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Thoracic endovascular repair has become the standard treatment for blunt thoracic aortic injury (BTAI). Occlusion of the left subclavian artery (LSA) is generally required for an adequate landing zone (ALZ). We propose that coverage of the LSA is not necessary for BTAI even with a short landing zone (SLZ).Retrospective review of BTAI patients, who were treated from January 2008 to December 2020, was analyzed. BTAI was categorized into 2 cohorts, SLZ20 mm and ALZ20 mm. Demographic data, trauma scores, grade of BTAI, procedure-related data, and clinical outcomes were analyzed. t-Test and chi-squared tests were used for statistical analysis.Thoracic endovascular repair was performed in 59 BTAI patients (mean age of 38.9 ± 14 years, mean Injury Severity Score of 40.4 ± 9.3). Two cohorts were identified: 49 patients had an SLZ, and 10 patients had an ALZ (14 ± 3.1 mm vs. 25 ± 4.1 mm, P = 0.03). The procedures were performed successfully with 59 patients (86.4%) deploying in zone 3. In-hospital mortality (SLZ group: 4.1% vs. ALZ group: 0, P = 0.318), endoleak (SLZ group: 4.1% vs. ALZ group: 20%, P = 0.45), stroke (SLZ group: 0 vs. ALZ group: 0, P = 1), spinal cord ischemia (SLZ group: 2% vs. ALZ group: 0, P = 1), left arm ischemia (SLZ group: 0 vs. ALZ group: 0, P =1), and reintervention rate (SLZ group: 0 vs. ALZ group: 0, P = 1) were not statistically different between cohorts.BTAI repair with an SLZ can be treated successfully without covering the LSA, analyzing technical success and in-hospital complications. Mid- and long-term data are necessary to confirm the durability of this technique.

Endovascular repair of the thoracic aorta (TEVAR) outcomes have been studied with an interest in complications related to left subclavian artery (LSA) coverage in patients with atherosclerotic pathologies; however, specific data on the management of the LSA in a trauma population are lacking. The objective of this study is to evaluate outcomes following TEVAR for traumatic aortic injury based on LSA coverage.The Vascular Quality Initiative thoracic endovascular aortic repair module (2010-2017) was analyzed. Patients were included if they had a traumatic aortic injury requiring TEVAR. Patients were placed in 2 groups based on coverage of the LSA. Patients were propensity score matched and the primary outcomes were cerebrovascular symptoms and spinal cord ischemia. Additional clinical and resource utilization outcomes were analyzed.Four hundred and fifty one patients were included in the analysis. There were 268 patients in the LSA not-covered group and 183 patients in the LSA covered group. The mean aortic injury grade was 2.88 ± 0.056 vs. 2.88 ± 0.049 in the covered versus not-covered group (P = 0.957). Glasgow coma scale and injury severity score were not different between the groups. There was no difference between groups for cerebrovascular symptoms or spinal cord ischemia, 1.4% vs. 2.8%, P = 0.684 and 0% vs. 2.1%, P = 0.247, after propensity score matching. Significant differences in access site complications and resource utilization were identified between groups.This is the largest series to evaluate complications based on LSA coverage following TEVAR in trauma patients. Our data demonstrate that coverage of the LSA during TEVAR following blunt trauma is associated with no difference in central nervous system outcomes. As such, LSA revascularization strategies, while possible, are not directly supported by these data and should be individualized based on each patient's specific clinical scenario.

To assess the outcome of stroke and nerve injury after supraclavicular revascularization of the left subclavian artery for proximal landing zone extension in thoracic endovascular aortic repair (TEVAR).Retrospective analysis of all patients undergoing left-sided carotid-subclavian bypass (CSB) and subclavian-carotid transposition (SCT) with simultaneous or staged TEVAR between January 2010 and June 2019. Endpoints were perioperative cerebrovascular events and nerve injuries, patency and re-intervention due to the debranching, and mortality at 30 days and during follow-up.Forty-eight patients (median age 66 years, 81 % male) had 25 (52%) CSB and 23 (48%) SCT. TEVAR was performed simultaneously in 39 (81%) patients, 11 (23%) of them in an emergent setting. There were 7 (15%) re-interventions within 30 days: 3 due to local hematoma, one for bypass occlusion, 2 for stenosis (of which one was not confirmed intraoperatively), and one after initially abandoned SCT with subsequent CSB on the next day. 30-day mortality was 2%; 1 patient died on the first postoperative day after emergency coronary artery bypass surgery and multiorgan failure. 4 (8%) patients suffered postoperative strokes; 3 occurred after simultaneous emergency procedures and none was fatal. There were 9 (19%) left neck nerve injuries in 8 patients, 5 patients had SCT and 3 CSB. During a median follow-up of 37.5 months (IQR 23-83) with a Follow-up Index of 0.77, there were no reinterventions or occlusions, and no graft infections. Primary patency was 90% and primary assisted patency 98% during follow-up. 8 patients died during follow-up, all of them with patent cervical debranching.Supraclavicular LSA revascularization for proximal landing zone extension in TEVAR is safe with an acceptable rate of early re-interventions. There is higher risk for perioperative stroke during concomitant emergency LSA revascularization and TEVAR. Left neck nerve injuries are common complications but resolve completely in vast majority of the cases during first postoperative year. During follow-up, excellent patency could be expected.

BACKGROUND: Duplex ultrasound (DU) is used in the diagnosis of neurogenic thoracic outlet syndrome (NTOS) to measure compression of the subclavian artery (SCA) which is thought to strengthen the NTOS diagnosis. However, the value of DU in NTOS remains unclear.METHODS: A retrospective review of a prospectively acquired database from the TOS center of the Catharina Hospital Eindhoven was performed of patients referred between January 2017 and December 2019. Only "proven NTOS" patients, defined as a successful response to thoracic outlet decompression (TOD) surgery based on patient-reported outcomes (NRS pain scale, CBSQ and DASH score) were included to exclude wrongfully diagnosed NTOS patient. The presence of vascular symptoms (defined as discoloration, edema or temperature changes of the hand or fingers), results of provocative maneuvers, and outcome of DU was used for analysis. To assess the link between vascular symptoms and compression on DU, a chi-squared test was performed. Further, we looked for a correlation between vascular symptoms, compression on DU and clinical outcome using a repeated measures analysis of variance (ANOVA).RESULTS: Vascular symptoms were seen in 49 of 133 patients (36.8%). In total, 51 of 133 patients (38.3%) had at least 50% variation in SCA peak systolic velocity (PSV) during DU at the level of SCA stenosis. SCA occlusion was seen in 11 patients (8.3%) during provocative maneuvers. The presence of clinical "arterial symptoms" was not significantly correlated with vascular laboratory findings, neither for alterations in PSV during DU (P = 0.245) nor for positional SCA occlusion (P = 0.540). No statistically significant correlations between the degree of SCA stenosis and postoperative outcomes, as measured with the DASH, CBSQ, or NRS scale for pain were found (P = 0.787).CONCLUSIONS: The role of DU in the work-up of NTOS in patients with vascular complaints is questionable. Changes in flow velocities are seen in NTOS patients and do not correlate with "vascular symptoms" or clinical outcome.

Background: We describe a simple and novel technique for cerebral protection during left subclavian artery (SA) stenting by inflation of a balloon-guiding catheter inside the aortic arch at the SA origin. Methods: A total of 12 patients with left SA stenosis underwent SA stenting with inflation of a balloon-guiding catheter inside the aortic arch at the left SA origin between January 2020 and December 2020. The SA stenting procedures under proximal protection were retrospectively reviewed to assess ischemic complications, hyperintense spots on diffusion-weighted imaging (DWI), and flow direction of left vertebral artery (VA) during balloon-guiding catheter inflation using ultrasonography (US). Results: The success rate of the SA stenting procedure was 100% with no symptomatic ischemic complications. None of the 12 patients showed small hyperintense spots in DWI. In all patients, the left VA on US during balloon inflation showed retrograde blood flow. Conclusions: The left VA on US had retrograde blood flow during inflation of the balloon-guiding catheter inside the aortic arch at the SA origin. Therefore, the proximal balloon protection inside the aortic arch at the SA origin is a simple and maybe a safe technique for cerebral protection during SA stenting.

