Brachiocephalic and subclavian stenosis: Current concepts for cardiovascular specialists

Brachiocephalic and subclavian artery stenoses are less common manifestations of peripheral arterial disease (PAD) compared to lower extremity PAD. However, even among asymptomatic patients, a diagnosis of PAD portends worse long-term mortality. Symptoms may include subclavian steal syndrome and arm claudication. Among patients with internal mammary coronary bypass grafts, symptoms may include those of myocardial ischemia. Symptomatic subclavian stenosis can be readily treated using endovascular techniques with durable outcomes.

Carotid artery stenting in a patient with an incidentally found double aortic arch: A case report

Double aortic arch is a type of congenital vascular ring, which rarely presents in adults. Herein, we report a case of carotid artery stenting (CAS) accompanied by an incidentally found double aortic arch. A 77-year-old man presented with bilateral severe carotid artery stenosis. The patient underwent truncal 3D-computed tomography angiography (CTA) to evaluate the access route before CAS, which lead to the diagnosis of an asymptomatic double aortic arch. Referring to the 3D-CTA images, a guiding catheter was successfully navigated to the targeted common carotid artery via the transfemoral approach despite the challenging, complex anatomy of the aortic arch. CAS was performed in both carotid arteries under distal balloon protection, without any neurological deficits. Considering the possible presence of anatomical variants such as double aortic arch, preoperative evaluation of the access route would be efficient for prospective CAS patients.

The Clinical Spectrum of Kommerell's Diverticulum in Adults with a Right-Sided Aortic Arch: A Case Series and Literature Overview

BACKGROUND

Kommerell's diverticulum is a rare vascular anomaly characterized as an outpouch at the onset of an aberrant subclavian artery. In the variant of a right-sided aortic arch, the trachea and esophagus are enclosed dorsally by the arch. In the configuration of an aberrant left subclavian artery, a Kommerell's diverticulum and persisting ductus arteriosus or ductal ligament enclose the lateral side, forming a vascular ring which may result in (symptomatic) esophageal or tracheal compression. Spontaneous rupture of an aneurysmatic Kommerell's diverticulum has also been reported. Due to the rarity of this condition and underreporting in the literature, the clinical implications of a Kommerell's diverticulum are not well defined.

CASE SUMMARY

We describe seven consecutive adult patients with a right-sided aortic arch and an aberrant course of the left subclavian artery (arteria lusoria), and a Kommerell's diverticulum, diagnosed in our tertiary hospital. One patient had severe symptoms related to the Kommerell's diverticulum and underwent surgical repair. In total, two of the patients experienced mild non-limiting dyspnea complaints and in four patients the Kommerell's diverticulum was incidentally documented on a computed tomography (CT) scan acquired for a different indication. The size of the Kommerell's diverticulum ranged from 19 × 21 mm to 30 × 29 mm. In the six patients that did not undergo surgery, a strategy of periodic follow-up with structural imaging was pursued. No significant growth of the Kommerell's diverticulum was observed and none of the patients experienced an acute aortic syndrome to date.

DISCUSSION

Kommerell's diverticulum in the setting of a right-sided aortic arch with an aberrant left subclavian artery is frequently associated with tracheal and esophageal compression and this may result in a varying range of symptoms. Guidelines on management of Kommerell's diverticulum are currently lacking. This case series and literature overview suggests that serial follow-up is warranted in adult patients with a Kommerell's diverticulum with small dimensions and no symptoms, however, that surgical intervention should be considered when patients become symptomatic or when the diameter exceeds 30 mm in the absence of symptoms.

