Subclavian artery revascularization for myocardial ischemia

A 54-year-old woman had a secondary occlusion of the subclavian artery proximal to the internal mammary artery, which had been used for an anterior interventricular artery bypass, and was the source of recurrent angina. A left carotid-to-subclavian bypass was performed with success. This rare complication underscores the need for careful selection and surveillance of candidates for myocardial revascularization using the internal mammary artery.     

A rare case of a blunt thoracic aortic injury in a patient with an aberrant right subclavian artery: A case report and literature review

IntroductionBlunt thoracic aortic injuries (BTAIs) are an uncommon traumatic injury that if not treated promptly, can result in death. We present the case of a BTAI with aberrant aortic anatomy.Presentation of caseA 60-year-old female was involved in a motor vehicle crash where she suffered significant polytrauma including a BTAI. She was also found to have an aberrant right subclavian artery originating from the aortic arch. Thoracic Endovascular Aortic Repair (TEVAR) with a right common carotid artery to right subclavian artery bypass was accomplished. She required three more vascular surgical interventions, two for persistent type II endoleak and the third for left upper extremity acute limb ischemia. She had a 2-month hospital course for her devastating injuries and was eventually discharged home. A follow-up CT angiogram showed a stable thoracic aortic arch stent.DiscussionBTAIs are uncommon in the trauma population. In our patient who had an aberrant right subclavian artery, further procedures were required in the form of a right common carotid artery to right subclavian artery bypass and embolizations to resolve endoleaks.ConclusionBlunt thoracic aortic injuries are life threatening and require urgent intervention. TEVAR is associated with better outcomes. An aberrant right subclavian artery originating from the aortic arch, distal to the left subclavian artery is an anatomic variant that adds significant complexity to TEVAR. TEVAR is still an option for repair of blunt thoracic aortic injuries despite anatomic variations as open repair still carries an increased risk of morbidity and mortality.     

Cervical origin of right subclavian artery associated with tetralogy of Fallot

We present a case of an infant with tetralogy of Fallot with pulmonary atresia with an incidentally detected cervical origin of right subclavian artery. We highlight the importance of identifying this rare variation and the potential complications that may ensue.     

Bilateral subclavian steal associated with severe coarctation of the thoracic aorta and an aberrant right subclavian artery

A 10-year-old girl having bilateral subclavian steal associated with severe coarctation of the thoracic aorta and an aberrant right subclavian artery was found, on admission, to have no difference between upper and lower extremity blood pressure, but echocardiography revealed severe thoracic aorta coarctation and systolic blood pressure in the carotid arteries exceeding 200 mmHg estimated by Doppler ultrasonography. Magnetic resonance imaging and angiography demonstrated bilateral subclavian steal without esophageal compression. We reconstructed the aortic arch using the left subclavian artery and a reversed Blalock-Park procedure, then repaired the coarctation with a 14 mm woven double velor vascular graft. The girl was symptom-free following uncomplicated recovery from surgery. Doppler ultrasonography 2 weeks after surgery showed the pressure gradient across the aortic arch had decreased from 180 mmHg to 60 mmHg. This residual gradient at the anastomosis between the ascending aorta and left subclavian artery may improve as native vessels grow.     

An aberrant left subclavian artery aneurysm with right aortic arch: Report of a case

The case of a 41-year-old man who developed an aneurysm in his aberrant left subclavian artery is described. The patient had a right aortic arch. After a successful aortosubclavian artery bypass, symptoms due to brain ischemia disappeared. This is a very rare disease that is sometimes associated with an aortic anomaly, therefore the optimal therapeutic procedure need to be carefully selected, including the operative indications and approach.     

