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Aberrant right subclavian artery, or arteria lusoria, is a common congenital anomaly of the aortic arch and may be associated with dysphagia. Surgical treatment, particularly in children, remains controversial. Current surgical interventions include supraclavicular and thoracotomy approaches, as well as hybrid endovascular techniques. However, these techniques have significant limitations and varying degrees of success. This case report describes a 2-site operation whereby the arteria lusoria is transected via a left thoracotomy and subsequently re-implanted into the right common carotid artery via a median sternotomy. This approach has provided complete symptom resolution for dysphagia lusoria in 2 children., (Copyright © 2020 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Hepatic artery stenosis is a complication of orthotopic liver transplant occurring in 3.1%-7.4% of patients that can result in graft failure and need for re-transplantation. Endovascular therapy with angioplasty and stenting has been used with a high degree of technical success and good clinical outcomes, but tortuous hepatic arteries present a unique challenge for intervention. Suitable stents for this application should be maneuverable and conformable while also exerting adequate radial force to maintain a patent lumen., Case Summary: Herein we report our experience with a neurovascular Wingspan stent system in a challenging case of recurrent hepatic artery stenosis and discuss the literature of stenting in tortuous transplant hepatic arteries., Conclusion: Wingspan neurovascular stent is self-expanding, has good conformability, and adequate radial resistance and as such it could be added to the armamentarium of interventionalists in the setting of a tortuous and stenotic transplant hepatic artery., Competing Interests: Conflict-of-interest statement: The authors have no conflicts to declare, (©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.)

Intrathoracic left subclavian to common carotid artery translocation is advocated for patients undergoing vascular ring division in the setting of an enlarged Kommerell's diverticulum and aberrant left subclavian artery. This approach poses technical challenges in larger patients and patients with unfavorable body habitus. Supraclavicular left subclavian artery to common carotid translocation greatly simplifies this procedure in select patients.

Aortic arch anomalies are not clinically important unless they cause compression symptoms due to aneurysmatic dilatation. Aortic anomalies need to be treated when they cause complex thoracic aortic diseases, and the treatment approach has evolved over time from open surgical methods, which have high mortality and morbidity rates, to hybrid methods. A case of a 68-year-old male patient with complex aortic arch anomaly treated with hybrid arch repair is reported in this study. Aortic branches were common carotid trunk and aberrant right subclavian artery with a saccular aneurysm.

A right aortic arch with an aberrant left subclavian artery and a Kommerell's diverticulum represents a rare anatomic variant carrying the risk of dissection or rupture. Resection of the diverticulum and re-implantation of the left subclavian artery during childhood have been recommended. Because of the risk of cerebral blood flow reduction during the aberrant subclavian artery re-implantation to the common carotid artery, monitoring and prompt measures to curb blood flow reduction are required. A 5-month-old boy was scheduled to undergo resection surgery. During the translocation of the aberrant subclavian artery to the common carotid artery, his regional oxygen saturation (rSO 2 ) in the left cerebrum began to decrease. We increased the end-tidal CO 2 (EtCO 2 ), mean arterial pressure, and a fraction of inspired oxygen, successfully restoring the rSO 2 to the initial level. No postoperative neurological complications were observed. Our experience with this patient suggests that rSO 2 monitoring is a useful, and intervention protocol including hypercapnia, elevated mean arterial pressure, and hyperoxia to counter the decreased cerebral blood flow is effective in infant patients undergoing right-sided aortic arch surgery.

Background: An aberrant right subclavian artery which arises from the proximal descending aorta may result in aortic dissection. The dissection may occur at either the site of the primary intimal tear or from an aortic branch. These conditions may lead to blood flow limitation and possible aneurysmal degeneration in the future., Case Presentation: We described the clinical presentation and management of a 54-year old patient diagnosed with a rare case of an aberrant right subclavian artery with Stanford Type B aortic dissection. A hybrid surgical approach was successfully performed and the patient had an uneventful recovery., Conclusion: Even though aortic dissection is often an incidental finding, this case highlighted that in rare situations, it can be associated with an aberrant right subclavian artery. It is important to disseminate this association as it has profound diagnostic and therapeutic implications in safeguarding the clinical outcomes of patients with such condition.

Background: To describe staging surgery for the treatment of a patient with aortic arch aneurysm combined with aberrant bilateral subclavian artery, persistent left superior vena cava (PLSVC), and airway compression., Case Report: A 42-year-old female was hospitalized for aortic arch aneurysm involving aberrant bilateral subclavian artery, PLSVC, and airway compression. The patient's aneurysm was successfully treated by stage I surgery, including total aortic arch replacement and stented elephant trunk procedure and stage II surgery, including tracheal stenting and tracheotomy. Aortic CTA examination showed an unobstructed lumen and a good stent position without tracheal stent migration. Regular postoperative follow-up showed no complications, such as dyspnea, cough, and sputum, or other discomfort symptoms., Conclusions: Total aortic arch replacement, elephant trunk surgery, and second-stage tracheal stent surgery are effective and safe for the treatment of aortic arch aneurysm combined with aberrant bilateral subclavian artery, PLSVC, and airway compression.

