Brachial Artery Repair Research Articles

Structural and Functional Salvaging of Traumatic Brachial Artery Cut with Multiple Nerve Cut: Case Series

Upper limb arterial injury is relatively rare among trauma cases. Among them, the majority is contributed by brachial artery injury. Brachial artery injury is associated with nerve injuries given that its anatomical course, which brings a significant impact to the patient. We reported 2 cases of patients who sustained a deep laceration wound over the right upper limb. Both presented to the Emergency department with active bleeding over the wound, and clinically cold right hand, associated with absent radial and ulnar pulses with profound sensory and motor deficit. Wound exploration and brachial artery repair with reverse saphenous vein interposition graft, followed by structural and nerve repair. This case series highlighted the importance of prompt detection and intervention of brachial artery injury. Any further delay might result missing the golden hour of revascularization for the patients. It also showed the importance of consideration of limb salvage in a patient who was deemed Rutherford III, especially nerve cut was uncertain. In conclusion, prompt intervention of traumatic brachial artery injury and proper intraoperative assessment are mandatory to properly decide if a limb is salvageable or not.

Pedicled thoracodorsal artery perforator flap in the soft-tissue reconstruction of an acute traumatic cubital fossa defect

Complex cubital fossa injuries with bony and vascular injuries are not an uncommon clinical presentation after trauma to the elbow. The revascularization of the upper limb by brachial artery repair with the venous graft is paramount, followed by immediate cover with a sturdy flap to salvage the limb. The use of local muscle and fasciocutaneous flaps is limited in the setting of vascular injury. The pedicled latissimus dorsi muscle flap and abdominal flaps are routinely used with few advantages. This article describes the use of a pedicled thoracodorsal artery perforator flap in the management of acute traumatic cubital fossa defect. A retrospective observational study was performed from September 2015 to December 2020 with patients who underwent the pedicled TDAP flap as a soft-tissue cover of cubital fossa injuries primarily. Patient variables, including the size of defect and flap, the number of perforators, the complications, and the outcome, were recorded. Eleven patients were included in the study. The majority of the patients were males (n=10) and presented with a history of trauma in a road traffic accident (n=6) or because of a fall from height (n=4). All of them (n=11) had some form of bony injury. Seven patients in this group required brachial artery repair with an interposition vein graft successfully covered with a TDAP flap. There was a constant dominant musculocutaneous perforator about 10-13cm from the apex of the axilla. At discharge, all flaps had settled well. On follow-up ranging from 2 months to 2 years, the patients reported satisfactory outcomes.

Late Presentation of Paediatric Pink Pulseless Supracondylar Fracture of Humerus: A Case Report

Supracondylar humeral fracture is the most common elbow injury in children. It may be associated with a vascular injury in nearly 20% of the cases with a pink pulseless limb. We present a unique case of a paediatric pink pulseless supracondylar humeral fracture, seen late, on the 16th-day post-trauma. Open reduction, cross Kirschner wiring, and brachial artery exploration and repair were performed, and the patient recovered well. Early open reduction and exploration of the brachial artery with or without prior CT angiography was a safe approach in treating patients who presented at 16 days.

Outcomes of Brachial Artery Access for Endovascular Interventions

A percutaneous brachial artery (BA) approach is a suitable or even favorable alternative to femoral artery access when performing certain endovascular interventions. However, this approach may have a higher complication rate compared to femoral artery access. We analyzed our results using percutaneous BA approach for noncardiac endovascular interventions. Between January 1, 2003 and December 31, 2017, BA access was used in 157 cases performed on 136 patients. The procedures included 102 (65%) therapeutic interventions and 55 (35%) diagnostic studies. The vessels studied or treated included lower extremity arteries (48), the aorta and iliac arteries (45), mesenteric arteries (45), failing arterial revascularizations (24), renal arteries (9), subclavian arteries (8), carotid arteries (2), and visceral aneurysms (2), or in conjunction with endovascular aneurysm repair (EVAR), fenestrated EVAR, or thoracic EVAR (8). More than 1 vessel was studied or treated in 34 cases. Sheath sizes included 5F in 38 (24%) cases, 6F in 93 (59%) cases, and 7F in 26 (17%) cases. Percutaneous puncture was utilized in 142 (90.4%) cases and planned surgical exposure with primary closure of the BA in 15 (9.6%) cases (10, 7F; 4, 6F; 1, 5F). Manual compression was used for hemostasis at the conclusion of all percutaneous cases. There were 2 (1.3%; 2/157 cases) deaths in the perioperative period, one due to myocardial infarction and the other from mesenteric ischemia. Access site complications occurred in 10.6% (15/142) of percutaneous cases, which required open surgical repair for bleeding (8) and BA thrombosis (7). There was an increased risk of complications with increasing sheath size in the percutaneous approach: 5.4% (2/37), 12.4% (11/89), and 12.5% (2/16) for 5F, 6F, and 7F sheaths, respectively (P=0.49). None of the 15 patients who underwent surgical treatment suffered long-term vascular or neuropathic complications. In our experience, percutaneous BA access was associated with a 10% complication rate with an increased risk of complications associated with increasing sheath size. There was approximately the same incidence of bleeding as thrombosis. For patients who require 6 or 7F sheaths via a BA approach, we recommend more liberal use of open surgical exposure and primary BA repair.

