Left recurrent laryngeal nerve palsy following aortic arch stenting: A case report

BACKGROUND Aortic arch stenting is continuously emerging as a safe and effective option to alleviate aortic arch stenosis and arterial hypertension.CASE SUMMARY We present a 15-year-old girl with aortic arch hypoplasia who had undergone implantation of an uncovered 22 mm Cheatham-Platinum stent due to severe(native) aortic arch stenosis. On follow-up seven months later, she presented a significant re-stenosis of the aortic arch. A second stent(LD Max 26 mm) was implanted and both stents were dilated up to 16 mm. After an initially unremarkable post-interventional course, the patient presented with hoarseness five days after the intervention. MRI and CT scans ruled out an intracranial pathology, as well as thoracic hematoma, arterial dissection, and aneurysm around the intervention site. Laryngoscopy confirmed left vocal fold paresis attributable to an injury to the left recurrent laryngeal nerve(LRLN) during aortic arch stenting, as the nerve loops around the aortic arch in close proximity to the area of the implanted stents. Following a non-invasive therapeutic approach entailing regular speech therapy, the patient recovered and demonstrated no residual clinical symptoms of LRLN palsy after six months.CONCLUSION Left recurrent laryngeal nerve palsy is a rare complication of aortic arch stenting not previously reported.     

Subclavian stenting in a hostile aortic arch facilitated by a low-profile brachial artery through-and-through access

Subclavian stenting can be extremely difficult in a hostile type II aortic arch (with acute angulation of the subclavian artery origin) or type III aortic arch. This case illustrates use of a low-profile system to gain through-and-through (flossing) access through the brachial artery to facilitate stenting via the femoral approach. This approach can be useful in patients with small brachial arteries where the risk of complication may be high if a standard vascular sheath was placed for stenting via the brachial approach. This technique also avoids the use of a surgical cut down.     

Hybrid therapy for interrupted aortic arch with aortopulmonary window in a low birth weight infant

Interrupted aortic arch (IAA) is rarely associated with aortopulmonary window. Single‐stage total correction is the preferred therapeutic option. When total correction is unfeasible, staged repair could be the therapeutic choice. Here, we presented a low birth weight infant who underwent bilateral pulmonary arteries banding and stenting ductus arteriosus by hybrid procedure. Hybrid procedure avoids long‐term central line insertion and guarantees ductal flow. It also avoids the side effects from prostaglandin infusion. © 2011 Wiley Periodicals, Inc.     

鼻咽癌放疗后主动脉弓上动脉狭窄血管内支架置入的疗效分析

目的探讨血管内支架置入治疗鼻咽癌放疗后主动脉弓上动脉狭窄病变的疗效。方法回顾性分析8例鼻咽癌放疗后症状性主动脉弓上动脉中重度狭窄行血管内支架置入术患者的临床资料,观察治疗后脑缺血症状的改善情况。通过颈部血管彩色多普勒血流显像随访。结果 8例患者均经全脑DSA证实,主动脉弓上颅外段共有中重度狭窄动脉24处,其中包括颈内动脉11处,颈总动脉2处,椎动脉10处,锁骨下动脉1处。(1)经血管扩张成形及支架置入后,血管腔残余狭窄率平均20%。术后复查头部CT未见出血。术后定期复查颈部血管彩色多普勒血流显像,显示血管形态良好,血流通畅,未见支架内血栓形成及再狭窄,无过度灌注等不良事件发生。(2)随访1年所有患者无再发脑缺血症状,颈部血管彩色多普勒血流显像未发现明显再狭窄。结论血管内支架置入是鼻咽癌放疗后主动脉弓上动脉狭窄可以选择的治疗方法。     

Repair of right carotid artery pseudoaneurysm in a patient with hostile aortic arch through left ventricular approach

We describe the case of an 81-year-old male who presented with a rapidly expanding neck hematoma from a common carotid artery pseudoaneurysm. Percutaneous repair using the right femoral artery approach was unsuccessful due to a hostile aortic arch. Using a small left thoracotomy and antegrade left ventricular access to the ascending aorta, a covered stent was successfully delivered at the site of the pseudoaneurysm. Our case provides proof-of-principle that complex carotid interventions can be performed expediently through a left ventricular approach in patients with hostile aortic arch.     

