Left Innominate Artery Research Articles

Prenatal diagnosis of isolated mirror-image right aortic arch with vascular ring by fetal echocardiography

Objective To improve the prenatal echocardiographic diagnostic accuracy for fetus with isolated mirror-image right aortic arch which combined with vascular ring by analyzing and accumulating its echocardiographic features. Methods Echocardiographic signs were analyzed retrospectively and fetal echocardiographic features were accumulated in 16 cases with prenatal diagnosis of isolated mirror-image right aortic arch with left-side ductus arteriosus which formed vascular ring between January 2014 and February 2016. All cases were confirmed by neonatal echocardiography. Results The fetal echocardiography characters: ① In 3-vessel and trachea view, fetal right aortic arch was demonstrated a U-shaped appearance of the great vessels, the right arm of the 'U’ represented the aortic arch and its left branch with ductal continuation. ② In 3-vessel and trachea view or upper axial mediastinal transverse view, left innominate artery passed straightly to the left of the trachea.Left innominate artery and right-side ductus arteriosus were overlapped and the distance of two vessels was very close. ③ In double arch view and longitudinal view for ductus, Left innominate artery did not connect to descending aorta or ductus arteriosus and did not involve in the formation of vascular ring. ④ Color Doppler played an important role in diagnosis of this disease. Power Doppler or high-definition imaging easily showed color overflow and wrongly displayed the crossed relationship of left innominate artery with descending aorta as the anatomical connection, and caused the misdiagnosis of this disease as double aortic arch. Conclusions Isolated mirror-image right aortic arch with vascular ring is not rare in the fetal period. Because ductus arteriosus is large and patent during the prenatal period, it is easily mistaken for the crossed relationship of left innominate artery with descending aorta as the anatomical connection and finally misdiagnoses this anomaly as double aortic arch. The keys to accurate diagnosis of the disease are clearly visualization of the innominate artery and its relationship with descending aorta and ductus arteriosus by scanning different views. Key words: Echocardiography; Fetal; Mirror-image right aortic arch; Vascular ring; Double aortic arches

In vivo and in vitro experimental studies of remote digital control endovascular robotic system in interventional angiography

Objective: To investigate the feasibility of the remote control endovascular robotic system in interventional angiography. Method: The endovascular robotic system Heifetz™ and the matched steerable catheter Mirage™ were used to cannulate all the target vessels in the vascular model and cerebral arteries originated from the aorta of Bama mini-pigs under fluoroscopic guidance. The technical success rate, cannulation time and exposure dose were all collected and compared with the result of using conventional techniques. Result: All the target vessels were successfully cannulated.The average cannulation time for the steerable catheter into left subclavian artery, left common carotid artery, brachiocephalic artery, right common carotid artery and right subclavian artery in the vascular model was (21.3±2.8)s, (28.8±5.2)s, (17.7±2.6)s, (31.5±5.1)s and (24.2±3.7) s, respectively, while the average exposure dose was (9.3±1.2)mGy, (12.4±2.2)mGy, (7.4±1.2)mGy, (14.2±2.5)mGy and( 10.4±1.9)mGy, respectively. The endovascular robotic system completed the cerebral angiography in Bama mini-pigs successfully. The average cannulation time for left innominate artery, right innominate artery, right subclavian artery, common internal carotid trunk, left internal carotid artery and right internal carotid artery was (41.5±6.8)s, (29.1±3.7)s, (40.7±5.5)s, (40.1±5.8)s, (59.6±9.0)s and( 60.3±10.1)s, respectively, while the average exposure dose was (40.6±6.5)mGy, (36.0±5.2)mGy, (39.8±6.1)mGy, (43.9±6.7)mGy, (51.0±7.4)mGy and( 50.1±7.8)mGy, respectively. There was no significant difference between robotic and conventional group in success rate, cannulation time and exposure dose. Conclusion: The remote digital control endovascular robotic system could cannulate the target vessel in both vascular model and complete the cerebral angiography in Bama mini-pigs, which shows the feasibility of using this robotic system in endovascular intervention procedures under remote control.

