Subclavian Artery Research Articles

Transcarotid-transcatheter aortic valve implantation in a patient with low cardiac function and haemodialysis accompanied by intracranial carotid stenosis: A case report

Abstract Background In transcatheter aortic valve implantation, the transfemoral approach is commonly used, but challenging access and procedural difficulties are sometimes encountered. Among alternatives, the transcarotid approach is increasingly used. We present a case of transcatheter aortic valve implantation in which a left common carotid approach achieved favourable outcomes in a patient with low cardiac function and dialysis. Case Summary The patient was a 67-year-old woman with a history of coronary artery bypass surgery and dialysis. Heart failure secondary to aortic stenosis and hypotension during dialysis required surgery. Echocardiography indicated severe aortic stenosis with low-flow low-gradient. Access was problematic, with 4.0-mm–diameter calcified external iliac arteries. Severe calcific stenosis was observed in the left subclavian artery, and the presence of right internal thoracic artery bypass rendered the bilateral subclavian artery approach unsuitable. Given the history of open-heart surgery and reduced left-ventricular function, the carotid approach was chosen; however, both internal carotid arteries showed moderate stenosis. Carotid compression magnetic resonance angiography confirmed intracranial communication, so we chose access through the more severely stenosed left common carotid artery. Under preoperative extracorporeal membrane oxygenation and general anaesthesia, transcatheter aortic valve implantation was performed with a Sapien3 Ultra RESILIA 23-mm valve. Postoperatively, there was no symptomatic cerebral infarction, and the dialysis-related hypotension resolved. Discussion Even with intracranial carotid stenosis, flow evaluations, such as Matas-test magnetic resonance imaging assessments, can reduce the cerebral infarction risk during transcarotid- transcatheter aortic valve implantation, providing a potentially safe and minimally invasive alternative access.

The "full rectangle" sign: a novel method for ultrasonographic diagnosis of fetal aberrant right subclavian artery.

To evaluate the feasibility and accuracy of a novel ultrasonographic screening method for an aberrant right subclavian artery (ARSA) using the novel "full rectangle" method. This prospective study was conducted at a tertiary care center, September 2022 to February 2023. The study included unselected pregnant women at 14-38weeks of gestation referred for routine or targeted anomaly scans. All participants underwent scanning by two experienced sonographers to ascertain the presence or absence of aberrant right subclavian artery (ARSA) using both conventional and novel "full rectangle sign" methods for validation purposes. This is a novel screening method for ARSA that demonstrates the retro-tracheal course at the level of the supra-aortic vessels, forming what we term the "full rectangle sign". A cohort of 138 patients was enrolled. The "full rectangle" sign was discerned in 6 fetuses with ARSA (4.3%), while the typical three-sided figure of the right subclavian artery was demonstrated in the remaining 132 fetuses (95.7%). The novel method demonstrated 100% feasibility and complete concordance with the conventional method. The study results indicate that the full rectangle sign serves as an effective and dependable screening tool for identifying ARSA. It offers the advantage of a clear, unobstructed view at a level unaffected by sternum shadowing and eliminates confusion with the azygous vein.

LVAD implantation with concomitant replacement of the ascending aorta

Dilated cardiomyopathy (DCM) is one of the main causes for end-stage heart failure. Until the transplantation, left ventricular assist devices (LVAD) have become an established treatment. We report a case of a 66-year-old patient with ischemic and dilated cardiomyopathy and suspected aortic ulcer formation. LVAD was implanted in the same session with a supracoronary aortic replacement. Bilateral cannulation of the subclavian arteries omitted the need of circulatory arrest and proximal aortic cross-clamping. Pneumonia associated decarboxylation failure prolonged the postoperative intensive care period. The patient was finally discharged home on the 115th postoperative day.

Anomalous Origin of the Right Subclavian Artery from the Right Pulmonary Artery in a Patient with d-Transposition of the Great Arteries: Diagnosis and Surgical Treatment.

Anomalous origin of the right subclavian artery (AORSA) from the right pulmonary artery is a rare congenital anomaly usually diagnosed by computed tomography, magnetic resonance imaging, or angiography. We present a very rare case of diagnosis and surgical correction of AORSA coexisting with d-transposition of the great arteries in a newborn's first hours of life. Due to the critical local hospital and patient conditions, additional cross-sectional imaging was not feasible. The diagnosis was suspected by clinical signs, confirmed by transthoracic echocardiogram, and the patient was urgently taken to the operating room. We discuss clinical and echocardiographic signs of this child with d-transposition of the great arteries and AORSA from the right pulmonary artery.