Percutaneous occlusion of posttraumatic aortic arch pseudoaneurysm by catheter-based delivery of thrombin.

PURPOSE: To report a patient in whom a posttraumatic pseudoaneurysm of the aortic arch was successfully treated by catheter-based delivery of thrombin with balloon occlusion of the entry tear. CASE REPORT: A 63-year-old male presented with pseudoaneurysm of the aortic arch after blunt chest trauma which was detected incidentally during routine chest X-ray. Using a percutaneous transfemoral approach, a 5 French Swan-Ganz catheter could be positioned into the aneurysm sac. Under balloon occlusion of the entry tear in order to prevent systemic embolization, 1,000 units of bovine thrombin were injected into the aneurysm sac resulting in complete occlusion of the aneurysm. Contrast-enhanced computed tomographic control showed complete thrombosis of the aneurysm over a follow-up period of 12 months. CONCLUSION: Percutaneous catheter-based delivery of thrombin is a feasible and effective minimally-invasive treatment alternative for patients with thoracic aortic pseudoaneurysms.     

Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels

OBJECTIVES: To compare stenting of aortic arch vessel obstruction with surgical therapy and to establish recommendations for treatment. BACKGROUND: Though surgery has been considered to be the procedure of choice for subclavian and brachiocephalic obstruction, little work has been done to compare it with stenting. METHODS: Eighteen patients with symptomatic aortic arch vessel stenosis or occlusion were treated with stenting, followed by periodic clinical follow-up and noninvasive arterial Doppler studies. Data were compared with the results as shown in a systematic review of a published series of surgery and stenting procedures which included comparison of technical success, complications, mortality and patency. RESULTS: Primary success in our series was 100% with improvement in mean stenosis from 84+/-11% to 1+/-5% and mean arm systolic blood pressure difference from 44+/-16 mm Hg to 3+/-3 mm Hg. There were no major complications (death, stroke, TIA, stent thrombosis or myocardial infarction). At follow-up (mean 17 months), all patients were asymptomatic with 100% primary patency. Literature review demonstrates equivalent patency and complications in the other published series of stenting. In contrast, there was a similar patency but overall incidence of stroke of 3+/-4% and death of 2+/-2% in the published surgical series. CONCLUSIONS: Subclavian or brachiocephalic artery obstruction can be effectively treated by primary stenting or surgery. Comparison of stenting and the surgical experience demonstrates equal effectiveness but fewer complications and suggests that stenting should be considered as first line therapy for subclavian or brachiocephalic obstruction.     

Echocardiographic Feature of Aortic Arch Pseudoaneurysm Resulting from Spontaneous Aortic Rupture

Atraumatic, spontaneous aortic rupture is a rare but potentially lethal event. In this report, we present two unusual cases of aortic arch pseudoaneurysm resulting from spontaneous aortic rupture. The appearance of aortic arch pseudoaneurysm and the rupture area was clearly visualized with echocardiography, as well as by three-dimensional reconstruction of multislice computed tomography (3DCT) images.     

Intimal sarcoma of aortic arch treated with proton therapy following surgery

Management of a rare case of intimal sarcoma of the aortic arch is reported, which was diagnosed unexpectedly after total arch replacement for pseudoaneurysm. The prognosis for this condition is poor, with death usually within a few months from diagnosis. The newly developed proton-beam radiation therapy was applied to treat a local recurrence of the sarcoma following surgery. Positron-emission tomography/computed tomography revealed complete remission of the lesion.     

Repair of tuberculous aneurysm of distal aortic arch

A 65 year old female patient presented with one episode of massive haemoptysis requiring transfusion and subsequently cough with streaky haemoptysis. Computerized tomographic scan and angiogram revealed aneurysm of the distal aortic arch. She underwent elective repair of the pseudoaneurysm through median sternotomy and the bronchial communication was closed through left thoracotomy. Tubercle bacilli were identified in the contents and excised wall of aortic tissue.     