Aberrant Left Subclavian Artery-Esophageal Fistula in a Patient with a Prolonged Use of Nasogastric Tube: A Case Report and Literature Review

Arterial-esophageal fistula is a rare but potentially fatal complication. Right aortic arch with aberrant left subclavian artery is a rare congenital vascular anomaly that can cause esophageal compression, particularly when the proximal portion of the aberrant subclavian artery forms a Kommerell's diverticulum. Prolonged use of a nasogastric tube can cause pressure necrosis of the esophagus. We report a patient with massive gastrointestinal bleeding secondary to aberrant left subclavian artery-esophageal fistula after a prolonged use of nasogastric tube. A high index of suspicion is essential for better prognosis when a patient with congenital aortic arch anomaly shows upper gastrointestinal hemorrhage.

Anomalous origin of left subclavian artery from ascending aorta in a right aortic arch: A case report with review of literature

We present a case of an 11-year-old boy with a double-outlet right ventricle and a right-sided aortic arch showing anomalous origin of the left subclavian artery from the ascending aorta as the first branch. This case highlights the importance of knowledge of this aberrant anatomy before planning any surgical or endovascular intervention.

Esophageal compression by a common left pulmonary venous trunk

Dysphagia is a symptom with diverse etiologies including luminal narrowing of the esophagus and motility disorders. Arterial vessels are known to compress the esophagus and cause luminal narrowing. However, identifying a pulmonary venous compression of the esophagus rarely occurs in a patient with dysphagia. The technology available at the time of the few prior case reports published more than three decades ago limited the analysis of the pulmonary vessels. We report a case that utilized CT-angiography as well as multiplanar reconstructions and three-dimensional imaging to demonstrate that esophageal compression in the patient presenting with dysphagia was caused by a large left common pulmonary vein.

Fetal Vascular Rings and Pulmonary Slings: Strategies for Two- and Three-Dimensional Echocardiographic Diagnosis

Fetal aortic arch anomalies and pulmonary slings can be difficult to accurately diagnose but have important clinical implications related to vascular rings, congenital heart disease, and chromosomal anomalies. In this article, the authors briefly review the embryology and development of the fetal arch to facilitate understanding of its diverse variants. Two-dimensional echocardiographic characteristics are summarized for each type of these malformations to propose a strategy for fetal diagnosis. The added benefits of three-dimensional echocardiography with spatiotemporal image correlation are also shown. Finally, the authors propose a strategy for volume acquisition and postanalysis to spur postanalysis clinical use of this technology.

Direct Common Carotid Artery Puncture for Endovascular Treatment of Acute Large Vessel Ischemic Stroke in a Patient With Congenital Rare Variant of the Great Vessels

This report describes a case of acute left middle cerebral artery ischemic stroke that occurred in a patient with unique anatomy of the vessels arising from the aortic arch that remained undiagnosed until the age of 36. The nature of the anatomical variance proved problematic in establishing access to the carotid artery via traditional transfemoral or transbrachial approaches, and direct access was established via left carotid puncture. The patient regained substantial neurologic function. The direct carotid approach described below serves as a viable alternate route to establishing reperfusion in patients with complex or problematic aortic arch anatomy.

CT evaluation of unrepaired/incidental congenital cardiovascular diseases in adults

Congenital heart disease (CHD) affects approximately one million people in the USA with the number increasing by 5% each year. Patients are usually both diagnosed and treated in infancy, however many of them may have subclinical CHD that remains undiagnosed until late adulthood. Patients with complex CHD tend to be symptomatic and are diagnosed at a younger age than those with a single defect. CHDs can be divided into three categories, including cardiac, great vessels and coronary artery anomalies. Recent advances in computed tomography (CT) technology with faster acquisition time and improved spatial resolution allow for detailed evaluation of cardiac morphology and function. The concomitant increased utilization of CT has simultaneously led to more sensitive detection and more thorough diagnosis of CHD. Recognition of and understanding the imaging attributes specific to each anomaly is important for radiologists in order to make a correct and definite diagnosis. This article reviews the spectrum of CHDs, which persist into adulthood that may be encountered by radiologists on CT.