Results From a Nationwide Registry on Scalloped Thoracic Stent-Grafts for Short Landing Zones

Purpose: To report the perioperative results and short-term follow-up of patients treated with scalloped thoracic stent-grafts. Methods: A multicenter registry in the Netherlands captured data on 30 patients (mean age 68 years; 17 men) with thoracic aortic pathology and a short (<20 mm) proximal or distal landing zone who received a custom-made scalloped stent-graft between January 2013 and February 2016. Patients were treated for saccular (n=13) aneurysms, fusiform (n=9) aneurysms, pseudoaneurysms (n=4), or chronic type B dissections (n=4). The scallop was used to preserve flow in the left subclavian artery (LSA) (n=17), left common carotid artery (n=5), innominate artery (n=1), and celiac trunk (n=7). In 7 (23%) patients, the scallop also included the adjacent artery. Results: Technical success was achieved in 28 (93%) patients. In 1 patient, a minor type Ia endoleak was observed intraoperatively, which was no longer visible on computed tomography angiography at 3 months. In another patient, the LSA was unintentionally obstructed due to migration of the stent-graft on deployment. Concomitant carotid-carotid or carotid-subclavian bypass was performed in 4 patients. There was no retrograde type A dissection or conversion to open surgery. In-hospital mortality was 3%, and the perioperative ischemic stroke rate was 3%. At a mean follow-up of 9.7 months (range <1 to 31), 29 of 30 target vessels were patent. Conclusion: The scalloped stent-graft appears to be a safe and relatively simple alternative for the treatment of thoracic aortic lesions with short landing zones. Larger patient series and long-term follow-up are required to confirm these early results.

Agenesis of the Left Internal Carotid Artery in the Right Aortic Arch with Isolation of the Left Innominate Artery Associated with Ruptured Cerebral Aneurysm: Case Report

As we occasionally encounter congenital blood vessel abnormalities, their variety, embryology, and associated clinical problems must be understood. We report a case of a 50-year-old man with subarachnoid hemorrhage due to a ruptured cerebral aneurysm at the internal carotid–anterior choroidal artery bifurcation who manifested extremely rare congenital anomalies, i.e., a right aortic arch, isolated left innominate artery, agenesis of the left internal carotid artery, and dysplasia of the basilar artery to the posterior cerebral arteries. This complex anomaly, to the best of our knowledge, has not been previously reported.

Asymptomatic mirror right aortic arch

[Extract] An asymptomatic right aortic arch with mirror configuration including a left innominate artery was incidentally identified on computed tomography (CT) neck angiogram of a 78-year-old male patient following transient ischaemic attack.

Heme oxygenase-1 and inflammation in experimental right ventricular failure on prolonged overcirculation-induced pulmonary hypertension.

Heme oxygenase (HO)-1 is a stress response enzyme which presents with cardiovascular protective and anti-inflammatory properties. Six-month chronic overcirculation-induced pulmonary arterial hypertension (PAH) in piglets has been previously reported as a model of right ventricular (RV) failure related to the RV activation of apoptotic and inflammatory processes. We hypothesized that altered HO-1 signalling could be involved in both pulmonary vascular and RV changes. Fifteen growing piglets were assigned to a sham operation (n = 8) or to an anastomosis of the left innominate artery to the pulmonary arterial trunk (n = 7). Six months later, hemodynamics was evaluated after closure of the shunt. After euthanasia of the animals, pulmonary and myocardial tissue was sampled for pathobiological evaluation. Prolonged shunting was associated with a tendency to decreased pulmonary gene and protein expressions of HO-1, while pulmonary gene expressions of interleukin (IL)-33, IL-19, intercellular adhesion molecule (ICAM)-1 and -2 were increased. Pulmonary expressions of constitutive HO-2 and pro-inflammatory tumor necrosis factor (TNF)-α remained unchanged. Pulmonary vascular resistance (evaluated by pressure/flow plots) was inversely correlated to pulmonary HO-1 protein and IL-19 gene expressions, and correlated to pulmonary ICAM-1 gene expression. Pulmonary arteriolar medial thickness and PVR were inversely correlated to pulmonary IL-19 expression. RV expression of HO-1 was decreased, while RV gene expressions TNF-α and ICAM-2 were increased. There was a correlation between RV ratio of end-systolic to pulmonary arterial elastances and RV HO-1 expression. These results suggest that downregulation of HO-1 is associated to PAH and RV failure.

