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Transradial access (TRA) has become increasingly utilized in neurointerventions because it reduces access site complications. However, radial artery anomalies can be difficult to navigate, often necessitating conversion to femoral access. We describe the case of a female patient in her early 70s who underwent preoperative embolization of a carotid body tumor via right TRA. Her radial angiogram demonstrated the presence of a radial artery loop which was successfully navigated with a triaxial system but would not spontaneously reduce, even after the guide catheter was advanced into the subclavian artery. However, manual manipulation of the catheters in the antecubital fossa under direct fluoroscopic visualization reduced the loop, allowing the procedure to continue transradially. Although most radial loops can be traversed and reduced using standard techniques, this case demonstrates that manual reduction can be successful when other measures fail. We recommend attempting this method prior to converting the access site.

Various surgical options have been described for the treatment of aberrant subclavian arteries and an associated Kommerell diverticulum.Between 1999 and 2019, 43 patients underwent a repair, comprising 26 (61%) endovascular and 17 (39%) open approaches. The endovascular approach consisted of initial subclavian revascularization followed by thoracic endovascular aortic repair. The open approach included total arch replacement (12%) and reverse hemiarch repair with left thoracotomy (53%) or right thoracotomy (35%). The perioperative and long-term outcomes were retrospectively reviewed.No mortality occurred in the endovascular group, whereas there was 1 (6%) in the open approach group. Patients in the endovascular group demonstrated a shorter hospital stay (3.5 days vs 10.0 days; P = .001) and less frequent prolonged mechanical ventilation (0% vs 24%; P = .019), with a lower occurrence of pneumonia (0% vs 24%; P = .019). Among patients who had the endovascular approach, shrinkage of Kommerell diverticulum or aberrant vessel origin was seen in 96%. Furthermore, relief of dysphagia was confirmed in 92% (12/13), including patients without Kommerell diverticulum (n = 3) after endovascular repair. The cumulative incidence of treatment failure or aortic reintervention at 7 years was 21% and 14 % in the endovascular and open approach groups, respectively (P = .62). Two (8%) patients in the endovascular group required an open reintervention. One reintervention was performed for persistent dysphagia in the setting of an untreated complete vascular ring, and the other was for persistent false lumen flow associated with aortic dissection.The treatment approach should be individualized on the basis of the aortic disease and comorbidities. The endovascular approach is a viable and effective alternative in the presence of suitable landing zones.

Kommerell diverticulum (KD) is a dilated proximal aberrant right or left subclavian artery associated with either right or left aortic arches (RAA-ARSA or LAA-ALSA). Although case series suggest that KD may be a liability for vascular complications, the risk, pattern of dilation throughout the life span, and differences between arch sides are not known.This study was a single-center retrospective review of patients of all ages with KD on cross-sectional imaging. Maximal short-axis diameter of KD (KDmax), absolute and indexed to descending aortic diameter (DAo), was correlated with age. Comparisons were made between arch sides. Patients with vascular complications were described.A total of 104 patients with KD were included: 68 (65%) with RAA-ALSA, 36 (35%) with LAA-ARSA, 43 (41%) asymptomatic. Although KDmax was correlated with age (RAA-ALSA r = 0.84; [P.0001]; LAA-ARSA r = 0.51 [P = .001]), KDmax indexed to DAo was not (RAA-ALSA r = 0.14 [P = .27]; LAA-ARSA r = -0.22 [P = .21]). Patients with RAA-ALSA had larger KDmax indexed to DAo (1.02 ± 0.20 mm/mm vs 0.89 ± 0.18 mm/mm; P = .002) and more symptoms (75% vs 28%; P.0001), and they were younger (median, 9.5 years vs 61.7 years; P.0001). Six patients (58 to 80 years of age) had vascular complications, and all 6 had LAA-ARSA and risk factors for acquired aneurysms.In older patients, KDmax indexed to DAo was not larger, thus arguing against isolated KD dilation with age. Diverticula from RAA-ALSA and LAA-ARSA demonstrated different phenotypes, a finding suggesting different disease processes and likely different risk. The incidence of vascular complications was lower than in previous reports, and these complications occurred exclusively in patients with LAA-ARSA and aneurysm risk factors. This finding suggests that conservative management of asymptomatic KD is often reasonable, especially in patients with RAA-ALSA.

