Thoracic Arch Research Articles

Hybrid Thoracic Endovascular Repair of a Large, Saccular Aortic Arch Aneurysm with Coil Embolization of the Left Subclavian Artery in a 31 Year Old Filipino Female with Takayasu Arteritis and Multiple Intracranial Aneurysms: A First in the Philippines

BACKGROUND: Takayasu Arteritis (TA) is a rare, primary large-vessel vasculitis frequently leading to stenosis and less commonly, aneurysm formation. Saccular aneurysms of the aortic arch in patients with TA are fatal, have rarely been reported and represent a significant technical challenge due to the difficult anatomical location and need for protection of the cerebral circulation. Concomitant intracerebral aneurysms in patients with TA are extremely uncommon and have mostly been documented in very few case reports in literature. CASE DISCUSSION: We present a case of a 31 year-old Filipino female with recurrent chest and neck pain radiating to the upper back. Computed tomographic (CT) angiography demonstrated a large saccular aortic arch aneurysm without branch stenosis. CTA of the cerebral circulation likewise demonstrated multiple, saccular, intra-cerebral aneurysms. She underwent hybrid thoracic arch repair with supra-aortic debranching via mini-sternotomy and proximal ligation of the left common carotid artery and staged endovascular aortic arch replacement with coil embolization of the ostial-to-proximal left subclavian artery segment. Post-operative aortogram showed optimal repair with thrombosed aneurysmal sac, optimal graft position, no endoleaks and preservation of cerebral circulation. Patient improved symptomatically post-procedure and remained symptom-free during follow-up after six months. Careful review of local literature suggests that this is the first Philippine TA case with a saccular aortic arch aneurysm successfully managed in this manner. CONCLUSION: Saccular aortic arch aneurysms in patients with Takayasu are unusual and presence of concomitant multiple cerebral saccular aneurysms have rarely been reported in literature. This case highlighted that hybrid endovascular arch repair in patients with TA is feasible, minimally invasive and effective. KEYWORDS: Takayasu arteritis, aortic arch aneurysm, cerebral aneurysm, hybrid endovascular arch repair, aortic de-branching

Effectiveness of Proximal Landing Zone 1 and 2 Thoracic Endovascular Aortic Repair for Type B Aortic Dissection by Comparing Outcomes With Thoracic Arch Aneurysm.

Hybrid thoracic endovascular aortic repair (TEVAR) for aortic arch aneurysms is a minimally invasive procedure with improved results. This study aimed to clarify the effectiveness and expand the possibilities of zone 1 and 2 landing TEVAR for type B aortic dissection (TBAD) using our treatment strategy. This retrospective, single-center, observational cohort study included 213 patients (TBAD, n=69; thoracic arch aneurysm [TAA], n=144; median age, 72 years; median follow-up period, 6 years) from May 2008 to February 2020. The following conditions were satisfied before performing zone 1 and 2 landing TEVAR: TBAD; proximal landing zone (LZ): diameter <37 mm, length >15 mm, and nondissection area, proximal stent-graft: size ≤40 mm and oversizing rate: 10% to 20%, and TAA; proximal LZ: diameter ≤42 mm and length >15 mm, proximal stent-graft: size ≤46 mm and oversizing rate: 10% to 20%. Of the 69 patients in the TBAD group, 34 (49.3%) had patent false lumen (PFL), and 35 (50.7%) had false lumen partial thrombosis (FLPT), including ulcer-like projections. Emergency procedures were performed in 33 (15.5%) patients. There were no significant differences in the in-hospital mortality (TBAD: 1.5% vs TAA: 0.7%, p=0.544) or the in-hospital aortic complications (TBAD: n=1 vs TAA: n=5, p=0.666). Retrograde type A dissection was not observed in the TBAD group. The aortic event-free rates at 10 years were 89.7% (95% confidence interval [CI]: 78.7%-95.3%) and 87.9% (95% CI: 80.3%-92.8%) in the TBAD and TAA groups, respectively (log-rank p=0.636). In the TBAD group, the early and late outcomes were not significantly different between the PFL and FLPT groups. Satisfactory early and long-term results were obtained with zone 1 and 2 landing TEVAR. The TBAD cases had the same good results as the TAA cases. Using our strategy, we especially might reduce complications and be an effective treatment for acute complicated TBAD. This study aimed to clarify the effectiveness and expand the possibilities of zones 1 and 2 landing TEVAR for type B aortic dissection (TBAD) using our treatment strategy. Satisfactory early and long-term results in the TBAD and thoracic arch aneurysm (TAA) groups were obtained with zones 1 and 2 landing TEVAR. The TBAD cases had the same good results as the TAA cases. Using our strategy, we especially might reduce complications and be an effective treatment for acute complicated TBAD.