Transradial carotid stenting in a patient with bovine arch anatomy

Carotid stenting in difficult arch anatomy can be safely done by transradial route depending upon operator's experience. Left carotid artery stenosis with Bovine arch anatomy can be approached by right arm approach (radial/brachial) easily. In cases with Bovine arch anatomy, left arm approach by modified looping technique is still possible. We report a case of carotid stenting in a patient with bovine arch anatomy using percusurge anchoring technique through left radial approach. © 2010 Wiley‐Liss, Inc.     

Pseudoaneurysm of the distal aortic arch in Beh?et's disease--a case report.

Beh?et's disease, manifested as a triform of relapsing iritis, stomatitis and genital ulceration, is now recognized as a systemic vasculitis that affects both veins and arteries. However, aneurysms of the aortic arch associated with Beh?et's disease are extremely rare. We report on a successfully resected pseudoaneurysm of the distal aortic arch in a patient with Beh?et's disease. The aneurysm was evaluated preoperatively by computed tomography (CT), magnetic resonance imaging (MRI) and intravenous digital subtraction angiography (DSA). We found that these non-invasive methods were quite useful for diagnosing the aneurysm in the aortic arch. Aneurysms enlarge rapidly when coupled with infection and are prone to rupture, thus requiring extensive surgical repair. However, since false aneurysm formations often occur at the site of anastomosis, postoperative follow-up should be monitored very closely.     

Double aortic arch with atretic left arch distal to the origin of left subclavian artery accompanied by dyspnea: A case report and literature review

Double aortic arch with atretic left arch distal to the origin of left subclavian artery is a rare type of vascular ring, and it can be easily confused with the right aortic arch with mirror branching. We provided a rare case of a 10‐month‐old infant with dyspnea. Echocardiography showed a suspicious double aortic arch with atretic left arch distal to the origin of left subclavian artery, which was confirmed intra‐operatively. We summarize ultrasonic image characteristics of the disease and combine it with computed tomography angiography, bronchoscopy, and clinical symptoms in order to improve the detection rate and treatment strategy.     

Interruption of the aortic arch in adults.

The interruption of the aortic arch is a rare cardiac congenital disease; such patients may occasionally survive to adulthood without surgery. The associated intracardiac malformations may modify survival. Our aim is to report three young adults (18-19 years of age) with interruption of the aortic arch. Two had type C, and the other had type B with subpulmonic ventricular septal defect and pulmonary valve insufficiency. We review 106 cases collected from the medical literature into 3 groups: 1) the whole group of patients; 2) patients with isolated interruption of the aortic arch, and 3) patients with interruption of the aortic arch associated with ventricular septal defect. In the whole group we found 18 cases of interruption of the aortic arch type A, and 25 cases of interruption of the aortic arch type B; 37 cases of isolated interruption of the aortic arch and 43 cases associated with ventricular septal defect. Fifty percent of the patients died before 15 days of life (0.042 years). According to the cumulative frequency graphic, only 5% of the patients survived beyond the age of 5 years. We found no information to relate patient's survival rate and anatomic type of the interruption of the aortic arch. From adolescence, the survival of the patients with interruption of the aortic arch associated to septal ventricular defect was 7%, and a 14% survival was found in patients with isolated interruption of the aortic arch. No statistical difference was found between the means of the ages of these two groups (P > 0.25).     

Feasibility of the 3D RCA catheter to engage the brachiocephalic vessels during carotid angiography and stenting

