Endovascular repair of a right-sided descending thoracic aortic aneurysm with a right-sided aortic arch and aberrant left subclavian artery

Aneurysms involving a right-sided aortic arch and a right-sided descending thoracic aorta with an aberrant origin of the left subclavian artery are rare. We describe the successful surgical repair of this vascular anomaly by the combined use of a left carotid to subclavian artery bypass followed by endovascular stent-graft placement to exclude the aortic aneurysm. We also review the literature associated with this particular anatomic presentation.     

Surgical treatment of an aneurysm of the aberrant right subclavian artery involving an aortic arch aneurysm and coronary artery disease.

A 55-year-old man presented with clinical signs of an aortic arch aneurysm. Angiography, MRI and CT demonstrated an aortic arch aneurysm and an aneurysm of the aberrant right subclavian artery. Coronary angiography revealed 95% stenosis in the right coronary artery. Right common carotid artery-right subclavian artery bypass, arch graft replacement and coronary artery bypass grafting were performed successfully. The use of internal shunt tube, hypothermic circulatory arrest and selective cerebral perfusion were useful methods in prevention of cerebral ischemia during surgical reconstruction of the aortic arch. To our knowledge, this is the first report in the literature of a successfully managed case with an aneurysm of an aberrant right subclavian artery involving an aortic arch aneurysm and coronary artery disease.     

Carotid artery stenting in a patient with internal carotid artery stenosis and ipsilateral persistent primitive hypoglossal artery presenting with transient ischemia of the vertebrobasilar system: case report

A 62-year-old man experienced transient episodes of vertigo associated with left upper extremity weakness. Cerebral angiography showed 75% right internal carotid artery (ICA) stenosis and divergence of a persistent primitive hypoglossal artery (PPHA) distal to the stenosis. The area of stenosis was at a high position and he had a past medical history of congestive heart failure, which contraindicated carotid endarterectomy (CEA). Therefore, carotid artery stenting (CAS) was performed with single distal balloon protection. The stenotic area was restored and he was discharged without suffering recurrent attacks. CAS may be an effective alternative treatment to CEA to prevent further ischemic attacks in the posterior circulation in patients with PPHA. CAS using simple embolic protection devices is possible if the distance between the distal end of the ICA stenosis and the origin of the PPHA is sufficiently long.     

RIGHT AORTIC ARCH WITH ABERRANT LEFT SUBCLAVIAN ARTERY: ANEURYSMAL DILATATION CAUSING SYMPTOMATIC COMPRESSION OF THE RIGHT MAIN BRONCHUS IN AN ADULT

A 60 year old woman presented with a cough, nocturnal stridor and dysphagia. Bronchoscopy showed tight compression of the right main bronchus. Digital subtraction angiography (DSA) and a computed tomographic (CT) scan showed the presence of a right-sided aortic arch with aberrant left subclavian artery. The distal right arch and proximal right-sided descending thoracic aorta were aneurysmal and were responsible for this compression. Surgical relief was accomplished by dividing the aberrant left subclavian artery and replacing the aneurysm with a vascular graft.     

Surgical repair for aortic dissection accompanying a right-sided aortic arch

Aortic anomaly in which a right-sided aortic arch associated with Kommerell's diverticulum and aberrant left subclavian artery is rare. The present report describes a patient with type-B aortic dissection accompanying aortic anomalies consisting of right-sided aortic arch and the left common carotid and left subclavian artery arising from Kommerell's diverticulum. As dissecting aortic aneurysm diameter increased rapidly, Single-stage surgical repair of extensive thoracic aorta was performed through median sternotomy and right posterolateral fifth intercostal thoracotomy, yielding favorable results. Our surgical procedures are discussed.     

Coarctation of aorta with right aortic arch and anomalous left subclavian artery]

The occurrence of coarctation in patients with right aortic arch is extremely rare. We have encountered a 21-year-old man with anomalous left subclavian artery. He was diagnosed when he was 13. On angiography he exhibited a right aortic arch. The left common carotid artery, right common carotid artery and the right subclavian artery diverged from the proximal side of the coarctation. The left subclavian artery diverged from the distal side. The right brachial arterial pressures measured 158-72 mmHg, while the left brachial arterial pressures measured 98-80 mmHg. Clinical studies revealed no vascular ring and no other anomalies were found in this patient. An attempt at treatment was made with extra anatomical bypass grafting from the ascending aorta to the descending aorta. No pressure difference due to coarctation remained after operation.     

Coronary artery bypass grafting in a patient with right aortic arch; report of a case

A 60-year-old man was admitted to another hospital because of chest oppression on effort. Chest X-ray showed radiographic evidence of a right aortic arch and double vessel coronary artery disease with 50% stenosis in the left main trunk was diagnosed by coronary angiography. He was transferred to our institute for surgical treatment of angina pectoris. Preoperatively, multi-detector row computed tomography (CT) was performed and it revealed a right aortic arch and an aberrant left subclavian artery with narrow left internal thoracic artery. A right internal thoracic artery was well demonstrated. Therefore, conventional coronary artery bypass grafting using a right internal thoracic artery and a saphenous vein graft was performed and his postoperative course was uneventful.     