Branched and Fenestrated Aortic Endovascular Grafts.

Endovascular repair of abdominal and descending thoracic aortic aneurysms has become the standard of care due to improvements in morbidity and mortality compared to open surgical repair. Late durability, however, remains an issue because persistent endoleaks can lead to continued aneurysm expansion and eventual rupture, sometimes years following the original repair. Branched, fenestrated, and physician-modified endografts in the thoracic arch and thoracoabdominal aorta have extended the seal zone in order to mitigate the risks of proximal and distal endoleaks. This review summarizes the current state of branched, fenestrated, and physician-modified endografts used in complex aortic pathologies.

The Outcomes of Thoracic Endovascular Aortic Repair in Japan in 2017: A Report from the Japanese Committee for Stentgraft Management.

Thoracic endovascular aortic repair (TEVAR) was initially used in treating descending thoracic aortic aneurysms back in 1992.1) It was then approved by the United States Food and Drug Administration in 2005. Since then, TEVAR has been adopted worldwide and has been improved dramatically, both procedurally and in terms of available materials. In Japan, TEVAR is identified as the standard treatment for descending thoracic aneurysms.2) The emergence of fenestrated stent grafts to better fit the angulated morphology of the thoracic arch and of the lower profile and the 2015 approval of TEVAR for aortic dissection have led to an increase in the annual number of TEVAR procedures performed in Japan. However, the outcomes of TEVAR are yet to be evaluated in a large cohort. Thus, in this study, we aim to report the number of TEVAR procedures conducted in Japan in 2017, including its mortality and complication rates, by using the data from the Japanese Committee for Stentgraft Management (JACSM) nationwide registry; this data covers the outcomes of nearly all of the stent grafts shipped to Japan.3,4) JACSM and database The JACSM nationwide registry, including its foundations, structure, and quality control, has already been previously described in detail.3,4) The JACSM, established in December 2006, is composed of 10 societies related to endovascular treatment and determined the practical standards for institutions and for practicing and supervising surgeons. Participating institutions were obligated to report their data on endovascular aneurysm repair (EVAR) and TEVAR, using a web-based case-registry form (http://www.stentgraft.jp/). The information collected as regards TEVAR included preoperative information, anatomical factors evaluated during operative planning, and data obtained in the immediate postoperative period, at discharge, at 6 months postoperative, and at each year after that. As of 2015, 366 institutes in Japan had been certified for TEVAR by the JACSM. This registry was conducted in accordance to the principles of the Declaration of Helsinki, the International Conference on Harmonization, and Good Clinical Practice guidelines. The use of registry data was approved by the Institutional Review Board of the University of Tokyo Hospital (approval number: 2019306NI).

Technical Aspects of Branched Thoracic Arch Graft Implantation for Aortic Arch Pathologies

Purpose: To describe the implantation steps and tips and tricks for the Inner Branch Arch Endograft designed to treat aortic arch aneurysm and chronic type A aortic dissection. Technique: Anatomical suitability criteria should be met in order to use this device. The proximal segment of the graft lands in the ascending aorta distally to the sinotubular junction and the distal segment lands in the descending aorta. The device includes 2 inner branches; the proximal branch is used for a connection to the innominate artery (positioned slightly posterior at 12:30 o’clock), while the second branch is positioned slightly anterior at 11:30 o’clock and is used as a connection to the left common carotid artery. Access, implantation technique, deployment of the device, and catheterization of the branches are described thoroughly. Conclusion: This Inner Branch Arch Endograft is an appealing alternative to treat aortic arch pathology, especially in patients unsuitable for open repair. Nevertheless, complex aortic arch repair is associated with a learning curve. Meticulous preoperative planning and a high level of concentration intraoperatively are mandatory.