Total arterial revascularization with RIMA-LIMA-Y configuration in patients with left subclavian artery stenosis.

Subclavian artery stenosis (SAS) occurs in 6% of patients undergoing coronary artery bypass grafting (CABG). Complications such as subclavian-coronary steal are common. Revascularization options in such cases remain debatable. In this case series, all patients with angina, had severe triple vessel disease on angiography. All tests including computed tomography (CT) angiography of neck vessels, were done as part of routine workup for CABG. The patients, all males, had a mean age of 66.5 years with three of them having hypertension and diabetes. All were ex-smokers with mean ejection fraction (EF) of 60.1%. CT angiography of neck vessels revealed that two patients had moderate to severe while one had severe left SAS and another had severe proximal left internal mammary artery (LIMA) stenosis. Total arterial revascularization was performed, with an average of 3.5 distal grafts. The LIMA graft was employed in a Y graft configuration, anastomosed to in-situ right internal mammary artery (RIMA). All patients had uneventful postoperative stay and were discharged with a mean hospital stay of 3.8 days. There were no postoperative strokes, myocardial infarction, neurological symptoms, or change in EF. At 6-month follow-up, they were asymptomatic and doing well. The RIMA-LIMA-Y configuration can be a safe, viable option in CABG for patients with left SAS. It is challenging, with re-entry and judicious utilization of the length of LIMA being of paramount importance. The importance of CT angiography of neck vessels to detect SAS cannot be under-emphasized.

Rare locations of peripheral aneurysms in Marfan syndrome treated surgically: a case report

Marfan syndrome (MFS) is a connective tissue disorder that can lead to cardiovascular and musculoskeletal abnormalities. Aortic aneurysms and dissections are frequently seen in patients with MFS whereas peripheral vascular aneurysms in subclavian and axillary arteries territory considered very unusual. We reported a case of 54-year-old female with known history of MFS who had undergone a mechanical valve Bentall procedure due to severe aortic regurgitation and ascending aorta aneurysm in addition to thoracoabdominal aortic repair and who presented with a pulsatile painful mass in her right axillary region that turn to be significant true aneurysms of right subclavian and axillary arteries. To relive symptoms and to avoid further complications patient underwent successful surgical repair. Our case demonstrated rare locations of true peripheral aneurysms as a possible manifestation of MFS appeared several years post Bentall procedure and thoracoabdominal aortic repair and highlights also the importance of long-term monitoring to detect earlier such manifestation and avoid complications by surgical repair.

Successful management of mycotic anastomotic pseudoaneurysm of interposition vein graft following a carotid endarterectomy: a case report

BackgroundAnastomotic pseudoaneurysms of interposition vein grafts are a rare entity that requires urgent management to prevent life-threatening complications, such as rupture and thromboembolism, especially when involving the carotid arteries. As these are rare complications and literature is sparse, we believe that this case report can aid the decision-making process in similar circumstances.Case presentationA 49-year-old Ukrainian male patient presented with a false aneurysm of both distal and proximal anastomosis of an interposition vein graft between the common carotid artery and the internal carotid artery, which was previously performed as a bailout procedure after the patient developed a complication of carotid surgery. The patient was successfully treated with extra-anatomical interposition of a vein graft from the subclavian artery to the remnant of extracranial internal carotid artery and en bloc excision of the previous vein graft with the false aneurysms.ConclusionMycotic anastomotic pseudoaneurysms following carotid endarterectomy represent a rare yet serious complication in vascular surgery that requires urgent treatment. While endovascular techniques could represent an alternative option, open surgical repair is still the standard of care for this pathology, offering advantages in preventing postoperative ischemic complications and ensuring optimal long-term outcomes. The open approach provides direct visualization of the pseudoaneurysm. It allows the meticulous debridement of the infected tissues and an accurate reconstruction of the arterial wall with autologous or synthetic grafts. In light of the substantial evidence supporting its superiority, open surgical repair should remain the preferred approach in addressing mycotic anastomotic pseudoaneurysms following carotid endarterectomy. Future research should continue to explore advancements in other surgical techniques and refine treatment strategies to enhance patient outcomes in this challenging clinical scenario.