We present a 54-year-old Caucasian woman, who presented with acute symptomatic type B aortic dissection with deteriorating renal function. She was a known smoker with a 2-year history of dysphagia. CT angiography documented the artery of lusoria arising from the mid-thoracic aorta, aneurysmal dilation of her descending aorta, and kinetic and static flaps around her visceral ostia. The patient was managed by staged hybrid single lumen reconstruction and bilateral subclavian to carotid transpositions. During follow-up, there was no aortic rupture or retrograde type A dissection. There were no renal, visceral, cardiac, pulmonary or spinal complications. The patient went off her antihypertensive medication with a normal estimated glomerular filtration rate and accelerated aortic modulation.

Isolation of the left subclavian artery or its anomalous origin from the pulmonary artery has been documented in several cases, especially in association with a right-sided aortic arch. However, similar anomaly involving the right subclavian artery has been less frequently reported. Isolated right subclavian artery in association with interrupted aortic arch (IAA) is extremely rare, and only three cases have been reported so far. Here, we have presented yet another case of isolated right subclavian artery associated with ventricular septal defect, type B IAA and bilateral patent ductus arteriosus.

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.

Subclavian artery aneurysms are rare peripheral artery aneurysms, and open surgical repair is the reference standard treatment. We have reported the case a patient with a right subclavian artery aneurysm who was not indicated for open surgical repair because of comorbidities. Thus, endovascular treatment using the Gore Excluder Iliac Branch Endoprosthesis (WL Gore and Associates, Flagstaff, Ariz) was performed, leading to complete aneurysmal exclusion without perioperative complications. Although anatomic limitations exist, this technique could be alternative treatment option for right subclavian artery aneurysms.

The Blalock–Taussig–Thomas Shunt (BTTS) procedure was first introduced by Alfred Blalock, Hellen B. Taussig, and Vivien Thomas in 1944. The procedure is performed by making a connection between the subclavian artery to the pulmonary artery to augment pulmonary blood flow. BTTS is used to palliate neonates born with restrictive pulmonary blood flow disorders (cyanotic congenital heart disease). The modified BTTS (MBTTS) procedure is still seen as high risk and has quite high morbidity and mortality rates, especially in the neonatal group. Recent studies suggest a mortality of up to 15% in the single ventricle group and 3% in the biventricular group. Based on a literature search, several risk factors such as patient weight, shunt size/body weight ratio, underlying cardiac malformations, use of mechanical ventilator support, sternotomy approach and use of CPB machines have been shown to increase mortality. Current perioperative risk assessment methods and recommendations are also covered. In addition, our review article specifically discusses perioperative strategies including strategies for surgeons using the MBTTS procedure (surgical approach, determining shunt size and anastomosis techniques) and postoperative strategies (anticoagulation management and strategy to deal with undershunting/overshunting problems). Resumen: El procedimiento de derivación de Blalock-Taussig-Thomas fue introducido por primera vez por Alfred Blalock, Hellen B. Taussig y Vivien Thomas en 1944. El procedimiento se realiza al hacer una conexión entre la arteria subclavia y la arteria pulmonar para aumentar el flujo sanguíneo pulmonar. El procedimiento de derivación de Blalock-Taussig-Thomas se utiliza para paliar a los recién nacidos que nacen con trastornos restrictivos del flujo sanguíneo pulmonar (cardiopatía congénita cianótica). El procedimiento MBTTS todavía se considera un procedimiento de alto riesgo y tiene tasas de morbilidad y mortalidad bastante altas, especialmente en el grupo neonatal. Estudios recientes sugieren que hay una mortalidad de hasta el 15% en el grupo de un solo ventrículo y del 3% en el grupo de anomalías cardíacas biventrículos. Según la búsqueda bibliográfica, se ha demostrado que varios factores de riesgo, como el peso del paciente, la relación tamaño de la derivación/peso corporal, malformaciones cardíacas subyacentes, uso de asistencia respiratoria mecánica, abordaje de esternotomía y uso de máquinas de CEC, aumentan la mortalidad. También se tratan los métodos y recomendaciones actuales de evaluación de riesgos perioperatorios. Además, nuestro artículo de revisión analiza específicamente las estrategias perioperatorias, incluidas las estrategias para los cirujanos en el procedimiento MBTTS (abordaje quirúrgico, determinación del tamaño de la derivación y técnicas de anastomosis) y las estrategias postoperatorias (manejo de anticoagulación y estrategia para lidiar con problemas de sobrecapacidad/sobrecadencia).