Combined fenestrated-branched endovascular repair of the aortic arch and the thoracoabdominal aorta

ObjectiveThe aim of our study was to evaluate patients who underwent extensive endovascular aortic stent graft coverage (from the aortic arch to abdominal aorta) in terms of early and midterm clinical outcomes. MethodsA retrospective multicenter study was undertaken. All patients were treated with extensive endovascular aortic stent graft coverage with fenestrated and branched endografts at three experienced endovascular centers. ResultsBetween 2012 and 2017, there were 33 patients (22 male [67%]) treated with a combination of fenestrated-branched stent grafts in the aortic arch and the thoracoabdominal aorta. Most of the patients (20/33 [61%]) had fenestrated-branched endovascular aneurysm repair (fb-EVAR) of the thoracoabdominal aorta as a second-stage procedure after thoracic arch (fb-Arch) repair, 10 had fb-Arch repair as the first procedure, and three patients had a single-stage procedure. The mean age was 67 ± 13 years, and the mean interval between procedures was 13 ± 12 months. For fb-Arch repair, 20 fenestrated and 13 branched devices were used; for fb-EVAR, 23 fenestrated, 5 branched, and 5 composite devices were used. The use of spinal drainage was more common in fb-EVAR (20/33 [61%]). Technical success was 100%. Mean hospital stay was 15 ± 13 days for fb-Arch repair and 12 ± 9 days for fb-EVAR. Two patients died in the hospital after fb-EVAR, resulting in a 30-day mortality of 6% (2/33). No deaths occurred during the fb-Arch repair component or in the single-stage cases. Four patients developed spinal cord injury (12%), 1 had permanent paraplegia (3%), and 2 patients had a neurologic event (1 stroke [3%] and 1 transient ischemic attack [3%]). Six patients (18%) died during a mean follow-up of 23 ± 17 months. The survival at 12 months after the second procedure was 72%, and the freedom from any reintervention was 82%. The 12-month freedom from reintervention was 87% for fb-Arch repair and 81% for fb-EVAR. ConclusionsExtensive endovascular coverage of the aorta for aortic disease seems to be a feasible procedure in experienced centers, with acceptable perioperative morbidity and mortality. Spinal cord ischemia appears acceptable despite extensive aortic coverage.

5234KAND567, the first selective small molecule CX3CR1 antagonist in clinical development, mediates anti-inflammatory cardioprotective effects in rodent models of atherosclerosis and myocardial infarction

Abstract Background Fractalkine is a chemokine that mediates recruitment and extravasation of CX3CR1-expressing subsets of leukocytes and monocytes and has been implicated in the inflammation-driven pathology of cardiovascular disease. More specifically, fractalkine signaling has been proposed to contribute to increased infarct size and enhanced atherosclerotic plaque vulnerability in patients and experimental models. Blocking fractalkine/CX3CR1 signaling is suggested as a promising anti-inflammatory strategy for the treatment of both acute and chronic cardiovascular disease. KAND567 is a small molecule, selective, non-competitive, allosteric antagonist of the fractalkine receptor CX3CR1, that is under preparation for a clinical phase IIa study in AMI patients. Purpose To explore the therapeutic effects of the short and long term administration of KAND567 in experimental rodent models of acute myocardial infarction and atherosclerosis, respectively. Methods Myocardial infarction was induced in Wistar rats (N=6–8 per group) by ligation of the left anterior descending (LAD) coronary artery for 30 minutes followed by 2 h of reperfusion. The drug or vehicle infusion started either 5 min before or 30 min after start of reperfusion and continued during the remainder of the experiment. Hearts were collected and subjected to triphenyl tetrazolium chlorine (TTC) staining and the infarction area/area at risk of the left ventricle was determined by planimetry and compared against vehicle group. Atherosclerosis-prone LDL-receptor deficient mice on a high-cholesterol diet, (N=15–25 per group) were treated with KAND567 for 15–23 weeks. Atherosclerotic plaque development in the thoracic arch was determined by ultrasound imaging and histology. Immunohistochemistry was used to follow changes in the cellular composition in the atherosclerotic lesions. Results In the acute myocardial infarction study, the infusion of KAND567 before the start of reperfusion significantly reduced infarcted/risk area (by up to 50%) as compared to the vehicle group. However, the infusion had no effect on the infarct size when administration was initiated 30 min after start of reperfusion. In the atherogenesis study, oral treatment with KAND567 significantly reduced vascular macrophage infiltration by 50% and reduced intima media thickness. Furthermore, reduced plaque volume and a more stable plaque phenotype was noted following treatment with KAND567. KAND567 experimental results Conclusion Specific inhibition of fractalkine-driven inflammation by KAND567 provides cardioprotective, anti-atherosclerotic and plaque stabilizing effects via mechanisms related to immune cell infiltration, in rodent models. Further studies should be initiated to test if KAND567 is a potential candidate drug, targeting the excessive inflammatory injury associated with ischemia/reperfusion in myocardial infarction and providing plaque stabilization by reducing inflammatory risk for recurrent coronary events.