Diagnosis and treatment of vascular ring associated with congenital tracheal stenosis in infants

Objective To investigate the operation method for congenital tracheal stenosis(CTS) with vascular ring(VR), in order to minimize surgical risk. Methods The data of 53 VR patients diagnosed by CT imaging, fiber bronchoscope and color doppler echocardiography were analyzed retrospectively.The age ranged from 5.0 days to 2.5 yeas old, median age was 12.5 months, including pulmonary artery sling, double aortic arch, right arch combined with abnormal left subclavian artery and innominate artery oppression, et al, in which 12 patients(8 male, 4 female) associa-ted with CTS symptoms.All patients were treated by operations, 8 patients were dead, others were followed up for 3 to 5 years at 6-month interval. Results Fifty-three patients with VR were categorized into 2 treatment groups.There were 41 patients(25 male, 16 female) without CTS symptoms treated by VR repair(3 cases died), mortality was 7.3%.Of the 12 patients(8 male, 4 female) with VR+ CTS symptoms, 7 cases were treated by selective VR repair with 2 cases deaths, 5 cases underwent combined VR and CTS repairs with 3 cases died, for an overall mortality of 41.7%.Of the 41 patients with VR but no CTS, 7 cases had intracardiac anomalies with 2 cases died.In contrast, 3 of 12 patients with VR+ CTS and intracardiac anomalies with 2 cases died; 5 patients received cardiac and CTS repairs(3 cases died) and 7 cases in selective VR repairs(2 cases died). Conclusions Not all cases of TN associated with VR require combined correction.CTS and the combined cardiac abnormalities increased the risk of VR surgery in children.The individualized treatment program should be developed for such children. Key words: Vascular ring; Congenital tracheal stenosis; Individualized; Infant

COMPUTATIONAL FLUID DYNAMICS OF TWO PATIENT-SPECIFIC SYSTEMIC TO PULMONARY SHUNTS

Tetralogy of Fallot is the most common cyanotic congenital heart defect. For severe cases, inserting a systemic to pulmonary shunt, which distributes part of systemic artery blood into the pulmonary artery, is the preferable palliative surgery. Based on the computed tomography images and three-dimensional geometry technologies, two patient-specific anatomical options of systemic to pulmonary shunts including the aorta to pulmonary shunt (APS) and innominate artery to pulmonary shunt (IPS) have been simulated for computational fluid dynamics. The objective of this study was to predict the hemodynamics within the shunts and confirm, through patient-specific simulations, the shunt with the optimal performance. Results indicated that both options created high velocity gradients and pressure gradients at the proximal end of the shunts. Obvious flow recirculation appeared at the inner region near the proximal end of the shunts. Part of the reverse flow from the descending aorta, left subclavian artery, left carotid artery and innominate artery was driven into the shunts during the diastolic period. The IPS provided better balanced and more adequate blood flow distributions between the systemic and pulmonary circulations. The APS provided slightly excessive pulmonary blood flow which can ultimately result in cardiac failure and pulmonary hypertension.

The monitoring and preventing of spinal cord ischemic injury during thoracic descending aortic operating

Background. A model of ischemic injury to the spinal cord was established in pigs by clamping the thoracic descending aorta. The feasibility of monitoring spinal-cord ischemia using the cortical somatosensory evoked potential (CSEP) was evaluated. Outcomes between the simple clamp (SC) group and left-heart bypass (LHB) group were compared. Methods. Twelve mini-pigs were randomly divided into two groups SC group and LHB group randomly. The left intercostal incision was adopted. The thoracic descending aorta was clamped under the left innominate artery outlet. CSEP was recorded to monitor the function of the spinal cord. The behavior score was observed every day after surgery. Mini-pigs were killed on the seventh postoperative day. Ultrastructural changes were observed by transmission electron microscopy. Results. The surgical procedures were successful. Two animals developed incomplete paralysis and the remainder developed paraplegia in the SC group. The animals in the LHB group recovered completely and paralysis/paraplegia was not observed. CSEP measurements showed that the amplitude decreased to <50% of baseline values and prolongation of latency was >10% of baseline values in the SC group but not in the LHB group. Changes in CSEP values were in accordance with changes in behavior score. The ultramicrostructure of spinal-cord tissue under clamping indicated severe damage to tissue layers as well as swelling and damage to mitochondria in the SC group, whereas the morphology was almost normal in the LHB group. Conclusions. These data suggest that during a 30-minute clamping time, left-heart bypass may provide superior spinal protection than simple clamping, and monitoring of spinal-cord ischemia using CSEP was rapid and feasible.