Retroesophageal left brachiocephalic vein with an ectatic aberrant left subclavian artery: A rare double vascular loop

We hereby present a rare variant course of left brachiocephalic vein coexisting with an aberrant right subclavian artery in a patient with a ventricular septal defect with pulmonary atresia. This case highlights the importance of CT angiography in diagnosing associated aortic arch and systemic venous anomalies in complex congenital heart diseases.     

A successful surgical case of chronic DeBakey IIIb dissecting aortic aneurysm associated with right-sided aortic arch]

A case of chronic DeBakey IIIb dissecting aneurysm associated with right-sided aortic arch and aberrant left subclavian artery is reported. A 51-year-old man was admitted to our institute for surgical treatment of chronic dissecting aortic aneurysm which occurred 3 years ago. A right posterolateral thoracotomy was made through the 4th intercostal space. Closure of entry was performed under temporary hypothermic circulatory arrest and then, this was followed by plication of false lumen under hypothermic CPB. Post-operative clinical course was uneventful and an intra-venous digital subtraction angiography demonstrated that false lumen in the thorax was completely closed. The patient was discharged from the hospital on 21th POD. Dissecting aortic aneurysm associated with right-sided aortic arch is extremely rare. In operative case, pertinent selection of operative methods considering anatomical diversity is required.     

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.     

Neonatal repair of right interrupted aortic arch with cerebro-myocardial perfusion technique

Right interrupted aortic arch and descending aorta is exceedingly rare and most likely cause respiratory presentation, since patent ductus arteriosus (PDA) courses over the right mainstem bronchus. We report a case of successful neonatal biventricular repair of a right interrupted aortic arch (type B), with an aberrant right subclavian artery ventricular septal defect (VSD) in a 2.7?kg term neonate with DiGeorge syndrome. Patient presented in severe respiratory distress and acidosis at one day old. Two-dimensional (2D) echocardiography revealed aortic arch interruption beyond the common carotid arteries with large perimembranous outlet VSD. Aortic annulus diameter was 4.8?mm and there was no left ventricle (LV) outflow tract obstruction. Three-dimensional (3D) CT-scan confirmed these findings and identified a right-sided ductal arch that continued over the right mainstem bronchus into a right-sided descending aorta and aberrant right subclavian artery. Brachiocephalic perfusion and ductal perfusion was employed for cooling during cardiopulmonary bypass. Under deep hypothermia (27 °C rectal temperature), selective cerebro-myocardial perfusion was used for successful aortic arch repair without sacrificing the aberrant right subclavian artery. A direct tension-free anastomosis was attained. Her postoperative course was uneventful and her respiratory symptoms disappeared postoperatively. Early surgical correction is mandatory for these patients with unique anatomy and presentation.     

Coronary artery bypass grafting for Takayasu arteritis with severe coronary, carotid, subclavian, and renal artery involvement and subsequent pregnancy

Takayasu arteritis is a rare idiopathic large-vessel vasculitis that involves the aorta and its major branches. It affects young women in their child-bearing period. We present a case of a 32-year-old lady with a history of remittent fever. Magnetic resonance angiography and arch aortogram showed aortic involvement with critical stenosis of both carotid and subclavian arteries. She also had critical ostial left main and right coronary artery stenosis as well as severe renal arteries involvement. The patient underwent coronary artery bypass grafting. She did well and after 12 months she got pregnant. She had an uneventful pregnancy and delivery without flaring of symptoms.     

Usefulness of computed tomography angiography for the detection of high-risk aortas for carotid artery stenting

This study evaluated the usefulness of computed tomography (CT) angiography for the detection of high-risk aortas for carotid artery stenting (CAS). We investigated changes in the treatment method and modifications of endovascular techniques according to the information from CT angiography. CT angiography using three-dimensional and multi-planar reconstruction was performed in 43 consecutive patients with carotid artery stenoses intended to undergo CAS. Two neurosurgeons evaluated the images and estimated the risk and difficulties of CAS. CT angiography clearly depicted the entire aorta, the supra-aortic vessels, and the ilio-femoral arteries in all patients. Abnormal vascular findings were found in 17 patients. High-risk aortic lesions for CAS were detected in 5 patients, including thick aortic plaques with thrombi in 2. We changed the treatment strategy from CAS to carotid endarterectomy (CEA) in these 2 patients. CT angiograms proved very useful in evaluating the approach routes of CAS in 12 patients. One patient had dissecting aneurysm of the thoracic aorta and another had aberrant right vertebral artery. In these two, the treatment strategy was changed from CAS to CEA. The treatment method was changed in 4 patients in total. CT angiography is useful for the detection of high-risk aortas for CAS and for the evaluation of safe approaches to the carotid artery.     

