Reconstruction Of Subclavian Artery Research Articles

Optimal antiplatelet therapy after revascularization of left subclavian artery during TEVAR

BackgroundThoracic endovascular aortic repair (TEVAR) is a minimally invasive technique used to treat type B aortic dissections. Left subclavian artery (LSA) reconstruction is required when treating patients with involvement of LSA. The best antiplatelet therapy after LSA reconstruction is presently uncertain.MethodsThis study retrospectively analyzed 245 type B aortic dissection patients who underwent left subclavian artery revascularization during TEVAR. Out of 245 patients, 159 (64.9%) were in the single antiplatelet therapy (SAPT) group, receiving only aspirin, and 86 (35.1%) were in the dual antiplatelet therapy (DAPT) group, receiving aspirin combined with clopidogrel. During the 6-month follow-up, primary endpoints included hemorrhagic events (general bleeding and hemorrhagic strokes), while secondary endpoints comprised ischemic events (left upper limb ischemia, ischemic stroke, and thrombotic events), as well as death and leakage events. Both univariate and multivariate Cox regression analyses were performed on hemorrhagic and ischemic events, with the Kaplan-Meier method used to generate the survival curve.ResultsDuring the six-month follow-up, the incidence of hemorrhagic events in the DAPT group was higher (8.2% vs. 30.2%, P < 0.001). No significant differences were observed in ischemic events, death, or leakage events among the different antiplatelet treatment schemes. Multivariate Cox regression analysis showed that DAPT (HR: 2.22, 95% CI: 1.07–4.60, P = 0.032) and previous chronic conditions (HR:3.88, 95% CI: 1.24–12.14, P = 0.020) significantly affected the occurrence of hemorrhagic events. Chronic conditions in this study encompassed depression, vitiligo, and cholecystolithiasis. Carotid subclavian bypass (CSB) group (HR:0.29, 95% CI: 0.12–0.68, P = 0.004) and single-branched stent graft (SBSG) group (HR:0.26, 95% CI: 0.13–0.50, P < 0.001) had a lower rate of ischemic events than fenestration TEVAR (F-TEVAR). Survival analysis over 6 months revealed a lower risk of bleeding associated with SAPT during hemorrhagic events (P = 0.043).ConclusionsIn type B aortic dissection patients undergoing LSA blood flow reconstruction after synchronous TEVAR, the bleeding risk significantly decreases with the SAPT regimen, and there is no apparent ischemic compensation within 6 months. Patients with previous chronic conditions have a higher risk of bleeding. The CSB group and SBSG group have less ischemic risk compared to F-TEVAR group.

Utility of transmanubrial osteomuscular sparing approach and its modification in vascular surgery: a case series study of surgeries related to subclavian artery

BackgroundThe operative field in subclavian vessel surgery is limited by thoracic inlet and outlet structures. Although endovascular therapy for the subclavian artery could be an option, open repair management is occasionally required in cases of large aneurysms, infectious vasculopathy, and trauma. The transmanubrial osteomuscular sparing approach, commonly used in thoracic surgery area to resect superior sulcus tumors, is a simple and safe procedure providing an excellent view of the operative field. Herein, we present three cases that underwent open repair of the subclavian artery using the transmanubrial osteomuscular sparing approach, and we also highlight the utility of the technique along with the procedural details.Case presentationCase 1: A 54-year-old man presented with a true aneurysm of the proximal portion of the right subclavian artery. The aneurysm measured 50 × 80 mm and compressed the right lung and trachea. We performed an aneurysm resection and a right subclavian artery reconstruction via the transmanubrial osteomuscular sparing approach under cardiopulmonary bypass support.Case 2: A 72-year-old man who presented with an abscess that formed around the left subclavian artery due to an unremoved guidewire during thoracic endovascular aortic repair for an aortic arch aneurysm in another hospital. After the antibiotics administration, debridement and axillary-axillary bypass were performed, and the guidewire was removed via a transmanubrial osteomuscular sparing approach with a use of cardiopulmonary bypass.Case 3: A 60-year-old man presented with misplacement of an indwelling dialysis catheter inserted for acute renal failure and hyperkalemia. The catheter was placed through the right neck, but had penetrated the right internal jugular vein and was misplaced from the right subclavian artery into the proximal aortic arch. Emergently, we removed the catheter using the transmanubrial osteomuscular sparing approach.ConclusionsThe transmanubrial osteomuscular sparing approach to the subclavian artery provides an excellent view and a wide surgical field, even in different pathological situations. This is a simple, safe, and highly useful procedure and could be the standard approach for subclavian artery surgeries.