Continued Ultrasound Surveillance Required after Hand Ischemia Associated with Trauma in Children

Hand ischemia following trauma in children is rare, and the natural history after upper extremity arterial bypass in children is unknown. We hypothesize children with brachial artery repair are at long-term risk of developing aneurysmal degeneration or thrombosis, thus necessitating annual duplex ultrasonography and physical examination. A retrospective review of children who had brachial artery repair (bypass or vein patch) for hand ischemia secondary to trauma at a level I trauma pediatric hospital was performed. Telephone interviews were conducted to assess the presence of arm/hand symptoms (pain, weakness, fatigue, sensory function, limb length discrepancy). Between 2003 and 2016, 16 children (12 males), mean age 8years (3-13years) underwent brachial artery repair (12 bypass with vein, 4 vein patch). Mechanism of injury included 11 supracondylar fractures and 5 lacerations. All patients were seen at 2 weeks with a duplex ultrasound. Thirteen patients were lost to follow-up. The 3 patients with follow-up had patent bypasses, but one patient 6years out from the repair had aneurysmal degeneration of the vein graft. Seven patients were never seen again. Phone interviews were conducted for the remaining 6 patients and 2 complained of arm fatigue and intermittent hand pain. Only one patient reported that the pediatrician checked pulses in the affected extremity. Eighty percentage of children had no further follow-up after the postoperative visit. Asymptomatic aneurysmal degeneration of the vein graft was noted 6years following repair in one patient, and 2 patients had unevaluated hand complaints. These patients are at risk for late complications and are unlikely to return for routine follow-up. The importance of graft surveillance must be more clearly emphasized at time of initial surgery.

Limb salvage after delayed arterial repair in compound Grade III C fracture humerus: a case report

<p>A combination of brachial artery injury and fracture shaft of humerus is a rare phenomenon. There is a general apprehension regarding survival of a limb after vascular injury. Only few studies exist in literature that discuss about the survival of such limbs. Our case is a 56 years old female patient who presented three hours after sustaining injury in the form of fracture shaft of humerus and complete transection of brachial artery distal to the origin of profunda brachii. Even though Doppler USG done initially revealed flow in the vessels distal to the injury, a CT Angiogram done later revealed cutting of the brachial artery. This prompted us to perform brachial artery exploration and repair. post operatively, digital subtraction angiography showed absence of flow in the brachial artery but limb survived due to extensive collateral circulation. Even after the golden period of vascular repair has lapsed, arterial repair is recommended if there is no evidence of gangrene. This should be supplemented with adequate systemic anticoagulants and/or fasciotomy.</p>

Efficacy of endovascular interventional minimally invasive techniques in treatment of acute brachial artery injury