Objective Isolated true subclavian artery aneurysm (SAA) without aberrant subclavian artery or coarctation of descending aorta is a rare peripheral aneurysm. Herein, the experience of our medical center in the treatment of this disease is presented. Methods The Division operative log was queried to identify cases of SAA repair between January 2012 and September 2019 that were not associated with coarctation of the aorta or the presence of an aberrant subclavian artery. A total of 22 cases were identified. The characteristics, treatment and clinical outcomes of these cases were assessed. Results The mean age of patients was 53.5 ± 14.3 years and 14 patients were male (63.6%). Half of the cases were attributed to atherosclerotic degeneration. The clinical symptoms of aneurysms were varied, including asymptomatic, pulsatile mass of supraclavicular fossa, local pain, upper limb embolism, Horner's syndrome and hoarseness. Aneurysms were located on the right in 17 cases, on the left in 3 cases and on both sides in 2 cases. Fifteen (68%) patients underwent an intervention, of which 11 (50%) underwent an open surgical repair, and 4 (18%) underwent endovascular repair. The mean diameter of the aneurysms was 39.5 ± 20.7 mm in the open surgery group, and 24.0 ± 4.7 mm in the endovascular group. The follow-up duration ranged from 2 months to 12 years. One patient died of cardiogenic disease in the untreated group. Patients undergoing open operative repair had 100% patency of the reconstruction. In the endovascular group, one patient had stent occlusion 2 years after the operation. Conclusions The most common cause of isolated subclavian aneurysm without aberrant subclavian artery or coarctation of descending aorta is atherosclerosis. The clinical symptoms of aneurysms are varied, and the aneurysms tend to occur on the right side. Based on the anatomical conditions of SAAs, open surgery and endovascular repair can be used for treatment.

Innominate artery ligation emerged in the 19th century as an early operation for right subclavian aneurysm. Clinical outcomes were often dire, but undeterred surgeons believed that ligation represented an opportunity that outweighed the risks of nonoperative aneurysm management. Valentine Mott of New York performed the procedure in 1818; his patient died 26 days later. Variations on Mott's approach were undertaken 13 more times from 1822 to 1861 by surgeons in the United States and abroad, all of which proved fatal. Andrew Woods Smyth of New Orleans was the first to successfully control a subclavian artery aneurysm with innominate ligation in 1864. The Charity Hospital house surgeon used a series of ligations on the innominate, common carotid, vertebral, and internal mammary arteries to prevent collateral and recurrent blood flow to the aneurysmal sac. These physiologically-oriented operations kept Smyth's patient alive and functional for ten years. New Orleans became an internationally-recognized hub for advancements in aneurysm surgery. One of Smyth's students, Rudolph Matas, went on to revolutionize vascular surgery. Along his path to becoming the Father of modern vascular surgery, Matas documented his own performance of Smyth's operation at Charity 4 times over the course of his career. Although later supplanted by primary vascular anastomosis and grafting, the first successful innominate ligation was a collaborative effort between New York and New Orleans that served as a foundation for the development of modern aneurysm repair.

Severe stenosis of the innominate artery occurs rarely amongst supraaortic occlusive diseases. Patients with hemodynamically significant innominate artery disease may present with hemispheric symptoms such as transient ischemic attacks, amaurosis fugax, or subclavian steal secondary to retrograde flow through a non-dominant right vertebral artery in a right handed individual. Endovascular revascularization or extra-anatomic surgical bypass with prosthetic grafts are the most commonly used techniques for treating these lesions in high-risk patients. Carotid-carotid artery bypass procedure is a durable option in patients who are not candidates for endovascular repair, but like any prosthetic reconstruction it has the potential for graft infection especially in the retropharyngeal space. We present a patient with a subclavian steal syndrome secondary to innominate artery occlusion treated with a total autogenous extra-anatomic revascularization. Introduction Clinically significant occlusive disease is distinctly uncommon in the upper extremity circulation, but especially on the right side. However, when they do occur the innominate artery is most commonly affected. In such cases, blood flow to the arm is reconstituted by reversal of flow through the right vertebral artery, resulting in a steal physiology similar to that seen in patients with lesions of the left subclavian artery. However, in addition to the subclavian steal innominate artery disease also can manifest as atherothromboembolic events both to the hand and the brain. General indications for revascularization include strokes, transient ischemic attacks, and symptoms of vertebrobasilar insufficiency. Although quite rarely performed, in-line ascending aortic bypass grafting combined with endarterectomy may be preferred in patients with multivessel disease and low surgical risk. Extra- anatomic cervical revascularization is a good option in high-risk patients because of decreased morbidity and similar patency rates. Carotid-carotid bypass (CCB) via a retropharyngeal route is a well-described technique that provides a short and straight graft path behind the pharynx, precludes the need for a median sternotomy, and avoids the cosmetically unsightly subcutaneous appearance of a pre-tracheally tunneled graft.1 In the original report of the retropharyngeal tunneling by Berguer, one patient was treated with direct carotid-carotid reimplantation.2 Since then, there have been two case reports3, 4, and one case series5 describing carotid-carotid transposition for cervical debranching in patients undergoing thoracic endovascular aneurysm repair (TEVAR). In 2003 Czerny et al. described combined sequential autologous transposition of the left common carotid artery (LCCA) into the brachiocephalic trunk, and the left subclavian artery into the previously transposed LCCA for aneurysmal disease of the arch through a median sternotomy.6 In our report, we describe a combined sequential transposition of the arch vessels entirely through a cervical approach. Case report A 76-year-old woman presented with dizziness and vertigo. The patient underwent a duplex ultrasound demonstrating severe innominate artery stenosis with reversal of flow in the right vertebral artery. The patient's history was notable for multivessel coronary artery bypass grafting, aortic stenosis, hypertension, hyperlipidemia, and acute right retinal artery occlusion six years prior. The patient was on dual antiplatelet therapy for stroke prevention. The right radial pulse was not palpable and there was a 45 mm Hg pressure gradient between upper extremities. A computed tomography angiography (CTA) of the neck and chest was obtained for case planning, and this actually showed a complete and densely calcified occlusion of the ostium of the innominate artery (Fig 1A). The patient was felt to be a poor candidate for endovascular treatment due to the CTA findings, and a direct transthoracic repair was deemed anatomically high risk due to her prior median sternotomy. Therefore, extra-anatomic revascularization was determined to be most appropriate. Operative Technique The right common carotid artery (RCCA) was exposed through a low, supraclavicular transverse cervical incision down to its origin from the innominate artery. This also afforded excellent exposure of the proximal segment of the right subclavian artery (RSCA). The LCCA was exposed through an oblique cervical incision along the anterior border of the sternocleidomastoid muscle. Both common carotid arteries were unusually redundant and tortuous and nearly entirety of their cervical course was circumferentially mobilized from the surrounding tissues to provide the necessary length for a tension- free anastomosis. The retropharyngeal tunnel was made with blunt dissection from both sides of the neck, following a plane posterior to the esophagus and anterior to the prevertebral fascia. After systemic heparinization, the distal RCCA was clamped distally, and ligated and transected proximally at its origin. The proximal end of the RCCA was then brought through the retropharyngeal tunnel and anastomosed end-to-side to the LCCA. Due to the brief duration of the clamp-time during the anastomosis, no shunt was used, and the mean arterial pressure was maintained greater than 90 mm Hg to maintain collateral cerebral perfusion. Download : Download high-res image (153KB) Download : Download full-size image Figure 1 . Three-dimensional computed tomography angiography (CTA) of the aortic arch vessels. A) Preoperative CTA demonstrating complete occlusion of the innominate artery origin (arrow) and redundant right common carotid artery (asterisk). B) Postoperative CTA demonstrating autogenous revascularization of the right common carotid artery and right subclavian artery via transposed retropharyngeal right common carotid artery (arrow) Next, the RSCA was further exposed through the transverse cervical incision. After division of the vertebral vein, the right vertebral artery (RVA) and RSCA just distal to the RVA origin were exposed. The RSCA was ligated and divided near the innominate bifurcation and clamped distal to the vertebral artery, which was controlled with a vessel loop. The proximal RSCA was directly anastomosed end-to- side to the previously transposed RCCA. The patient was discharged home on postoperative day two and is doing well on follow-up with complete resolution of her previous symptoms. Postoperative CTA at 6 months showed a widely patent right common carotid and subclavian artery tandem transpositions (Fig 1B). The right vertebral artery flow was now antegrade on follow-up duplex ultrasound. Discussion Carotid-carotid bypass is a well-described technique for revascularization of the innominate artery with excellent patency rates approaching 100% at three years.7 However, for retropharyngeal tunnels there is a small but real potential of graft contamination from contact between the prosthesis and the digestive tract with chance of erosion. 8 Transposing one of the carotid arteries to the contralateral artery is an alternative approach that avoids using a prosthetic graft in the retropharyngeal space. Furthermore, when anatomically feasible, performing the double transposition with transposition of the RSCA to the transposed RCCA avoids a bypass graft altogether and may have improved long-term patency compared to carotid-subclavian bypass.9 This technique has some limitations. Sufficient redundancy of the carotid arteries is required to enable mobilization and transposition in a tension-free manner, and therefore this approach can be applied only in selected cases. In conclusion, in select patients with innominate artery occlusive disease not amenable to endovascular repair a totally autogenous extra-anatomic revascularization is possible using carotid-carotid transposition and subclavian-carotid transposition provided these supraaortic branches have sufficient redundancy. This technique avoids a prosthetic graft in the retropharyngeal space, can potentially decrease the risk of infectious complications, and result in improved patency.