Background Resection of lung cancer infiltrating the aortic arch or the subclavian artery can be accomplished in selected patients with the use of cardiopulmonary bypass (CPB). Direct cross-clamping of the aortic arch and the left subclavian artery without CPB for radical resection of the tumor can be an alternative. This study presents one group’s experience with this technique. Methods Between October 2016 and May 2019, 9 patients (5 male, 4 female) underwent radical resection of lung cancer infiltrating the aortic arch (n = 5) or the left subclavian artery (n = 4) by direct cross-clamping technique at Sapienza University of Rome, Italy. Seven left upper lobectomies, 1 left pneumonectomy, and 1 left upper sleeve lobectomy were performed. Reconstruction of the aortic arch was performed by direct suturing or polyethylene terephthalate (Dacron) patch, whereas the subclavian artery was reconstructed with a Dacron conduit. Three patients received neoadjuvant chemotherapy. Results Patients’ mean age was 64.7 ± 13.3 years (range, 36 to 78 years). Aortic arch resection was partial in all cases (adventitial in 1 and full thickness in 4); left subclavian artery resection was adventitial in 2 patients and circumferential in 2. All the resections were complete. Prosthetic reconstruction was performed in 4 cases. Mean operative time was 130 ± 25.6 minutes; mean vascular clamping time was 28.2 ± 3.2 minutes. No mortality occurred. The major complication rate was 11.1 %. At a mean follow-up of 17 ± 9 months (range, 5 to 29 months), the recurrence rate was 33.3%. Median survival was 20 months. Conclusions Direct cross-clamping as an alternative to CPB for resection of lung cancer infiltrating the aortic arch or the subclavian artery is a feasible, safe, and reliable procedure in selected patients.

OBJECTIVES Our goal was to evaluate the morphology of the aortic arch, focusing on the left subclavian artery (LSA), and to anticipate implications for single-branched endovascular aortic arch repair. METHODS We performed a morphological analysis of computed tomography angiography scans of 322 patients between January 2002 and December 2018. Arch type and distance between arch vessels on the convexity were evaluated. We defined 3 morphological types: U-type distance between the left common carotid artery (LCCA) and LSA offspring >10 mm; V-type distance between the LCCA and LSA offspring RESULTS Most patients presented a type III arch [50% (n = 161)]. The median distance from the brachiocephalic trunk offspring to the LCCA offspring measured 2.5 mm (2.0–3.0 mm) and that between the LCCA offspring and the LSA offspring was 6.5 mm (4.0–11.0 mm). We observed no significant difference based on the morphological type (V versus U versus W) in the brachiocephalic trunk–LCCA distance, but there were significant differences in the LCCA–LSA distance between types V and U (P CONCLUSIONS Our categorization of the U, V and W types of the LSA can help us anticipate shapes and distances and thereby function as an initial evaluation tool for predicting single branched endovascular aortic arch repair involving the LSA.

INTRODUCTION Inadvertent implantation from the subclavian/axillary arteries is uncommon and has been rarely reported. Complications are frequent, mainly driven by thromboembolic events. Lead extraction, depending on the dwell time may be challenging and associated with thromboembolic events Case Report: We report the case of an 87-year-old man who had involuntarily pacemaker lead implanted into the left ventricle through the left subclavian artery. An extraction procedure was performed with surgical dissection to the artery and simple traction of the probe without complication. CONCLUSION Percutaneous lead extraction using surgical dissection is a therapeutic option for less than one year old left ventricle inadvertent lead implantation.