Objective To evaluate the efficacy of endovascular interventional minimally invasive techniques in treatment of acute brachial artery injury. Methods A retrospective case series study was designed to analyzed data of 16 cases (11 males and 5 females) sustaining acute brachial artery injury treated from March 2011 to August 2016. Mean age was 47.9 years (range, 27-66 years). Left upper extremity vascular injury occurred in 7 cases and right upper extremity vascular injury occurred in 9. There were 13 cases of arterial intima injury and 3 of arterial pseudoaneurysm. All patients underwent endovascular therapy including stent implantation and balloon dilatation. Angiography was used to evaluate the repair of brachial artery and the operation time was recorded. Improvements of distal limb arterial pulse and limb ischemic symptoms were observed, and the patients who were followed up with stent lumen stenosis more than 50% received endovascular treatment again. Results The procedures was successful in all patients, with operation time of 30-75 minutes (mean, 45 minutes). After the insertion of a stent, recovered brachial artery blood flow and disappeared pseudoaneurysm were observed on angiography, without occurrence of stent stenosis or contrast extravasation. Symptoms of local pain and numbness were alleviated, and blood supply of the distal brachial artery was improved after operation. All patients were followed up for 3-36 months(mean, 16.7 months). The false aneurysm did not recur. Two cases of stent stenosis more than 50% had a second balloon dilation procedure and the blood flow returned to normal. Stent patency was found in 14 cases with stent stenosis of less than 50%. During the follow-up period, no ischemic necrosis, displacement of the stent or stent fracture were found. Conclusion For acute brachial artery injury, endovascular management exhibits higher technical success rate and good clinical outcome with a low incidence of complications. Key words: Brachial artery; Stents; Vascular system injuries

Brachial Artery Reconstruction in Trauma Using Reversed Arm Vein from the Injured Upper Limb

Background:Brachial artery repair may be technically challenging with a paucity of guidelines. The use arm vein (AV) from the traumatized limb is herein described.Methods:Data were prospectively collected from 2002 to 2016 on brachial artery injury including age, sex, mechanism/site of injury, and repair technique. Categories included AV and non-arm vein (NAV) groups. One-year outcomes were noted.Results:All 31 cases studied were of men with an age range of 16 to 73 years (mean = 28). Injuries included 13 gunshots, 7 stabbings, 6 glass injuries, 2 dislocated elbows, 1 crush, 1 impalement, and 1 avulsion. Site of injuries included the antecubital region in 25, midbrachial in 5, and proximal brachial in 1, with 4 associated fractures. Repair was done using reversed AV from the traumatized limb in 15 cases and NAV in 16. In the AV group, the adjacent basilic vein was used in 9 cases, the adjacent cephalic vein in 3, and the distal (or wrist area) cephalic vein in 3. The limb salvage rates in the AV versus NAV groups were 100% and 94%, respectively (Fisher’s exact t test, P = 1.00), with no major technique-related complications.Conclusions:The outcomes of using reversed AV from the traumatized limb are equivalent to those of other standard techniques such as primary repair, polytetrafluoroethylene, or reversed great saphenous vein, with a 1-year limb salvage rate of 100%. Additionally, advantages include decreased wound complications, better vein graft--artery caliber match, and shorter operating times while maintaining acceptable patency rates.

Brachial artery repair using the basilic vein as a reliable conduit in a 3-year-old child

A supracondylar fracture of the humerus is the most common upper extremity fracture in children with concurrent neurovascular complications. However, bypass grafting in the management of a pediatric open elbow dislocation with an arterial injury has rarely been reported in the literature. Hence, an adequate conduit for a vessel graft interposition remains questionable when a primary anastomosis is limited in an arterial reconstruction. The purpose of this study is to present a brachial artery reconstruction in a 3-year-old patient with an open supracondylar fracture of the humerus. In the clinical and surgical examination of the patient, an open wound in the left antecubital fossa presented with accompanying brachial artery injury. To repair the artery, a reverse end-to-end anastomosis was conducted using basilic vein graft from the ipsilateral arm under general anesthesia. The patient had palpable radial pulses in the postoperative clinical examination and was discharged without complications. The great saphenous vein (GSV) has proven to be the most common and the best conduit for arterial reconstruction of the upper extremity in the adult patients. However, the GSV graft is known to have the propensity for becoming aneurysmal in pediatric patients. Some studies have demonstrated the basilic vein as a suitable conduit in pediatric patients, in that it has durable patency, fewer branches, size compatibility for anastomosis, and proximity to the brachial artery. Our case confirms the safety of using this autogenous vein from within the zone of injury for arterial reconstruction, after a supracondylar humeral fracture. The management of pediatric elbow fractures accompanying vascular injuries can be technically demanding due to relatively small, delicate structures and concurrent neurovascular network. Nonetheless, a vascular injury should be treated with high level of suspicion and immediate intervention to avoid any limb ischemia or loss. In situations where the brachial artery is compromised and needs repair with a bypass, the basilic vein should be considered as a conduit for its greater accessibility and long-term patency.

