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Background Many anatomical variations of the branching pattern of the aortic arch have been documented in the literature. These find their origin in alterations to the embryological development of the arch and have significant implications for surgical and radiological interventions. Methods Embase and Medline database searches were carried out in June 2021 and identified 1197 articles, of which 24 were considered eligible. Results Twenty-eight variations were found. The prevalence of the six main variations found is as follows: normal configuration (61.2–92.59%); bovine arch type 1 (4.95–31.2%); bovine arch type 2 (0.04–24%); origin of left vertebral artery (0.17–15.3%); aberrant right subclavian artery (0.08–3.33%); thyroid ima artery (0.08–2%). Concomitant variations present in conjunction with these variations are also documented, as were other variations which could not be classified into these six groups. Conclusions Anatomical variations in the branching pattern of the aortic arch are present in over one-third of individuals in some populations. These are important pre- and intra-operatively during thoracic, neck and thyroid surgery. A greater effort should be employed to construct an official classification to facilitate greater understanding among clinicians.

The review presents the anatomical and physiological features of the system of brachiocephalic arteries (BCA) ofatherosclerotic and non-atherosclerotic nature. The prevalence of various types of BCA anomalies and the possible impact on the development of cerebral and coronary events are estimated. The modern diagnostic methods and approaches to the treatment of the problem under study are described. The need to prevent ischemia of the brain and heart in individuals with asymptomatic BCA diseases is discussed, as well as an understanding of the anatomy of the abnormal structure and variability of the BCA course, which is of paramount importance during surgical interventions.

Symptomatic aneurysms of the innominate and subclavian arteries are rare and pose unique challenges for endovascular repair particularly in a patient with a “bovine” arch. Previous publications have described back table modifications of standard iliac endografts to conform to the innominate artery for exclusion of the lesion. Others have proposed extra-anatomic bypass or carotid-subclavian transposition with occlusion of the innominate artery. We were unable to find a report of repair when aneurysms of the innominate and subclavian arteries were in continuity. We present such a case of endovascular repair using commercially available endografts without compromise of the left common carotid artery origin as this patient had a “bovine” arch. Surgeons will benefit from adding this endovascular option to their “tool box” when confronted with such a challenging clinical scenario.

The aim was to investigate whether the "bovine" aortic arch (i.e. arch variant with a common origin of the innominate and left carotid artery (CILCA)) is associated with a consistent geometric configuration of proximal landing zones for thoracic endovascular aortic repair (TEVAR).Anonymised thoracic computed tomography (CT) scans of healthy aortas were reviewed to retrieve 100 cases of CILCA. Suitable cases were stratified according to type 1 and 2 CILCA, and also based on type of arch (I, II, and III). Further processing allowed calculation of angulation and tortuosity of the proximal landing zones. Centre lumen line lengths of each proximal landing zone were measured in a view perpendicular to the centre line. All geometric features were compared with those measured in healthy patients with a standard arch configuration (n = 60). Two senior authors independently evaluated the CT scans, and intra- and interobserver repeatability were assessed.The 100 selected patients (63% male) were 71.4 ± 7.7 years old. Type 1 CILCA (62/100) was more prevalent than type 2 CILCA (38/100), and the two groups were comparable in age (p = .11). Zone 3 presented a severe angulation (i.e. 60°), which was greater than in Zone 2 (p .001), and a consistently greater tortuosity than Zone 2 (p = .003). This pattern did not differ between type 1 and type 2 CILCA. A greater tortuosity was also observed in Zone 0, which was related to increased elongation of the ascending aorta (i.e. Zone 0), than the standard configuration. The CILCA had an overall greater elongation, and Zone 2 also was specifically longer. When stratifying by type of arch, reversely from Type III to Type I, the CILCA presented a gradual flattening of its transverse tract, which entailed a consistent progressive elongation (p = .03) and kinking of the ascending aorta, with a significant increase of Zone 0 angulation to even a severe degree (p = .001). Also, from Type III to Type I, Zone 2 presented a progressively shorter length (p = .004), which was associated with increased tortuosity (p .05). Mean intra- and interobserver differences for angulation measurements were 1.4° ± 6.8° (p = .17) and 2.0° ± 10.1° (p = .19), respectively.CILCA presents a consistent and peculiar geometric pattern compared with standard arch configuration, which provides relevant information for TEVAR planning, and may have prognostic implications.