Puerarin inhibits the inflammatory response in atherosclerosis via modulation of the NF-κB pathway in a rabbit model.

The isoflavone puerarin [7-hydroxy-3-(4-hydroxyphenyl)-1-benzopyran-4-one 8-(β-D-glucopyranoside)] possesses many biological activities. In this study, we investigated the effects of puerarin on adhesion molecules (AMs), including serum levels of intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and endothelial leukocyte adhesion molecule-1 (E-selectin), and the activation of nuclear factor kappa B (NF-κB) in rabbits with experimental atherosclerosis. In total, 24 rabbits were divided into control (standard diet), high-lipid diet (HLD), and PUE (HLD supplemented with puerarin) groups. At the end of weeks 0, 8, and 16, serum levels of AMs were measured. At the end of week 16, the thickness of the intima was detected. Protein and mRNA levels of AMs were checked by immunohistochemistry and RT-PCR, respectively. Protein levels of p65 NF-κB and phosphorylation of inhibitor-κB (I-κB) were investigated by Western blotting. Atherosclerotic lesions in the thoracic arch were found in the HLD and PUE groups, but not in the control group. Compared with the HLD group, the thickness of the intima in the PUE group was reduced. Our results indicate that puerarin reduced the protein and mRNA levels of AMs in this rabbit model. We also found that the reduced AM levels were due to inhibition of the phosphorylation and degradation of I-κB, resulting in reduced p65 NF-κB nuclear translocation. This study indicates that the effect of puerarin on the suppression of atherosclerosis was connected with an inhibited inflammatory response and reduced NF-κB activation.

TCT-323 Geometric analysis of thoracic aorta and arch branches before and after TEVAR

TCT-323 Geometric analysis of thoracic aorta and arch branches before and after TEVAR

Endovascular Total Arch Repair Using In Situ Fenestration for Arch Aneurysm and Chronic Type A Dissection

Total arch replacement and ascending aorta and arch replacement are the gold standard treatments for aortic arch aneurysm and are possible treatment strategies for chronic type A dissection, with good reported outcomes. However, because total arch replacement is extremely invasive, it can be difficult to perform in some patients. We designed an endovascular total arch repair procedure with the use of in situ fenestration and commercially available devices, and we present our initial experience. Seven patients (chronic type A aortic dissection, n= 3; thoracic arch aneurysm, n= 4) who underwent endovascular total arch repair with the use of in situ fenestration thoracic endovascular aortic repair from a zone 0 landing were retrospectively analyzed. All the procedures were performed under general anesthesia and cardiopulmonary bypass. The triple branches were manually punctured in a retrograde manner with the use of an 18-gauge/30-cm needle or a 21-gauge aspiration needle, and all the branches were reconstructed with the use of stent grafts; balloon touch-up was performed if appropriate. The procedure was successful in 6 of the 7 patients; the remaining 1 patient additionally underwent an axillary-axillary artery bypass during the operation because the left subclavian artery was difficult to puncture. All the patients had an acceptable postoperative course, with no 30-day and in-hospital deaths. None of the patients had endoleaks, and all the patients exhibited a reduction in aneurysm diameter or thrombosed false lumen during a mean follow-up period of 17.6 months. Endovascular total arch repair with the use of in situ fenestration can be performed with commercially available devices with acceptable interim results.