Repeated Brain Infarction Caused by Atherosclerosis of the Bovine Aortic Arch Successfully Treated With Arch Replacement

A 62-year-old man presented with repeated embolic infarction over the last 3 years. Computed tomography angiography of the aortic arch revealed that the patient had a common trunk for the innominate and left carotid arteries, the so-called bovine aortic arch, with stenosis extending to both the left common carotid artery and innominate artery. Since antiplatelet therapy was not adequate for prevention of recurrent infarction, total replacement of the aortic arch was performed. Since then, no further ischemic events have manifested. Endovascular procedures are not safe enough for atherosclerotic lesions in the aortic arch, especially in a patient with bovine aortic arch, so surgical aortic arch replacement should be considered.

Prolonged overcirculation-induced pulmonary arterial hypertension as a cause of right ventricular failure

Three-month chronic systemic-to-pulmonary shunting in growing piglets has been reported as an early pulmonary arterial hypertension (PAH) model with preserved right ventricular (RV) function. We sought to determine whether prolonged shunting might be associated with more severe PAH and RV failure. Fourteen growing piglets were randomized to a sham operation or the anastomosis of the left innominate artery to the pulmonary arterial trunk. Six months later, the shunt was closed and the animals underwent haemodynamic evaluation followed by tissue sampling for pathobiological assessment. Prolonged shunting had resulted in increased mean pulmonary artery pressure (22 ± 2 versus 17 ± 1 mmHg) and pulmonary arteriolar medial thickness, while cardiac output was decreased. However, RV-arterial coupling was markedly deteriorated, with a ~50% decrease in the ratio of end-systolic to pulmonary arterial elastances (Ees/Ea). Lung tissue expressions of endothelin-1, angiopoietin-1, and bone morphogenetic protein receptor-2 were similarly altered compared with previously observed after 3-month shunting. At the RV tissue level, pro-apoptotic ratio of Bax-to-Bcl-2 expressions and caspase-3 activation were increased, along with an increase in cardiomyocyte size, while expressions in voltage-gated potassium channels (Kv1.5 and Kv2.1) and angiogenic factors (angiopoietin-2 and vascular endothelial growth factor) were decreased. Right ventricular expressions of pro-inflammatory cytokines [interleukin (IL)-1α, IL-1β, tumour necrosis factor-α (TNF-α)] and natriuretic peptide precursors (NPPA and NPPB) were increased. There was an inverse correlation between RV Ees/Ea and pro-apoptotic Bax/Bcl-2 ratios. Prolonged left-to-right shunting in piglets does not further aggravate pulmonary vasculopathy, but is a cause of RV failure, which appears related to an activation of apoptosis and inflammation.

Perioperative Care of an Infant With an Anomalous Left Innominate Artery Arising from the Main Pulmonary Artery

A 1.4-kilogram, male infant was born at 27 weeks gestation at an outside hospital. After birth, the patient's trachea was intubated and surfactant administered. Initial echocardiogram showed a patent ductus arteriosus (PDA) and a ventricular septal defect (VSD), with a possible aberrant vessel arising from the carotid artery. The patient was transferred to our hospital for further management. Repeat echocardiogram showed a right aortic arch with the left common carotid/innominate artery arising from the pulmonary artery. The infant was subsequently brought to the operating room where following sternotomy, the aberrant left innominate artery was reimplanted into the aorta. The origin of the left carotid artery or innominate artery from the pulmonary artery is an extremely rare form of congenital heart disease with a limited number of reports in the literature. The differential pressure gradient between the systemic and pulmonary beds may lead to a steal phenomenon, with shunting of blood from the carotid system into the pulmonary vascular bed, resulting in decreased cerebral blood flow. The left-to-right shunting from the systemic to pulmonary bed may also lead to volume overload of the left side of the heart. In the perioperative care of such patients, control of physiologic factors that control the balance between the pulmonary and systemic vascular resistance is mandatory to ensure that cerebral blood flow is maintained.