A 50-year-old woman was referred to the noninvasive vascular laboratory for carotid artery evaluation because of a bruit in the neck. Color Doppler ultrasound examination demonstrated absence of the right common carotid artery and parallel internal and external carotid arteries originating at the brachiocephalic trunk. Computed tomography angiography further described anomalous anatomy, demonstrating a common origin of the innominate artery and left common carotid artery. Knowledge of such unusual anatomy may become valuable in future evaluation or treatment of this patient. Keywords: Carotid artery, Common origins of the innominate artery and left common carotid artery, Bovine arch, Cerebrovascular disease

Ascending aortic pseudoaneurysms are rare, but life-threatening conditions, that often require intervention. While endovascular techniques have advanced significantly, the majority of these clinical scenarios preclude endovascular options and the primary treatment modality remains open surgical repair. Repair of an aortic pseudoaneurysm eroding through the sternum resulting in a pulsatile chest wall mass is technically challenging. We report the successful repair of a large ascending aortic pseudoaneurysm in a 62-year-old male with bovine arch anatomy and prior Type A dissection repair, presenting with contained rupture and a pulsatile chest wall mass.

A bovine arch is the most common aortic arch variant, characterized by a common origin of the innominate artery and the left common carotid artery. Data have shown that children with bovine arch anatomy and coarctation are at a significantly higher risk of recoarctation following coarctation repair. This study aims to explain the higher coarctation rates, assess the branching of the arch vessels, understand their embryologic origins, and delineate the patterns of displacement of the arch vessels in bovine versus normal anatomy. This retrospective study reviewed the medical records of 178 infants (

A 24-year-old man presented with rapidly progressive dyspnea due to mixed aortic stenosis and insufficiency. Unicommissural unicuspid aortic valve, ascending aortic aneurysm, and a bovine arch were identified on computed tomography angiography. Uncomplicated surgical mechanical valve replacement and ascending aortic graft placement improved his symptoms. Aortopathy is common in unicuspid valve patients.

Background Transcarotid transcatheter aortic valve implantation (TAVI) is a worthwhile substitute in patients who might otherwise be inoperable; however, it is applied in Case summary We report a case of concomitant transcarotid TAVI and carotid endarterectomy (CEA) in a patient with bovine aortic arch and previous complex infrarenal EndoVascular Aortic Repair (EVAR). The integrity and positioning of the previous EVAR endograft was risked by transfemoral access. The right subclavian artery was only 4.5 mm and the left subclavian was totally occluded so transcarotid access was chosen. The patient recovered well, with no neurological deficit and was discharged home after 72 h. He was last seen and was doing well 6 months post-procedure. Discussion In patients with severe aortoiliac disease, or previous aortic endografting, transfemoral access for TAVI can be challenging or even prohibitive. Alternative access sites such as transapical or transaortic are associated with added risk because they carry increased risk of major adverse cardiovascular events, longer intensive care unit and hospital stay, and increased cost. A transcaval approach for TAVI has also been reported but was not suitable for our patient due to prior EVAR. Concomitant TAVI via transcarotid access and CEA can be successful in experienced hands. This case highlights the importance of a team-based approach to complex TAVI cases in high-risk patients with complex vascular access.