The subclavian steal syndrome (SSS), also called subclavian steal steno-occlusive disease, is defined as reversal of the vertebral artery flow secondary to significant hemodynamically ipsilateral occlusion or stenosis of the proximal subclavian artery. It is usually seen secondary to atherosclerosis and aberrant right subclavian artery (ARSA), resulting in SSS which is even less common. Aberrant right subclavian artery is a kind of vascular anomaly associated with coarctation of the aorta (CoA). It usually originates from the descending aorta distal to the site of CoA. Here, we present a young man who was a case of ARSA and CoA. He developed SSS after transcatheter aortic stenting secondary to unusual origin of ARSA from the site of CoA. Awareness of this rare anomaly helps to overcome this complication in patients undergoing interventional stenting for CoA and ARSA with anomalous origin.

Aberrant right subclavian artery is the most frequent anomaly of the aortic arch, and in 60% of cases is associated with Kommerell diverticulum. It is usually asymptomatic but may present with dysphagia or asthma due to esophageal and tracheal compression. Indications for surgical repair have not been established; however, when Kommerell diverticulum is complicated by aortic dissection the treatment is surgery. We present the case of a 54-year-old man with thoracic pain due to dissection of an aberrant right subclavian artery associated with Kommerell diverticulum. Elective surgical treatment was performed., (Copyright © 2019 Sociedade Portuguesa de Cardiologia. Publicado por Elsevier España, S.L.U. All rights reserved.)

A right aortic arch vascular ring consists of an anomalous aortic arch course with a ligamentum arteriosum and an aberrant left subclavian artery arising from a Kommerell diverticulum. Division of the ligamentum arteriosum is required for the relief of symptoms in these patients. However, to prevent recurrent symptoms, resection of the Kommerell diverticulum and reimplantation of the subclavian artery to the left carotid artery is advocated. Here we describe our standardized surgical approach to this pathology., (Copyright © 2018. Published by Elsevier Inc.)

Purpose: To evaluate the early and midterm outcomes of endovascular repair of Stanford type B aortic dissection (TBAD) with an aberrant right subclavian artery (ARSA)., Materials and Methods: From November 2012 to July 2018, 15 patients (13 male, 2 female) who had TBAD with ARSA underwent total endovascular repair, including thoracic endovascular aortic repair (TEVAR), left subclavian artery (LSA) chimney technique, LSA fenestration technique, and double chimney technique (LSA chimney and ARSA periscope). The mean age was 55 years. Kommerell diverticulum (KD) occurred in 2 patients, which were covered by means of oversized aortic stents. All patients had preoperative imaging examinations for assessing cerebral blood flow and the dominant vertebral arteries., Results: All procedures were completed successfully. There was no in-hospital mortality. The mean procedural time was 98 ± 40 minutes (range 50-190). The mean preoperative diameters of the maximum descending aorta, false lumen, and true lumen in the descending aorta versus postoperative were 37 ± 10 mm (range 28-67), 18 ± 9 mm (range 9-41), and 19 ± 6 mm (range 10-35) versus 34 ± 9 mm (range 25-64), 5 ± 8 mm (range 0-28), and 28 ± 5 mm (range 19-37), respectively. Right upper extremity weakness was observed in 2 patients, which recovered gradually during follow-up. Immediate type Ia endoleak was detected in 1 patient. The mean follow-up time was 33 ± 20 months. During follow-up, no ARSA steal syndrome, spinal cord ischemia, or strokes were not observed., Conclusions: Endovascular treatment for TBAD with ARSA was feasible and safe with a satisfactory midterm follow-up outcome., (Copyright © 2019 SIR. Published by Elsevier Inc. All rights reserved.)