Effect of region-of-interest placement in bolus tracking cerebral computed tomography angiography

Premature or delayed triggering of semiautomatic contrast tracking during intracranial computed tomographic angiography can occur due to artifact from dense contrast in the superior vena cava or brachiocephalic veins near the anterior aortic arch. We determine if placement of bolus tracking region-of-interest in the posterior thoracic aorta can prevent suboptimal intracranial arterial opacification. Intracranial computed tomography angiographies from 80 patients performed on the same scanner were retrospectively evaluated. Thirty-seven consecutive patients with bolus tracking region-of-interest (ROI) placed in the anterior thoracic aorta (group A) and 43 consecutive patients with ROI placed in the posterior thoracic arch (group B) were identified. Two neuroradiologists scored the quality of intracranial computed tomography angiography on a four-point scale. Quantitative measurement of intracranial arterial opacification was also performed. The proportions of patients with poorest quality score as well as the proportions of the patients with the worst degree of intracranial arterial opacification (<10th percentile) were compared between groups A and B using two-sample proportion test. Qualitative evaluation of the intracranial computed tomography angiography showed 4 (11%) patients in group A with poor quality (score of 1), while all patients in group B scored 2 or higher (p = 0.028). Seven (19%) patients in group A had the lowest quantitative score (mean arterial opacification < 10th percentile) while 1 (2.5%) patient in group B had the lowest score (p = 0.018). Bolus tracking in the posterior thoracic aorta reduces the chance of suboptimal intracranial computed tomography angiography.

Antero-lateral partial sternotomy for extensive thoracic aortic aneurysm

Surgical strategies for patients with aortic arch aneurysm extending to the descending aorta remain controversial. The antero-lateral partial sternotomy (ALPS) approach has been developed as a less invasive alternative single-stage strategy for extensive thoracic arch aneurysm (ETAA). From September 2007 to April 2011, 18 patients underwent elective total arch replacement for ETAA by the ALPS approach (ALPS group). In this approach, a skin incision was made from the bottom of the xiphoid to the anterior axillary line at the third intercostal space with a convex curved line. The thorax was entered through the third intercostal space and a partial lower sternotomy was done. Surgical outcomes were compared with those of 22 patients with ETAA who underwent elective total arch replacement by median sternotomy alone (MS) with regard to the level of distal anastomosis, postoperative complications and mortality. In the ALPS group, no hospital mortality occurred and one patient experienced pneumonia. No significant difference between the ALPS and MS groups was seen in operative time (384.1 ± 41.6 min vs 402.3 ± 85.3 min P = 0.423) and cardiopulmonary bypass time (220.8 ± 47.1 min vs 236.9 ± 45.4 min P = 0.286). In contrast, distal anastomosis was at a significantly lower vertebral level in the ALPS than in the MS group (5.5 ± 0.4 vs 4.3 ± 0.9, respectively: P < 0.0001). The ALPS approach provides good surgical exposure for distal aortic arch aneurysms extending to the descending aorta and ensures the accurate reconstruction of the distal anastomosis without major complications.

Aortic Arch Debranching: Advanced And Hybrid Techniques

Aortic arch procedures have traditionally involved complex surgery with increased risk of mortality and morbidity. Throughout the last decade, however, novel and safe surgical approaches aimed at debranching the great vessels with definitive aortic arch repair have been developed. Currently, hybrid arch procedures allow for open or minimally invasive aortic access to be complemented by endovascular stent-graft techniques, which may eliminate the need for prolonged hypothermic circulatory arrest and its associated complications. Hybrid thoracic aortic and arch repairs have become the preferred approach, with open procedures performed only if hybrid approaches are not possible for technical reasons. In the future, aortic pathology may also benefit from the development of branched and fenestrated endografts that would be deployed in a modular fashion. This article describes the rationale, procedural steps, and recent outcomes data of novel aortic arch procedures.