Objective/Background To investigate the prevalence of bovine arch (BA) among patients with type A and B aortic dissection, and to provide insight into the implication of this variation on the outcome of patients with acute or subacute type B aortic dissection (a/sTBAD). Methods This retrospective cohort analysis includes patients with a/sTBAD admitted between January 2006 and December 2016. Computed tomographic angiograms (CTAs) of patients referred because of type A aortic dissection were also re-evaluated with regard to the presence of BA. As a control group, 110 oncological patients who had undergone a chest CTA for disease staging during the study period were enrolled. A total of 154 patients with a/sTBAD and 168 with type A aortic dissection were identified during the study period. Results An overall prevalence of 17.6% for BA variants was revealed. The comparison between patients with aortic dissection and the control group showed no statistically significant difference in BA prevalence (17.7% vs. 17.3%; p = 1.0). No statistically significant difference in BA prevalence was observed when comparing patients with type A aortic dissection with those with type B aortic dissection (16.6% vs. 18.8%; p = .66). During a median follow-up period of 27.8 months, 30 patients died. The mortality rate among patients presenting a BA variant was 34.5%, whereas among patients without, it was 16.0% (p = .04). Multivariate analysis revealed the presence of a BA as an independent predictor of mortality (adjusted odds ratio 3.4, 95% confidence interval 1.2–9.8). Conclusion The BA should be considered as a predictor of the outcome for patients with type B aortic dissection.

Objectives Arch branching has never been shown to influence recoarctation after extended end-to-end anastomosis via thoracotomy, yet in each study bovine arch identification is grossly underreported. This study aims to (1) assess chart review reliability in bovine arch identification; (2) determine recoarctation risk with a bovine arch; and (3) explore an anatomic explanation for recurrent arch obstruction based on arch anatomy. Patients A total of 49 consecutive patients underwent thoracotomy with extended end-to-end aortic coarctation repair at a single institution (2007-2012). Methods Echocardiograms from these patients were reviewed for arch anatomy and compared with the echocardiographic reports. Recurrent arch obstruction was defined as an echocardiographic gradient across the repair of 20 mm Hg or greater. For cases with angiographic images (n = 17), a scaled clamping distance between the left subclavian artery and the maximal proximal clamp location on orthogonal projections was then calculated across arch anatomies. Results Chart review identified 6.1% (3/49) of patients with a bovine arch compared with 28.6% (14/49) on targeted image review. A total of 28.6% (4/14) of patients with a bovine arch had a follow-up gradient of 20 mm Hg or greater. Only 5.7% (2/35) of patients with normal arch branching had a follow-up gradient of 20 mm Hg or greater. The mean clamping index was significantly diminished in patients with bovine arch anatomy. Conclusions Arch anatomy often goes undocumented on preoperative imaging, yet children undergoing extended end-to-end repair with bovine arch anatomy are at a significantly increased risk of recoarctation. This may be due to a reduced clampable distance to facilitate repair. These results should be considered in the preoperative assessment, parental counseling, and surgical approach for children with discrete aortic coarctation.

Yılmaz İnanç,1 Yusuf İnanç,2 Halil Ay3 1Department of Neurology, Faculty of Medicine, Kahramanmaraş Sutcu Imam University, Kahramanmaraş, 2Department of Neurology, Faculty of Medicine, Gaziantep University, Gaziantep, 3Department of Neurology, Faculty of Medicine, Harran University, Harran, Turkey Purpose: The aim of this study was to retrospectively evaluate the distribution of aortic arches, the relationship with demographic characteristics, and the results of carotid and vertebral artery stenting procedures in patients diagnosed with cerebrovascular disease through the intra-arterial digital subtraction angiography (DSA) technique. Methods: A retrospective examination was performed on 288 patients diagnosed with cerebrovascular disease, who underwent DSA in the Department of Neurology of Gaziantep University Medical Faculty and Kahramanmaras¸ Sütçü Imam University Medical Faculty. The patients were examined in respect of demographic features and aortic arch anatomic structure characteristics. All demographic characteristics, DSA, carotid, and vertebral artery stent results were recorded. Results: The patients comprised 60.1% males and 39.9% females with a mean age of 58.25years. Type 2 aortic arch was found in 175 (60.7%) patients, Type 2 aortic arch in 99 (34.3%) patients, and Type 3 aortic arch in 14 (4.8%) patients. The right carotid artery stenosis rate was found to be higher in patients with Type 2 aortic arch (P=0.013). When the patients were evaluated according to the presence of a bovine arch, there was no significant difference in terms of age, carotid, and vertebral artery lesions (P>0.05). Conclusion: The aortic arch and its branching properties were not found to have a direct effect on increased risk of cerebrovascular disease or stenting rates. This study can be considered to raise awareness for new studies to demonstrate the effect of aortic arch anatomic differences on cerebrovascular diseases. Keywords: aortic arch, stroke, bovine arch, aorta, invasive neurology