Background The aim of our study is to examine the perioperative outcomes of carotid–subclavian bypass or transposition (CS-BpTp) versus endovascular techniques (ETs) for left subclavian artery (LSA) revascularization during nontraumatic zone 2 thoracic endovascular aortic repair (TEVAR). Methods We used prospectively collected data from the Society for Vascular Surgery Vascular Quality Initiative (VQI) to identify patients who had undergone TEVAR at participating centers (2013–2018). Patients were eligible for inclusion if they had undergone nontraumatic zone 2 TEVAR and concomitant LSA revascularization. Our main exposure of interest was LSA revascularization technique, CS-BpTp, or any ET. If a patient underwent multiple TEVAR procedures during the study period, the first case involving zone 2 was used for analysis. Preoperative patient characteristics were reviewed between treatment groups. The primary outcomes were mortality, transient ischemic attack (TIA)/stroke, and spinal cord ischemia (SCI). All outcomes were assessed up to 30 days postoperatively. Results A total of 837 patients were included in the study. The pathologies most frequently treated were aneurysm in 248 (34%) and dissection in 326 (45%). Overall, 721 subjects (86%) underwent CS-BpTp while 116 subjects (16%) underwent ETs. The latter included the following techniques: 23 chimney grafts, 3 scallops, 15 fenestrated grafts, and 75 branched grafts. Mortality was equal at 3% for both groups (P = 0.67). The rate of TIA/stroke was not significantly different in both groups (5.5% vs. 5%, P = 0.78). Similarly, the rate of SCI was 3% in the entire cohort without significant differences seen between treatment groups (P = 1). Multivariate logistic regression could not identify either CS-BpTp or ETs as independent predictors for death or TIA/stroke. Conclusions Within VQI, LSA revascularization during nontraumatic zone 2 TEVAR is safely and effectively achieved with either CS-BpTp or ETs across all nontraumatic thoracic aortic diseases. These techniques appear to be associated with similar perioperative outcomes in selected patients with low rates of mortality and major neurologic morbidity. Although no differences were seen in the proportion of early type I or III endoleaks, further prospective studies are warranted to elucidate the long-term durability of ETs compared with CS-BpTp.

Type Ia endoleaks are common after thoracic endovascular aortic repair (TEVAR). However, the repair of type Ia endoleaks involving the distal arch is challenging because of the presence of the interventional endografts, potential damage to the aortic arch vessels, and the location and size of the aneurysmal body. We retrospectively reviewed our experience of the surgical treatment of type Ia endoleaks with distal arch involvement using left subclavian artery (LSCA)-left common carotid artery (LCCA) transposition with a stented elephant trunk.Sixteen patients (male = 16; mean age, 47 ± 9 years, range 31-63 years) with type Ia endoleaks involving the distal arch underwent LSCA-LCCA transposition with a stented elephant trunk from July 2010 to July 2018. TEVAR failure occurred in 12 patients, re-TEVAR was performed in two patients, hybrid aortic arch repair in one patient, and the chimney technique in one patient.There were no in-hospital deaths. Fourteen patients required mechanical ventilation for24 h and one for48 h. One patient required reintubation after mechanical ventilation for 19 h and continuous renal replacement therapy because of renal failure. One patient received pericardial drainage, and recurrent laryngeal nerve injury occurred in one patient. Three patients died during follow-up.The LSCA-LCCA transposition with a stented elephant trunk can produce satisfactory results in patients with a type Ia endoleak involving the distal arch. Using this technique, it is possible to exclude the aneurysm sac distal to the LCCA origin and seclude the failed interventional endograft. These encouraging outcomes suggested that this technique could be a suitable surgical treatment for this type of lesion.

Background The prevalence of a bovine aortic arch configuration is higher in patients treated for thoracic aortic aneurysms and type B dissection; its prevalence in aortic isthmic trauma has not been described. Methods A case control study was performed comparing consecutive patients treated at our institution for acute isthmic aortic transection after blunt trauma between 2002 and 2019 and a control group of consecutive sex-matched individuals undergoing imaging for nonaortic disease. Imaging and clinical findings were reviewed. Subjects were divided into bovine and nonbovine groups and prevalence was compared. The length of the aortic segment between the left subclavian artery (LSA) and the next proximal great vessel was measured in the control population and a comparison was performed between bovine and nonbovine aortic arch subjects. Results Thirty-three consecutive (30 male) patients were reviewed, 66 individuals (60 male) were included in the control group. A higher incidence of bovine arch in trauma patients was found: 57.6% vs. 34.8% (P = 0.007). The median (range, mm) and mean (SD) distance between the bovine trunk and the LSA were 13 mm (2–27) and 12.4 mm (5.9), respectively, compared with 5 mm (1–27) and 7.8 mm (6.1) between the left common carotid and LSA in nonbovine aortic arches (P Conclusion A higher incidence of bovine arch in patients reaching out for surgical treatment for traumatic isthmic aortic transection was found in our population. Clinical interpretation of this finding can lead to several alternatives. Confirmation with larger series and data on prevalence of this anatomic variation in nonsurvivors is needed to provide a better understanding of this finding.

Background Arterial traumas of the extremities are quite rare in civilian records; nevertheless, patients with trauma of limbs are admitted daily in emergency departments worldwide. The up-to-date information about epidemiology and treatment (open vs. endovascular surgery) comes from war records and it is not always easy getting data on mortality and morbidity in these patients. The aim of this study is to analyze the approach (open or endovascular) and the outcome of patients with vascular trauma of upper limbs (from the subclavian artery) and/or lower limbs (distal to the inguinal ligament), in the greater Milan area. Methods A retrospective analysis was conducted on data recorded by the emergency departments of two hospitals of the greater Milan between 2009 and 2017. We collected all patients with arterial injuries of the limbs in terms of demography, injury patterns, clinical status at admission, therapy (open or endovascular approach), and outcomes in terms of limb salvage and survival. Results We studied 52 patients with vascular trauma of extremities. The main mechanism of trauma was road accident (48.1%), followed by criminal acts (32.7%), self-endangering behavior (13.5%), work (3.8%), and sport accidents (1.9%). Associated lesions (orthopedic, neurological, and/or venous lesions of the limbs) were present in 39 patients (75%). All patients underwent emergency surgery, forty-six patients (88.5%) by open repair (polytetrafluoroethylene or greater saphenous vein bypass grafts, arterial suture or ligation), whereas endovascular approach was used only in 6 patients (11.5%), all treated with embolization. The overall postoperative mortality rate was 5.7% (3 patients). Among survivors, we report 5 major amputations of the lower limbs, 3 of them after bypass graft infection, and 2 after graft failure. The rate of limb salvage was 90.4%. Conclusions Isolated arterial trauma of the extremities are rare, usually they occur in the setting of multiple trauma patients. Despite progresses in surgical techniques, there are still controversies in diagnosis and treatment of these patients. We treated most cases with open surgery (n = 46), choosing endovascular approach (embolization performed mainly by interventional radiologists) in difficult anatomic districts. We believe that, during decision-making of the surgical strategy, it is important to consider the anatomical site of lesions and the general condition of the patients. Moreover, in case of multiple trauma, we suggest a multidisciplinary approach to provide the best medical care to the victims.

Background The goal of this study is to evaluate the safety and efficacy of a novel catheter for right radial artery approach cerebral angiography. Methods Patients from the Neurology Department of The Second Affiliated Hospital of Guangxi Traditional Chinese Medical University who underwent diagnostic cerebral angiography of either the left vertebral artery dominant type or balanced type were enrolled in this study. Results A total of 167 patients were treated between February 2016 and December 2017, of whom 44 were excluded based on study exclusion criteria and 123 were enrolled in the present analysis. Bilateral subclavian artery catheterization and bilateral common carotid artery catheterization were conducted successfully in all 123 patients. The success rate of selective catheterization of the left vertebral artery was 87.8% (108/123). The success rate of selective catheterization of the right vertebral artery using the novel catheter was 89.0% (73/82). The average fluoroscopy time was 6.5 ± 3.4 min, the average operation duration was 47 ± 3.7 (range 50–90) min, and the average dosage of contrast agent was 112.3 ± 8.1 mL. One patient exhibited an absence of pulse in the punctual radial artery after the removal of the arterial compression band, but there was no evidence of ischemia of the distal hand. One patient who was undergoing dual anti-platelet drug treatment suffered from bleeding at the puncture point when deflated for 2 hr after operation; this patient was re-pressurized and re-timed. Conclusions This novel catheter improved the success rate of selective left vertebral artery catheterization, and allowed for simplification of the relevant surgical steps. The controllability of this novel catheter was satisfactory, and its associated surgical risk was found to be low.