锁骨下动脉、腋动脉、肱动脉血管广泛血栓形成1例

1病例资料患者,男,44岁。右上肢肿胀刺痛1个月加重伴手指麻木发凉5d,于2007年12月13日18：00急诊入院。患者自述于1个月前出现右侧手指指尖麻木,近5d右上肢麻木、胀痛明显加重,自测不到脉搏,右上肢皮肤苍白,皮温低,呈持续性,伴胸闷、气短、大汗。心电图：窦性心率（正常心电图）;右上肢血管超声：右侧锁骨下动脉下段、腋动脉、肱动脉血管闭塞（完全性血栓形成）;血压16／10kPa;血糖正常。以“左上肢动脉栓塞”收住入院。患者既往有小儿麻痹症病史,右下肢发育短小、无力,长期扶双拐行走;常伴有右上肢苍白,皮肤发凉,肱动脉、桡动脉、尺动脉脉搏测不到。     

Surgical strategies for anomalous origin of the left coronary artery from the right pulmonary artery with an intramural aortic course: A report of 10 cases

Objective

Few data are available regarding the surgical strategies for an anomalous origin of the left coronary artery (LCA) from the right pulmonary artery (RPA) with an intramural aortic course. We reviewed our experience in a case series of 10 children.

Clinical significance of retrograde flow in the vertebral artery

Although retrograde vertebral artery flow was described over 100 years ago, its relationship to symptoms remains unclear. We documented 43 patients who were found by duplex scanning to have reverse flow in the vertebral artery. Of this group, seven patients (16%) were found to have symptoms described as typical for the subclavian steal syndrome. Nearly one-third were asymptomatic. Of the remaining patients, 13 (30%) presented with nonhemispheric symptoms while nine (21%) had hemispheric symptoms. Nine patients had to and fro flow in the vertebral artery. This variant was not found in subclavian steal patients but correlated with nonhemispheric symptoms. During follow-up (mean: 19 months) none of the asymptomatic patients became symptomatic, and there were no strokes or stroke-related deaths. Surgical procedures which restored antegrade vertebral artery flow did not necessarily improve symptoms of posterior circulation ischemia. In some patients improvement in posterior circulation symptoms was noted following carotid endarterectomy. It is concluded that retrograde flow in the vertebral artery is, per se, a benign entity. Accurate selection of surgical candidates remains imprecise. It will require not only identification of vertebrobasilar disease but as yet undefined tests to assure symptoms are due to these stenoses.     

分期介入治疗主动脉缩窄合并右锁骨下动脉瘤1例

主动脉缩窄(CoA)是指主动脉局限狭窄,管腔缩小,造成血流量减少.主动脉缩窄可以单独出现,也可以合并二叶式主动脉瓣、室间隔缺损、动脉导管未闭、大动脉转位等病变.主动脉狭窄合并右锁骨下动脉瘤非常罕见,本文报导一例主动脉缩窄合并右锁骨下动脉及降主动脉瘤,一期应用定制的Armada 35球囊扩张导管及覆膜支架治疗主动脉狭窄,...     

Repair of tetralogy of Fallot associated with anomalous origin of right pulmonary artery and accessory left anterior descending coronary artery

We present an unusual combination of lesions in an 8-month-old child diagnosed with tetralogy of Fallot, anomalous origin of right pulmonary artery, and anomalous coronary artery crossing the pulmonary annulus. The association of anomalous origin of branch pulmonary artery from aorta and tetralogy of Fallot (TOF) is extremely rare with an incidence of 0.4%. The incidence of anomalous coronary artery in TOF is 10.3%. However, a combination of all three lesions poses challenges to surgical repair and has not been previously reported.     

Hand muscle atrophy and digital ischemia as an unusual presentation of an occluded aberrant right subclavian artery: Endovascular or open approach?

INTRODUCTIONAn aberrant right subclavian artery (ARSA) or lusorian artery is one of the most common variations of the aortic arch. Although usually without symptoms, some ARSA's occasionally become symptomatic.PRESENTATION OF CASEA 51-year old woman presented with a painful right middle finger. Clinical examination showed thenar muscle hypotrophy and blue discoloration of the distal phalanx suggestive of embolization. Magnetic resonance angiography revealed a non-aneurysmal proximally occluded ARSA. A venous common carotid artery to subclavian artery bypass was combined with ARSA ligation proximal to the right vertebral artery.DISCUSSIONOcclusive symptomatic ARSA disease without aneurysmal dilatation is uncommon. Treatment may include bypass grafting by open surgery or angioplasty with stenting.CONCLUSIONTreatment for occlusive non-aneurysmal ARSA must be tailored to the individual. Whether an endovascular or surgical approach is preferred depends on localization of the lesion in relation to the esophagus and on the general condition of the patient.     