Combined carotid endarterectomy with transluminal angioplasty and primary stenting of the supra-aortic vessels

BACKGROUND: Carotid endarterectomy (CEA) is the standard of care for patients with high-grade carotid artery stenosis who are acceptable surgical candidates. Focal occlusive lesions of the origin of aortic arch vessels can be effectively and safely treated with balloon angioplasty and primary stenting. The purpose of this study was to retrospectively review results of carotid endarterectomy for high-grade carotid bifurcation stenosis combined with intraoperative retrograde transluminal angioplasty and primary stenting of a hemodynamically significant stenosis at the origin of a proximal ipsilateral aortic arch vessel. METHODS: Between October 1994 and August 1998, 592 patients underwent CEA. Six patients were found to have hemodynamically significant tandem lesions affecting one of the aortic arch vessels and the ipsilateral ICA for an overall incidence of 1%. Age ranged from 63 to 78 years (mean 74.7). Four of 6 (67%) patients had asymptomatic lesions, and 2 of 6 (33%) had symptoms of cerebral ischemia. Five patients had tandem lesions affecting the proximal left common carotid artery and the left ICA. One patient had a tandem lesion affecting the innominate artery and the right ICA. Carotid duplex imaging and arch and cerebral arteriography was performed in all six patients. Arteriography confirmed high-grade stenoses in both the ICA and ipsilateral proximal aortic arch vessel. The range of stenoses in the ICA was 70 to 95% (mean 80.8%) measured arteriographically. The range of stenoses at the origin of the aortic arch vessels was 75-90% (mean 79.2%). All six patients underwent combined retrograde transluminal balloon angioplasty and primary stenting of the ipsilateral CCA or innominate artery with temporary occlusion of the ICA for cerebral protection. The endovascular procedure was then followed with standard surgical endarterectomy using an inline shunt. RESULTS: All six procedures were successfully completed. There were no periprocedural strokes or other morbidities. Follow-up ranged from 6 to 43 months (mean 23.6) and showed no evidence of recurrent stenosis by carotid duplex imaging. No TIAs or strokes related to the surgically corrected lesions were noted during the follow-up period. One patient suffered a right hemispheric stroke secondary to a high-grade right carotid stenosis which occurred two months after her procedure surgically correcting tandem lesions on the opposite side. CONCLUSIONS: Carotid endarterectomy with balloon angioplasty and primary stenting of an ipsilateral hemodynamically significant aortic arch trunk vessel stenosis can be safely and successfully accomplished and avoids the need for an intra/extrathoracic bypass procedure.     

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.     

Simultaneous surgery for left lung cancer and the aneurysm of an aberrant left subclavian artery in a patient with right aortic arch

A 69-year-old man with right aortic arch was diagnosed as having left lung cancer (cT2aN1M0, cStage IIA) and an aneurysm of an aberrant left subclavian artery. The aneurysm measured 36 mm in diameter and was located 1 cm peripheral from the origin in the area known as "Kommerell's diverticulu Left carotid artery-to-left subclavian artery bypass graft was placed through a left supraclavicular incision prior to thoracotomy. This bypass graft effectively prevented neurological and ischemic complications of the brain and left upper extremity while we safely and successfully performed resection of the aneurysm along with radical surgery for left lung cancer through left thoracotomy. There have been only 10 case reports, including the present case, that have described surgical resection of lung cancer in a patient with right aortic arch. In addition, this is the 1st report to describe simultaneous surgery for both left lung cancer and an aneurysm of an aberrant left subclavian artery in a patient with right aortic arch.     

One stage combined repair of intracardiac defects with vascular ring employing sternotomy approach

We present an unusual case of atrial septal defect and ventricular septal defect with a vascular ring formed by a right-sided aortic arch with an aberrant left subclavian artery that gave rise to a patent ductus arteriosus connecting to the main pulmonary artery. We performed a single-stage repair of the intracardiac defects and division of vascular ring with a sternotomy instead of the traditionally practiced dual approach. This included division and reimplantation of the aberrant left subclavian artery to the left carotid artery after transection. This approach has not been described so far.     

Separate arch origin of the left external carotid artery with common trunk giving rise to the left internal carotid artery and left subclavian artery

We present a case of a 3-year-old boy with tetralogy of Fallot having the direct origin of the left external carotid artery from the aorta with a common trunk giving rise to the left internal carotid artery and left subclavian artery, in a right-sided aortic arch. We also highlight the potential implications in management.     

Emergent ascending and arch replacement for acute type A aortic dissection with anomalies of the aortic arch

We experienced 4 cases that had to be performed emergent ascending and arch replacement for acute type A aortic dissection with anomalies of the aortic arch (aberrant right subclavian artery in 2 case and isolated left vertebral artery in 2 cases). As for the aberrant right subclavian artery, preoperative diagnosis is possible by CT scan. We must not overlook aberrant right subclavian artery in order to prevent brain complication in emergency arch replacement for acute type A aortic dissection. For the isolated left vertebral artery, incision of the aortic arch is recommended for its reconstruction.