Paradigm Shift in the Management of Isolated Interrupted Aortic Arch in Adulthood

An interrupted aortic arch (IAA) is a rare type of congenital heart disease, and few patients survived into the adulthood. Surgical reconstruction is still the recommended approach, despite its complexity and considerable complication. In addition, patients with IAA usually suffer from several other important congenital heart anomalies, which increase the complexity of surgical management of IAA. Although endovascular therapy has replaced surgery in the treatment of the majority of non-IAA, its applicability in IAA is still matter of debate. In the present review, we have discussed about various therapeutic solutions of IAA, and present a stepwise approach for its endovascular management.

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.

Congenital malformations potentially affecting respiratory function: multidisciplinary approach and follow-up

Background and aim.

Congenital malformations such as oesophageal atresia (OA) and tracheoesophageal fistula (TOF), congenital pulmonary airway malformations (CPAMs), congenital diaphragmatic hernia (CDH) and vascular rings (VRs) can affect lung development and respiratory function. This observational study describes our multidisciplinary approach and respiratory follow-up of children with such congenital malformations.

Methods.

Clinical data of children followed at the Pediatric Respiratory Unit of Parma University Hospital (Italy) between January 2015 and January 2020 were collected.

Results.

Twenty-three patients with congenital malformation affecting lung development were identified. Almost half of our patients were diagnosed with fetal ultrasound. Children attended the clinic at a mean age of 3 (3.7) years and follow-up visits were scheduled every 6 months average. More than half of our patients were hospitalized for lower respiratory tract infections. Six out of 9 children able to perform spirometry showed anomalies in lung function. Chest physiotherapy was recommended especially in children with OA.

Conclusions.

Children with congenital malformations affecting lung development are at risk of short and long-term respiratory complications, especially in the first years of life. OA was the malformation more associated to respiratory problems. Multidisciplinary approach and appropriate personalized follow-up are recommended for the best management of these children. (www.actabiomedica.it)

The “No ARSA” Sign: A Novel Method of Prenatal Screening for Aberrant Right Subclavian Artery

An aberrant right subclavian artery (ARSA) can be overlooked by the conventional method as described by Chaoui et al., due to acoustic shadowing. The aim of this study was to evaluate the feasibility and accuracy of a novel screening method for ARSA by demonstrating the brachiocephalic artery bifurcation, referred to as the “No ARSA” sign. A prospective study conducted at a tertiary care center between 2018 and 2019 included unselected pregnant patients at a median gestational age of 15.1 (14.2–22.1; IQR (inter-quartile range)) weeks, who had been referred for a routine or targeted anomaly scan. All participants were scanned for the presence or absence of ARSA using both the conventional and the novel “No ARSA” methods for validation purposes. A total of 226 unselected patients were enrolled in the study. The “No ARSA” sign was visualized in 218 fetuses (96.5%). In the remaining 8 cases (3.5%), the “No ARSA” sign was not demonstrated. In these fetuses, an ARSA was visualized by the conventional method. The new method exhibited 100% feasibility and was in complete agreement with the conventional method. Intra- and inter-observer agreement was excellent (κ = 1). The results of the study suggest that the “No ARSA” sign is an efficient and reliable screening tool for ARSA.

Right aortic arch with mirror image branching pattern and isolated left brachiocephalic artery: A case report

We present a very rare case of right aortic arch with an isolated left brachiocephalic artery in a 35-year-old female. This entity is an extremely uncommon aortic arch anomaly which has associated multisystem symptoms. We briefly discuss the hypothetical double aortic arch model originally described by Edwards. The aortic embryology can explain the anatomic findings and imaging manifestations of the isolated left brachiocephalic artery. Multimodality imaging evaluation can be helpful in detection and categorization of aortic arch abnormalities. A diagnostic imaging approach should focus on elucidating the abnormal aortic arch and great vessels arrangement with determination of associated cardiac, vascular or visceral congenital abnormalities.