International audience; BACKGROUND:The aim of this study is to report long-term functional results following cervical rib (CR) resection for thoracic outlet syndrome (TOS).METHODS:This monocentric study included all cases of resection of CR for TOS performed between January 2004 and December 2016. Data were retrospectively collected from the hospital electronic database including preoperative symptoms and the evaluation of occupational well-being, intraoperative data, and early clinical evaluation and occupational well-being during the postoperative period. Patients were categorized as neurogenic TOS (NTOS), arterial TOS (ATOS), arterial and neurogenic TOS (ANTOS), venous TOS (VTOS), or asymptomatic according to preoperative evaluation. We evaluated the improvement in work life between the preoperative and the postoperative period. Further assessment was a negative Roos or elevated arm stress test (EAST) during the postoperative period.RESULTS:Thirty-three patients with a median age of 38.5 years (30-46) were included. Thirty-six procedures were performed: 33% to treat ATOS (12/36), 39% for NTOS (14/36), 19% for ANTOS (7/36), 3% for VTOS (1/36), and 6% (2/36) for asymptomatic lesions. There were 9 cases of subclavian artery aneurysms leading to additional arterial repair. Due to distal embolization, a cervical sympathectomy was associated in 5 procedures. First rib resection was associated in 4 procedures (11%) and C7 transverse process resection was performed in 15 procedures (42%). The technical success rate was 100% and intraoperative complications were observed in 4 patients (11%) with favorable postoperative outcomes. During the early postoperative period, 3 Claude Bernard-Horner's syndrome and 1 asymptomatic subclavian dissection were detected. Late complications included 2 bypass thromboses (6%) at 6 weeks and 16 months. Postoperative EAST improved in 16 limbs (44%). Prior to the procedure, only 27% (9/33) patients had normal work lives. After the procedure, 64% (21/33) of patients were able to return to their normal work activity.CONCLUSIONS:CR resection for TOS seems to be a safe procedure leading to good short- and long-term clinical results with a favorable impact on recovering a normal work life in these young patients.

BACKGROUND In traumatic axillo-subclavian vessel injuries, endovascular repair has been increasingly described, despite ongoing questions regarding infection risk and long-term durability. We sought to compare the clinical and safety outcomes between endovascular and surgical treatment of traumatic axillo-subclavian vessel injuries. METHOD A search query of the prospectively maintained PROOVIT registry for patients older than 18 years of age with a diagnosis of axillary or subclavian vessel injury between 2014-2019 was performed at a Level 1 Trauma Center. Patient demographics, severity of injury, Mangled Extremity Severity Score (MESS), Injury Severity Score (ISS), procedural interventions, complications, and patency outcomes were collected and analyzed. RESULTS Twenty-three patients with traumatic axillo-subclavian vessel injuries were included. There were similar rates of penetrating and blunt injuries (48% vs 52%, respectively). Eighteen patients (78%) underwent intervention: 11 underwent endovascular stenting or diagnostic angiography; 7 underwent open surgical repair. There was similar severity of arterial injuries between the endovascular and open surgical groups: transection (30% vs 40%, respectively), occlusion (30% vs 40%, respectively). The open surgical group had worse initial clinical comorbidities: higher ISS scores (17.0 vs 13.5, p = 0.034), higher median MESS scores (6 vs 3.5, p = 0.001). The technical success for the endovascular group was 100%. The endovascular group had a lower estimated procedural blood loss (27.5 mL vs 624 mL, p = 0.03). The endovascular arterial group trended toward a shorter length of hospital stay (5.6 days vs 27.6 days, p = 0.09) and slightly reduced procedural time (191.0 minutes vs 223.5 minutes, p = 0.165). Regarding imaging follow up (average of 60 days post-discharge), 7 patients (54%) underwent surveillance imaging (5 with duplex ultrasound, 2 with computed tomography angiography CTA) that demonstrated 100% patency. Regardless of ISS or MESS scores, at long term clinical follow up (average of 214 days), there were no limb losses, graft infections or vascular complications in either the endovascular or open surgical group. CONCLUSION Endovascular treatment is a viable option for axillo-subclavian vessel injuries. Preliminary results demonstrate that endovascular treatment, when compared to open surgical repair, can have similar rates of technical success and long term outcomes in patency, infection and vascular complications.

Background Arterial thoracic outlet syndrome (aTOS) is characterized by compression of the subclavian artery as it exits the thoracic girdle. Chronic and repetitive compression leads to several degrees of arterial wall damage. The treatment is varied and depends on the presentation severity. This study aimed to describe the contemporary experience in managing arterial thoracic outlet syndrome at a large tertiary hospital. Methods We conducted a single-institution retrospective review of aTOS cases from January 2009 to January 2020. Demographic data, clinical presentation, medical images, operative notes, and outcomes were assessed. Results Thirteen aTOS cases were identified. The mean age was 43 ± 10 years, and 11 (85%) were women. Both sides were equally affected: right (7 cases, 54%) and left (6 cases, 46%). The most common clinical presentation was arm claudication (7 cases, 54%). Other presentations were: acute arm ischemia, pulsatile neck mass and distal embolization. Cervical ribs were identified by plain X-rays in most cases. All patients were submitted to surgical decompression through the supraclavicular approach. Patients with early disease stages were not submitted to arterial reconstruction and were followed with duplex scan. Arterial reconstruction was done in advanced disease stages (5 cases, 38%): end-to-end anastomosis, interposition graft, and bypass graft. The mean follow-up duration was 32,6 ± 25 months. In all patients, the subclavian artery/graft was patent, and the vascular symptoms were entirely resolved. There were no deaths or amputations. Conclusions Arterial thoracic outlet syndrome has a varied clinical presentation. Cervical ribs are the most common anatomic abnormalities. The diagnosis was based on history, physical examination, and imaging exams. Surgery consisted of supraclavicular decompression, arterial resection, and vascular reconstruction, according to the disease stage. The outcomes were excellent.

Objective Subclavian artery aneurysms (SAAs) are uncommon but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for SAAs. Methods The clinical data of 18 SAA patients who underwent endovascular repair at 3 hospitals from January 2009 to December 2019 were retrospectively collected and analyzed. Results Eighteen patients (12 men and 6 women) with a mean age of 61 years were included. Six patients (33.3%) had a history of hypertension, and 5 (27.8%) had a history of chest trauma. Five patients (27.8%) were asymptomatic. Thirteen (72.2%) SAAs were true aneurysms, and the others (27.8%) were posttraumatic false aneurysms. Endovascular stent graft repair was performed in all patients without conversion to open surgery. The immediate technique success rate was 94.4%, with no postoperative death and only one case (5.6%) of endoleak that was observed on intraoperative angiography and later resolved spontaneously. All patients survived over a median follow-up time of 57 months. Follow-up imaging showed that all stent grafts remained patent, with no endoleak. Conclusions Endovascular stent graft repair is feasible, safe, and effective for true and posttraumatic false SAAs and represents a promising treatment option for these SAAs.

Background: An aberrant right subclavian artery (ARSA) is in most cases an asymptomatic aortic arch anomaly. However, dysphagia, aneurysm formation (ARSAA), associated Kommerell diverticulum, or cerebellar/arm malperfusion may require invasive therapy. Large-scale clinical trials do not exist in current literature. We report our patient's outcome of a single-center experience and delineate indications for treatment and surgical techniques. Methods: A single-center retrospective study was conducted between January 1, 2012 through March 1, 2018. Symptomatic or asymptomatic patients with ARSAA who received invasive treatment at the Department for Vascular and Endovascular Surgery, University Hospital Dusseldorf, Germany were included. Results Eight patients (4 men, 63 ± 14 (39–78) years) were treated with single-stage (n = 4) or multistage (n = 4) procedures. Treatment for ARSAA (n = 4) included ARSA revascularization (subclavian-carotid transposition (SCT) = 3; carotid-subclavian bypass (CSB) = 1), aortic arch debranching (left SCT = 2, bilateral aorto-carotid bypass + left CSB = 1, right-to-left CSB + left-carotid-to-bypass transposition = 1), and thoracic endovascular aortic repair (TEVAR; n = 4). Other strategies included SCT for dysphagia (n = 2) or subclavian steal syndrome (n = 1) and balloon angioplasty for arm claudication (n = 1). Complications involved vascular access (n = 2) and each one partial common carotid artery overstenting without stroke during TEVAR and Horner syndrome after SCT. Mean follow-up was 23 ± 26 (9–67) months. After 7 months, 1 patient required vertebral artery coiling due to type II endoleak with ARSAA progression. Overall mortality was 0%. Technical and clinical success rates were 100%. Conclusions: Surgical concepts for ARSA aim on preventing aneurysm rupture and alleviate dysphagia or ischemic symptoms. To generate satisfying patient outcomes, individualized therapy planning in specialized centers is vital.