Hemodynamic analysis of thoracic endovascular aortic repair with left subclavian artery reconstructed by chimney stent.

The purpose of this study was to investigate the hemodynamic consequences of thoracic endovascular aortic repair which reconstructed left subclavian artery by chimney stent (ch-TEVAR). Two patients who underwent thoracic endovascular aortic repair (TEVAR) and left subclavian artery (LSA) reconstruction using chimney stents were selected. Preoperative and postoperative CTA images were collected to reconstruct hemodynamic models for comparing and analyzing blood pressure, blood flow velocity, and wall shear stress in the aortic arch and its major branches. Concurrently, morphological alterations and position of chimney stent were also assessed. After the reconstruction of LSA in ch-TEVAR, no endoleak was seen, but the stent in LSA was compressed. The blood flow velocity of the LSA increased and disordered, the pressure was reduced, and the WSS was increased. Even more, there were a large amount of turbulence found in the LSA of one case, and its LSA was blocked. Chimney stent reduces the occurrence of endoleak due to its excellent deformation ability, but the compressed stent has a greater impact on the hemodynamics of LSA and eventually leads to LSA occlusion; in order to keep the LSA unobstructed, it is necessary to pay attention to the position of the chimney stent and keep it straight and do not fold or twist. Chimney stent has little influence on the aortic arch and the rest of the aortic arch branches.

Clinical comparative analysis of 3D printing-assisted extracorporeal pre-fenestration and Castor integrated branch stent techniques in treating type B aortic dissections with inadequate proximal landing zones

BackgroundThis study aims to compare the clinical effects of two distinct surgical approaches, namely 3D printing-assisted extracorporeal pre-fenestration and Castor integrated branch stent techniques, in treating patients with Stanford type B aortic dissections (TBAD) characterized by inadequate proximal landing zones.MethodsA retrospective analysis was conducted on 84 patients with type B aortic dissection (TBAD) who underwent thoracic endovascular aortic repair (TEVAR) with left subclavian artery (LSA) reconstruction at our center from January 2022 to July 2023. Based on the different surgical approaches, the patients were divided into two groups: the group assisted by 3D printing for extracorporeal pre-fenestration (n = 44) and the group using the castor integrated branch stent (n = 40). Clinical indicators: including general patient information, operative time, surgical success rate, intraoperative and postoperative complication rates, re-intervention rate, and mortality, as well as postoperative aortic remodeling, were compared between the two groups. The endpoint of this study is the post-TEVAR mortality rate in patients.ResultsThe surgical success rate and device deployment success rate were 100% in both groups, with no statistically significant difference (P > 0.05). However, the group assisted by 3D printing for extracorporeal pre-fenestration had a significantly longer operative time (184.20 ± 54.857 min) compared to the group using the castor integrated branch stent (152.75 ± 33.068 min), with a statistically significant difference (t = 3.215, p = 0.002, P < 0.05). Moreover, the incidence of postoperative cerebral infarction and beak sign was significantly lower in the group assisted by 3D printing for extracorporeal pre-fenestration compared to the castor-integrated branch stent group, demonstrating statistical significance. There were no significant differences between the two groups in terms of other postoperative complication rates and aortic remodeling (P > 0.05). Notably, computed tomography angiography images revealed the expansion of the vascular true lumen and the reduction of the false lumen at three specified levels of the thoracic aorta. The follow-up duration did not show any statistically significant difference between the two groups (10.59 ± 4.52 vs. 9.08 ± 4.35 months, t = 1.561, p = 0.122 > 0.05). Throughout the follow-up period, neither group experienced new endoleaks, spinal cord injuries, nor limb ischemia. In the castor-integrated branch stent group, one patient developed a new distal dissection, prompting further follow-up. Additionally, there was one case of mortality due to COVID-19 in each group. There were no statistically significant differences between the two groups in terms of re-intervention rate and survival rate (P > 0.05).ConclusionBoth 3D printing-assisted extracorporeal pre-fenestration TEVAR and castor-integrated branch stent techniques demonstrate good safety and efficacy in treating Stanford type B aortic dissection with inadequate proximal anchoring. The 3D printing-assisted extracorporeal pre-fenestration TEVAR technique has a lower incidence of postoperative cerebral infarction and beak sign, while the castor-integrated branch stent technique has advantages in operative time.