X-RAY-GUIDED ENDOVASCULAR SURGERY FOR SUBCLAVIAN STEAL SYNDROME (CLINICAL CASE)

Defining the sequence and methods of revascularization in patients with multifocal atherosclerosis should be associated with a minimal risk of adverse events and identification of predictors of adverse outcomes of operations, which is of great importance for improving the results of surgical treatment. We present a clinical case of successful treatment of a patient with multifocal atherosclerosis. The case included atherosclerotic disease of the left subclavian artery with complete steal syndrome of the brachiocephalic arteries, arteries of the lower limbs and arteries of the heart. It is shown that, when choosing a method for treating multifocal atherosclerosis, treatment should begin with preserving and restoring blood supply to the brain, and followed by restoring blood supply to other body parts.

Improving culprit artery identification with intraprocedural cone-beam CT aortography and its clinical impact in bronchial artery embolization.

To evaluate the impact of intraprocedural cone-beam CT (CBCT) aortography on culprit artery identification and clinical outcomes in patients undergoing bronchial artery embolization (BAE). Two hundred eighty-two patients with 317 BAE procedures were retrospectively reviewed. Patients who underwent preprocedural chest CT angiography (CTA) without intraprocedural CBCT aortography were categorized as Group A (n = 177). Patients who underwent both preprocedural chest CTA and intraprocedural CBCT aortography were categorized as Group B (n = 105). Whether CBCT can provide improved culprit artery identification and whether this improvement has a clinical impact were evaluated by comparing the two Groups. In Group B, CBCT aortography detected more culprit non-bronchial systemic arteries originating from the subclavian arteries compared to chest CTA (16 vs 3, p = 0.026), and the average number of embolized vessels was significantly higher than in Group A (2.47 ± 1.61 vs 2.03 ± 1.17, p = 0.016), while the procedure time was shorter (37.4 ± 22.0 vs 43.6 ± 22.7 min, p = 0.024). The recurrent hemoptysis rate was lower in Group B (17.5% vs 8.7%, p = 0.041), and the proportion of patients requiring subsequent procedures was significantly lower (12.4% vs 4.8%, p = 0.035). The changes in estimated glomerular filtration rate before and 3 days after the procedure (0.1 ± 12.8 vs 0.3 ± 11.0 mL/min/1.73 m2, p = 0.909) and total dose area product (DAP, 6119.5 ± 5725.7 vs 6906.2 ± 5978.6 uGym2, p = 0.279) were not significantly different between the two groups. BAE with intraprocedural CBCT aortography enabled the embolization of more culprit arteries, leading to lower recurrent hemoptysis rates without increasing the risk of renal deterioration and radiation hazards when compared to procedures without it. Question Does intraprocedural CBCT aortography improve culprit artery detection and clinical outcomes in BAE for hemoptysis? Findings CBCT aortography significantly improved the detection of additional culprit arteries, especially from non-bronchial systemic arteries, increasing the number of vessels treated during BAE. Clinical relevance Using CBCT aortography during BAE results in better long-term outcomes by reducing recurrent hemoptysis and the need for additional procedures, without increasing the risk of renal impairment.

Comparative effectiveness of Castor single-branch stent and hybrid surgery for the left subclavian artery in managing acute Type B aortic dissection with an inadequate proximal landing zone