Purpose: The purpose of this study was to evaluate the association between the distance from the primary intimal tear (PIT) to the left subclavian artery (LSA) (PIT–LSA distance) and the risk of aortic enlargement after thoracic endovascular aortic repair (TEVAR). Methods: This is a retrospective cohort study. A total of 228 patients were reviewed from the database of the Registry Of type B aortic dissection with the Utility of STent graft (ROBUST) study performed from January 1, 2011, to December 31, 2016. Of them, 196 patients were eligible for analysis. The PIT–LSA distance was defined as the length from the distal edge of the LSA orifice to the proximal edge of the PIT along the centerline of the true lumen. According to the border between zone 3 and zone 4 of the Ishimaru classification, patients were divided into group A (n = 117, PIT–LSA distance ≤ 2 cm) and group B (n = 79, PIT–LSA distance > 2 cm). Thoracic aortic enlargement (TAE) was defined as a thoracic aortic volume increase of ≥20%. Multivariate Cox regression was used to estimate the association between the PIT–LSA distance and risk of TAE after TEVAR. Results: The mean age was 52.3 ± 11.6 years, and 88.8% of patients were male. There were no significant differences between groups in demographic and baseline characteristics. The PIT–LSA distance was 1.1 cm (range, −1.6 to 2.0 cm) in group A, and 2.9 cm (range, 2.1–12.6 cm) in group B. TAE occurred in 27 patients in group A, and 6 in group B. The mean follow-up was 12.4 months (range, 0.10–83.1 months) in group A, and 12.63 months (range, 0.10–82.77 months) in group B. The cumulative 12- and 24-month rates of freedom from TAE were 79.0% and 71.3% in group A, versus 92.5% and 92.5% in group B, respectively. Multivariate Cox regression analysis revealed that the PIT–LSA distance was an independent predictor of TAE after TEVAR (adjusted hazard ratio, 0.66; 95% confidence interval, 0.48–0.90; p = 0.009). Conclusion: Patients with a more proximal PIT location have a higher incidence of thoracic aortic enlargement after TEVAR. The location of the PIT in relation to the LSA can be used to identify patients who need closed surveillance after TEVAR or early preemptive intervention.

A 75-year-old man, who underwent inadvertent misplacement of pacemaker leads into the left coronary artery and left ventricle through the subclavian artery, was referred to our hospital. We safely performed percutaneous lead extraction in collaboration with surgeons and with the patient under general anesthesia. (Level of Difficulty: Advanced.), Central Illustration

BACKGROUND Iatrogenic aortic dissection (IAD) is a rare but fatal complication of interventional treatment for the proximal supra-aortic large vessels. Several cases of IAD after endovascular treatment of subclavian artery have been reported. Nevertheless, the pathogenesis of IAD is still unclear. Here we report a patient with IAD following a balloon expandable stent implanted into the left subclavian artery (LSA). CASE SUMMARY An 84-year-old man with a history of hypertension was admitted to the Neurology Department of our hospital complaining of dizziness and gait disturbance for more than 1 mo. Computed tomography angiography of the head and neck showed severe stenosis at the proximal LSA and the origin of the left vertebral artery. Magnetic resonance diffusion-weighted imaging of the brain revealed subacute infarctions in cerebellum, occipital lobe and medulla oblongata. He suffered a Stanford type B aortic dissection after the proximal LSA angioplasty with a balloon expandable stent. Thoracic endovascular aortic repair was performed immediately with the chimney technique and he was discharged 20 d later. After exploring the pathogenesis with multimodal imaging analysis, an easily neglected focal intramural hematoma (IMH) in the aorta near the junction of the LSA was found to be the main cause of the IAD. The risk of IAD should be sufficiently evaluated according to the characteristics of aortic arch lesions before the proximal LSA angioplasty. CONCLUSION Focal aortic IMH is a potential risk factor for IAD during a seemingly simple stenting of the proximal LSA.