Modified transmanubrial approach for complicated type 1 cervical rib resection requiring subclavian artery reconstruction.

The transmanubrial musculoskeletal sparing approach (TMA) is commonly used for resecting apical lung tumours with vascular involvement. Non-neoplastic conditions which might require surgical exploration of the thoracic outlet include the 'cervical rib', a clinical condition consisting of an additional rib forming above the first rib and growing from the base of the neck just above the clavicle. Type 1 cervical rib-when a complete cervical rib articulates with the first rib or manubrium of the sternum-is the most challenging scenario where the subclavian artery can be damaged by continuous compression due to the narrow space between clavicle, first rib and supernumerary cervical rib, requiring prosthetic reconstruction of the involved tract. Here, we describe a modified TMA in which the incision in the neck is conducted posteriorly to the sternocleidomastoid muscle, thus allowing safe dissection of the superior and middle trunk of the brachial plexus.

Deposition of Sevelamer crystals in gastrointestinal tract and lung parenchyma: A rare autopsy finding

Abstract Introduction/Objective Sevelamer carbonate is a non-calcium-based phosphate binder used for the management of hyperphosphatemia in patients with end stage renal disease. The well-known side effects of sevelamer include nausea, vomiting and abdominal pain. However, there are few case reports which described the deposition of sevelamer crystals in the gastrointestinal tract causing mucosal injury, pseudotumor or obstruction. Methods/Case Report We hereby present a case of a 43-year-old decedent female with past medical history of seizures, hypertension, cocaine use, type B aortic dissection status post thoracic endovascular aortic repair, total arch replacement, reconstruction of innominate, carotid, and subclavian artery who presented with hematochezia concerning for possible aorto-esophageal fistula on 10/06/2022 and acute kidney injury. Imaging showed a thrombus in mid-esophagus, blood in trachea and narrowing of the left main stem bronchus. Labs revealed worsening of BUN and creatinine and up trending hyperphosphatemia and therefore sevelamer carbonate via nasogastric route was started on 10/13/22. Unfortunately, the patient’s hospital course was complicated, and she passed away on 11/14/2022. At autopsy, the deceased had gross evidence of acute lung injury with diffuse alveolar hemorrhage, aorta-bronchial ruptured aneurysm defect and aorto-esophageal fistulas. On histopathological examination, the stomach, small and large bowel showed autolysis, necrosis, and numerous rectangular shaped, non-polarizable crystals. The crystals with characteristic morphology of “fish scale” with hues of pink in the center and yellow to orange in the periphery were identified as sevelamer crystals. Interestingly, crystal deposition was also identified in lung parenchyma and rarely in aortic wall and the fistula. Results (if a Case Study enter NA) NA Conclusion As one of the more commonly used resins in end stage kidney disease, gastrointestinal adverse effect of sevelamer carbonate is often underrecognized. Our case report heightens the awareness of the characteristic morphology of this biologically inert agent, sevelamer to those who are unaware of their morphology. This case also highlights the adverse effect of sevelamer in all patients presenting with gastrointestinal symptoms, such as gastrointestinal bleeding and abdominal pain with the use of sevelamer.

Surgical Outcome of Proximal Isolated Subclavian Artery Aneurysms: A Single-Center Retrospective Observational Study