Abstract Background Our study aims to compare the clinical outcomes and risk factors for adverse events between TEVAR with branch stent-graft and Hybrid surgery for the reconstruction of the left subclavian artery. Methods We retrospectively analyzed data from patients with insufficient proximal landing zones of acute Type B aortic dissection treated at our hospital from January 2017 to December 2022. According to the surgical method, patients were divided into TEVAR group (n=58) and Hybrid group (n=69). The primary endpoint was all-cause mortality. Results The diameter of the proximal landing zone in the TEVAR group was larger than that in the Hybrid group (31.5mm vs 30.3mm, P=0.037). Early Results: There was no significant difference in major adverse events and 30-day mortality between the TEVAR and Hybrid groups. The Hybrid group had significantly longer surgery time (110min vs 238min), hospital stay (8d vs 12d), and ICU stay (0d vs 1d) compared to the TEVAR group (P<0.001). Mid-Term Results: There was no statistical difference in mid-term mortality rates (3.4% vs 8.7%; P=0.398) between the TEVAR and Hybrid groups. The rate of mid-term adverse events was significantly higher in the Hybrid group compared to the TEVAR group (23.2% vs 6.9%; P=0.023). The rate of re-intervention was significantly higher in the Hybrid group compared to the TEVAR group (17.4% vs 3.4%; P=0.027). The 18-month freedom from mid-term adverse event rate was 93.1% (95% CI, 86.4% - 99.8%) for the TEVAR group and 76.8% (95% CI, 66.6% - 87.0%) for the Hybrid group. There was a significant difference in the rate of mid-term adverse events between the TEVAR and Hybrid groups, with the Hybrid group being higher (6.9% vs 23.2%, P=0.013). COX regression results showed: Diameter of the proximal landing zone (HR=0.6, 95%CI=0.4–0.9, P=0.009) was an independent risk factor for postoperative aortic-related adverse events. Conclusions TEVAR reconstruction of LSA and hybrid surgery are both safe and effective treatments for acute Type B aortic dissection with insufficient proximal landing zones. There is no difference in early adverse events and 30-day mortality rates between TEVAR reconstruction of LSA and hybrid surgery. Compared to hybrid surgery, TEVAR reconstruction of LSA has the advantages of shorter operation time, hospital stay, and ICU duration. There is no difference in aortic-related mortality and all-cause mortality between TEVAR reconstruction of LSA and hybrid surgery. However, TEVAR has significantly lower rates of mid-term adverse events and re-intervention compared to the hybrid group. The diameter of the proximal landing zone are risk factors for all-cause mortality.

Exome sequencing identifies a novel FBN1 variant in a Chinese family with Marfan syndrome that includes aberrant right subclavian artery

Abstract Background Marfan syndrome (MFS) is an inherited autosomal dominant disorder that affects connective tissue with an incidence of about 1 in 5,000 to 10,000 people. Ninety percent of MFS is caused by mutations in the fibrillin-1 (fbn1) gene. We recruited a family with MFS phenotype in South China and identified a novel variant in fbn1 by whole exome sequencing (WES). The zebrafish share high genetic similarity to humans. This study aimed to generate this novel mutation in the fbn1 gene of zebrafish using the CRISPR/Cas9 technology and researched whether this variant is pathogenic. Methods A three-generation consanguineous family was recruited in this study, which was visited and interviewed for the clinical data and family history. Peripheral blood samples were collected from family members for DNA isolation and WES. The 3D structure of the protein was predicted by Alphafold. CRISPR/Cas9 was applied to generate an fbn1 nonsense mutation (fbn1+/−) in zebrafish. Morphological abnormalities were assessed in F2 fbn1+/− zebrafish by comparing with the wild-type (WT) controls at different development stages. Results Our study recruited a family with MFS phenotype in South China and identified a novel variant [NM_000138.5; c.7764C>G: p.(Y2588*)] in fbn1. Through Sanger sequencing, we found that family members Ⅲ-1 (son) and Ⅲ-2 (daughter) had the fbn1 variant segregated with MFS in the family. The p.Y2588* mutation resulted in the absence of 283 amino acids, thereby leading to the deficiency of 17 β-folded structures, 4 α-helix structures, and various loop structures. Compared with WT zebrafish, F2 fbn1+/− zebrafish exhibited aortic arches bleeding, abnormal angiogenesis, decreased cardiac volume, cardiac function defects, curly tail, and cartilage malformations. Conclusion A novel variant [NM_000138.5; c.7764C>G: p.(Y2588*)] was identified in fbn1 gene, which has not been reported in previous literature. The variant caused loss of function through premature protein truncation or nonsense-mediated mRNA decay. In zebrafish, we identified functional evidence of the detected nonsense mutation, which aligns with the clinical significance, suggesting a pathogenic variant of fbn1. Zebrafish as a novel, efficient tool to allow for the quick classification of unknown variants in fbn1 and improve the clinical diagnosis and treatment of MFS. It has brought the implementation of personal and precision medicine in the clinic within reach and made it possible to find patient-specific treatments.Marfanoid symptoms of the patient.Phenotypic Spectrum of fbn1+/− Zebrafish