Background The costoclavicular space is a common site of thoracic outlet syndrome. When there is no anatomical alteration, the diagnosis of thoracic outlet syndrome is difficult. Several authors relate costoclavicular distance to symptoms of thoracic outlet syndrome; however, there is no standardized site for measurement of the costoclavicular distance. This study aimed to determine the standard costoclavicular distance at neurovascular bundle crossing points (near the subclavian vein [Measure V] and the subclavian artery/brachial plexus branches [Measure NA]) using high-resolution chest computed tomography (CT) scans and evaluate its variations with respect to age, sex, height, and body mass index. Methods This prospective cross-sectional observational study analyzed 150 of 156 CT scans from consecutive adult patients (72 females and 78 males). Costoclavicular distance was measured at the subclavian vein and brachial plexus/subclavian artery sites, where narrowing of the costoclavicular distance could lead to symptoms of thoracic outlet syndrome. Costoclavicular distance was analyzed with respect to sex, laterality, age group ( Results Measures of V and NA were normally distributed. The measured costoclavicular distances were 1.23 cm (±0.40) and 1.24 cm (±0.47), respectively. Age (≥50 years) and body mass index (≥25 kg/m2) increased the costoclavicular distance. Measurements V and NA below the fifth percentile indicated a narrowed costoclavicular distance and a greater chance of developing thoracic outlet syndrome. For young ( Conclusions Standardization of costoclavicular distance measurements at neurovascular bundle crossing points (subclavian vein and brachial plexus/subclavian artery) is possible. It may aid the diagnosis and help direct the therapeutic indications for symptomatic patients with thoracic outlet syndrome.

Background The authors have published their design of a pulsatile fresh frozen human cadaver circulation model (PHCM) for endovascular training the face validity of the PHCM for training endovascular practitioners was subsequently assessed. Methods Twelve endovascular clinicians performed the same 2 procedures (catheterization of the left renal artery and left subclavian artery) on PHCM and Simbionix angiomentor virtual reality simulator (SVR). They were randomized to begin on either the PHCM or SVR. A pretrial questionnaire determined participants' endovascular experience. After training, participants rated statements relating to their experience on a numerical scale from 1 to 5, with 1 representing the strongest agreement with the statement. Results When participants were asked to compare the realism of training modalities with live patients, PHCM scored significantly higher than SVR on statements regarding “realism of vascular access” (P = 0.002), “guide-wire manipulation” (P = 0.001), and “vessel catheterization” (P = 0.004). Candidates again favored PHCM as “a valuable learning exercise” (P = 0.016) and strongly favored PHCM as a “useful training model” compared to SVR (P = 0.004). Conclusions This is the first published trial in world literature to assess the validity of a PHCM for training endovascular practitioners. The PHCM demonstrates good face validity when compared to both real patients and the SVR model and holds exciting potential.

Kommerrell's diverticulum of the right aberrant subclavian artery is a rare disease, its treatment is still controversial. We report the case of a patient with a six cm aneurysmal dilation successfully treated in a hybrid surgical/endovascular way.

The coronary-subclavian steal syndrome is a hemodynamic phenomenon in which a subclavian artery stenosis or occlusion impairs blood flow at the origin of the left internal mammary artery used for coronary artery bypass grafting (CABG), causing retrograde blood flow and thus provoking symptoms of cardiac ischemia and its complications. Once considered the gold-standard operation of choice, open revascularization has now been abandoned as a first line treatment and replaced by endovascular techniques. In all cases, detailed and oriented physical examination in combination with further imaging in high clinical suspicion for coronary-subclavian steal syndrome remains the sine qua non of the preoperative examination of the patient. We report the case of a 50-year-old male patient suffering from acute onset angina post- coronary artery bypass grafting and managed by endovascular means.

The aberrant right subclavian artery or arteria lusoria (AL) is the most frequent anatomical variation of the supra-aortic trunks (SAT). Treatment is only warranted in the presence of an aneurysm because of the risk of rupture, or in symptomatic cases with signs of compression of the esophagus or the trachea, with embolisms causing right upper limb ischemia of vertebrobasilar cerebrovascular accidents. The conventional surgical treatment of AL is the closure of the origin of AL and the revascularization of the right subclavian artery through a left thoracotomy. With the appearance of endovascular techniques, some of these patients can be treated with minimally invasive hybrid techniques. The aim of this study is to evaluate the feasibility of the endovascular treatment of AL based on the radioanatomical analysis of the thoracic angio-computed tomographies.We analyzed 180 thoracic angio-computed tomographies using millimeter cuts (1.2 mm) performed between 2010 and 2015 in the Nancy University Hospital in which an AL was fortuitously discovered. Symptomatic ALs and pediatric patients were excluded. The diameters of the SATs and the aorta and the distances between the SATs were measured. The data were processed with the t-test using the SPSS 22 software.Our results showed the presence of a Kommerell diverticulum in 36 cases (20%) and of a bi-carotid trunk in 91 cases (50.5%). The average distance between the left subclavian artery (LSCA) and AL was 5.4 ± 4.3 mm. To obtain a proximal neck20 mm for the implantation of a thoracic stent graft, a double transposition or bypass was always necessary (LSCA to left common carotid artery, AL to right common carotid). An additional debranching of the left common carotid artery was necessary in 33.8% of the cases and of all the SATs in 2.9% of the cases.The radio-anatomical study showed that no patient was eligible for conventional thoracic endovascular aneurysm repair to treat an aneurysmal AL. The hybrid approach is feasible using a double transposition or a bypass before the implantation of a stent graft, if needed associated with a debranching of the common carotid arteries.

Background The status of the left arm, the need of revascularization, and the occurrence of type II endoleakes from de left subclavian artery (LSA) after intention LSA coverage for thoracic aortic aneurysm endovascular repair need to be better understood. This systematic review was developed for contributing with such issue. Methods Systematic literature review of studies published from January 2000 through December 2015 identified 7 studies comprising 201 patients submitted to elective endovascular repair for thoracic aortic aneurysms requiring intentional LSA coverage. Outcomes of interest included left-arm complications (ischemia, symptoms of claudication, and subclavian steal syndrome [SSS]) requiring postoperative revascularization of LSA, as well as endoleaks from the subclavian artery requiring postoperative embolization of LSA. Results Left-arm complication rate was 4.5% (9 patients), requiring postoperative revascularization of LSA in 1 case (0.5%) of SSS. Type II endoleaks from the subclavian artery requiring postoperative embolization of LSA were reported in 2 cases (1.0%). Conclusions Low-quality evidence suggests very low rates of arm complications with need of LSA revascularization and of type II endoleaks requiring embolization in elective endovascular treatment of thoracic aortic aneurysms with intentional coverage of LSA without prophylactic revascularization of LSA.

Background The aim of this study was to evaluate outcomes of left subclavian artery (LSA) revascularization for hybrid aortic arch debranching. Methods Between 1998 and 2015, 68 patients (41 men; mean age, 67 ± 16 years) underwent thoracic endovascular aortic repair (TEVAR) with LSA coverage, 19.2% ( n = 13) were never revascularized, and the remaining patients underwent LSA revascularization ( n = 55; 80.8%). Revascularization was achieved by LSA–carotid transposition via a medial approach in 81.8% ( n = 45) and a lateral approach in 18.2% ( n = 10). The indication for TEVAR was aneurysmal disease in 30.9% ( n = 17), dissection in 29% ( n = 16; acute, n = 5), traumatic aortic injury in 21.8% ( n = 12), pseudoaneurysm in 10.9% ( n = 6), aortobronchial fistula in 5.5% ( n = 3), and penetrating atherosclerotic ulcer in 1.9% ( n = 1). Elective cases accounted for 52.7% ( n = 29). Follow-up computed tomography scans were performed at 1 week, 3 and 6 months, and annually thereafter. Results LSA revascularization was achieved in all the cases. Thirty-day mortality rate was 12.7%. Thirty-day mortality related to LSA revascularization was 0%. No patient suffered a stroke. Vocal cord paralysis was detected in 7.2% of patients ( n = 4). Hematoma requiring surgical drainage was observed in 3.6% of patients ( n = 2). Lymph leak requiring revision surgery was observed in 1.8% of patients ( n = 1). Phrenic nerve palsy was not observed. The local complication rate was significantly higher ( P = 0.03) in patients with LSA transposition via a lateral approach (20%; n = 2) when compared to patients with LSA revascularization via a medial approach (11.1%; n = 5). After a mean follow-up of 31.5 months (range, 2–171 months), the patency of the LSA revascularization was maintained in all patients. Conclusions During TEVAR, when LSA coverage is required, LSA revascularization is a durable procedure associated with a low morbidity rate. LSA transposition via a medial approach would appear to be associated with significantly fewer complications.