Objective: The objective of this study was to introduce our institutional experience of treatment strategies (cervical subclavian artery reconstruction, thoracotomy subclavian artery reconstruction and endovascular treatment) for proximal isolated subclavian artery aneurysms (PISAAs). Methods: we retrospectively analyzed 15 consecutive patients with PISAAs treated by different treatment strategies (cervical reconstruction, thoracotomy reconstruction and endovascular treatment) in our institution from May 2016 to May 2022. Baseline data, surgery-related data, postoperative information and long-term follow-up were assessed. Results: A total of 17 PISAAs in 15 consecutive patients were treated in our institution. The success rates of subclavian artery reconstruction in the cervical reconstruction, the thoracotomy reconstruction and the endovascular treatment were 100%, 100 and 83.33%, respectively. About the involved vertebral artery, the reconstruction rates in the cervical reconstruction, the thoracotomy reconstruction, and the endovascular treatment were 80%, 75%, and 0, respectively. The intraoperative blood loss in the thoracotomy reconstruction was significantly higher than that in the cervical reconstruction and the endovascular treatment ( p&lt;0.05). The total operation time of the thoracotomy reconstruction was significantly longer than that of the cervical reconstruction and the endovascular treatment ( p&lt;0.05). In terms of postoperative ventilator use time, total postoperative drainage fluid, total postoperative drainage time, and ICU duration, both the thoracotomy reconstruction and the cervical reconstruction were significantly more than the endovascular treatment ( p&lt;0.05). During the follow-up, one patient in the endovascular treatment underwent re-intervention 22 months after surgery due to in-stent occlusion. Conclusions: For patients with PISAAs, different treatment strategies are recommended depending on the size of the aneurysms and whether the involved vertebral arteries require reconstruction. Clinical impact This article is the largest study on the treatment strategies of PISAAs. By comparing the prognosis and complications of endovascular treatment with those of open surgery, it provides a certain reference basis for the choice of treatment for patients with PISAAs. For patients with aneurysms’ diameter of &gt;50 mm, the thoracotomy subclavian artery reconstruction is recommended; for patients with aneurysms’ diameter of &lt;30 mm requiring reconstruction of the involved vertebral arteries, the cervical subclavian artery reconstruction is recommended; for patients with aneurysms’ diameter of &lt;30 mm not requiring reconstruction of the involved vertebral arteries, the endovascular treatment is recommended.

Impact of post-implantation syndrome on outcomes in acute type B aortic syndrome patients undergoing endovascular repair.

Background: The aim of this study was to explore the impact of post-implantation syndrome (PIS) on prognosis outcomes in individuals with type B acute aortic syndrome (AAS) undergoing thoracic endovascular aortic repair (TEVAR). Patients and methods: Data from type B AAS individuals who underwent TEVAR from January 2014 to April 2021 were retrospectively reviewed. Study subjects were divided into PIS and non-PIS (nPIS) groups and postoperative clinical outcomes were analyzed. Results: Our study cohort of 74 individuals with type B AAS included 40 aortic dissection (AD), 30 intramural hematoma (IMH), 4 penetrating aortic ulcer (PAU). The incidence of PIS was 14.9%. No statistically significant differences were found in baseline characteristics. The left subclavian artery (LSCA) reconstruction was performed more frequently among the PIS group (45.5% vs 9.5%, p=.008). Major adverse events (MAE) tended to be more frequent in the PIS group, but the difference was not significant (27.3% vs 22.2%, p=.707). At 2-year follow-up, results were comparable between the two groups. Kaplan-Meier analysis showed that PIS was not associated with a higher incidence of mortality, endoleak, new-onset AD, or stroke. A baseline neutrophil-to-lymphocyte ratio (NLR) >10.3 was associated with greater incidence of MAE. In individuals with IMH, better aortic remodeling evaluated by lower total aortic diameter/true lumen diameter (TAD/TLD) was achieved in the nPIS group (1.23±0.10 vs 1.43±0.07, p<.001), and a TAD/TLD ratio >1.32 was associated with significantly more MAE. Cox multivariate regression analysis also showed that a postoperative TAD/TLD ratio >1.32 was an independent risk factor for MAE (OR, 11.36; 95% CI, 1.53-84.26; p=.017). Conclusions: PIS was associated with a trend toward a higher incidence of MAE after TEVAR. In individuals with IMH, a TAD/TLD ratio >1.32 was an independent predictor of postoperative MAE.