Multimodality serial follow-up of thoracic aortic aneurysms

Abstract. We identified 520 diagnostic imaging tests (MRI, CT, ECHO) performed in 205 patients (79 female 126 male) (age 20-94, mean 63.9) being followed at Yale- New Haven hospital for progression in size of their thoracic aortas. Estimated growth rates did not differ significantly across imaging modalities. The average maximal size of the thoracic aorta was 5.3 cm (range 3.5-10.0). Mean maximal size was 5.3 cm in the 326 imaging studies without dissections. Mean size at time of dissection (N = 22) was 6.2 cm, and a time of rupture (N = 7), 6.5 cm. Survival at 3 and 5 years was 66% and 45%, respectively. Subjects having aortic dissection had lower survival (58% 3 year; 15% 5 year) than the non-dissected cohort (70% 3 year; 60% 5 year). Mean estimated growth rate on 53 patients followed seri- ally for aortic expansion was 0.1 cm/yr. Stepwise multivari- ate risk factor analysis indicated that large (> = 6.0 cm) aneurysms grew significantly more rapidly (p < 0.02), that aneurysms located in the ascending aorta or arch grew more slowly than aneurysms located in the descending thoracic or thoraco-abdominal aorta (p < 0.04), and that aneurysms grew more rapidly among male patients than among females (p < 0.02). We conclude that (1) the overall growth rate in thoracic aorta aneurysms is 0.1 crrdyr. (2) Large aneurysms grow more rapidly than smaller ones. (3) Aneurysms grow more slowly in the ascending thoracic aorta or arch than on other locations of the thoracic aorta. (4) Aneurysms appear to grow somewhat more rapidly among male patients than among females. (5) One-half of aortic dissections and rup- tures occur at sizes <6.0 cm. (6) Long-term survival pros- pects are less for patients having dissected aortas. (7) 5.0- 5.5 cm is an appropriate criterion for surgical intervention in Presented at the 37th Annual World Congress International College of Angiology, Helsinki, Finland, July 1995.

The Use of Rapid Ventricular Pacing to Facilitate Stent Graft Deployment in the Distal Aortic Arch

Systemic hypotension has been traditionally used to facilitate deployment of thoracic stent grafts. Decreasing blood pressure with vasodilating agents further increases cardiac output and, consequently, the cardiac output-mediated windsock effect during deployment. Use of rapid ventricular pacing reduces the windsock effect during stent graft deployment and allows the graft to appose to the aortic wall under zero cardiac output, thus minimizing aortic wall shear stress. In this case we report the use of transvenous rapid ventricular pacing, a safe and reproducible technique to allow precise deployment of a Valiant Captivia stent graft in the distal thoracic arch for a saccular thoracic aneurysm.

Novel Approach to a Type I Endoleak Following a Hybrid Repair of an Arch Aortic Aneurysm

Hybrid surgical and endovascular approaches such as open visceral vessel debranching and subsequent endovascular exclusion of thoracic abdominal aortic aneurysms (TAAA) represents a significant development in treatment of TAAAs. As compared to traditional endovascular aneurysm repair, hybrid repairs commonly have a higher rate of endoleak and other endograft-related complications. In this report, we present a 71 year-old man with significant comorbidities including chronic obstructive pulmonary disease, hypertension and prostate cancer. The patient after undergoing debranching of the thoracic arch followed by endograft repair of an arch aneurysm developed a proximal type I and type II endoleak fed by the previously ligated left subclavian artery. Despite coiling of the left subclavian artery and proximal extension of the endograft, a type I endoleak persisted. Several months after the left subclavian artery was coiled, a catheter was advanced through the coils and beyond the site of ligation directly into the aneurysmal sac. Once in the aneurysmal sac, multiple coils were deployed resulting in successful treatment of the type I endoleak. This report highlights the unique challenges in treating proximal descending thoracic aneurysms and represents the first report of the treatment of a type I endoleak with reaccess through a previously coiled vessel for deployment of embolics directly into the aneurysmal sac.