Objectives: Indications and techniques of repair for symptomatic or aneurysmal aberrant subclavian arteries (ASA) are controversial. This study analyses presentation, treatment and outcome of patients with symptomatic and/or aneurysmal ASA., Methods: Retrospective analysis of consecutive adult patients undergoing symptomatic and/or aneurysmal ASA repair between January 2000 and June 2016., Results: Of 12 patients (4 females) with a median age of 66 years (range 24-75), 10 had right ASA and 2 had left ASA originating from a right aortic arch. Six patients (50%) had Kommerell's diverticulum and 6 patients had aneurysmal dilatation of the ASA itself. Six patients presented with symptoms (dysphagia n = 4, chest pain n = 1, recurrent aspiration n = 1). Nine patients (75%) were treated by open ASA resection/ligation with or without aortic repair. Three patients (25%) underwent hybrid repair using thoracic endovascular aortic repair to exclude the aberrant artery. ASA revascularization was achieved by subclavian-carotid transposition (n = 7), carotid-subclavian bypass (n = 1), aorto-subclavian bypass (n = 3) or reimplantation after aortic graft replacement (n = 1). Thirty-day mortality was 8% (n = 1). The median follow-up duration was 44 months (range 24-151). Symptoms were relieved in 4 and persisted partially in 1, while symptom relief remained unknown in 1 patient who died during follow-up. Imaging after a median of 34 months (range 2-134) after the operation showed patent ASA revascularization in all patients and no endoleaks in the hybrid group., Conclusions: Surgical and hybrid repair allows satisfying results in patients with symptomatic and/or aneurysmal ASA. The optimal procedure has to be defined on an individual patient basis. Further studies, preferably with a multicentre approach, are required to answer more specific questions on the management of these patients and especially to assess long-term results following hybrid repair., (© The Author(s) 2019. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Aberrant right subclavian artery is the most common aortic arch anomaly that frequently occurs in coexistence with other congenital cardiovascular anomalies. A 32-year-old male patient was hospitalized with ventricular septal defect, chronic heart failure NYHA class III, pulmonary arterial hypertension. Contrast-enhanced multislice computed tomography revealed membranous ventricular septal defect, persistent left superior vena cava, bicuspid aortic valve and aberrant right subclavian artery. Aberrant right subclavian artery was clinically silent and discovered accidentally. The patient underwent heart-lung transplantation due to pronounced, irreversible pulmonary hypertension. This article reports a rare coexistence of aberrant right subclavian artery with other congenital anomalies of the heart and great vessels in living men.

Reconstruction of the aortic arch in type B interruption requires extensive mobilization of the descending aorta and the proximal branches of the arch to perform a tension-free anastomosis. The association of a coexistent type II aortopulmonary window and an aberrant subclavian artery reduces the degree of mobility that can be achieved by dissection alone, and it usually entails sacrifice of the aberrant artery to achieve satisfactory mobilization. We report a novel technique to use the aberrant subclavian artery as autologous tissue in the reconstruction of the aortic arch for repair of type B interruption associated with type II aortopulmonary window., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Kommerell's diverticulum is a rare congenital anomaly, consisting in aneurysmal dilatation at the origin of an aberrant subclavian artery. Depending on concomitant anatomical characteristics, different endovascular and open surgical procedures have been proposed. The following report describes the first single-stage hybrid repair of a type I Kommerell's diverticulum associated with an aortic arch aneurysm and anomalous origin of the brachiocephalic vessels by total aortic arch replacement with a composite frozen elephant trunk prosthesis and endovascular treatment of the right subclavian artery. This hybrid procedure may represent an alternative to more challenging open repairs when totally endovascular approach is unfeasible., (© 2019 Wiley Periodicals, Inc.)

Objective: This study sought to summarize the clinical experience of surgical treatment of anomalous origin of pulmonary arteries from the ascending aorta (AOPA) in Fuwai hospital., Methods: Fifty-two patients (28 males, 17.2 ± 27.2 months old and 8.7 ± 10.2 Kg weight) who have AOPA undertook surgical treatment between 1998 and 2017 were reviewed in this study, 47 out of 52 are anomalous origin of the right pulmonary artery (AORPA), among the rest of the patients are anomalous origin of left pulmonary artery (AOLPA). 27 out of 52 associate with simple cardiac abnormalities, 20 out of 52 associate with complex cardiac malformations, the remaining 5 patients without cardiac abnormalities. Among all patients who underwent surgical treatment, the direct end-to-side anastomosis strategy was applied in 26 patients, autologous pericardial-homograft patch and aortic flap were employed in 20 patients, and synthetic graft was used in 6 patients., Results: No patient died during the perioperative period. 50 out of 52 patients were followed-up for 100.1 ± 70.9 months. The rate of pulmonary arterial free restenosis for 2 years, 5 years, and 10 years is 98.0, 96.0 and 92.0%, respectively., Conclusions: The correct diagnosis and appropriate surgical treatment for AOPA could obtain excellent early and medium-term result.

Backround: The right aortic arch and aortic coarctation are rare congenital anomalies with the incidence of 0.1% and 0.03-0.04%. We present a case report of a 51-year-old woman with the right aortic arch with aberrant left subclavian artery and coarctation of the aorta with post-stenotic aneurysm., Case Presentation: Resection of the coarctation and aneurysm with replacement by tubular prosthesis was performed on partial cardiopulmonary bypass via femoral vessels., Conclusion: Partial cardiopulmonary bypass is an applicable method for ensuring the perfusion of the distal part of the body and an aberrant left subclavian artery is not a contraindication of this technique.

Kommerell diverticulum (KD) with aberrant left subclavian artery (ALSA) is a rare congenital variation of vascular structure. We reported a case of 3-year-old boy with KD and ALSA, which was preliminarily diagnosed by transthoracic echocardiography and verified by computed tomography angiography (CTA). The patient was treated successfully with KD resection and anastomosed the left subclavian artery directly to the left carotid artery under cardiopulmonary bypass. Our case illustrates that echocardiography and CTA should be used to comprehensively assess all the internal and external cardiac structures in order to determine the appropriate surgical plan., (© 2019 Wiley Periodicals, Inc.)