Yılmaz Ä°nanç,1 Yusuf Ä°nanç,2 Halil Ay3 1Department of Neurology, Faculty of Medicine, Kahramanmaraş Sutcu Imam University, Kahramanmaraş, 2Department of Neurology, Faculty of Medicine, Gaziantep University, Gaziantep, 3Department of Neurology, Faculty of Medicine, Harran University, Harran, Turkey Purpose: The aim of this study was to retrospectively evaluate the distribution of aortic arches, the relationship with demographic characteristics, and the results of carotid and vertebral artery stenting procedures in patients diagnosed with cerebrovascular disease through the intra-arterial digital subtraction angiography (DSA) technique. Methods: A retrospective examination was performed on 288 patients diagnosed with cerebrovascular disease, who underwent DSA in the Department of Neurology of Gaziantep University Medical Faculty and Kahramanmaras¸ Sütçü Imam University Medical Faculty. The patients were examined in respect of demographic features and aortic arch anatomic structure characteristics. All demographic characteristics, DSA, carotid, and vertebral artery stent results were recorded. Results: The patients comprised 60.1% males and 39.9% females with a mean age of 58.25years. Type 2 aortic arch was found in 175 (60.7%) patients, Type 2 aortic arch in 99 (34.3%) patients, and Type 3 aortic arch in 14 (4.8%) patients. The right carotid artery stenosis rate was found to be higher in patients with Type 2 aortic arch (P=0.013). When the patients were evaluated according to the presence of a bovine arch, there was no significant difference in terms of age, carotid, and vertebral artery lesions (P>0.05). Conclusion: The aortic arch and its branching properties were not found to have a direct effect on increased risk of cerebrovascular disease or stenting rates. This study can be considered to raise awareness for new studies to demonstrate the effect of aortic arch anatomic differences on cerebrovascular diseases. Keywords: aortic arch, stroke, bovine arch, aorta, invasive neurology

Background The stabilization of a guide catheter is an important factor for performing successful neurointerventional procedures. We present our technique for navigating guide catheters using parent and child balloons. Methods In 9 patients with severe atherosclerosis or anatomic variations such as a bovine arch, 8–9-F balloon-mounted guide catheters were navigated using balloon-attached guidewires. Both balloons were used complementarily for flow navigation and vessel fixation at the appropriate positions and times. Results In all cases, the balloon guide catheter could be inserted up to the required positions, and the procedures were completed without any complications. Conclusions The parent and child balloon technique is useful for inserting guide catheters in hostile vascular anatomies.

The most common aortic arch branching variation described in literature is the common origin of the brachiocephalic trunk and left common carotid artery ("bovine arch" / type II aortic arch), with an incidence of 7.2-21.1%. The first aim of this study was to investigate the prevalence of bovine arch in the fetuses. The second aim was the hemodynamic evaluation of the epiaortic vessels.In two years we examined 742 pregnant women and it was possible to obtain a good hemodynamic evaluation in 39 patients. Among the 39 fetuses, we found 6 with bovine arch. The blood flow of all epiaortic vessels and of MCA was evaluated.Among the 742 fetuses examined, the bovine aortic arch was identified in 45 patients (6.06%). The hemodynamic evaluation of the epiaortic vessels showed statistically significant differences between the bovine arch and normal aortic arch.The presence of bovine aortic arch in the fetus is characterized by some hemodynamical differences. They could have a possible relationship with the incidence of some pathologies in adult life. Prenatal knowledge of anatomic variants of the aortic arch can bring benefits to the individual's health for future possible cardiovascular investigations.