3D Printing-Assisted versus Conventional Extracorporeal Fenestration Tevar for Stanford Type B Arteries Dissection with Undesirable Proximal Anchoring Zone: Efficacy Analysis

Background: To compare the outcomes of two Thoracic Endovascular Aortic Repair (TEVAR) techniques of Left Subclavian Artery (LSA) reconstruction for Stanford Type B Aortic Dissection (TBAD) patients with undesirable proximal anchoring zone. Methods: We retrospectively reviewed 57 patients with TBAD who underwent either three dimensional (3D)-printing-assisted extracorporeal fenestration (n = 32) or conventional extracorporeal fenestration (n = 25) from December 2021 to January 2023. We compared their demographic characteristics, operative time, technical success rate, complication rate, secondary intervention rate, mortality rate, and aortic remodeling. Results: Compared with the conventional group, the 3D-printing-assisted group had a significantly shorter operative time (147.84 ± 33.94 min vs. 223.40 ± 65.93 min, p &lt; 0.001), a significantly lower rate of immediate endoleak (3.1% vs. 24%, p = 0.048) and a significantly higher rate of true lumen diameter expansion in the stent-graft segment (all p &lt; 0.05), but a significantly longer stent graft modification time (37.63 ± 2.99 min vs. 28.4 ± 2.12 min, p &lt; 0.001). There were no significant differences in other outcomes between the two groups (p &gt; 0.05). The degree of false lumen thrombosis was higher in the stent-graft segment than in the non-stent-graft segment in both groups and the difference was statistically significant (X2 = 5.390, 4.878; p = 0.02, 0.027). Conclusions: Both techniques are safe and effective for TBAD with an undesirable proximal landing zone. The 3D-printing-assisted extracorporeal fenestration TEVAR technique has advantages in operative time, endoleak risk, and aortic remodeling, while the traditional extracorporeal fenestration TEVAR technique has advantages in stent modification.

Hemodynamics of different configurations of the left subclavian artery parallel stent graft for thoracic endovascular aortic repair

Background and objectiveParallel (chimney and periscope) graft technique is an effective approach for left subclavian artery (LSA) reconstruction in patients treated by thoracic endovascular aortic repair (TEVAR) for the inadequate landing zone. However, certain stent graft (SG) configurations may promote thrombosis and reduce distal blood flow, increasing risks of cerebral infarction and reintervention. MethodsIn this paper, we first attempt to systematically evaluate the hemodynamic performances of different parallel graft techniques as potential determinants of complication risks. Based on the patient-specific 3D aortic geometry undergoing parallel graft technique, fifteen models in total for five kinds of LSA branched SG configurations (Forward, Backward, Extended, Elliptical and Periscopic) were designed virtually, and the hemodynamic discrepancies between them were analyzed by computational fluid dynamics. ResultsResults show that flow rate of patients undergoing periscope technique reduces by half compared with chimney technique, suggesting that periscope SG may cause more serious flow obstruction to LSA, leading to stroke. For chimney stent structure, the extension length 0has little influence on energy loss and other parameters. Conversely, hemodynamic differences between the retrograde curvature and the antegrade curvature are significant (time average WSS: 47.07%), so the retrograde curvature might prompt SG displacement. Furthermore, the flatter chimney SG induces more aggressive hemodynamic forces, among which the difference of the maximum WSS between the flatter SG and nearly round SG reaches 65.56%, leading to the greater risk of vascular wall damage. ConclusionsResults obtained might provide suggestions for physicians to formulate appropriate parallel graft technique schemes in TEVAR.

Postoperative results of the in situ fenestrated open stent technique for acute aortic dissection type A

ObjectiveTotal arch replacement is commonly used for acute aortic dissection type A at some facilities, especially since open stent grafting became commercially available in Japan. Left subclavian artery (LSCA) reconstruction involves deep view manipulation, is difficult to expose and anastomose, and involves the risk of complications and surrounding vascular injury.MethodsWe evaluated 137 patients (mean age 73.8 ± 15.6 years) who underwent total arch replacement for acute aortic dissection type A, at our hospital between September 2014 and March 2022, and divided them into two groups: 70 patients for total arch replacement with fenestrated open stent technique (FeneOS), and 67 for conventional total arch replacement with the reconstruction of three-branch cerebral vessels. We performed FeneOS by deploying the graft from the entry of the left subclavian artery into the descending aorta and fenestrating the LSCA side of the stenting portion. The four-branched artificial vessel was then anastomosed between the left common carotid artery and LSCA.ResultsThe surgical results of FeneOS were satisfactory and enabled significant reductions in operative time, selective cerebral perfusion time, cardiopulmonary bypass time, and lower body circulatory arrest time. Long-term observation (mean follow-up = 5.5 years) showed no left recurrent laryngeal nerve palsy or postoperative problems with left subclavian artery blood flow.ConclusionsFeneOS can minimize LSCA exposure because there is no need for LSCA reconstruction, reducing operation time and avoiding the risk of left recurrent laryngeal nerve injury and bleeding problems associated with LSCA exposure and anastomosis during left subclavian artery exposure.