Background: This study aimed to evaluate the early and long-term outcomes of graft replacement of Kommerell diverticulum and in situ reconstruction of aberrant subclavian arteries in adults., Methods: Seventeen patients, 6 symptomatic and 11 with right aortic arch, underwent open repair of Kommerell diverticulum from October 1999 to September 2017. Two of these patients underwent open surgical treatment of a ruptured aneurysm. Surgical indications were dilatation of Kommerell aneurysm (n = 9), the presence of a nondissecting aneurysm with Kommerell diverticulum (n = 6), acute type A aortic dissection (n = 1), and complicated acute type B aortic dissection (n = 1). Ten patients underwent total arch replacement and descending aorta replacement through a thoracotomy. Five patients underwent arch replacement and in situ reconstruction through a median sternotomy. All patients except 1 also underwent in situ reconstruction of their aberrant subclavian artery., Results: In-hospital death occurred in 1 patient (5.9%), who underwent total arch replacement for a ruptured aneurysm. Permanent neurologic deficit did not occur in any patient, whereas transient neurologic deficit occurred in 2 patients (11.8%). Five- and 10-year survival rates were 85.2 ± 9.8% and 75.8 ± 12.5%, respectively. There was no symptom recurrence or stenosis of the reconstructed subclavian arteries., Conclusions: Early outcomes of graft replacement of Kommerell diverticulum and in situ aberrant subclavian artery reconstruction were acceptable. As for long-term outcomes, symptomatic improvement and an excellent patency rate among reconstructed aberrant subclavian arteries suggest that in situ surgical repair is an effective treatment option., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: Tortuous vascular anatomy is one of the greatest challenges in mechanical thrombectomy. This study examines the impact of vascular tortuosity on the performance of stent retrievers and evaluates the efficacy of the newer generation stent retrievers with segmented design., Materials and Methods: Models with mild, moderate, and severe tortuosity with an internal carotid artery (ICA) and a middle cerebral artery (MCA) were created. An elastic and cohesive clot was placed in the MCA lying from distal M1 and proximal M2. We assessed the revascularization rates of two commonly used stent retrievers (Trevo XP and Solitaire FR) and two newer stent retrievers with segmented design (Embotrap and Versi) in each vascular model., Results: Both the type of stent retriever and the severity of vessel tortuosity significantly affected the successful recanalization rate. Post-hoc tests showed that the rate of revascularization was significantly less in severe tortuosity than in mild or moderate tortuosity (P<0.001). The Versi resulted in higher success rates than the Solitaire (P<0.01) and the Trevo (P<0.05). The success rates of the Embotrap were higher than the Solitaire and Trevo stent retrievers, although the difference was not statistically significant., Conclusions: Severe tortuosity reduces the performance of mechanical thrombectomy. The segmented design in stent retrievers could improve the efficacy of mechanical thrombectomy in tortuous vessels., Trial Registration: ESCAPE NCT01778335;SWIFT PRIME >NCT01657461; REVASCAT >NCT01692379; All post-results., Competing Interests: Competing interests: NK has been a consultant for Neurovasc. ST holds stock in Neurovasc and has been a consultant for Cerenovus, Medtronic, Neurovasc and Stryker., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: An aberrant right subclavian artery (ARSA) is a relatively prevalent vascular anomaly. What is the most appropriate treatment for thoracic aortic aneurysm combined a non-aneurysmal change ARSA?, Case Presentation: A 52-year-old man was admitted to our institute due to a history of chronic cough, dysphagia and an abnormal chest radiographic finding. Because of his progressive symptoms and large fusiform thoracic aneurysm, we performed the hybrid repair for simultaneous relief of an ARSA causing dysphagia and thoracic aneurysm., Conclusion: In case without aneurysm of ARSA, especially in conjunction with approximate thoracic aneurysm, our approach is suitable because the revascularization using the right carotid to subclavian artery re-routing prior to endograft deployment is justified in order to preserve circulation of posterior brain, spinal cord, internal mammary artery and upper limb and to prevent large retrograde type II endoleaks, as well as simplicity and durability.

Kommerell's diverticulum with a right aortic arch and aberrant left subclavian artery is a rare anomaly, and the optimal operative strategy has not yet been established. In particular, the approach to the diverticulum is controversial, with the greatest concern being whether or not to add a right thoracotomy to the median sternotomy for distal anastomosis. We successfully performed total arch replacement through a median sternotomy only, by referring to preoperative computed tomography. We think that if the aneurysm is in a shallow position from the tracheal bifurcation, total arch replacement is possible with a midline incision only.