Aortic dissections after deceleration traumas are mainly located in the region of the proximal descending thoracic aorta. Less common are brachiocephalic trunk ruptures, which are not automatically amenable to an endovascular treatment. We present a poly-traumatized patient with an intimal tear at the origin of the brachiocephalic tunk with intramural haematoma extension to the ascending aorta. In addition, the left common carotid artery originated from the proximal brachiocephalic trunk, forming a ‘bovine arch’. Aortic arch and supra-aortic arteries were successfully replaced. The case demonstrates the importance of an individualized treatment in complex intrathoracic vascular injuries in poly-traumatized patients, including a careful risk assessment.

The artery allegedly forming in the fifth pharyngeal arch has increasingly been implicated as responsible for various vascular malformations in patients with congenitally malformed hearts. Observations from studies on developing embryos, however, have failed to provide support to substantiate several of these inferences such that the very existence of the fifth arch artery remains debatable. To the best of our knowledge, in only a solitary human embryo has a vascular channel been found that truly resembled the artery of the fifth arch. Despite the meager evidence to support its existence, the fifth arch artery has been invoked to explain the morphogenesis of double-barreled aorta, some unusual forms of aortopulmonary communications, and abnormalities of the brachiocephalic arteries. In most of these instances, the interpretations have proved fallible when examined in the light of existing knowledge of cardiac development. In our opinion, there are more plausible alternative explanations for the majority of these descriptions. Double-barreled aorta is more likely to result from retention of the recently identified dorsal collateral channels while abnormalities of brachiocephalic arteries are better explained on the basis of extensive remodeling of aortic arches during fetal development. Some examples of aortopulmonary communications, nonetheless, may well represent persistence of the developing artery of the fifth pharyngeal arch. We here present one such case - a patient with tetralogy of Fallot and pulmonary atresia, in whom the fifth arch artery provided a necessary communication between the ascending aorta and the pulmonary arteries. In this light, we discuss the features we consider to be essential before attaching the tag of "fifth arch artery" to a candidate vascular channel.

Background purpose Clinical outcome in acute ischemic stroke (AIS) patients depends on onset-to-reperfusion time. Therefore, in case of emergency thrombectomy (ET), difficult carotid access leads to worse clinical outcome. Transfemoral approach is common but limited by aortic or peripheral artery conditions and then transbrachial or -radial access is an alternative one. The aim of our study was to investigate the feasibility of transbrachial carotid cannulation (TCC) of a particular long guide-sheath in ET for AIS in the anterior cerebral circulation (ACC). Methods We included in our retrospective study patients who underwent transbrachial ET as the first line in the ACC with a particular long guide-sheath (MSK-guide 7.5 × 90, 0.088(ID)) from October 2011 to August 2016. We evaluated the patient’s baseline features, sides of occlusion vessels, types of aortic arch (AA), success rate of carotid cannulation and puncture to carotid cannulation time (PTCC_time). Results Twenty four patients matched our inclusive criteria and were analyzed. Median age was 80.5 years, 16 patients ( 67%) were men, 15 left-sided lesions (63%) were involved. There were 11 patients (46%) with type3 AA, 7 (29%) with type2 AA and 2 with type1 AA. Among them, 4 patients had a bovine arch. Success rate of TCC was 100% and median PTCC_time was 13 min (6 – 18). Conclusion TCC of a particular long guide-sheath was feasible for ET in the ACC and AA type or peripheral artery conditions didn’t affect procedures. Disclosures K. Yoshioka: None. T. Mori: None. Y. Tanno: None. N. Nakai: None.

Bovine arch commonly refer a group of congenital variations in the branches of arch of aorta, in which there is aberrant origin of left common carotid artery. These are usually detected incidentally, however rarely they can cause dysphagia lusoria. We report a case of bovine arch and aberrant left common carotid artery in a 62 years old female who had come with complaint of mild dyspnea. On radiograph there was superior mediastinal widening and shift of trachea to right side. CT scan was advised for further evaluation. On CECT there was only two main branches arised from arch of aorta, brachiocephalic trunk and right subclavian artery. There was aberrant origin of left common carotid artery seen from brachiocephalic trunk. The brachiocephalic trunk was very tortuous and displacing trachea to right side.

