. J. Conway, The power of blood. Nature 450 , 180-181 (2007). [PubMed] K. Yashiro, H. Shiratori, H. Hamada, Haemodynamics determined by a genetic programme govern asymmetric development of the aortic arch. Nature 450 , 285-288 (2007). [PubMed]

Respiratory vasculatures of the intertidal air-breathing eel goby, Odontamblyopus lacepedii (Gobiidae: Amblyopinae)

Lacking a propensity to emerge over the mud surface, the eel goby, Odontamblyopus lacepedii, survives low tide periods by continuously breathing air in burrows filled with hypoxic water. As with most marine air-breathing fishes, O. lacepedii does not possess an accessory air-breathing organ, but holds air in the buccal–opercular cavity. The present study aimed to clarify how the respiratory vasculature has been modified in this facultative air-breathing fish. Results showed that the gills apparently lacked structural modifications for air breathing, whereas the inner epithelia of the opercula were richly vascularized. Comparison with two sympatric gobies revealed that the density of blood capillaries within 10μm from the inner opercular epithelial surface in O. lacepedii (14.5 ± 3.0 capillaries mm−1; mean ± s.d., n = 3) was significantly higher than in the aquatic non-air-breathing Acanthogobius hasta (0.0 ± 0.0) but significantly lower than in the amphibious air-breathing mudskipper, Periophthalmus modestus (59.1 ± 8.5). The opercular capillary bed was supplied predominantly by the 1st efferent branchial arteries (EBA1) and drained by the opercular veins, which open into the anterior cardinal vein. Deep invaginations at the distal end of the EBA1 and the junction with EBA2 are suggestive of blood flow regulatory sites during breath-holding and apnoeic periods. It remains to be investigated how blood flow through the gills is maintained during breath holding when the buccal–opercular cavity is filled with air.

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

Although an aberrant right subclavian artery (ARSA) is the most common abnormality of aortic arch development, it is an unusual entity to encounter associated with thoracic aortic dissection. We report the successful endovascular treatment of this association in a critically ill patient. An 80-year-old man was referred to our institution with the diagnosis of an acute aortic Stanford type B dissection (Figure 1, A). The computed tomographic scan images also showed a thoracoabdominal aortic aneurysm extending from an ARSA (Figure 1, B) to the esophageal hiatus (Crawford type I). Because of persistent back pain despite correct intravenous treatment, a new computed tomographic scan was repeated 8 hours later, revealing progression of the aortic dissection and the appearance of a left-sided hemothorax. Blood analysis also showed a fall of 10 points in the hematocrit value. Because of the patient’s critical status and high surgical risk, emergency endovascular treatment was indicated. Notwithstanding, the procedure was technically demanding, because the endograft had to be deployed while avoiding occlusion of the ARSA. However, the diameter of the aortic aneurysm distal to the origin of the ARSA was greater than 46 mm, which is the maximum diameter amenable for the standard Medtronic Valiant thoracic endograft (Medtronic, Inc, Santa Rosa, Calif). Therefore, the deployment of the endoprosthesis was adjusted to the origin of the ARSA, where the thoracic aneurysm had a neck of 42 mm. A Valiant endograft, 160 mm in length and 46 mm in diameter, was deployed at the level of ARSA origin, so that its floppy FreeFlo straight portion (Figure 2, A), which is fenestrated, allowed blood flow through the artery. In this way, the flow through the aberrant artery was preserved (control computed tomographic scans, Figure 2, A and B). There were no significant variations of invasive radial pressure (<10 mm Hg) between the two arms. The patient was discharged from the hospital 6 days later. Aberrant subclavian artery, also called arteria lusoria, was first described by Bayford in 1794. It is the most common form of aortic arch anomaly and has a reported incidence of 0.5% to 2%. It results from regression of the right fourth aortic arch between the carotid and subclavian arteries.1Felson B. Cohen S. et al.Anomalous right subclavian artery.Radiology. 1950; 54: 340-349PubMed Google Scholar The association of aortic dissection and ARSA is rarely encountered; however, it has very important implications in treatment, either surgical or endovascular. A number of surgical techniques have been proposed for treatment of this pathologic condition. These include transposition or bypass of the distal portion of the aberrant artery into the adjacent carotid artery, resection of the origin of the aneurysm from the descending thoracic aorta, and repair of the aortic dissection/aneurysm with the elephant trunk technique.2Borst H.G. Walterbusch G. Schaps D. Extensive aortic replacement using “elephant trunk” prosthesis.Thorac Cardiovasc Surg. 1983; 31: 37-40Crossref PubMed Scopus (483) Google Scholar The use of partial or total cardiopulmonary bypass, hypothermia, and circulatory arrest is normally necessary. Nevertheless, endovascular therapy has revolutionized this surgery. Complex open surgical procedures may be replaced by endovascular treatment, which is associated with a lower perioperative morbidity and mortality.3Kouchoukos N.T. Masetti P. Aberrant subclavian artery and Kommerell aneurysm: surgical treatment with a standard approach.J Thorac Cardiovasc Surg. 2007; 133: 888-892Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar In this case, the very high surgical risk of the patient led us to choose an endovascular treatment. We decided to use the Valiant system, which is a third-generation endoprosthesis designed specifically for the exclusion of thoracic aortic disease.4Brooks M. Loftus I. Morgan R. Thompson M. The Valiant thoracic endograft.J Cardiovasc Surg (Torino). 2006; 47: 269-278PubMed Google Scholar Its floppy FreeFlo straight portion allowed us to deploy the endograft without occluding the ARSA and, therefore, without compromising either the right arm blood supply or the right vertebral artery flow. Dr Mosquera