Background The authors identified as ‘acute vascular chest’ a syndrome characterized by respiratory-thoracic signs, mimicking pleuro-pulmonary or chest wall diseases, that, on the contrary, are caused by proper acute thoracic vascular lesions, traumatic or not, but not cardiac. Results As typical examples, we mention two cases: one of traumatic left extrapleural hematoma, secondary to rupture of the subclavian artery, and another concerning an aneurysm of the mid descending thoracic aorta, fissured into the upper left pulmonary lobe. In both these cases, angiographic examinations allowed a prompt and correct diagnosis. Conclusion Today, precise radiological studies of the extrapleural and upper thoracic spaces support the identification of this particular syndrome.

The aim of the study was to report early and late outcomes of surgical and endovascular management of subclavian artery atherosclerotic disease (SAAD).Data about consecutive patients treated for subclavian artery atherosclerotic occlusive disease between 2001 and 2018 either by open surgical repair (OSR) or by endovascular repair (ER) were retrospectively collected and analyzed. Primary outcomes included 30-day death, as well as cardiac and neurologic events, reported separately for occlusion and stenosis. Secondary outcomes included primary patency in the long term, reported separately for occlusive and stenotic lesions. The Kaplan-Meier analysis with the logrank test was used to estimate long-term primary patency. Chi-squared and t-tests were used as appropriate to compare the outcomes of the 2 groups. A P value 0.05 was considered statistically significant.Sixty-eight patients were treated using ER (49 patients) and OSR (19). Technical success rate was 100% in both groups. During in-hospital stay, 1 brachial hematoma and 2 acute upper limb ischemia occurred in the ER group and in the OSR group, respectively. At 30 days, no deaths or neurological/cardiac events were recorded in both ER and OSR groups. Symptoms resolution and upper limb salvage were 100% in both groups. In the ER group, primary patency was 100% at 7 years in patients who had been treated for stenotic lesions and 62.5 ± 21.3% in patients who had been treated for occlusive lesions (P = 0.0035). In the OSR group, primary patency was 100% at 7 years in patients treated for stenotic lesions and 25 ± 21.6% in patients who had been treated for occlusive lesions (P 0.0001). Overall, long-term primary patency in the OSR group was 76.9 ± 11.7% at 7 years, being lower than that reported after ER (93.4 ± 4.5%, P = 0.02).Both ER and OSR proved to be safe, effective, and durable in the treatment of SAAD. In particular, the primary patency rates at long term for both ER and OSR showed better outcomes for stenotic lesions.

The purpose of this study was to compare the outcomes of thoracic endovascular aortic repair (TEVAR) without and with left subclavian artery (LSA) revascularization using the Nationwide Inpatient Sample (NIS) database.NIS records from 2005 to 2013 were retrospectively analyzed to identify patients undergoing TEVAR without and with LSA revascularization. Perioperative outcomes were compared between the two groups. The LSA revascularization group was further subdivided to compare perioperative outcomes if the revascularization was performed pre- or post-TEVAR or if the revascularization was performed open versus endovascular. Comparisons were examined using univariable analysis and multivariable logistic regression. Multivariable models were constructed using a forward selection approach with P 0.05 required for model entry. Odds ratios are expressed per standard deviation change for continuous covariates. Continuous variables were compared between different groups using t-test, and categorical variables were compared using the chi-squared test. All statistical analyses were performed using R (cran.r-project.org).7,773 TEVAR patients were included in this study. 6,411 (82.5%) were performed without and 1,362 (17.5%) with LSA revascularization. The rate of revascularization for LSA coverage during TEVAR doubled after the Society for Vascular Surgery Guidelines recommending revascularization were published in 2009. Groups were not significantly different in age (65.5 ± 15.8 and 66.1 ± 14.4 years old, respectively), gender, or race. Multivariable analysis showed that although rates of spinal cord ischemia and upper extremity ischemia were similar, perioperative cardiac complications (OR 1.5, 95% CI [1.2, 1.9], P = 0.025), stroke (OR 2.1, 95% CI [1.6, 2.8], P = 0.001), and pulmonary complications (OR 1.9, 95% CI [1.7, 2.3], P 0.001) were significantly higher in the patients undergoing TEVAR with LSA revascularization than those without. Of the 1,362 patients with LSA revascularization, 1,251 (91.9%) were performed pre-TEVAR and 111 (8.1%) were performed post-TEVAR. Among the 1,251 patients with pre-TEVAR LSA revascularization, 583 had open surgery and 553 had stenting. In 115 patients, LSA revascularization was coded as both open and endovascular. Compared with pre-TEVAR revascularization, post-TEVAR revascularization was associated with higher risks of pulmonary complications and spinal cord ischemia. Endovascular LSA revascularization had lower pulmonary and stroke morbidity versus open LSA revascularization. The perioperative outcomes for the LSA revascularization subgroups are summarized.TEVAR with LSA revascularization is associated with significantly increased rates of perioperative stroke and cardiopulmonary complications. LSA revascularization before TEVAR, compared with post-TEVAR revascularization, had lower perioperative complications. In high-risk patients, endovascular LSA revascularization may be recommended over open surgery.

Objectives This study aimed to analyze the perioperative stroke rate, stroke lesions, outcome, risk factors, and stroke prevention following debranching with thoracic endovascular aortic repair (TEVAR). Design Retrospective study. Methods Between February 2011 and February 2015, 74 consecutive patients underwent debranching with TEVAR at our institution. Of these, the TEVAR proximal landing zone was “zone 0” in 23 patients, “zone 1” in 28, and “zone 2” in 23. Left subclavian artery (LSA) occlusion with coil embolization, balloon occlusion, or vascular plugging was performed in 27 patients. Mean follow-up time was 19.2 months (range 2–52 months). Results The in-hospital mortality rate was 4.1%. Stroke developed in 7 patients (9.5%), zone 0 in 4 patients, zone 1 in 2, and zone 2 in 1. Six of these patients had stroke lesions arising from the vertebral/basilar artery. Univariate analysis revealed a significant increase in the risk of postoperative stroke in patients with intraluminal atheroma (P = 0.001), those who underwent prior percutaneous transluminal coronary angioplasty or coronary artery bypass graft (P = 0.002), and those with a long operative duration (P = 0.001). Additionally, LSA occlusion significantly decreased the incidence of stroke (P = 0.041). The postsurgical 1- and 2-year cumulative survival rates were 87.3% and 77.0%, respectively, in those without stroke, and 68.6% and 22.9%, respectively, in those with stroke (P = 0.012). Conclusions Stroke after debranching with TEVAR was associated with a high mortality. To prevent stroke, careful patient selection and protection of the vertebral artery are important. Prophylactic LSA occlusion at the time of stent-graft deployment might reduce the risk of perioperative stroke.

It is essential to establish cardiopulmonary bypass by percutaneous insertion of a large-bore catheter via both the femoral vein and internal jugular vein (IJV) for minimally invasive cardiac surgery (MICS). Complications associated with IJV catheterization during MICS have been reported in the literature; however, vascular injury of the subclavian artery (SCA) is rare. We herein present a rare case in which an iatrogenic arteriovenous fistula (AVF) between the right SCA and IJV after MICS was successfully treated by endovascular coil embolization. A 61-year-old man who had undergone mitral valve repair by MICS 10 months before presentation was referred because of pulsatile cervical bruit and tinnitus. Radiographic examination revealed a right SCA pseudoaneurysm associated with an AVF located between the right common carotid artery and vertebral artery. The AVF was completely occluded with detachable coils using a double-catheter technique to avoid coil migration into the IJV. This technique has been used to treat high-flow or complex AVFs, including pulmonary and renal AVFs. As shown in the present case, it is also useful to treat an iatrogenic AVF between the SCA and IJV.

The endovascular repair of subclavian aneurysms or pseudoaneurysms is now widely adopted. However, controversies still prevail in the management of dominant vertebral arteries originating close to aneurysms, as coverage of the vertebral artery might be complicated by either endoleaks or ischemic events. Here, we present a rare case of multiple aneurysmal lesions involving the right subclavian artery and bilateral internal carotid arteries treated by way of a total endovascular method using parallel stent grafts for the simultaneous exclusion of a subclavian artery pseudoaneurysm and flow preservation of the adjacent vertebral artery. To the best of our knowledge, this is the first study to report the use of this technique for the endovascular repair of juxta-vertebral subclavian artery pseudoaneurysms.