介入治疗左锁骨下动脉闭塞术中胸膜外血肿1例

患者男,64岁,体检超声发现右颈内动脉闭塞、左颈内动脉狭窄收入院;3年前接受冠状动脉支架植入术,术后规律口服抗凝及抗血小板药;无高血压、糖尿病等病史。入院后查体及实验室检查均未见明显异常。颈动脉CT血管造影:右颈内动脉闭塞,左颈内动脉狭窄(70%~90%),前交通动脉开放。经股动脉插管全脑血管造影:右颈内动脉闭塞,左颈内动脉狭窄约90%,前交通动脉开放,左锁骨下动脉闭塞,左椎动脉盗血。     

Combined percutaneous transluminal angioplasty and extraanatomic bypass for symptomatic unilateral iliac artery occlusion with contralateral iliac artery stenosis

We have reviewed our experience with percutaneous transluminal angioplasty of contralateral iliac stenosis and extraanatomic bypass of the occluded iliac artery. Twenty-two men and nine women with a mean age of 65 years (range 46 to 84) presented with symptomatic iliac occlusive disease. Twenty-four (77%) had disabling claudication, four (13%) rest pain, and three (10%) ischemic tissue loss. Six (19%) had undergone previous vascular reconstructive procedures. All had an occluded iliac artery on the symptomatic side and greater than 50% stenosis of the contralateral iliac artery. Percutaneous transluminal angioplasty of the iliac stenosis was done prior to extraanatomic bypass, using polytetrafluoroethylene. There were six late deaths after discharge. The only significant complication was a femoral artery thrombosis which was corrected when the bypass graft was performed. Cumulative primary graft patency was 89% at one year and 81% at three years. The crossover graft occluded in six patients, five within 48 months of surgery, and one after nine years. One of these occluded grafts was salvaged by thrombectomy, for a secondary patency rate of 85% at three years. Two patients required aortobifemoral bypass, one an iliobifemoral bypass and one an ilioprofunda bypass. One patient operated upon for rest pain came to below-knee amputation. Mean resting ankle/brachial systolic pressure index increased significantly on the side of the iliac occlusion from 0.35 ±0.21 to 0.70 ± 0.20 (p < 0.05, paired t test) after the combined procedure. There was no significant difference in the mean resting ankle/brachial systolic pressure index on the contralateral side (0.60 ± 0.22 to 0.65 ± 0.27, ns). Combined iliac percutaneous transluminal angioplasty and femorofemoral bypass is a safe alternative to aortobifemoral bypass for selected patients with aortoiliac arterial occlusive disease. Presented at the Royal Australasian College of Surgeons, General Scientific Meeting, May 1989, Melbourne, Australia.     

Two-stage surgical and endovascular treatment of an aneurysmal aberrant right subclavian (Lusoria) artery

We report a case of a 75-year-old male patient with an asymptomatic aneurysm of an aberrant right subclavian artery (ARSA). Timely elective therapy of this entity is indicated due to the high risk of rupture. Because of the patient's reduced physical state, we performed an interdisciplinary endovascular aortic stent-grafting for the exclusion of the ARSA aneurysm. However, the proximal landing zone for the thoracic stent had to be chosen proximal to the origin of the left subclavian artery. Thus, 2 days before the endovascular procedure, a left-sided carotido-subclavian bypass was accomplished. The peri- and postoperative course was uneventful. The technical results in our patient were excellent, no leakage was visible so far.     

Atherosclerotic occlusive disease of the superior mesenteric artery: Late results of reconstructive surgery

Between 1975 and 1988, 103 patients underwent reconstruction of the superior mesenteric artery for atherosclerotic occlusive disease. Patients undergoing revascularization with associated mesenteric infarction were excluded. There were 89 men and 14 women whose mean age was 57.2 years. Six patients were operated on emergently for impending mesenteric infarction; six patients underwent revascularization after intestinal resection for ischemic lesions; 20 patients had typical abdominal angina; 39 patients had nonspecific abdominal symptoms, and 32 patients underwent revascularization of their superior mesenteric artery for asymptomatic lesions. Revascularization of the celiac axis and inferior mesenteric artery was associated in 36 and four cases, respectively. Four patients (4%) died postoperatively. Four early occlusions (4%) were observed. During the follow-up period (mean=69 months), 18 patients died; five patients had recurrent intestinal ischemic symptoms, four of whom died. All surviving patients underwent follow-up duplex scanning, examination, and arterial or venous digitalized angiograms in selected cases. Nine patients (9%) had anatomical abnormalities: two stenoses and seven occlusions. Failure of revascularization of the superior mesenteric artery was observed in patients with severe initial intestinal ischemia. Late complications were not statistically significantly related to the different techniques of revascularization used. Presented at the Annual Meeting of the Société de Chirurgie Vasculaire de Langue Française, June 23–24, 1989, Strasbourg, France.     