We present a series of 4 patients with carotid restenosis following carotid endarterectomy (CEA) who underwent transcervical carotid artery stenting (CAS) using a novel prosthetic conduit technique. The patients were high risk for repeat CEA (short and obese necks) and had contraindications to transfemoral CAS (bovine arch, prior dissection). CAS was thus performed via a transcervical approach with a polytetrafluoroethylene conduit anastomosed to the proximal common carotid artery. The addition of a conduit allowed stent placement via a secure, stable platform. All patients recovered from their procedure without incident and are free from restenosis at follow-up.

Introducción. El arco aórtico (AA) es el origen de estructuras vasculares que suplen los miembros superiores y el encéfalo. Se han descrito hasta ocho diferentes tipos de distribución con implicaciones clínicas y quirúrgicas. Objetivo. Determinar la frecuencia de las variaciones anatómicas del AA y establecer los diámetros vasculares de sus ramas emergentes en una muestra de población colombiana. Materiales y métodos. Se realizó un estudio descriptivo analítico transversal mediante disección de 35 plastrones cervicotorácicos obtenidos con muestreo a conveniencia. Resultados. La distribución de los AA resultó muy similar a la reportada en Colombia y otros países, siendo más frecuente el AA Tipo I seguido del AA Tipo II o arco bovino. Los diámetros vasculares arrojaron resultados análogos a otros obtenidos en población colombiana, pero medias evidentemente menores a las reportadas en estudios internacionales. Conclusión. Aunque las frecuencias de los tipos de AA de la población colombiana resultan ser similares a las de otros países, los diámetros vasculares en Colombia son menores. ntroduction: The aortic arch (AA) is the origin of the vascular structures that supply the upper limbs and the brain. Up to eight different types of distributions have been described with clinical and surgical implications. Objective: To determine the frequency of anatomical variations of the AA, and to establish the vascular diameters of its branches in a sample of Colombian population. Materials and methods: A descriptive cross-sectional study was conducted by dissecting 35 cervicothoracic grafts obtained through convenience sampling. Results: The distribution of AA was similar to that reported in Colombia and other countries, being Type I the most frequent, followed by Type II or bovine arch. The vascular diameters showed results similar to those obtained in the Colombian population, but evidently lower than those reported in international studies. Conclusion: Although the frequency of AA types in the Colombian population happen to be similar to those in other countries, the vascular diameters in Colombia are smaller.

To investigate the efficacy and safety of a tailored approach to fit access and engagement techniques to the individual arch anatomy in patients with bovine-type aortic arch (BTAA) to overcome the perceived increased risk of technical failure and cerebral embolization during left internal carotid artery (LICA) stenting.Thirty-five high surgical risk patients (23 men; mean age 68.6 years, range 62-90) with BTAA and LICA stenosis underwent carotid artery stenting (CAS). Left common carotid artery (LCCA) engagement was achieved by means of different techniques according to the configuration of the BTAA, arch type (I, II, or III), and angle between the innominate artery and the LCCA. The clinical, anatomical, and procedural data were retrieved from a prospectively maintained database and analyzed retrospectively to identify technical modifications required during the procedure compared with planning.The technical success rate was 100%. Transfemoral access was used in 21 (60%) cases. In this group, the soft engagement technique with hockey stick (HS) guiding catheter and buddy wire in the external carotid artery (ECA) was used in 13 (62%) cases, a simple telescopic technique with 6-F armed introducer or 7-F 40° guiding catheter in 5 (24%) cases, and a sequential technique with a MOMA proximal protection system in the remaining 3 (14%) cases. Among the 14 (40%) right brachial access cases, the telescopic technique with 6-F armed introducer was used in 13 cases. The remaining case was the only one in which the planned technique was changed (from the telescopic to sequential technique with ECA wire exchange). There were no intraprocedural or 30-day neurological events.An appropriate tailored interventional strategy, planned by means of preprocedural recognition of bovine arch anatomy, is associated with satisfactory safety and good success.