Background Degenerative aortic arch aneurysms are known to develop through a pathological process of arterial atherosclerosis, which could be accompanied by peripheral artery diseases and resultant development of intrapelvic collateral arteries to the ischemic lower limbs. The aim of this study was to investigate the relationship between peripheral collateral circulation and postoperative paraplegia after total arch repair with a frozen elephant trunk in patients with degenerative aortic arch aneurysms and peripheral artery diseases. Methods Between October 2014 and March 2020, 27 patients (20 men; 69.8 ± 7.7 years old) underwent total arch repair with a frozen elephant trunk. Two of the 27 patients developed paraplegia postoperatively. The patients were divided into two groups, spinal cord ischemia (SCI) group (2 patients) and no-SCI group (25 patients). The aortic shagginess score, arterial calcification (subclavian artery; hypogastric artery) score, and the number of hypogastric artery branches, assessed using preoperative contrast-enhanced computed tomography images, were compared between the two groups. Results The ankle brachial artery pressure index (i.e., lower side value each patient) was lower in the SCI group than that in the no-SCI group (0.64, 0.71, and 1.09±0.07, respectively). There was no difference between the two groups in the arterial calcification scores or the aortic shagginess score. The number of hypogastric artery branches was greater in the SCI group than in the no-SCI group (66, 66, and 30.7±7.5, respectively). Conclusions Enhanced collateral circulation to the ischemic lower limbs in patients with combination of degenerative aortic arch aneurysms and peripheral artery diseases may be involved in paraplegia the upper thoracic spinal cord injury after total arch repair with a frozen elephant trunk.

Purpose: Acute thromboembolic disease of the innominate artery (IA) poses a unique set of therapeutic challenges, owing to its contribution to both the cerebral and upper extremity circulation, and risks of distal embolization via the carotid and subclavian arteries, respectively. Herein, we present a 74-year-old female who presents with acute IA thrombus treated successfully with right axillary and common carotid exposure and aspiration catheter-directed mechanical thrombectomy (CDT). Furthermore, an emerging use of CDT and its application in acute thromboembolism are outlined. Case report: A 74-year-old female with history of right lung transplant for pulmonary fibrosis with severe pulmonary hypertension, and stage IIIA left lung adenocarcinoma status post left lower lobectomy undergoing adjuvant chemotherapy presented with acute IA thrombus and right-sided stroke. She was treated successfully with right axillary and common carotid exposure and aspiration CDT. Computed tomography angiography performed 1 month postoperatively confirmed patent IA with no evidence of residual or recurrent thrombus. Conclusion: There are currently no standard guidelines on the management of acute IA thromboembolism, with mostly individual cases reported in the literature describing this rare entity. Nevertheless, this unique clinical entity mandates expeditious diagnostic and therapeutic approaches in order to avoid permanent neurologic deficits from distal embolization. Our case demonstrates that aspiration CDT may be an effective treatment modality for patients with acute IA thrombus.

OBJECTIVES Vascular rings are rare anomalies of congenital heart disease that cause respiratory and gastrointestinal symptoms. This study assessed the long-term outcomes of patients with vascular ring division. METHODS A multi-institution retrospective review of 371 patients with vascular rings undergoing surgical division at 3 paediatric cardiac institutions between November 2007 and October 2019 was performed. RESULTS The complete vascular rings consisted of a double aortic arch (24.5%), right aortic arch with left ligamentum arteriosum (36.7%) and left aortic arch, with right ligamentum arteriosum (0.5%). The incomplete vascular rings consisted of a pulmonary artery sling (22.9%), left aortic arch with aberrant right subclavian artery (15.1%) and innominate artery compression syndrome (0.3%). Respiratory symptoms included stridor (71.4%), wheezing (49.1%), coughing (31.5%), gastrointestinal symptoms included choking (12.4%), dysphagia (3.2%) and emesis (1.9%). Only one patient died after discharge, yielding a late mortality rate of 0.3% (1/360). The 10-year overall survival rate was 96.8%. Postoperative complications were reported in 51 patients, 15 of whom required reoperation. The 10-year freedom from reoperation rate was 95.9%. Follow-up was completed in 95.4% (354/371) of patients, with a mean follow-up time of 4.3 ± 2.9 years (range from 1 to 13 years). Twenty patients (5.6%) experienced residual symptoms during long-term follow-up. CONCLUSIONS The outcomes of vascular ring division are excellent. A Kommerell diverticulum >1.5 times the aberrant left subclavian artery origin is an operative indication for primary resection. Tracheomalacia is a risk factor for reoperation and residual symptoms, and preoperative fibrobronchoscopy is important for evaluation.