Right Aortic Arch With Isolation of the Left Innominate Artery Arising From the Pulmonary Artery and Atrial Septal Defect

A 6-month-old child (weight, 6.250 kg) was referred for evaluation of a systolic murmur and congestive heart failure. Echocardiography revealed right-sided cardiac chamber enlargement and an atrial septal defect, with right aortic arch and no clear visualization of the left pulmonary artery take-off. Angiography confirmed the diagnosis of right aortic arch, with the right carotid artery being the first branch and perfusing through the vertebrobasilar circulation the left carotid and subclavian vessels in a retrograde fashion. The former emptied through a left innominate artery into the pulmonary vessels, displaying a left-to-right shunt. In addition, the left subclavian artery was fed from a plexus of collaterals coming from the upper intercostal branches (Fig 1; A = aorta; AA = ascending aorta; IA = innominate artery; LBP = left branch-pulmonary; LCC = left common carotid; LDA = left descending coronary aorta; LSC = left subclavian; P = pulmonary artery; RDA = right descending coronary aorta; RPB = right pulmonary branch; RSC = right subclavian). On cardiopulmonary bypass, the atrial septal defect was closed. Then the ductus was transected, the pulmonary stump was oversewn, and the free end was reimplanted end-to-side to the ascending aorta, thus creating a mirror-like arrangement of the branches (Fig 2; LCC = left common carotid; LPA = left pulmonary artery; LS = left subclavian; RCC = right common carotid; RS = right subclavian). Edwards proposed in 1948 that all abnormalities of the aortic arch could be explained by a model involving a double aortic arch with right and left ductus, followed by resorption and remodeling of particular segments. In the case of our patient, the regression of the portion proximal to the left common carotid (so-called D) and the segment distal to the left subclavian (so-called A), plus the patency of the left ductus, gave rise to the arrangement of an isolated left innominate artery in the setting of a right-sided aorta (Fig 1). Because our patient presented an atrial septal defect, surgery was scheduled through a mid-sternotomy and under extracorporeal circulation. On reimplanting the left innominate artery in the ascending aorta, a physiological setting was achieved (ie, a right aortic arch with mirror-image arrangement of the neck vessels, plus interruption of the left-to-right shunt).

A rare association of ruptured left middle cerebral artery aneurysm and dextrocardia with situs inversus totalis

The association of dextrocardia with situs inversus totalis and ruptured cerebral aneurysm is a rare event. There have been no reports concerning this rare association in the literature. Asymmetric positioning of internal organs is one of the characteristics of vertebrates. The normal left–right anatomic positioning, situs solitus, does not occur normally always, leading to laterality defects. In this letter, we describe the clinical course of a patient with a ruptured aneurysm of the left middle cerebral artery and dextrocardia with situs inversus totalis, and discuss the radiological importance with the help of literature review of pathogenesis of this rare association. A 57-year-old woman was hospitalized with sudden onset of headache and nausea with a score on the Glasgow Coma Scale of 15 (E4V5M6). A computed tomography (CT) revealed subarachnoid hemorrhage. Routine chest X-ray on admission revealed dextrocardia. Serial angiography disclosed the right carotid artery and the right vertebral artery emanating directly from the aorta, and the left carotid artery and the left vertebral artery branching off from the left innominate artery (Fig. 1). The cannulation of the bilateral carotid and vertebral arteries was difficult due to this anomalous branching. Cerebral angiography showed a ruptured aneurysm of the right middle cerebral artery (Fig. 2).