We present a case of Kommerell's diverticulum with the aberrant left subclavian artery and a right-sided aortic arch in a 70-year-old male patient who was treated with total arch replacement using the Gelweave Lupiae graft. The Lupiae graft fitted well to total arch replacement for this pathology because the structure was consistent with the anatomical features.

We treated a 70-year-old patient with Kommerell's diverticulum associated with an aberrant left subclavian artery and right aortic arch using single-stage total arch replacement with a commercially available open stent graft through only a median sternotomy. A four-branched prosthetic graft was implanted after insertion of the open stent graft through the anastomotic site under moderate hypothermia and cardiopulmonary bypass with selective cerebral perfusion. The aberrant subclavian artery was occluded by coil embolization from the distal site and anatomically reconstructed from the prosthetic graft. This approach is safe and effective and allows avoidance of a right thoracotomy and second stage intervention.

Endovascular aortic treatment is being performed more often and offers some advantages over open surgery. Nevertheless, open repair of thoracoabdominal aortic aneurysms is still relevant in complex cases, including combined chronic aortic dissection, congenital aortic abnormalities such as aberrant right subclavian artery, and dense pleural adhesions after a previous thoracotomy. We describe our successful use of open repair in a 46-year-old man who had these multiple abnormalities.

Objective: To report our single-center experience of the hybrid procedure for type B aortic dissection (TBAD) with an aberrant right subclavian artery (ARSA) and the early to midterm outcomes in these patients., Methods: From December 2011 to February 2016, 16 patients (12 males; median age, 51 years; range, 40-66 years) underwent thoracic endovascular aortic repair and extraanatomic bypass hybrid procedure for TBAD with an ARSA in our center. Demographics, coexisting medical conditions, imaging features, operation details, and follow-up outcomes of these patients were collected retrospectively and analyzed., Results: Duration from onset to hybrid procedure ranged from 5 to 57 days, with a median duration of 17 days. The median duration of stay in the intensive care unit and duration of in-hospital stay was 126 hours (range, 14-450 hours) and 21 days (range, 11-31 days), respectively. The overall technique success rate was 100%. No perioperative death, major stroke, or spinal cord ischemia was registered. Immediate type Ia endoleak was detected in three patients (18.8%) and immediate type II endoleak was detected in one patient (6.3%). One access-related complication occurred, which was a femoral artery pseudoaneurysm requiring compression bandage. Brachial plexus injury was observed in two patients (12.5%) with weakness of the upper extremity. The median follow-up was 33 months (range, 11-59 months). During follow-up, a retrograde type A aortic dissection was found in one patient (6.3%) 3 months after procedure. The occlusion of left common carotid artery to left subclavian artery bypasses were confirmed by computed tomography angiography in two patients (12.5%). They were left untreated for no symptoms. Reintervention was required in one patient (6.3%) for persistent type II endoleak by using Amplatzer plugs to seal the origin of the ARSA 20 months after the operation. There was no recorded death or stroke during the study period., Conclusions: Our limited experience demonstrates that a hybrid procedure is a viable and relatively safe treatment strategy for patients with TBAD and an ARSA. A larger series of cases with a longer follow-up is needed to substantiate these results., (Copyright © 2017 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The aim of the study was to describe a single-center experience using combined extra-anatomic open arch branch revascularization with aortic arch endovascular exclusion for treatment of aberrant subclavian artery aneurysms., Methods: All patients undergoing management of aberrant subclavian aneurysms were identified from a prospective patient registry. Means of revascularization included carotid-subclavian bypass or subclavian transposition, and origin occlusion was performed by surgical ligation or endovascular embolization at surgeon discretion. Completion of aneurysm exclusion was performed using available distal arch/thoracic aortic endografts (TEVARs) using standard oversizing. Procedures were staged as appropriate based on patient condition., Results: Ten patients, 8 females and 2 males ranging from 32 to 85 years of age, were identified. Presenting symptoms were dysphagia (n = 9) and acute type B aortic dissection (n = 1). All patients required revascularization/exclusion of bilateral subclavian arteries to enable >20 mm proximal aortic fixation distal to the common carotid origins for the arch endograft. TEVAR with planned coverage of both subclavian origins extending into the proximal descending thoracic aorta was performed using transfemoral access (n = 9) or iliac conduit (n = 1) and required a single device (100-157 mm) in all cases except the aortic dissection which required total length coverage of the descending thoracic aorta. Extra-anatomic revascularization and thoracic endografting were staged by 1-2 days in most cases to minimize potential airway edema from bilateral neck exposures. Subclavian revascularization was performed by carotid-subclavian bypass using polytetrafluoroethylene (n = 17) or subclavian transposition (n = 3) with proximal occlusion using embolization with an Amplatzer II plug (n = 11) or ligation (n = 9). No major complications occurred including spinal cord ischemia, stroke, cranial nerve deficit, arm ischemia, access site complications, or wound complications. Length of stay ranged from 6 to 21 days with all patients having resolution of dysphagia on follow-up (mean 41 months). Directed imaging was available for 7 patients demonstrating the absence of endoleak, regression or stability of aneurysm size, and patency of all subclavian revascularizations., Conclusions: We present a hybrid repair technique with low operative morbidity that has shown to be durable in follow-up and to provide symptomatic relief for patients with aberrant subclavian artery aneurysms causing esophageal compression., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives: To characterize the morphology of type B aortic dissection with aberrant right subclavian artery (ARSA) and present early and midterm outcomes of total endovascular treatment for affected patients., Methods: From January 2010 to December 2015, patients with ARSA and type B aortic dissection treated with total endovascular techniques were enrolled. The angle of the aortic arch was measured on pre-operative CTA. Sixty age and gender matched normal aortic arch patients with type B aortic dissection served as controls. Primary outcomes were technical success, 30 day mortality, and late survival. Secondary outcomes included in hospital morbidity, re-intervention rate, and patency of the subclavian artery., Results: A total of 13 patients (8 men, 5 women; mean age 58 years) were included. The mean angle of the aortic arch in patients with ARSA was significantly smaller than in normal aortic arch patients (117.2° ± 10.8° vs. 124.2° ± 9.4°, respectively; p = .024). Simple thoracic endovascular aortic repair (TEVAR) and TEVAR plus a parallel graft technique were performed in six and seven patients, respectively. Primary technique success was achieved in 11 of the 13 (84.6%) patients. A bird beak configuration occurred significantly more frequently in patients with ARSA than in normal aortic arch patients (91.7% vs. 48.3%, respectively; p = .035). The median follow-up time was 36 months. One patient received a secondary procedure because of a new onset entry tear at the distal end of the stent graft. No posterior circulation stroke, permanent spinal cord ischaemia, or ischaemia of the upper arm was observed., Conclusions: Type B aortic dissection with ARSA was associated with a steep aortic arch. Total endovascular treatment for these patients was feasible and safe. Stent grafts with better flexibility and appropriate extension of the proximal landing zone with a parallel graft technique are suggested based on the observed outcomes., (Copyright © 2017 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.)