Salvage of upper extremities with humeral fracture and associated brachial artery injury

BackgroundHumeral fractures with brachial artery injury present a challenge for treating surgeons. Treatment practices vary, including use of vascular shunts, multispecialty teams versus an upper-extremity surgeon, and temporizing external fixation. Our objectives were to describe our treatment approach, to define “absolute ischaemia,” to determine whether to use a vascular shunt, and to identify variables that could improve limb salvage rate. MethodsWe conducted a retrospective study of 38 patients with humeral fracture and brachial artery injury from 1999 through 2012 at a level I trauma centre. Demographic and treatment characteristics were compared between blunt and penetrating injuries and between treatment by multispecialty teams and treatment by an upper-extremity surgeon. We investigated other variables of interest, including immediate internal fixation, shunt use, time to brachial artery repair, and flap coverage. This study focused on immediate limb salvage and not on eventual functional outcomes of the limb or patient satisfaction regarding the extremity. The main outcome measure was salvage versus amputation. ResultsThirty-six upper extremities were successfully salvaged, and two underwent eventual amputation. Immediate internal fixation (33 of 38 patients) did not have an adverse effect on the rate of successful limb salvage (p>.05). Shunt use and treatment by an upper-extremity surgeon were not associated with improved salvage rate (p>.05). The need for flap coverage was significantly associated with failed salvage of the extremity (p=.02). ConclusionsSalvage of the upper extremity with humeral fracture and associated brachial artery injury is not dependent on time to brachial artery repair, shunt use, or specialty of treating surgeon. Immediate internal fixation can be performed without adversely affecting the potential for successful salvage. Flap coverage, which is an indicator of severity of soft-tissue injury, correlates with amputation in these severe injuries. Type of study/level of evidenceTherapeutic III.

Proximal paraparesis due to aortic dissection extending into bilateral carotid arteries in a patient with Loeys-Dietz syndrome

The authors report a 66year-old female with past medical history relevant for thoracic abdominal aneurysm who presented with a complaint of chest pain radiating into her neck. The physical examination was significant for the distinctive facial features of wide spaced eyes and V-shaped uvula. Thoracic CT scan revealed a type I aortic dissection which warranted immediate surgical repair. On post-op day one she was noted to be confused and was found to have acute bilateral lower extremity paraparesis with proximal predominance. Furthermore, her left radial artery line had no pulse waves and no brachial, radial, or ulnar pulses could be detected with Doppler ultrasound. Emergent head CT scan revealed bilateral postcentral gyri infarctions and the thoracic CT scan demonstrated extension of the dissection into the aortic branches, including the left brachial and the bilateral carotid arteries. Consequently, surgical brachial artery repair ensued. In the interim, a repeated head CT scan demonstrated new ischemic infarcts involving the bilateral frontal lobes. Anticoagulation was not indicated due to the high risk of bleeding at surgical site. Genetic testing confirmed the presence of a mutation in the TGFBR2 gene at exon 5. Loeys-Dietz syndrome is an autosomal dominant disease caused by heterozygous mutations in the genes encoding type I or II transforming growth factor-β (TGF-β) receptor. Loeys-Dietz syndrome manifests with aggressive vascular pathology. This case underscores the importance of recognition of this spectrum of clinical and pathologic manifestations to identify and manage Loeys-Dietz syndrome.

Anastomotic Rupture after Brachial Artery Repair is Associated with Soft Tissue Deficiency

Anastomotic Rupture after Brachial Artery Repair is Associated with Soft Tissue Deficiency

Axillary Sheath Hematomas Causing Neurologic Complications Following Arterial Access

Iatrogenic brachial plexus injuries secondary to expanding hematomas and pseudoaneurysms have been described in limited nature in previously published data. We present the case of a 55-year-old woman who developed neurologic deficits because of a compressive hematoma after axillary arteriography. She underwent emergent exploration of her left arm with decompression of the axillary sheath and brachial artery repair with complete recovery. We describe the presentation, relevant anatomy, and importance of this condition and stress the need for early recognition and surgical intervention to prevent permanent neurologic deficits.