Right Aortic Arch With Aberrant Left Innominate Artery in a 4-Week-Old Infant: Contrast-Enhanced Magnetic Resonance Angiography Findings With Three-Dimensional Reconstructions

Right Aortic Arch With Aberrant Left Innominate Artery in a 4-Week-Old Infant: Contrast-Enhanced Magnetic Resonance Angiography Findings With Three-Dimensional Reconstructions

Endovascular Treatment of Innominate Artery Occlusion With Simultaneous Vertebral and Carotid Artery Distal Protection

Atherosclerotic stenosis or obstruction of the innominate artery is rare. Traditional surgical management is a technically demanding intervention with acceptable, but not negligible, rates of morbidity and mortality. Endovascular approaches to supraaortic lesions have been successful and are now the preferred treatment for stenoses of the brachiocephalic vessels. The use of cerebral protection devices in subclavian and innominate interventions is less established. A 58-year-old woman had Takayasu giant cell arteritis with a history of a left middle cerebral artery stroke 3 weeks after undergoing placement of a left common carotid artery (CCA) stent and right innominate artery stent in 1998. She recently presented with worsening dizziness, ataxia, and right arm numbness and was referred to the endovascular neurosurgery service for management. Initial angiography revealed left CCA stenosis and right innominate occlusion. The patient initially underwent left CCA angioplasty, planned as a staged procedure. This was followed by recanalization of the right innominate artery through an approach using both femoral arteries and the right brachial artery. This 3-site technique allowed simultaneous distal protection of both the right cervical vertebral and carotid arteries. Reopening a chronically occluded innominate artery risks an embolic shower through both the right vertebral and carotid arteries. Using multiple sites of arterial access, distal protection devices can be deployed in both the cervical vertebral and carotid arteries to reduce the risk of stroke.

Incomplete Isolation of the Left Innominate Artery in a Patient with Right Aortic Arch and Double Outlet Right Ventricle

Isolation of the left innominate artery (IA) with right aortic arch is a rare congenital anomaly in which the IA loses its connection to the aorta and is connected to the pulmonary artery via a left ductus arteriosus. Here, we report a case of a 9-month-old girl with incomplete isolation of the IA and double outlet right ventricle. Along with repair of the intracardiac anomaly, the IA was reimplanted to aortic arch to ensure adequate blood flow from the aorta.

Aberrant Left Innominate Artery From the Left Descending Aorta in Right Aortic Arch: Echocardiographic Diagnosis

A right aortic arch with a left descending aorta and an aberrant left innominate artery is a rare but recognized vascular anomaly that can result in compression of the trachea and the esophagus. This vascular anomaly has been diagnosed using cardiac catheterization and angiography. Recently, computed tomography and magnetic resonance imaging have been used for noninvasive diagnosis. The aim of this report is to highlight the possibility of echocardiographic diagnosis.

Right Aortic Arch With Aberrant Left Innominate Artery

Two children referred for cardiac imaging were found to have an unusual form of a vascular ring. The first patient was an asymptomatic 10-year-old girl with a membranous ventricular septal defect, prolapse of the right coronary aortic cusp, and mild aortic regurgitation. Her past history was notable for gastroesophageal reflux disease as an infant, which had prompted a barium swallow at a few months of age demonstrating a posterior compression defect on the esophagus. Detailed imaging of the thoracic vasculature was not pursued at the time given the lack of respiratory symptoms and resolution of her reflux. She was now referred for cardiac magnetic resonance imaging to quantify the degree of left-to-right shunt, aortic regurgitation, and left ventricular dilation. Cardiac magnetic resonance demonstrated a small membranous ventricular septal defect with pulmonary-to-systemic flow ratio of 1.2, mild aortic regurgitation, and a mildly dilated left ventricle with normal systolic function. A right aortic arch was incidentally detected with branches arising in the following order: proximal to distal: right common carotid artery, right subclavian artery, and left innominate artery. The left innominate artery originated from a …

Right aortic arch and isolated left innominate artery from a left sided patent ductus arteriosus: a very rare aortic arch anomaly

Malformation of the aortic arch system has been described in details by Stewart et al. in 1964. Innominate artery originating via the ductus arteriosus from the pulmonary artery is a very rare type of congenital aortic arch anomaly that has been seldomly reported. We report the case of an aortic arch anomaly revealed by a pulmonary hypertension because of left to right shunt. Surgical procedure was performed through a median sternotomy, without cardiopulmonary bypass. After section. of the ductus arteriosus, the left innominate artery was extensively dissected and mobilized to be implanted on the left side of the ascending aorta under lateral clamping.