Background : Engagement of the brachiocephalic vessels during carotid angiography is performed using a JR‐4, Vitek, or other catheters with variable success. These catheters require additional training for safe manipulation. In this study, we evaluated the feasibility of using the 3D RCA catheter which requires less manipulation in the aorta, and less training, to engage the brachiocephalic vessels. Methods : We prospectively studied consecutive high‐risk patients undergoing carotid angiography and stenting from August 2005 to March 2009 at our institution. A baseline aortogram was performed to define the arch type in all patients. Engagement of the brachiocephalic vessels was initially attempted using the 3D RCA catheter using the following approach: The 3D RCA catheter is positioned in the ascending aorta beyond the brachiocephalic vessels take off. The natural curve of the catheter usually makes it point cephalad spontaneously in most patients and as it is gently withdrawn it engages the aortic arch vessels without much manipulation. Clinical follow‐up with a neurological exam was performed at one month and six months. Results : A total of 52 patients were enrolled in this study. Baseline demographics and aortic arch types encountered are listed in Table I . The 3D RCA catheter readily engaged the brachiocephalic vessels in 50/52 patients (96.0 %) in our cohort of patients undergoing carotid angiography. Of the 52 patients, 43 subsequently underwent carotid stenting and shuttle sheath placement was facilitated by initial engagement of the relevant common carotid artery with the 3D RCA catheter. There was one transient neurologic complication that resolved by 5 days in a patient that underwent carotid stenting. Conclusions : The 3D RCA catheter can be used with a high success rate to engage the brachiocephalic vessels in all 3 arch types, including a bovine arch during carotid angiography and facilitates shuttle sheath placement for carotid stenting. It requires less manipulation and therefore may be a more operator friendly approach. © 2010 Wiley‐Liss, Inc.     

Hypoplastic right retro-oesophageal aortic arch: similarities to interrupted aortic arch

At echocardiography a dysmorphic neonate was found to have a hypoplastic mitral valve, left ventricle, and ascending aorta with interruption of the aortic arch between the left common carotid and the left subclavian arteries--the left subclavian artery arose from a normal sized left descending aorta. Cardiac catheterisation and subsequent necropsy confirmed this arrangement but also showed a tortuous right retro-oesophageal aortic arch. This arch was severely hypoplastic distal to the right subclavian artery. These cardiovascular anomalies occurred in the child of a family in which other members showed the velo-cardio-facial syndrome, a condition known to be associated with right aortic arch. This aortic arch arrangement may be impossible to distinguish from simple aortic interruption by echocardiography alone.     

Aortic arch plaque in stroke

Patients with severe aortic arch plaque are at high risk for stroke. This article addresses the complex nature of the association between aortic arch plaque and stroke. The aortic arch plaque poses a diagnostic and therapeutic challenge to the clinician. The different imaging modalities currently available for evaluating aortic plaque are discussed. Therapy to prevent emboli from aortic plaque is not yet established. Retrospective data in patients with severe aortic plaque support using oral anticoagulation and statins to prevent stroke. Iatrogenic embolization can occur as a result of aortic manipulation during invasive vascular procedures or cardiovascular surgery. The risks and benefits of these procedures must be carefully weighed, and alternate approaches should be considered for patients with severe aortic arch plaque. Assessing aortic arch plaque combined with a specific prevention strategy may reduce the risk of its feared complication, stroke.     

Hypoplastic right retro-oesophageal aortic arch: similarities to interrupted aortic arch.

At echocardiography a dysmorphic neonate was found to have a hypoplastic mitral valve, left ventricle, and ascending aorta with interruption of the aortic arch between the left common carotid and the left subclavian arteries--the left subclavian artery arose from a normal sized left descending aorta. Cardiac catheterisation and subsequent necropsy confirmed this arrangement but also showed a tortuous right retro-oesophageal aortic arch. This arch was severely hypoplastic distal to the right subclavian artery. These cardiovascular anomalies occurred in the child of a family in which other members showed the velo-cardio-facial syndrome, a condition known to be associated with right aortic arch. This aortic arch arrangement may be impossible to distinguish from simple aortic interruption by echocardiography alone.     

Cervical aortic arch with ventricular septal defect. A differential diagnosis from interrupted aortic arch.

A case of right cervical aortic arch with a large ventricular septal defect and a bicuspid aortic valve is reported. The angiographic diagnosis was interruption of the aortic arch type II, with aberrant right subclavian artery, a closed ductus arteriosus and retrograde vertebral-subclavian flow to the descending aorta. The cervical arch, demonstrated post mortem, was located high and deep in the neck. This differential diagnosis may have potential importance, as reported experience shows that a surgical aortic anastomosis is not required in cervical aortic arch.