Endovascular aneurysm repair for ruptured abdominal aortic aneurysm: The Albany Vascular Group approach

Improvements in endovascular technology and techniques have allowed us to treat patients in ways we never thought possible. Today, endovascular treatment of ruptured abdominal aortic aneurysms is associated with markedly decreased morbidity and mortality compared with the open surgical approach, yet there are several fundamental obstacles in our ability to offer these endovascular techniques to most patients with ruptured aneurysms. This article will focus on the technical aspects of endovascular aneurysm repair for rupture, with particular attention to developing a standardized multidisciplinary approach that will help vascular surgeons deal with not just the technical aspects of these procedures but also address some of the challenges, including the availability of preoperative computed tomography, the choice of anesthesia, the percutaneous vs femoral cutdown approach, use of aortic occlusion balloons, need for bifurcated vs aortouniiliac stent grafts, need for adjunctive procedures, diagnosis and treatment of abdominal compartment syndrome, and conversion to open surgical repair.

“The pink pulseless hand”—not a benign condition. Neurovascular compromise in paediatric supracondylar fracture of the humerus

<h3>Aims</h3> Supracondylar fracture of the humerus is the most common upper limb fracture in children, accounting for 70% of elbow fractures. There is a high incidence of associated neurovascular injury and management of these cases is much debated, particularly indications for surgical exploration of the antecubital fossa in a pulseless, but clinically well-perfused hand. Several publications have suggested that the “pink pulseless hand” is a benign condition that can be managed expectantly and exploration need only be undertaken if there are further signs of neurovascular compromise. This study aims to assess whether this is a safe message. <h3>Methods</h3> A retrospective case note review was undertaken of cases of paediatric supracondylar fracture requiring manipulation/fixation from January 2000 to July 2009 in a regional vascular unit. Medical notes were analysed, focusing on neurovascular compromise and complications. <h3>Results</h3> The age range of children was 2–13 years. 25 children sustained a fracture requiring reduction. Five (20%) did not have a palpable radial pulse, but had a well-perfused hand. Two were immediately explored as compound fractures. Both required brachial artery repair and one median nerve release. The antecubital fossa was explored in two of the remaining three cases (one with documented normal neurology and one with no neurological status documented). Both required brachial artery repair, one median nerve release and one a fasciotomy. The final case was initially managed conservatively and developed a persistent median nerve palsy and ischaemic forearm contracture leading to significant disability. Thus, three of the five children with a pink pulseless hand had nerve entrapment and one developed ischaemic complications due to failure to explore the brachial artery. All explored brachial arteries required repair. One child who underwent exploration developed a hypertrophic scar. <h3>Conclusion</h3> The pink pulseless hand is not a benign condition that can be managed conservatively, but rather should be recognised as an indicator of likely neurovascular compromise. Any message suggesting otherwise, leads to the unacceptable risk of missed neurological injury, nerve ischaemia and muscle ischaemia leading to contracture and subsequent disability. Unless there is a compelling reason not to explore these cases, the brachial artery and associated nerves should be released routinely.

Outcome of delayed brachial artery repair in patients with traumatic brachial artery injury: Prospective study

A large proportion of patients with traumatic brachial artery injury have delayed referral for arterial repair in Iran. In this paper, we review the early outcome of delayed surgical repair of these patients. Patients with traumatic brachial artery injury who had been referred later than 24 h from occurrence of trauma were selected from May 2003 to October 2004. Presence of mottling was the main exclusive criterion. Pre- and post-operative data were registered in data sheets. Among 27 patients who entered the study, the mechanism of trauma was stabbings in 74% of cases. End-to-end anastomosis ( n = 14) and interposition graft with saphenous vein ( n = 12) were the techniques used. Amputation was inevitable due to progressing infection in one case. Upper limbs were saved in the remaining 26 cases (96%). Based on these data we recommend arterial repair in patients with traumatic brachial artery injury even after golden time of arterial repair.