Background. Central venous catheter represents an important tool in the management of critically ill patient. In this report, we described a COVID-19-positive case who had COVID-related complications and iatrogenic left subclavian artery pseudoaneurysm after central venous catheter insertion. Case Presentation. A 58-year-old male patient presented with a high-grade fever, myalgia, and shortness of breath due to COVID-19 infection. He required mechanical ventilation support and hemodialysis. He also developed uneventful deep vein thrombosis and myocardial infarction. As a complication of central line insertion, the patient developed pseudoaneurysm that originated from the subclavian artery with significant bleeding and large hematoma. Balloon-assisted percutaneous thrombin injection was done under ultrasound guidance. The patient was extubated 2 days later with no evidence of flow in the pseudoaneurysm. However, he lost movement in the left arm secondary to the compression of the brachial plexus from the pseudoaneurysm/hematoma, and therefore, 1.5 litres of the hematoma was evacuated in the operating room through a lateral left chest wall incision along the anterior axillary line to relieve the compression over the brachial plexus. The patient declined surgical reconstruction of the brachial plexus, and the flaccid paralysis of the arm did not recover during the follow-up. Conclusion. This is a case of unusual complications of COVID infection and iatrogenic left subclavian artery pseudoaneurysm postcentral vein cannulation. Balloon-assisted percutaneous thrombin injection for treatment of left subclavian artery pseudoaneurysm is feasible; however, delayed diagnosis could be associated with long-term or permanent disability.

Objectives This study investigated whether there was a relationship between steno-occlusion of the vertebral artery (VA) segments and the dominant VA side. Materials and methods Angiography results of 215 patients (146 men; 69 women) were retrospectively analyzed in this study. The patients were divided into three groups: dominant, non-dominant and co-dominant. These groups were compared according to the presence of steno-occlusion in the vertebral artery segments. The results were evaluatedusing X2, Mann-Whitney U and Kruskal-Wallis tests. For correlation analysis, Spearman's Rho test was used. Results The findings showed that 55 of 215 patients (25.6%) had a right dominant VA, and 103 (47.9%) had left dominant VA. There was no significant relationship between dominance and age or gender (p > 0.05). More vertebral artery stenosis (VAS) was found on the dominant side. However, a significant relationship only in the right dominant V1 segment (p = 0.044) was noticed. Hypoplastic VA was detected in 13 patients (6%). Most of the VAs (98.4%, n = 423) arose from the subclavian artery. Conclusions In conclusion, we found more vertebral artery stenosis on the dominant side than the co-dominant side, especially on the origin of the vertebral arteries. However, it was only significant on the right dominant V1 segment, regardless of age and gender of the patients (p > 0.05).

Introduction The aetiology of subclavian artery stenosis can be very different, but typically the most common form is due to atherosclerotic disease. Interventional treatment is generally indicated for upper limb ischemia, vertebrobasilar symptoms and subclavian steal syndrome, coronary steal syndrome. Endovascular stenting is preferred over surgery because of its high success rate, less invasive nature, and minimal complication rate. In this study the characteristics of patients treated endovascularly due to subclavian artery stenosis in our centre and their procedural details will be examined. Methods: We retrospectively analyzed patients with subclavian artery stenosis treated by endovascular techniques in our centre between January 2019 and January 2021. Result Twelve (80%) of 15 patients with stenotic subclavian arteries were successfully treated with endovascular techniques. In 3 patients, the procedure was terminated with failure.The mean age of the patients was 64.66 years old and 3(20%) of the patients were female. All of the patients were receiving antihypertensive treatment with the diagnosis of hypertension, and 4 (26.66%) patients had Diabetes mellitus, 13 (86.66%) patients had hyperlipidemia, 13 (86.66%) patients had coronary artery disease. In 2 patients, the lesion was diagnosed in the right subclavian artery. In 7 patients, the procedure was performed with the telescopic method from a transfemoral approach. In 5 patients, the transradial approach was used. In 3 patients, the procedure was performed directly over the transbrachial approach. Balloon expandable stent implantation was performed in 10 (66.66%) patients at the end of the procedure, and self-expandable stent implantation was performed in 1 patient. Conclusion In conclusion, signs and symptoms can be managed effectively with endovascular techniques in patients with significant subclavian artery disease. In this study, we shared our real-life data on subclavian artery endovascular treatment.