Single-center experience with a unibody single-branched stent graft for zone 2 thoracic endovascular aortic repair.

To provide an adequate proximal landing zone, left subclavian artery (LSA) reconstruction has become an important part of thoracic endovascular aortic repair (TEVAR). This study evaluates the short and medium term efficacy of a novel unibody single-branched stent graft for zone 2 TEVAR. Fifty-two patients (mean age, 56 ± 10.9 years; 42 men) with distal aortic arch lesions requiring LSA reconstruction received unibody single-branched stents from September 2019 to March 2021. Computed tomography angiography was performed 6, 12, and 24 months after surgery to observe stent morphology, branch patency, endoleaks, stent-related adverse events, and changes in the diameter of true and false lumens. All stents were deployed adequately, and the technical success rate was 100%. The mean operation time was 121.8 ± 47.0 min. The mean postoperative hospital stay was 6.2 ± 3.7 days, and the mean follow-up was 16.8 ± 5.2 months (range, 12–24 months). During follow-up, there were no deaths and complications such as stent displacement or fracture, stenosis, fracture, occlusion, and type Ia endoleaks. The patency rate of the branched segment was 100%. In 42 patients with aortic dissection (AD), the true lumen diameter of the aortic isthmus was 29.4 ± 2.9 mm after surgery, significantly larger than before surgery (20.6 ± 5.4 mm, P < 0.05). Postoperative aortic isthmus false lumen diameter was significantly smaller than that before operation (6.1 ± 5.2 mm vs. 16.0 ± 7.6 mm, P < 0.05). The new unibody single-branched stent for zone 2 TEVAR is safe and accurate, and its efficacy is good in the short and medium term.

Hybrid repair of a distal aortic arch aneurysm with aberrant right subclavian artery and Kommerell's diverticulum: A case report

Introduction and importanceAberrant right subclavian artery (ARSA) and Kommerell's diverticulum (KD) are common vascular anomalies of the aortic arch. Anatomic reconstruction of ARSA is difficult with only the median sternotomy approach.Case presentationA 55-year-old woman was referred to our hospital for a thoracic aneurysm. CT showed 46 mm diameter of distal aortic arch aneurysm with ARSA and KD. ARSA branched from the distal aortic arch and crossed behind the esophagus. It was difficult to reconstruct ARSA anatomically via the median sternotomy approach. We performed coil embolization of ARSA and total aortic arch replacement (TAR) and extra-anatomic right subclavian artery reconstruction for the distal aortic arch aneurysm with ARSA and KD. The patient was discharged home with no complications.Clinical discussionThere were differences in blood pressure of the upper extremities after coil embolization of ARSA; however, subclavian steal syndrome or cerebral complications did not occur. If there is no abnormal finding in head and neck arteries before surgery, coil embolization of ARSA is safe and open distal anastomosis of the distal aortic arch can be performed in a bloodless field.ConclusionHybrid repair by coil embolization and TAR for the distal aortic arch aneurysm with ARSA and KD were considered to be a useful in the absence of cerebral vascular stenosis or obstruction.