Arterial reconstruction with deep leg veins for the treatment of mycotic aneurysms

Purpose: Mycotic pseudoaneurysms (MPA) remain challenging clinical problems. Primary surgical management includes control of hemorrhage and debridement of the infected arterial wall. Because critical ischemia may develop after arterial resection, revascularization has been a secondary goal of treatment. Standard anatomic graft placement or prosthetic bypass grafting has been compromised by a high rate of recurrent infection. Extra-anatomic reconstruction is preferred, with the basic goals being threefold: (1) the use of autogenous graft material to reduce the risk of reinfection; (2) the avoidance of significant size mismatches; and (3) graft placement that is anatomically inaccessible, because drug abuse causes many of these lesions. This study reviews a recent series of MPAs applying these treatment goals. Methods: In a 2-year period, the superficial femoral and proximal popliteal veins were used in the repair of eight MPAs of the common femoral (5), common iliac (1), and brachial (1) arteries, and the infrarenal aorta (1). Most patients (5 of 7) were known intravenous drug users, who had a painful pulsatile mass in an injection area. Two patients had systemic sepsis, one patient with an infected common iliac pseudoaneurysm and one patient with an MPA of the infrarenal aorta. The diagnosis of MPA was made by means of duplex/computed tomography scanning and confirmed by means of arteriography in all cases. Results: Obturator bypass grafting was performed by using a reversed deep leg vein in the five femoral MPAs. An ilioiliac, cross-pelvic bypass grafting procedure with a deep vein was used to repair an MPA of the common iliac artery. A deep vein was also used as a “pantaloon” aortobiiliac graft and for a brachial artery repair. Staphylococcus aureus was revealed by means of cultures in nearly all cases. Distal arterial perfusion was normal after reconstruction. Patients had no significant postoperative leg swelling. No new venous thrombosis below the level of deep vein harvest was revealed by means of duplex scanning. There were no septic complications. Conclusion: The superficial femoral/popliteal veins may be particularly useful for limb revascularization in patients with MPAs. This autogenous conduit provides an excellent size-match and a suitable length for reconstruction, because peripheral, axial arteries are generally affected. No clinically significant limb morbidity was related to deep vein removal. Late follow-up is challenging in such cases, but will be required to accurately determine the durability of this strategy. (J Vasc Surg 1999;30:1004-15.)

TRAUMA TEAM ACTIVATION FOR `MECHANISM OF INJURY' BLUNT TRAUMA VICTIMS

Excessive overtriage prompted a review of all stable blunt trauma victims ≤ age 65 years transported to our trauma center from 1990 through 1992 only by virtue of mechanism of injury. Of 4392 blunt trauma patients, 2298 (52%) met review criteria. In this group 1712 (75%) were discharged home from the emergency room, and 586 were hospitalized: 367 (63%) for ≤1 day; 465 (79%) for ≤2 days. Of 93 ICU patients, 61 (66%) stayed ≤24 hours, and 78 (84%) ≤48 hours. Most ICU admissions were for neurologic or cardiac monitoring. The mean ISS of the population was ≤2.8; only 15 patients had an ISS ≤16. No patient required urgent transfer from the emergency room to the operating room for hemodynamic or neurologic instability. Four patients (0.17%) had early surgery following appropriate radiologic evaluation and underwent hemisplenectomy; brachial artery repair; ligation of a mesenteric bleeder; or evacuation of a subdural hematoma. Early open reduction/internal fixation of extremity fractures was done in 22 other patients (0.96%). Initial trauma team evaluation of hemodynamically stable blunt trauma victims whose only reason for trauma center transport is mechanism of injury is needlessly labor intensive and is not cost effective. Rather, a competent trauma center emergency medicine physician should be able to safely perform an initial assessment of such patients and summon the surgery team for specific clinical or radiologic indicators.

反復する鈍的外傷が誘因と考えられた真性上腕動脈りゅうの１手術例

反復する鈍的外傷が誘因と考えられた真性上腕動脈りゅうの１手術例

Complications of Anomalous Origin of the Right Subclavian Artery: Case Report and Review of the Literature

A 35-year-old black woman presented with thrombosis of an anomalous right subclavian artery and distal arterial embolization. Initially, her right subclavian artery was reimplanted onto the common carotid artery, and a brachial artery embolectomy plus intraoperative thrombolytic therapy were used to reopen her distal arterial circulation. When her brachial artery repair thrombosed the following day, a distal ulnar artery bypass and repeat thrombolytic therapy were required to restore arterial patency. Six months later, she returned with severe, progressive, neointimal hyperplasia of her brachial artery and a second attempt at arterial reconstruction was unsuccessful. She eventually required a right below-elbow amputation. This patient demonstrated an anomalous right subclavian artery that presented with distal embolization without an antecedent history of severe atherosclerotic disease or the development of a right subclavian artery aneurysm. A review of the medical literature relating to complications of this anomaly is provided.