Background Endovascular stent and prosthetic graft placement are commonplace techniques for correction of subclavian artery (SCA) lesions. However, when initial surgical repair of the SCA becomes complicated by subsequent infection or thrombosis of the repair site, stents and prosthetic grafts are no longer suitable for secondary repair due to the risk of recurrent failure and limited longevity. Autogenous tissue is more resistant to infection and has improved long-term patency, and thus may be a better option for secondary reconstruction in these complex clinical scenarios. The most commonly used autogenous conduit for SCA reconstruction is the great saphenous vein; however, the significant size mismatch makes this unsuitable in many circumstances. The autogenous femoral vein is a promising alternative conduit for SCA repair. Here we present 3 successful cases of its use as a salvage technique following iatrogenic complications of prior surgical repair. Methods From 2015 to 2019, 3 patients underwent harvest of the femoral vein for use in SCA repair, with 2 carotid-axillary bypasses and 1 carotid-subclavian bypass. Indications included a mycotic pseudoaneurysm secondary to an infected SCA stent, an SCA avulsion secondary to an infected carotid-subclavian bypass graft, and an occluded SCA stent in a young patient. Postoperative graft patency was monitored via clinical resolution of symptoms and maintenance of perfusion, intact pulses, and arterial duplex or computed tomography (CT) scan. Results All these patients had a good outcome following their procedures. Each had intact radial pulses immediately postoperatively and maintained normal perfusion to the upper extremity for the duration of follow-up, with bypass patency confirmed via CT scan or arterial duplex. The SCA repair also allowed for salvage of the upper extremity and symptomatic relief in all patients. None of the patients developed deep vein thrombosis in the donor extremity, and neither of the infected patients developed recurrent infection of the repair site. Conclusions The success of these cases demonstrates that the autogenous femoral vein is an effective and safe option for SCA reconstruction. It is particularly useful for secondary salvage when prior surgical repair via standard techniques is complicated by infection or thrombosis, and when target vessel size precludes the use of the great saphenous vein. This is an excellent choice of conduit that vascular surgeons should consider for use in complex SCA repairs.

Background In recent years, endovascular treatment of subclavian artery pseudoaneurysm (SAP) has been recommended by many experts. The aim of this study is to evaluate the safety and efficacy of the endovascular treatment of SAP, and to introduce our experience in the diagnosis and treatment of SAP. Methods A total of 8 consecutive patients with SAP were treated with endovascular treatment in our hospital between 2010 and 2018. We retrospectively reviewed the patients' clinical characteristics, physical examinations findings, diagnostic imaging results, endovascular treatment, clinical outcome, and follow-up results. Results All the 8 patients received endovascular treatment with covered stents initially. The technical success rate was 87.5% (7/8). In 1 patient with severe tortuosity of the proximal subclavian artery, the stent could not be released through the femoral artery approach in the primary operation but was successfully released via the brachial artery approach in the secondary operation. No complications occurred in the perioperative period. All the symptoms and signs were significantly relieved. During a follow-up of 4.5–84.5 months (average 31.5 months), 1 patient developed an endoleak 4 months after operation and reintervention was attempted but failed. No adverse events occurred in other patients during the follow-up period. Conclusions Endovascular treatment of SAP is safe and effective, and should be used as a first-line treatment. Stent placement through the brachial artery approach is recommended for SAP with severe proximal vascular tortuosity.

Left subclavian artery revascularization during endovascular repair of aortic dissection is often accomplished by left carotid-subclavian artery bypass or transposition. In situ fenestration of thoracic stent grafts provides an alternative method of revascularization without manipulation of the left carotid artery. We describe a case whereby in situ laser fenestration, combined with catheter-directed thrombectomy, was utilized to revascularize a thrombosed left subclavian artery following a frozen elephant trunk repair of type A aortic dissection. A 75-year-old male presented with pericardial tamponade and aortic insufficiency, secondary to type A aortic dissection. Patient underwent an emergent replacement of the aortic root, valve, arch, and ascending aorta in the frozen elephant trunk configuration. The innominate and left carotid arteries were revascularized with a bifurcated bypass graft from the ascending aortic graft. The left subclavian artery (LSCA) was covered with an antegrade deployment of a cTAG stent graft. During the immediate postoperative period, the patient was found to have a dissection of the left common carotid artery (LCCA) and pseudoaneurysm of the bypass graft anastomosis. The left carotid artery was replaced up to the proximal internal carotid. During rehabilitation, the patient developed left subclavian steal syndrome, with a CT angiography demonstrating thrombosis of the subclavian origin, and duplex ultrasound showing a reversal of the left vertebral flow. In order to revascularize the left subclavian artery without using the left carotid as the inflow, the in situ laser fenestration technique was planned. The vertebral artery origin was protected with a neuroclip through a supraclavicular incision. Through a brachial artery cutdown, a 9Fr flex sheath was positioned at the origin of the subclavian artery. A suction thrombectomy catheter was used to create a central channel in the thrombus. A 0.035″ 3.2 mm over-the-wire laser atherectomy catheter was used to create a fenestration through the cTAG stent graft. The subclavian branch stent was stented with an iCast balloon-expandable covered stent, excluding the mural thrombus. The patient recovered well with resolution of symptoms and was discharged home. Postoperative CT scan showed patent left subclavian branch stent and no endoleak across the fenestration of the aortic stent graft. Delayed laser in situ fenestration of a PTFE stent graft can be performed safely. The vertebral artery protection and catheter-directed thrombectomy are important adjuncts to reduce the risk of posterior stroke.

Background Cerebellar strokes are a rare complication related to thoracic endovascular aortic repair (TEVAR). This can manifest in an indolent manner or as a neurological catastrophe. Often it is unclear when a surgical intervention is needed. Patients at risk for this relatively rare complication are not easily identified. Case We describe an endovascular option with flow reversal for left vertebral artery transposition using stent grafts in order to relocate arterial inflow and exclude a floating thrombus at the proximal subclavian artery (SCA) related to a previous TEVAR. Conclusion Ligation of the subclavian artery proximal to the vertebral artery should be considered when performing carotid subclavian bypass for elective TEVAR. This case details a unique, less invasive approach for vertebral artery transposition and thrombus exclusion in a high risk patient with previous neck dissection.

Type A aortic dissection is a highly lethal condition, which warrants swift open surgical intervention to prevent death by rupture or malperfusion. The aim is to resect the proximal intimal tear and realign the dissected wall layers. We describe two patients who recently presented in our center with a retrograde type A intramural hematoma and a clear intimal tear distal to the left subclavian artery, that were treated in emergency by endovascular means instead of open surgery, with satisfactory short-term and one-year follow-up results. In conclusion, in selected cases, less invasive thoracic endovascular aortic repair can treat retrograde type A intramural hematoma originating from an intimal tear distal to the left subclavian artery, with good one-year results.

Background 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. Methods 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. Results 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 24.9 months (range 1–60). Two patients required reintervention for stent thrombosis (1.5 months, 36 months) and 1 required balloon angioplasty for in-stent restenosis (24 months). Limb salvage was achieved in all patients with no major amputations, no minor amputations, and restoration of normal function in all. Conclusions 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.

Subclavian artery aneurysms (SAAs) are rare but potentially life- and limb-threatening. We present the case of a 69-year-old man with a true right SAA; the vertebral artery branched off the aneurysm and was the dominant one. A hybrid (combined open surgical and endovascular) repair was performed; the vertebral artery was anastomosed end to side to the common carotid artery through a right supraclavicular incision, then using a percutaneous high brachial artery access, a covered stent was deployed to exclude the SSA. The procedure was technically successful, and computed tomography angiography at 24 months showed regular placement of the endograft with blood flow within it and absence of any endograft-related complication (i.e., stent fracture/thrombosis/displacement or any-type detectable endoleak). This hybrid treatment is safe and feasible with good midterm results and may represent a valuable, less invasive alternative to conventional open surgical approaches.

A pseudoaneurysm located at the subclavian artery ostium is an infrequent but life-threatening pathology that usually requires major thoracic surgery with a high risk of mortality and morbidity. Endovascular therapy applied to the aortic arch branches is a recent alternative technique, which is still in its early stages because dedicated endovascular devices for the aortic arch are lacking. In this article, we present the emergency endovascular management of a symptomatic pseudoaneurysm of the left subclavian artery ostium which was presumably secondary to an atherosclerotic plaque rupture. Endovascular exclusion required a combination of an abdominal aortic stent-graft extension cuff, which was placed via a retroperitoneal iliac access, and a subclavian artery periscope stent graft.