Background: Cervical rib, though it is seen incidentally in the radiographic examination of chest and cervical spine, a particular subset of it can present with thoracic outlet syndrome. This article mainly focuses on the symptom causation of articulating cervical rib, as compared to non-articulating cervical rib which is often asymptomatic. There are many articles describing a cervical rib, but those highlighting this particular relation between the types of cervical rib and symptom causation are not present in present database. The review of serial radiographs upon correlating clinically, lead us to conclude that articulating variant of cervical rib is majorly symptomatic and caused grave arterial complications. The article consists brief discussions on the types of cervical ribs, thoracic outlet syndrome and role of imaging in diagnosing a cervical rib. Main Body: We have illustrated five such cases from our tertiary care hospital and highlighted the relationship between the magnitude of symptoms and variations of cervical rib. In compliance with PRISMA guidelines, we screened 33 articles dealing with cervical rib and 13 with thoracic outlet syndrome. Overall, 46 articles were filtered on studying the abstract. Further, 15 more had to be excluded as they were case reports and case series, and finally 31 articles were included in our study. We studied and discussed these articles and research papers in relation to variant anatomy of cervical rib, its types and symptom causation. In our study, also routine sequential chest radiographs were reviewed during the period of January 2020 to January 2021 and those with cervical rib and/or elongated C7 transverse process were included. Conclusion: Thus, to conclude we can state that articulating cervical ribs pose a greater threat and cause arterial occlusion. Key words: Cervical rib, thoracic outlet syndrome, subclavian artery.

Background Congenital aortic arch anomalies are commonly encountered during neurointerventional procedures. While some anomalies are identified at an early age, many are incidentally discovered later in adulthood during endovascular evaluations or interventions. Proper understanding of the normal arch anatomy and its variants is pivotal to safely navigate normal aortic arch branches and to negotiate the catheter through anomalies during neurointerventional procedures. This is particularly relevant in the increasingly “transradial first” culture of neurointerventional surgery. Moreover, some of these anomalies have a peculiar predilection for complications including aneurysm formation, dissection, and rupture during the procedure. Therefore, an understanding of these anomalies, their underlying embryological basis and associations, and pattern of circulation will help endovascular neurosurgeons and interventional radiologists navigate with confidence and consider relevant pathologic associations that may inform risk of cerebrovascular disease. Methods Here, we present a brief review of the basic embryology of the common anomalies of the aortic arch along with their neurological significances and discuss, through illustrative cases, the association of aortic arch anomalies with cerebral vascular pathology. Conclusions Understanding the aortic arch anomalies and its embryological basis is essential to safely navigate the cerebral vascular system during neurointerventional surgeries.

Background: The current study aims to determine the prevalence of variations of the aortic arch using computed tomography angiography (CTA), as well as morphometries and gender correlations. Materials and methods: A retrospective, transverse, observational and descriptive study of 220 CTA was performed. The branching pattern, most cranial vertebral level of the aortic arch, area of the proximal, middle and distal segments of the arch, area of each branch, and the path of atypical arteries were recorded. Results were analysed and stratified by gender. Results: The typical aortic arch branching pattern was present in 77.7% without statistical significance between genders. The most common variant was a two-branch pattern with a common trunk and a left subclavian (13.6%), followed by a typical branching pattern with an added left vertebral artery (7.3%). T3 was the most frequent cranial level (32.3%), followed by T2–T3 (26.8%), and T3–T4 (23.2%). The mean areas of the aortic arch were 685.5 ± 183.9, 476.1 ± 124.1, and 445.0 ± 145.1 mm2 for the proximal, middle and distal segments, with statistical difference between men and women in the middle and distal segments. Three paths of atypical arteries were identified: bifurcated vertebral artery (0.5%), aberrant right subclavian artery (0.5%), and left subclavian ostium obstruction (0.5%). Conclusions: Mexican population has one of the highest prevalence of variations in the aortic arch branching pattern. The high probability of finding these should be taken into consideration when assessing patients. A standardised classification method would contemplate future un-reported findings, without causing confusion by the different numbers assigned by each author.