Thirty-year single-center experience with arterial thoracic outlet syndrome

ObjectiveArterial thoracic outlet syndrome (ATOS) is rare. We present our 30-year experience with the management of ATOS at a high-volume referral center. MethodsA retrospective review of all patients who had undergone primary operative treatment for ATOS from 1988 to 2018 was performed. ATOS was defined as subclavian artery pathology caused by extrinsic compression from a bony abnormality within the thoracic outlet. ResultsA total of 41 patients (45 limbs) underwent surgery for ATOS at a median age of 46 years (interquartile range [IQR], 34-58 years). Chronic symptoms (>6 weeks) were present in 31 limbs (69%). Of the 45 limbs, 13 (29%) presented with acute limb ischemia (ALI), requiring urgent brachial artery thromboembolectomy (BAT) in 9 and catheter-directed thrombolysis and thrombectomy (CDT) in 4. All patients underwent thoracic outlet decompression. 31 limbs (69%) required subclavian artery reconstruction. No perioperative deaths and only one major adverse limb event occurred. Patients with ALI underwent staged thoracic outlet decompression after initial BAT or CDT at a median of 23 days (IQR, 11-140 days). Of the 13 limbs with an initial presentation of ALI, 8 (62%) had recurrent thromboembolic events before thoracic outlet decompression subsequently requiring 10 additional BATs and 1 CDT. The cumulative probability of recurrent embolization at 14, 30, and 90 days was 8.33% (95% confidence interval [CI], 1.28%-54.42%), 16.67% (95% CI, 4.70%-59.06%), and 33.33% (95% CI, 14.98-74.20%), respectively. The median follow-up for 32 patients (35 limbs) was 13 months (IQR, 5-36 months). Subclavian artery/graft primary and secondary patency was 87% and 90%, respectively, at 5 years by Kaplan-Meier analysis. Of the 35 limbs, 5 (14%) had chronic upper extremity pain and 5 (14%) had persistent weakness. Preoperative forearm or hand pain and brachial artery occlusion were associated with chronic pain (P = .04 and P = .03) and weakness (P = .03 and P = .02). Of the 13 limbs that presented with ALI, 11 had a median follow-up after thoracic outlet decompression of 6 months (IQR, 5-14 months), including 9 (82%) with oral anticoagulation therapy. Anticoagulation therapy had no effect on subclavian artery patency (P = 1.0) or the presence of chronic symptoms (P = .93). ConclusionsThe presentation of ATOS is diverse, and the diagnosis can be delayed. Preoperative upper extremity pain and brachial artery occlusion in the setting of ALI were associated with chronic pain and weakness after thoracic outlet decompression. Delayed thoracic outlet decompression was associated with an increased risk of recurrent thromboembolic events for patients who presented with ALI. An early and accurate diagnosis of ATOS is necessary to reduce morbidity and optimize outcomes.

Hybrid Repair of Kommerell Diverticulum and Aberrant Subclavian Artery with Compressive Symptoms and a New Strategy: Case Report.

Surgical indication and treatment for patients with Kommerell diverticulum and aberrant subclavian artery are still not well established. A patient with esophageal and tracheal compression resulting from these anatomical abnormalities was successfully treated with a hybrid approach of total arch replacement, frozen elephant trunk technique, aberrant left subclavian artery transection, and left subclavian artery reconstruction through median sternotomy. Compressive symptoms were relieved without resecting the enlarged diverticulum. In this case, the importance of preoperative investigation for the main cause of compressive symptoms is illustrated and a novel treatment strategy is outlined.

Analysis of the short-term results of pre fenestration and external branched thoracic endovascular aortic repair for aortic lesions

Objective: To evaluate the short-term effect of left subclavian artery (LSA) reconstruction with pre fenestration and external branch thoracic endovascular aortic repair (TEVAR) in the treatment of aortic arch descending lesions. Methods: The clinical data of 79 patients with aortic diseases who received LSA reconstruction in Tianjin Medical University General Hospital from November 2015 to October 2019 were analyzed retrospectively. According to different LSA reconstruction methods, they were divided into the fenestrated group (group f) 50 cases and the external branched group (group b) 29 cases. The surgical success rate, intraoperative and postoperative complication rate, re-intervention rate, mortality rate, and the change of the true and false lumen area of the dissection were compared and analyzed. Results: There were no significant differences in the perioperative and recent total complication rate, secondary intervention rate and mortality between the two groups (χ²=0, 1.246, 0.156, all P>0.05). The operation time of group f [(123.0±40.7 min)] was significantly longer than that of group b ((84.2±16.3) min, t=2.173, P=0.034). The degree of false lumen thrombosis of the stent segment was better than that of the non-stent segment (χ²=7.213, 14.359, both P<0.05) in the two groups after surgery, but no significant difference between the two groups (χ²=1.510, 0.886, both P>0.05). There was no significant difference in the change rate of the true and false lumen on each plane of the dissection between the two groups (all P>0.05). Conclusions: Both fenestrated and external branched TEVAR reconstruction LSA have good safety and effectiveness in treating aortic arch descending lesions. The external branched TEVAR takes less time, has higher effectiveness for lesions with shorter landing zone, and has better aortic remodeling effect in the stent segment soon; and the fenestrated TEVAR has better economy.