In a 74-year old male patient, brachiocephalic trunk and left common carotid artery are sharing a common root (bovine arch) and right vertebral artery (VA) variation was detected incidentally during computed tomography angiography for occlusion of common carotid artery. Right VA branches from the aortic arch (aberrant VA) and forwards retroesophageally and retrotracheally during its course and then entered cervical 7th transverse foramen whereas left VA branches from the subclavian artery and entered cervical 6th transverse foramen. The patient has not any symptom such as dyspnea and dysphagia. The most common anatomic variation of aortic arch is the bovine aortic arch. Incidence of the bovine aortic arch varies between 0.9% - 27.4% in the literature. Like in the present case, branching of the right vertebral artery from aortic arch is very rare. [Arch Clin Exp Surg 2017; 6(3.000): 171-174]

We describe a patient with ascending aorta aneurysm and bovine aortic arch who initially presented with fever. A 65-year-old man with a 2-month history of intermittent fever was referred to our hospital and diagnosed as having a gonococcal ascending aorta aneurysm with penetrating ulcers. He was successfully treated by resection of the ascending aorta and ulcers, replacement of the aortic valve, and prolonged postoperative antibiotic therapy.

In patients with severe arteriosclerosis or anatomical variations such as a bovine arch, the insertion of a guiding catheter for carotid artery stenting is difficult. The authors use a guide wire system as an anchor and advance the guiding catheter to an area proximal to the stenotic structure. This method is useful and safer than others for carotid artery stenting.

Aortic arch disease has conventionally been a subject for open surgical repair, which may require circulatory arrest, accompanied by a long perfusion and extended cross-clamp time. A 2-stage approach utilizing an elephant trunk procedure followed by a descending aortic replacement, or utilizing a frozen elephant trunk with endovascular extension is not well tolerated by multimorbid patients. On the other hand, the endovascular repair of an aortic arch disease is limited by aortic branching. Hybrid repair consists of revascularization of arch vessels followed by endovascular stenting.

Carotid stenting in difficult arch anatomy can be safely done by transradial route depending upon operator's experience. Left carotid artery stenosis with bovine arch anatomy can be approached by right arm approach (radial/brachial) easily. In cases with bovine arch anatomy, left arm approach by modified looping technique is still possible. We report a case of carotid stenting in a patient with bovine arch anatomy using percusurge anchoring technique through left radial approach.

We present a case of a 78-year-old gentleman who was found to have a large saccular aneurysm of the inner aortic arch after complaining of change in the character of his voice. This lesion was successfully excluded using purely fenestrated endovascular techniques without compromising the origins of supra-aortic vessels. A novel technique with modification of fenestrated design was used to ensure accurate placement of the custom-made endograft. This technique has not been published before.

in the literature that ectopic acromegaly is more often seen in women younger than 40 years. Unfortunately, the neuroendocrine tests cannot differentiate between ectopic GHRH secretion and pituitary adenoma. High GH plasma levels and excessive production of GHRH can be suggestive of ectopic secretion, with the exception of very rare cases of excessive GHRH of hypothalamic origin. The somatostatin receptor scintigraphy could have been an alternative diagnostic tool, but it was not performed in our case. In inoperable cases or incomplete operations, octreotide seems to be effective. Surgical excision of the bronchial carcinoid tumor leads to a rapid decrease of GHRH and to a benign clinical course, as is also mentioned in other reports.

We report our experience in stent-supported angioplasty of the left internal carotid artery in patients with anomalous origin of the left common carotid, the so-called bovine arch, in which the right brachiocephalic and left carotid share a common trunk from the aortic arch. The occurrence of the anatomic variant is discussed, and techniques of femoral, brachial, and radial approaches are described.

Blunt injury to the aortic arch vessels is rare and can be life-threatening. Historically urgent repair of these injuries is emphasized. We describe the initial nonoperative management of a blunt injury to the brachiocephalic trunk in the setting of bovine arch anomaly, followed by delayed surgical management.

I knew that the congenital variation of the human aortic arch, with the left common carotid artery originating from the innominate artery, has nothing to do with the anatomy of the bovine arch; however, it was very useful of Layton et al[1][1] to point out the discordance of the anatomic terminology