Invasive validation of central blood pressure measurements using a suprasystolic monitor

Abstract Interest in the assessment of Central Blood Pressure (cBP) is steadily growing since it is a better predictor of myocardial infarction, stroke, or death than Peripheral Blood Pressure (pBP). However, pBP remains the first line for the diagnosis of hypertension (HTN) due to the ease and speed of the measurement. We sought to validate a new method to estimate cBP from brachial sphygmomanometer measurements. We estimated cBP using a sphygmomanometer that can record, after conventional pBP measurements, the pressure in the cuff maintained at a constant suprasystolic pressure. cBP is calculated using a method based on applying a physics-based model of the left subclavian artery to the brachial arterial branch to the suprasystolic brachial artery pressure waveforms. We compared this noninvasive estimated cBP to an invasive gold-standard measurement during cardiac catheterization. After clinically indicated cardiac catheterization requiring a haemodynamic assessment of a moderate coronary artery stenosis by Fractional Flow Reserve (FFR), the wire that incorporates a high fidelity electronic pressure transducer was positioned into the guiding catheter left in the ascending aorta. Simultaneous measurements were performed with a cuff placed on the patient's left arm. The output signals were recorded in a custom-based acquisition system. The comparison was obtained on the same 10 seconds recorded by the cuff and the pressure wire. The goal will be to reach 85 patients as recommended by the ARTERY Society Task Force. It recommends as an accuracy criterion to achieve a mean difference ≤ 5 mmHg with a standard deviation (SD) ≤ 8 mmHg, which are the standards adopted for this study. Patients with aortic stenosis, atrial fibrillation, or frequent (supra)ventricular extrasystoles were excluded. A total of 197 pairs of measured-estimated cBP were analysed in 78 patients with a mean age of 63 ± 8 yo, 75% of whom were men, 70% had hypertension, 26% fdiabetes, 93% dyslipidemia, 41% were tobacco users and 14% suffered from clinical peripheral artery diseases without history of revascularization. The median (InterQuartiles 25-75%) pBP was 123 [112 134] / 70 [64 77] mmHg. Measured cBP was 102 [92 11] / 78 [70 84] mmHg with a central augmentation index of 34 [23 44] %. The mean difference between estimated and measured systolic cBP was 4.9 ± 6.5 mmHg, while it was -3.9 ± 5.8 mmHg for diastolic cBP, meeting the prespecified accuracy criteria. In conclusion, our approach based on an exact matching and comparison of non-invasive suprasystolic arm cuff measurements and high-fidelity aortic BP validates that an estimation of central aortic blood pressure that can be easily carried out in daily practice and might improve HTN management. It remains to be demonstrated that more cardiovascular complications will be avoided by guiding the antihypertensive therapy with cBP instead of pBP measurements.Bland-Altman of estimated - measured cBP

Double arch technique - a novel surgical procedure for the hypoplastic aortic arch syndrome