Castor单分支支架与单烟囱支架在胸主动脉疾病中重建左侧锁骨下动脉的疗效分析及评价

Castor单分支支架与单烟囱支架在胸主动脉疾病中重建左侧锁骨下动脉的疗效分析及评价

Thoracic endovascular aortic repair with left subclavian artery reconstruction for blunt traumatic aortic injury in elderly patients

IntroductionBlunt thoracic aortic injury (BTAI) is rare in elderly patients. As the population ages and life expectancy increases, the frequency of this injury will increase, while the treatment and outcomes remain unclear. MethodsWe retrospectively analyzed the collected data of patients >60 years old with BTAI to investigate the mechanism of trauma; time interval from injury to diagnosis; type and timing of surgical intervention; aortic arch pattern; choice of left subclavian artery reconstruction; endograft to treat BTAI; length of the endovascular procedure; endoleaks; complications including stroke, paraplegia, and renal failure; length of hospital stay (LOS) and intensive care unit stay (L.ICUS); and 30-day mortality. ResultsFive elderly trauma patients were found to have BTAI. Four (80%) were males, the cohort mean age was 68 years, the major mechanism of trauma was fall injury, and the associated injury was thoracic trauma. All patients were transferred to our hospital, and emergency computed tomography angiography showed BTAI in each patient. The average time interval from injury to diagnosis was 2.7 days. Two patients suddenly showed signs of instability in their vital signs and underwent immediate endovascular repair, while 3 patients underwent delayed endovascular repair. The injury site was located in the aortic isthmus just distal to the origin of the left subclavian artery; the aortic arch pattern was II (80.0%) in 4 cases and III in 1 case (20.0%). The choice of left subclavian artery reconstruction included chimney, double chimney, prefenestration, and chimney combined with in situ fenestration. Endografts to treat BTAI included the Ankura (Lifetech Scientific, Shenzhen, China) and the C-TAG (W.L. Gore & Associates, Flagstaff, AZ USA).The length of the endovascular procedure was 75.4 min; there were no endoleaks and no complications including stroke, paraplegia, or renal failure. The average LOS was 25 days, and the average L.ICUS of 2 patients was 15 days, with no 30-day mortality. ConclusionElderly patients with fall injury should promptly exclude BTAI. Thoracic endovascular aortic repair (TEVAR) with a left subclavian artery reconstruction technique provided good results without procedure-related or neurological complications. Because of the low incidence of this type of injury, we are unable to provide any evidence to guide the treatment option for this life-threatening condition.

Checklists for left subclavian artery reconstruction in thoracic endovascular aortic repair

Checklists for left subclavian artery reconstruction in thoracic endovascular aortic repair

Endovascular Reconstruction of Subclavian Artery Aneurysms in Patients with Arterial Thoracic Outlet Syndrome

Subclavian artery aneurysms associated with thoracic outlet syndrome (TOS) have traditionally been managed by open surgical reconstruction. Endovascular subclavian artery reconstruction is novel in the setting of arterial TOS (aTOS). Our objective is to report our results with endovascular subclavian artery reconstruction in aTOS patients over a 10-year period with attention to surgical approach and late results. Patients who underwent stent-graft reconstruction of subclavian artery aneurysms associated with aTOS between 2006 and 2016 were identified in a prospective database. Data collected included age, gender, presentation, surgical details, and outcomes. Over the study period, 869 TOS procedures were performed. Of these, 7 (0.8%) were aTOS related subclavian artery aneurysms managed with stent-graft repair. All presented with upper extremity pain (7) and a majority with limb-threatening ischemia (6). Other significant findings included subclavian artery aneurysm (7), cervical rib (4), and clavicular fracture (3). TOS decompression was accomplished via transaxillary cervical and first rib resection. Stent-graft deployment was performed concurrently with TOS decompression via brachial artery approach. The mean follow-up period was 24.9months (range 1-60). Two patients required reintervention for stent thrombosis (1.5months, 36months) and 1 required balloon angioplasty for in-stent restenosis (24months). Limb salvage was achieved in all patients with no major amputations, no minor amputations, and restoration of normal function in all. Our experience indicates that stent-graft reconstruction of subclavian artery aneurysms associated with aTOS is successful. This procedure was characterized by short surgical times, low blood loss, and no complications. It may be subject to late graft thrombosis or stenosis and requires life-long surveillance.