Arterial-ureteral fistula: Case study with review of published reports

Arterial-ureteral fistula, a rare cause of gross hematuria, may be associated with life-threatening hemorrhage if not rapidly diagnosed and treated. Recently, a patient at the Hunter H. McGuire Veterans Administration Medical Center developed an arterial-ureteral fistula at the site of the confluence of the external iliac artery and a superior mesenteric artery bypass graft. Review of the world's literature revealed 31 additional reported cases of arterial-ureteral fistulas [1—31]. This current case is only the second one reported in which the diagnosis was made with arteriography. Several common features of arterial-ureteral fistulas were present in this case: a history of ureteral obstruction and urinary tract infections, upper urinary tract disease, and previous vascular surgery. The condition is usually associated with either prior upper urinary tract instrumentation or vascular surgery, and an antecedent period of intermittent hematuria, followed by life-threatening hematuria, is common. A high index of suspicion and early surgical intervention are required for successful management. The major surgical challenges are to establish unobstructed urinary drainage and restore vascular continuity. Exclusion of prosthetic material from potentially infected areas is mandatory.     

Giant aneurysm of the azygos pericallosal artery: case report and review of the literature

BACKGROUND: Pericallosal aneurysms are encountered less than 6.7%, and giant aneurysms among them even less. Giant azygos pericallosal artery aneurysm at the callosomarginal bifurcation is extremely rare, and our case presented herein is the second one. The case is discussed with thorough review of the literature. METHODS: A 65-year-old woman presented with an extremely rare giant aneurysm on the azygos pericallosal artery manifesting as subarachnoid hemorrhage in World Federation of Neurosurgical Societies Grade 3. Computed tomography (CT), magnetic resonance angiography (MRA), and four vessel angiography revealed a giant azygos pericallosal artery aneurysm associated with a second aneurysm at the left M1. RESULTS: After recovery to Grade 2, she underwent surgery via the right frontal interhemispheric approach for the azygos artery aneurysm on the 17th day after bleeding. The true dimensions of the aneurysm were greater than indicated by angiography because of partial thrombosis. Trilobulate aneurysm was carefully dissected from the surrounding structures. Postoperative cerebral angiography showed no filling of the clipped aneurysm and preservation of circulation. CONCLUSIONS: The treatment of distal anterior cerebral artery aneurysms is often difficult, because of their broad-based irregular configurations and adherence to surrounding tissue, tendency to bleed irrespective of size and the coexistence of other cerebral aneurysms. However, excellent outcomes can be obtained based on thorough preoperative radiologic evaluation, including magnetic resonance imaging (MRI), and correct selection of surgical approach.     

A reoperation for anomalous origin of right pulmonary artery: report of a case

A reoperation to upsize the conduit placed at infancy for the repair of an anomalous origin of the right pulmonary artery (AORPA) was successfully performed in an 8-year-old girl because of an elevated right ventricular pressure and a reduced right pulmonary blood flow. Although primary direct anastomosis is essential for AORPA, one should not hesitate to perform a conduit repair (interposition with a tube prosthesis) on an infant with AORPA whose right pulmonary artery is distant from the main pulmonary artery, because a reoperation can safely be performed even in cases where the conduit is relatively narrow as the patient grows. This is the first report of a reoperation, including a complete replacement of the conduit, after an initial conduit repair for AORPA. Received: July 21, 2000 / Accepted: January 9, 2001     

Tetralogy of Fallot,right aortic arch with isolated left subclavian artery: Rare synchronous triple occurrence!!!

We present a rare synchronous occurrence of tetralogy of Fallot, right aortic arch, and isolated left subclavian artery, highlighting potential clinical and therapeutic implications.