In early embryogenesis, aortic anomalies occur as a consequence of disorders in the development of the primitive aortic arches system. Aberrant right subclavian artery, also known as arteria lusoria, is one of the important congenital anomalies of the aortic arch, in which the right subclavian artery arises from the arch of aorta instead of the brachiocephalic trunk. During routine dissection of a female cadaver, we observed retro-oesophageal aberrant right subclavian artery arising as the fourth branch from the aortic arch. In this case, the brachiocephalic trunk was absent. Early detection of aortic arch anomalies through diagnostic interventions is helpful to avoid complications during surgical procedures.

Objectives To describe clinical and imaging characteristics of an isolated subclavian artery (ISA) in pediatric patients. Background ISA is a rare congenital aortic arch anomaly defined as a loss of connection between the subclavian artery and aorta. The clinical manifestations and complications of ISA in children are unclear. Methods This retrospective study included clinical and imaging data of ISA patients younger than 18 years whose data were recorded in the electronic radiology database during January 2006–August 2019. Results Of 102 enrolled patients, 59 had been diagnosed in the first year of life. The majority of the patients also had congenital heart diseases, of which tetralogy of Fallot was the most common. The vertebral artery and collateral branch of the descending aorta served as blood flow supplies in 94 and 8 patients with ISA, respectively, as confirmed using computed tomography or magnetic resonance imaging. However, the blood supply did not influence the development of ISA. Eleven patients exhibited mild or moderate stenosis of the ISA, although only two exhibited coldness or a blood pressure gradient in the upper extremities. These two symptomatic patients also presented with patent ductus arteriosus, and this association was significant (P = 0.008). Conclusion ISA management is often determined based on symptoms and associated congenital heart diseases. The ISA is prone to stenosis in patients with ipsilateral patent ductus arteriosus. We recommend early surgical ligation or percutaneous closure of the ductus arteriosus in patients with ISA.

Penetrating injuries to the subclavian artery carry a high mortality rate, especially when the patient presents in shock. Rapid and effective haemorrhage control is challenging due to the anatomical location at the thoracic outlet. Historically, vessel ligation has been used to control bleeding, but this is often performed late, when metabolic exhaustion is established, and is associated with upper-limb ischaemia and limb loss. Rapid proximal control through the chest with temporary intravascular shunting is the damage control technique of choice to temporise blood loss and restore perfusion until the patient is physiologically optimised for a delayed definitive vascular repair. We describe a case of vascular damage control in a patient after gunshot wound.

Subclavian artery aneurysms (SAAs) are rare, and their repair can be technically complex. We have reported the redo repair of a large, expanding, right SAA after primary repair consisting of total aortic arch replacement with bilateral subclavian artery ligation and bypass. The redo repair used claviculectomy to facilitate exposure, ligation of the right deep cervical and internal thoracic arteries from within the aneurysm sac, and revision of the previous axillary artery bypass that had thrombosed owing to the mass effect of the expanding SAA. Claviculectomy can facilitate repair of large SAAs that are poorly suited to more routine exposure approaches, with acceptable risk and functional outcomes.

Patients with hostile chests are often precluded from the use of left ventricular assist device therapies for advanced heart failure. We describe a technique for left ventricular assist device implantation using a left thoracotomy approach with outflow graft anastomosis to the left subclavian artery and placement of a distal band to the left subclavian artery. Distal banding of the left subclavian artery prevents over-circulation to the left upper extremity. This technique provides an alternative approach for left ventricular assist device implantation in patients who otherwise would be deemed inoperable because of hostile chest.

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.

We present a case of subclavian artery perforation with mediastinal hematoma following elective percutaneous coronary intervention. A conservative approach was preferred over invasive correction. Although no outcome data exist specifically for subclavian artery injury, registry data in patients with iatrogenic aortic dissection suggest that long-term outcomes are good without vascular repair. (Level of Difficulty: Advanced.), Central Illustration