A type B aortic dissection with an aberrant right subclavian artery is an uncommon entity. Most cases have been treated by open or hybrid surgery. We present a case that was managed by endovascular aortic repair with the periscope technique. A thoracic stent graft was implanted into the aortic arch beyond the origin of the right subclavian artery. Two overlapping periscope grafts were placed to maintain perfusion to the right subclavian artery. The presented technique is a feasible and minimally invasive approach for this rare entity., (Copyright © 2017 Elsevier Inc. All rights reserved.)

We herein report two cases of progressive left ventricular outflow obstruction after primary repair of arch obstruction and ventricular septal defect that was successfully resolved with Yasui conversion. Patients who require surgical reintervention for progressive left ventricular outflow tract (LVOT) obstruction after primary biventricular repair of interruption of the aortic arch or coarctation of the aorta complex are occasionally experienced. The modified Konno procedure and Ross operation are well recognized as useful for these cases. However, in some patients, these procedures are difficult to perform because of anatomic restrictions or previous procedures. Although the indications are limited, the Yasui conversion is a safe, simple, and useful option for LVOT obstruction after primary biventricular repair., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Introduction: We report a case of a 57-year-old man with a successful total endovascular treatment of a symptomatic penetrating arterial ulcer (PAU) of a lusorian artery (LA) together with a standard endovascular abdominal aortic aneurysm (AAA) repair. The LA is an aberrant subclavian artery and a congenital aortic arch anomaly with a reported prevalence of 0.4-2.6%. Typical for the base of the LA is a Kommerell diverticulum making an endovascular approach even more difficult., Methods: The patient was admitted to our hospital due to an unspecific retrosternal and hypopharyngeal pulsation feeling. The contrast computed tomography scan revealed a PAU in the middle of the aberrant right subclavian artery, apart from the size progression of an asymptomatic and followed-up AAA. Beside a standard abdominal endovascular aortic repair (EVAR), a total endovascular PAU exclusion was achieved using an Endurant tapered leg extension. The system was released in a back-table procedure and then remounted reversed on the system which now could be introduced via a transverse arteriotomy of the right axillary artery., Results: The technical result was excellent, no endoleak was observed, and the symptoms disappeared immediately. The patient was discharged symptom free after 5 days., Summary: This is so far the first reported total endovascular therapy of a symptomatic PAU of an LA. There are no tapered leg extensions or main bodies with a necessary working length for a femoral approach and correct sizing at the same time available on the market. The technical success was, therefore, based on the possibility of releasing and remounting parts of the Endurant Stent Graft System in emergency cases in a back-table setting. Although this is off-label use in experienced hands, it is easy to handle and can surely help the endovascular surgeon in some challenging situation where no standard stent-graft system is available., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: 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., Methods: 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., Results: 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 neck >20 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., Conclusions: 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., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Cardiovascular malformations are frequently associated in patients with esophageal atresia (EA). We observed azygos continuation mimicking an aortic arch anomaly in four newborns with type III EA. They presented concomitant rib anomalies indicating a common developmental defect. Foreknowledge is important for planning thoracotomy or interventional cardiac catheterization in this population., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Background: Left aberrant subclavian artery (LASA), is a type of right aortic arch (RAA) branching, which takes-off distally to the right subclavian artery and usually crosses behind the esophagus to the left upper limb. Taking into account the rarity of RAA, LASA is much more rarely seen than the right aberrant subclavian artery (RASA) originating from the left aortic arch. However, RAA may be associated with much more frequent presence of LASA, than left aortic arch with RASA. Anatomical LASA characteristics were not described up to date., Methods: Individual patient records filed in the electronic database from a single high-volume tertiary cardiac center were retrospectively screened for the presence of RAA in the consecutive patients who underwent chest computed tomography from 2008 to 2016., Results: 14 patients with LASA were identified. Only 3 were free of coexisting intra- or extra-cardiac anomalies. The most common defect was tetralogy of Fallot (3 patients). One patient had five congenital defects. Kommerell's diverticulum (KD) was present in 9 patients. In all patients the LASA course was retrotracheal and retroesophageal. In all but one patients esophageal modelling or compression by KD or LASA was present., Conclusions: Knowledge of Kommerell's diverticulum presence and morphology as well as the LASA course during preinterventional work-up of patients with congenital heart defects is critical, since it may have surgical implications during corrective procedures., (Copyright © 2017 Elsevier B.V. All rights reserved.)