Successful endovascular repair of thoracic aorta for type B aortic dissection requires correct stent-graft sizing, particularly of distal landing zone which is mainly based on operator experience. The present study aimed to quantitatively define proximal-to-distal tapering of descending thoracic aortic diameter and its consistency.The novel parameter HDP (Hundred times Distance accounts for Percentage)-measured as distance from the distal end of the left subclavian artery to each level along the aortic central line/length from the distal end of the left subclavian artery to the proximal end of the celiac artery along the aortic central line × 100-was calculated per 1% unit of descending thoracic aorta based on 3-mensio software-derived measurements from 281 consecutive individuals who had undergone enhanced chest computer tomography scanning. Association between HDP and maximal diameter of descending thoracic aorta was assessed by using the generalized additive mixed model with smoothing function and threshold saturation effect analyses with generalized estimating equations. Nonadjusted and adjusted models were performed to illuminate its consistency.Three inflection levels (HDPs of 15.01, 36.63, and 77.74) were identified which allowed to divide the descending thoracic aorta into 4 segments. The taper was consistent before and after adjusting for age, sex, height, body mass index, hypertension, smoking habits, hyperlipidemia, and diabetes. Although 1% unit of descending thoracic aorta decreases, the maximal diameter reduces to 0.007 mm (-0.025, 0.010; P = 0.414) in the segment with HDP15.01, to 0.151 mm (-0.158, -0.145; P 0.001) in the segment with 15.01 ≤ HDP 36.63, to 0.038 mm (-0.040, -0.036; P 0.001) in the segment with 36.63 HDP ≤ 77.74; and to 0.026 mm (-0.049, -0.002; P = 0.035) in the segment with HDP 77.74, respectively.The maximal diameter of descending thoracic aorta decreases gradually and consistently among individuals free of aortic diseases.

Background A custom-made unibody single-branch endograft (USBE) could provide great gains in the landing zone, while maintaining a left subclavian artery (LSA) perfusion in some patients with Stanford type B dissections (TBADs). We performed a computed tomography (CT)-based planning study to determine the proportion of TBAD patients who could benefit from this custom-made USBE and ascertained the possibility of an off-the-shelf USBE in an emergency setting. Methods We carried out a retrospective study of TBAD patients with optimal CT scans at our center from 2007 to 2013. Patients' CT scans were analyzed using 3-dimensional reconstruction software. After generating a centerline of flow, measurements (including numerous morphologic characteristics of anatomy) were evaluated. A selected subset of patients suitable for USBE was determined. Finally, the most frequently used configurations of endografts were figured out by subgroup analysis. Results A total of 314 patients with optimal digital imaging communications in medicine (DICOM) data were included in our study. The main primary entry tears (MPETs) were located at 22.8 ± 17.3 and 36.3 ± 18.6 mm distal to the LSA and the left common carotid artery, respectively. Overall, 169 (54.2%) patients with MPET distal to LSA (＞20 mm) could be treated by tubular stent grafts. Of the 143 patients who had intimal tears adjacent to the LSA (≤20 mm), there were 111 (35.4%) patients who could benefit from treatment using USBE based on our selection criteria. Subgroup analysis estimated the number of graft configurations needed to treat a proportion of patients: 1 design would treat 6.7% of the population, 5 designs would treat 23.1%, 10 designs would treat 37.6%, and 20 configurations would treat 54.8% . Conclusions In all, 35.4% patients with TBAD could potentially benefit from USBE. The use of off-the-shelf endografts might be possible in cases of emergency, given the evidence of recurrent configurations.

Background Subclavian carotid transposition (SCT) is a safe, effective, and durable treatment in atherosclerotic disease of the proximal subclavian artery. We report about our experience in SCT in a retrospective study with a long-term outcome in 126 cases and discuss our results with the current literature. Methods From January 1995 to December 2013, we treated 126 patients (51 men, 75 women; mean age, 60.9 years; range, 25–80 years) for proximal subclavian atherosclerotic lesions. Preoperative angiography revealed 58 stenoses (46.0%) and 68 occlusions (54.0%). We performed 126 SCTs. The following parameters were documented through a retrospective chart review: demographic data, occlusion site, preoperative symptoms, cardiovascular risk profile, coexisting cerebrovascular disease, and postoperative outcome. Continuous variables are summarized as mean. Categoric variables are expressed as frequency and percentage. Survival and patency rates were estimated using Kaplan–Meier analysis. Results Four immediate occlusions and 1 hemodynamic relevant stenosis (4.0%) occurred postoperatively. Thrombectomy was successful in 2 and a carotid axillary bypass was performed in 3 cases. Three strokes occurred, one during concomitant carotid endarterectomy. The 30-day mortality was 0%. Follow-up data were obtained on 106 of 126 patients (84.0%). The mean follow-up period was 53.8 months (range, 3–159 months). Twenty-three (18.3%) late deaths occurred. Estimated survival was 121.48 ± 6.86 months (range, 3–112 months). Ninety-five percent reported continuous resolution of symptoms. Primary patency rate was 96.0% and secondary patency rate was 100% at 30 days. The long-term patency rate was 96.3% at a mean follow-up of 53.8 months. Conclusions SCT is safe, effective, and durable in the long term. SCT is a standard procedure for occlusion and stenosis. Vessel occlusions, ineffective angioplasty, and preparation for thoracic stent grafting make SCT an important procedure in the surgeon's repertoire.

Pseudoaneurysm due to a swallowed fishbone rarely involves subclavian arteries. A 46-year-old male with nonaberrant right subclavian artery (RSA) presented pseudoaneurysm and brachial plexus septic necrosis. Open surgery with sternotomy and right transverse supraclavicular cervicotomy was done in emergency to achieve revascularization using in situ cryopreserved arterial allograft. Infection severity led to septic allograft rupture that necessitated ligation without new arterial reconstruction. During follow-up, patient remained alive 8 months after surgery. Neurological deficit slowly regressed, and no upper arm ischemic sign appeared.

We report the case of a young woman who experienced ischemia of upper limb after osteopathic manipulation. Duplex and computed tomography scan showed wall hematoma of the ostium of subclavian artery. The patient spontaneously recovered so that no surgery was necessary. Dissection of vertebral and carotid arteries has been reported after osteopathic manipulations. We report ischemia of upper limb secondary to dissection of subclavian artery. Arterial dissections associated with manipulation should be recorded in a register in order to assess more carefully the vascular risk that this method carries.

Background Aneurysms of the subclavian artery are usually the result of trauma, atherosclerosis, or thoracic outlet syndrome. Until the 90s, open surgical repair was considered the only therapeutic choice, exhibiting high complication rates. Since the first report of endovascular repair of subclavian aneurysms in 1991, promising results have been published. The aim of this review was to summarize all available data on subclavian artery (SA) true and false aneurysm stenting to reach conclusions regarding morbidity, mortality, and other procedure-related characteristics. Methods A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analysis guidelines. Eligible studies were sought in the Medline (PubMed), ClinicalTrials.gov , and Cochrane library–Cochrane Central Register of Controlled Trials (CENTRAL) databases through February 2017 using the following MeSH terms: “endovascular”, “hybrid”, “aneurysm”, “pseudo-aneurysm”, “pseudo-aneurysm”, “false aneurysm”, “arterial injury”, “subclavian artery”, “axillo-subclavian,” and “axillosubclavian artery”. The reference lists of eligible articles and pertinent reviews were screened for potential relevant studies. Results Seventy-three studies encompassing data on 142 patients who underwent endovascular or hybrid SA aneurysm repair were deemed eligible. One hundred forty-seven stents and stent grafts were used. Median age of all patients was 56 years, and males comprised 46% of the study sample. Trauma was the most common mechanism of injury. Pulsatile mass or hematoma was the most frequent presenting sign. Pseudoaneurysms were the most frequent type of aneurysms, followed by true aneurysms. Most authors used self-expanding polytetrafluoroethylene-covered stents. Access was obtained by either brachial, femoral, or both arteries. Through-and-through technique was also used in angulated vessels. All-cause mortality was 10.6%, slightly higher to that already reported in literature and lower to the respective rate of the open repair. Reintervention rate was 8.5% despite the high 15.5% complication rate. Conclusions Endovascular SA aneurysm repair is a technically feasible technique, useful in both elective and emergency cases. Although preliminary results quote its safety and efficacy, larger cohort studies are warranted to elucidate its benefit in treating SA aneurysms.

Atherosclerosis is a systemic disease, and multiarterial involvement is common. Involvement of all the supra-aortic arteries may occur in the same patient making cerebral revascularization challenging. In this report, we present complete supra-aortic revascularization, that is, revascularization of the bilateral common carotid and subclavian arteries in a 51-year-old male patient with occluded brachiocephalic trunk, left subclavian artery, and proximally stenotic left common carotid artery. A temporary ascending aorta to left external carotid artery bypass provided meticulous cerebral protection with pulsatile cerebral flow in the presence of a proximal arterial clamp; hence, a neurologically uneventful procedure during bilateral common carotid artery revascularization.