Abstract Background The hypoplastic aortic arch syndrome was defined as a combination of hypoplastic aortic arch and complex proximal descending aortic anomalies (such as aortic aneurysm, aortic coarctation, aortic tortuosity, or aortic dissection). In this study, we proposed a novel 'double arch' technique as a simple surgical procedure to treat the hypoplastic aortic arch syndrome, which could eliminate the requirement for cardiopulmonary bypass. Purpose This study aimed to investigate the surgical outcomes of patients who underwent the 'double arch' technique, and further evaluate the effectiveness and safety of this novel technique. Methods Briefly, J-shaped mini-sternotomy and left posterolateral thoracotomy were both performed in this technique. The ascending aorta, aortic arch, and proximal descending aorta were dissociated. After that, the ascending aorta was occluded using a side-biting clamp, followed by an end-to-side anastomosis between the proximal end of vascular graft and the ascending aorta. Similarly, the thoracic descending aorta was occluded with two aortic clamps beyond the opening of the left subclavian artery, and was then transected between the clamps, followed by an end-to-end anastomosis between the distal end of vascular graft and the distal descending aorta, while the proximal descending aorta was closed with sutures. The transection site of the aorta could be adjusted according to the extent of the lesions, and the vascular graft was placed in the left thoracic cavity. The operation was performed at room temperature. The primary endpoint was early mortality, which referred to in-hospital death and/or death within 30 days after surgery (including intraoperative death), whichever is longer. Critical secondary endpoints included aortic reoperation, newly developed aneurysms, and the blood pressure difference between the upper and lower extremities. Results Twelve patients with hypoplastic aortic arch syndrome were enrolled from December 2015 to February 2022. Patients were diagnosed using computed tomography. The median age (interquartile range, IQR) was 26.5 (17.0, 39.0) years (ranging from 12.0 to 55.0), and 8 patients were female (66.7%). The median operation time (IQR) was 4.7 (3.8, 5.5) hours (ranging from 2.8 to 7.3). All patients survived to discharge and completed the follow-up. The median follow-up time (IQR) was 5.42 (3.25, 5.97) years (ranging from 0.02 to 6.25). During the follow-up, no patient died or was required for reoperation. In addition, no newly developed aneurysm was found, and no severe adverse event was recorded. The median blood pressure difference (IQR) between the upper and lower extremities was 9 (4, 17) mmHg (ranging from 3 to 27). Conclusions The 'double arch' technique is a viable alternative surgical treatment for the hypoplastic aortic arch syndrome. This technique is expected to significantly simplify the surgical procedure and improve the long-term prognosis of patients.Diagram of the 'double arch' techniqueCT scans of pre- and post-operation

Accidental Subclavian Artery Catheterization After Central Venous Catheter Placement

Accidental Subclavian Artery Catheterization After Central Venous Catheter Placement

Antegrade in-situ needle assisted fenestration during thoracic endovascular aortic repair for preserving left subclavian artery.

Antegrade in-situ needle assisted fenestration during thoracic endovascular aortic repair for preserving left subclavian artery.

Clinical Characteristics of Patients with Takayasu Arteritis Undergoing Open or Endovascular Operations in China.

The operation rate for different involved arteries and the manifestation of vessel involvement of patients with Takayasu arteritis undergoing open or endovascular operations remain unclear. We aimed to investigate the clinical characteristics, vessel involvement, angiographic classification and operations information in a large cohort of patients with Takayasu arteritis undergoing open or endovascular operations at a single centre in China. From January 2017 to October 2022, a total of 153 consecutive patients undergoing open or endovascular operations were recruited from the Department of Vascular Surgery of Beijing Hospital. The demographic characteristics, clinical presentations, pattern of vascular involvement and operation information were collected and analysed. The majority of patients were female (128/153, 83.7%). The most common vascular finding was hypertension (66.7%). The subclavian (74.2%), carotid (70.1%) and renal (68.9%) arteries were the most commonly involved arteries. Type V (40.5%) was the most common angiographic classification pattern. A total of 296 open or endovascular operations were performed, including 73 percutaneous transluminal angioplasties (PTAs), 50 stent placements and 173 bypass graft operations. Patients with renal (83.3%) or carotid (65.2%) artery involvement had markedly higher rates of undergoing operations. The subclavian and carotid arteries, as well as the type V (40.5%) pattern, exhibited the highest frequency of involvement among patients with Takayasu arteritis who underwent open or endovascular operations. Variations in angiographic features can result in differences in clinical manifestations and significantly impact the possibility and modality of operations.

Left aortic arch and aberrant right subclavian artery in children: spectrum of symptoms and response to surgical intervention.

Children with left aortic arch and aberrant right subclavian artery may present with either respiratory or swallowing symptoms beyond the classically described solid-food dysphagia. We describe the clinical features and outcomes of children undergoing surgical repair of an aberrant right subclavian artery. This was a retrospective review of children undergoing repair of an aberrant right subclavian artery between 2017 and 2022. Primary outcome was symptom improvement. Pre- and post-operative questionnaires were used to assess dysphagia (PEDI-EAT-10) and respiratory symptoms (PEDI-TBM-7). Paired t-test and Fisher's exact test were used to analyse symptom resolution. Secondary outcomes included perioperative outcomes, complications, and length of stay. Twenty children, median age 2 years (IQR 1-11), were included. All presented with swallowing symptoms, and 14 (70%) also experienced respiratory symptoms. Statistically significant improvements in symptoms were reported for both respiratory and swallowing symptoms. Paired (pre- and post-op) PEDI-EAT-10 and PEDI-TBM-7 scores were obtained for nine patients, resulting in mean (± SD) scores decreasing (improvement in symptoms) from 19.9 (± 9.3) to 2.4 (± 2.5) p = 0.001, and 8.7 (± 4.7) to 2.8 (± 4.0) p = 0.006, respectively. Reoperation was required in one patient due to persistent dysphagia from an oesophageal stricture. Other complications included lymphatic drainage (n = 4) and transient left vocal cord hypomobility (n = 1). Children with a left aortic arch with aberrant right subclavian artery can present with oesophageal and respiratory symptoms beyond solid food dysphagia. A thorough multidisciplinary evaluation is imperative to identify patients who can benefit from surgical repair, which appears to be safe and effective.