We report a case of esophageal cancer with a non-recurrent inferior laryngeal nerve associated with aberrant right subclavian artery treated with neck dissection followed by thoracoscopic esophagectomy. A 60-year-old man experienced esophageal cancer, hoarseness, and left supraclavicular lymph node swelling was noted on endoscopy. Computed tomography revealed an aberrant right subclavian artery between the esophagus and vertebrae. We administered neo-adjuvant chemotherapy and performed thoracoscopic esophagectomy. During the neck dissection, we confirmed a non-recurrent inferior laryngeal nerve along the inferior thyroid artery. After the neck dissection, we performed thoracoscopic esophagectomy. We confirmed an aberrant right subclavian artery arising from the aortic arch, and resected the left recurrent nerve due to cancer invasion. No postoperative complication was observed, and the patient was discharged 17 days after surgery. Thus, we recommend prior neck dissection in cases involving aberrant right subclavian artery during esophagectomy., (Copyright© 2017, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved.)

Background: Kommerell diverticulum is a rare aortic arch anomaly. The indications for operative intervention and surgical strategy are still controversial. The standard surgical procedure at our institution is total aortic arch plus descending aortic replacement using anterolateral thoracotomy with partial sternotomy. The aberrant subclavian artery is reconstructed anatomically or extraanatomically., Methods: From 2002 to 2014, 6 patients (1 woman), aged 55 to 78 years, underwent graft replacement through an anterolateral thoracotomy or anterolateral thoracotomy with a partial sternotomy approach for Kommerell diverticulum. All patients underwent graft replacement of the descending aorta or total aortic arch plus descending aorta in addition to aberrant subclavian artery reconstruction., Results: No hospital deaths or major complications occurred. Recurrent nerve injury developed at discharge in 1 patient. All patients were well during the follow-up period (range, 11 to 116 months)., Conclusions: Kommerell diverticulum and its associated symptoms were surgically treated with acceptable outcomes., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

A 7-week-old, 1.045kg female beagle dog was referred to investigate a supposed vascular ring anomaly. Cone beam computed tomography with contrast enhanced arterial phase accomplished by a rapid manual intravenous injection of iodinated agent during the scanning process revealed a persistent right aortic arch and an aberrant left subclavian artery that compressed dorsally the esophagus in the cranial mediastinum. Third left intercostal thoracotomy was performed to transect the left subclavian artery. This is the first description of a vascular ring anomaly that was diagnosed with a cone beam computed tomography in veterinary medicine., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: The purpose of the study was to determine the role of cardiopulmonary exercise test (CPET) indices in predicting cardiovascular adverse events (CAEs) in patients with Fontan palliation. CAE was defined as death or cardiac surgery., Methods: Retrospective review of adult Fontan patients who had treadmill CPET at Mayo Clinic, 1994-2013. Patients with loss of follow-up defined as ≥2years without clinical follow-up were excluded. The results of serial CPETs were reviewed, and patients with CPETs meeting the following criteria were selected for analysis: maximum effort on serial CPETs, minimum of 3-year interval between CPETs, and absence of CAE between CPETs., Results: A total of 145 patients met inclusion criteria for the study; age at baseline CPET was 24±3years; age at Fontan operation was 11±5years; and 91 (63%) were males. Baseline peak oxygen consumption (VO 2 ) was 22.7±5.4ml/kg/min (63±11% predicted), peak heart rate was 135±31beats per minute, and oxygen saturation at peak exercise was 86±7%. Serial CPETs were performed in 71/145 patients (49%); mean duration between CPETs was 3.8±0.3years. The % predicted peak VO 2 decreased by 1.7±0.9 percentage points/year. CAE (deaths n=22; cardiac surgery n=45) occurred in 54/145 patients (37%) within 8±3years. Decline in % predicted peak VO 2 ≥3 percentage points/year was the only predictor of 5-year risk of CAE (HR 1.86, 95% CI 1.11-3.48, P=0.02)., Conclusions: Serial CPET is prognostic of CAE in the adult Fontan population, and can be used to risk stratify these patients., (Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.)