Gut emptying affects dietary fat contribution to postprandial lipemia following sequential meals in healthy subjects

Objective The present study examined the kinetic of plasma triacylglycerol (TAG) and gut emptying after sequential ingestion of breakfast and lunch, and the contribution of dietary fat ingested at breakfast to subsequent TAG after lunch. Methods Nine subjects ingested a breakfast (0730 h) and a lunch (1200 h) containing 25 and 44 g of fat, respectively. [1- 13C] palmitate was added in breakfast only. Plasma TAG and chylomicron-TAG (CM-TAG) concentrations and [1- 13C] palmitate enrichment were sequentially measured. On a consecutive day, an identical breakfast labeled with 123I-Lipiodol was ingested, followed by a lunch for three controls. 123I-Lipiodol dynamics was followed in vivo by scintigraphic imaging focused on the stomach, small bowel, and thoracic duct arch. Results An early rise in plasma and CM-TAG was observed after lunch ingestion. After breakfast, [1- 13C] palmitate enrichment was maximal 150 and 210 min in plasma TAG and CM-TAG, respectively, decreased thereafter, and increased rapidly (50 min for plasma TAG and 30 min for CM-TAG) after lunch ingestion. Scintigraphic imaging appeared to show that fat ingested at breakfast was retained in part within the gut at lunch time. For the three subjects who ingested a lunch, a decrease of activity in the stomach and small bowel and a tendency for increased activity in the thoracic arch were observed. Conclusion Contribution of fat ingested at breakfast to lipemia after lunch is confirmed. Fat ingested at breakfast was partly retained within the gut and was mobilized after lunch ingestion, as assessed by acceleration of gut emptying and thoracic duct flow after lunch.

Use of the right brachio-femoral wire approach to manage a thoracic aortic aneurysm in an extremely angulated and tortuous aorta with an endoluminal stent graft

The presence of a tortuous, elongated thoracic aorta and an angulated arch poses a technical challenge for the delivery of an endoluminal graft to the target site to exclude management of a thoracic aortic aneurysm. Despite the availability of a flexible delivery sheath system, adjunct techniques are necessary to deal with extremely tortuous thoracic aortas. The use of a brachio-femoral wire with tension applied at both ends is a useful technique to deliver an endoluminal graft in an angulated thoracic arch. We describe the use of a right brachio-femoral wire approach to treat a thoracic aortic aneurysm in a 75-year-old man with an elongated, tortuous and angulated arch aorta.

An Extra Anatomic, Close Chest Approach to Manage an Aortic Arch Aneurysm in an 88-Year-Old Woman

Repair of thoracic arch aneurysms in the octogenarian is associated with a high morbidity and mortality. In this report we describe a minimally invasive approach to repair and arch aneurysm using an endoluminal graft with an extrathoracic, extra anatomic de-branching of the arch vessels. The advantage of this technique includes avoidance of a median sternotomy, cardiopulmonary bypass, and circulatory arrest with a rapid postoperative recovery.

Post-Traumatic Occlusion of Subclavian Artery With Clavicle Fracture

20-year-old man, who was the driver in a motor ehicle accident, was referred to the Emergency Departent of our hospital. He presented in shock, with a lasgow Coma Scale score of 7. He showed eye opening n response to pain, and had a motor response that ocalized painful stimuli. He had no other significant ead injuries or extremity injuries. He was intubated in he Emergency Department, and was given intravenous uid and placed on inotropic support. Chest examination revealed a flail segment in the left pper chest with extensive subcutaneous emphysema. ight upper limb pulses were normal, whereas the left pper limb pulses (axillary, brachial, radial, and ulnar) ere not palpable. The left upper limb was cold and pale. Chest radiograph revealed a fracture of the left clavcle, left first and second ribs with left hemothorax (Figre 1). Ultrasound of the abdomen did not reveal evience of hemoperitoneum or solid organ injury. A omputed tomography scan of the head was also normal. An emergent digital subtraction angiogram (DSA) of he aorta and its thoracic branches was performed (Figre 2). Thoracic arch aortogram revealed that the brahiocephalic trunk and left common carotid artery were ormal in course and caliber. There was complete occluion of the proximal left subclavian artery, approxiately 2 cm beyond its origin, with compression caused y the displaced medial segment of the fractured left lavicle. Delayed images (Figure 3) demonstrated faint