A stented elephant trunk procedure with retrograde cerebral perfusion for a rare type of pseudoaneurysm with an aberrant right subclavian artery.

Aberrant right subclavian artery (ARSA) is a rare congenital vascular anomaly that increases the risk of aortic dissection (AD). Although several treatment options for cases of AD with ARSA have been proposed, such as traditional surgery, thoracic endovascular aortic repair, and a hybrid procedure, a consensus regarding the optimal treatment strategy has not yet been established. And there are no reported cases of pseudoaneurysm combined with ARSA. A 44-year-old male was admitted with a 7-days history of chest pain. A physical examination was almost normal. Computed tomography angiography (CTA) showed an ARSA arose from the distal aortic arch and pseudoaneurysm located distal to the origin of the ARSA. The stented elephant trunk (SET) procedure with retrograde cerebral perfusion (RCP) was performed under moderate hypothermic circulatory arrest. The postoperative CTA demonstrated a well-perfused ARSA, left subclavian artery (LSA), left common carotid artery (LCCA), and right common carotid artery (RCCA), and occluded pseudoaneurysm with no endoleaks. He was discharged on postoperative day 9 and was doing well during his 6-months follow-up. With a smaller incision, a simple cannulation method, shorter surgical and circulatory arrest times, fewer blood transfusion requirements, and effective brain protection, the SET procedure with RCP can be a safe and feasible treatment option for complicated aortic arch anomalies with ARSA.

Large Right Subclavian Artery Aneurysm Presenting in a Young Patient.

Subclavian artery aneurysms are extremely rare, accounting for less than 1% all of peripheral aneurysms. They are often due to atherosclerosis or thoracic outlet syndrome and present at an average age of 47years. Here, we present an incidental finding of an 18mm rapidly increasing aneurysm involving the first and second part of the right subclavian artery in a woman in her 20s. To our knowledge, this is the youngest patient presenting with a right subclavian artery aneurysm who underwent surgical resection of the aneurysm with repair using interposition graft and successful re-implantation of the vertebral artery with antegrade flow. This report highlights the multidisciplinary care between vascular, interventional radiology and cardiothoracic teams at our tertiary hospital due to the complex nature of the aneurysm.

The course of the phrenic nerve in the neck region and its relationship with adjacent anatomical structures in the thoracic inlet.

This study aims to reveal the relationship of the phrenic nerve (PhN) with its neighboring structures in the lower neck region more comprehensively than previous studies and to minimize nerve damage by enabling invasive procedures in this region to be performed with high accuracy. Forty-one heminecks were evaluated. The relationship between the PhN and the anterior scalene muscle (ASM), internal thoracic artery (ITA), branches of subclavian artery (SA) and subclavian vein (SV) was examined. It was observed that the PhN was located medial to the ASM in all cases. The distances were higher in male cadavers. The PhN was found to enter the thorax lateral to the ITA in 15/41 and medial to it in 25/41 sides. In 17/41 cases, the closest SA branch to the PhN was the thyrocervical trunk (TT) and in 24 cases the ITA. The PhN was located behind the SV in 38 cases and in front of it in 2 cases.The accessory PhN was found in 4/41 sides. There was no significant difference in morphometric findings between genders (p > 0.05). However, significant differences were observed between the parameters (p < 0.05). The anatomy and variations of the PhN are of great importance in surgical interventions and invasive procedures in the neck region. The study provides important information to reduce the risk of damage to the PhN in surgical procedures. In addition, knowledge of the anatomical variations of the nerve may contribute to more successful results in nerve grafting and other surgical applications.