Background: Aberrant right subclavian artery is an uncommon entity incidence ranging from 0.5 to 2.5%. Management of thoracic aortic injury in the presence of such anomalies can be a challenge. We present here a case of traumatic aortic injury, which was incidentally found to have an asymptomatic aberrant right subclavian artery. The patient was managed by an endovascular repair of thoracic aortic injury with an endograft and a right carotid to subclavian artery bypass as a hybrid procedure., Methods: A 40-year male patient was brought to the emergency in shock with an alleged history of road traffic accident an hour back. After initial resuscitation as per advance trauma life support protocol, imaging revealed thoracic aortic injury with aberrant right subclavian artery with multiple rib and bilateral humerus fracture. After primary stabilization of arm fractures, the patient was shifted to a hybrid operation room. As the aortic injury was within 10 mm of the origin of both subclavian arteries, it was decided to cover the origin of both subclavian arteries and land the endograft distal to the left carotid artery origin. Since there was a right dominant vertebral artery on imaging, right carotid to right subclavian artery bypass was done with expanded polytetrafluoroethylene graft to prevent posterior circulatory stroke along with thoracic endovascular aortic repair to seal the thoracic aortic injury., Results: After endovascular repair of thoracic aortic injury, left subclavian artery perfusion was maintained through left vertebral artery; and hence, revascularization of left subclavian artery was deferred. After management of all fractures, the patient was discharged 3 weeks after the date of admission without any complications. At 6 months follow-up, patient was stable and images showed patent bypass graft and sealed aortic injury., Conclusions: In a trauma setting with multiple injuries, hybrid procedure with a thoracic endograft is associated with low mortality and morbidity; hence, it is the treatment of choice for thoracic aortic injury over open surgical repair. A hybrid suite can be life and time saving in situations which mandate simultaneous endovascular repair along with surgical revascularization when indicated, especially in cases with aberrant aortic arch anatomy., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Kommerell diverticulum is uncommon, and it carries risks of dissection or rupture. Hybrid aortic arch repair is being used increasingly for this pathology. We report the hybrid arch repair of Kommerell diverticulum in a 72-year-old woman known for muscular dystrophy and right aortic arch with aberrant left subclavian artery. Head-vessel debranching was performed through median sternotomy using a handmade, bifurcated, Dacron graft. Stent-grafting was performed from the ascending aorta to the proximal descending aorta. To our knowledge, this report is the first description of debranching using a custom-made graft for hybrid repair of Kommerell diverticulum., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objectives: Complete vascular rings are rare and cause tracheoesophageal compression. Following surgical division, some patients have persisting tracheomalacia. We aim to assess the long-term outcomes of complete vascular ring division., Methods: All patients (n = 132) who underwent surgical division of a complete vascular ring between 1978 and 2014 were identified from the hospital database and retrospectively reviewed., Results: Complete vascular rings consisted of a double aortic arch (n = 80), right aortic arch with an aberrant subclavian artery and left ligamentum arteriosum (n = 50), right aortic arch with mirror image branching and left ligamentum arteriosum (n = 1), and a left aortic arch with right descending aorta and right ligamentum arteriosum (n = 1). Kommerell's diverticulum was identified in 10 patients. Preoperative tracheomalacia was identified via bronchoscopy in 25 patients. Concomitant tracheal reconstruction was not performed in any patient. Kommerell's diverticulum was resected in 1 patient. The hospital mortality rate was 1.5% (2/132). There were no late deaths. The overall survival rate was 98.3 ± 1.2% (95% CI: 93.4, 99.6) at 20 years. Postoperatively, persistent tracheal compression was reported in 3 patients, and tracheomalacia in 16 patients. The rate of freedom from reoperation was 88.6 ± 4.0% (95% CI: 77.9, 94.3) at 20 years. No patient required tracheal surgery during the follow-up period. Follow-up was 92% (121/132) complete, with a median follow-up of 11.4 years (range 44 days to 36 years). At the last follow-up, 7 patients had mild tracheomalacia., Conclusions: Outcomes of division of a complete vascular ring are excellent. Tracheomalacia often improves following division of the vascular ring. Respiratory symptoms following complete vascular ring division are uncommon., (© The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)