Atretic Double Aortic Arch: Imaging Appearance of a Rare Anomaly and Differentiation From Its Mimics

A double aortic arch (DAA) with atresia is an uncommon cause of a symptomatic vascular ring resulting in trachea-esophageal compression. An atretic double aortic arch can resemble the right aortic arch with a mirror image branching pattern or the right arch with an aberrant left subclavian artery depending upon the level of atresia. The double aortic arch with atresia is difficult to detect on pre-surgical computed tomography angiography or magnetic resonance angiography due to a lack of contrast in the obliterated arch segment. Differentiation of a double arch with atresia from the right aortic arch is vital as an atretic double arch is a form of the complete vascular ring while the right aortic arch may or may not be symptomatic. Knowledge of some key imaging features can help distinguish these entities. In this case report, we discuss an uncommon case of a double aortic arch with atresia between the left common carotid and left subclavian artery. We also describe its close mimics, their embryological basis, and ways to differentiate it from the right aortic arch.

Is a Fetal Echocardiography Necessary in IVF-ICSI Pregnancies After Anatomic Survey?

PURPOSE

In vitro fertilization with intracytoplasmic sperm injection (IVF-ICSI) is generally regarded as an indication for fetal echocardiography due to a reported increased risk of congenital abnormalities including cardiac anomalies. In this study we evaluated the utility of fetal echocardiography after anatomic survey in an experienced center.

METHODS

This was a retrospective case review of in vitro fertilization with intracytoplasmic sperm injection pregnancies who had echocardiography in our institution from January 1996 to October 2010.

RESULTS

Records from 85 mothers and 110 fetuses were identified. During anatomic survey, six cardiac anomalies were identified, including four ventricular septal defects, one pulmonary-aortic disproportion, and one post-valvular pulmonary artery dilatation. At fetal echocardiography, two of the four ventricular septal defects were confirmed and an additional three were identified. The most common cardiac anomaly seen in our population of IVF-ICSI pregnancies was ventricular septal defect, which was identified in 3.6% of all cases in the neonatal period. Of ventricular septal defects identified in the prenatal period, 71% resolved before birth.

CONCLUSION

In experienced centers, a fetal echocardiography may not be necessary if the 3 vessels tracheal view of the heart is evaluated and the heart is evaluated carefully for a ventricular septal defect.

Neuroangiography: Review of Anatomy, Periprocedural Management, Technique, and Tips

Neuroangiography (NA) is a minimally invasive procedure used to diagnose patients with neurovascular diseases. Noninvasive imaging has improved dramatically in recent years and is utilized more frequently; however, further evaluation with NA is still required in certain cases. NA indications include intracranial (cerebral aneurysms, arteriovenous malformations, dural arteriovenous fistula, cerebral vasculitis, cerebral vasospasm, ischemic stroke, nontraumatic subarachnoid hemorrhage, intracerebral hemorrhage, Moyamoya, vein of Galen malformation, intracranial tumors, and pseudotumor cerebri) and extracranial (internal and common carotid artery stenosis, vertebral artery stenosis, carotid artery blowout, vertebral artery blowout, epistaxis, oropharyngeal bleeding, and carotid body tumor) pathologies which can help with diagnosis and potential subsequent endovascular treatment. A thorough understanding of normal and variant cervical/cranial vascular anatomy is required. In addition, periprocedural management, catheter technique, equipment needed, and underlying disease pathology are paramount to successful and safe outcomes. This article will review basic neurovascular anatomy, periprocedural management, NA technique, and tips for safe and successful outcomes.

An unusual spirometric shape that you must not forget

A 37-year-old woman, who is a mother of a 5-year-old girl, presented to our outpatient pulmonary clinic because of cough and yellowish expectorate for 20 days. She was a former smoker of 10 cigarettes a day for 20 years (10 pack-years) and worked as agricultural day labourer. Since the age of 25 years, the patient reported one or two episodes of lower respiratory tract infection (LTRI) during the winter months that resolved within a few days of antibiotic and mucolytic treatment. The persistence of cough and expectorate of the last LTRI let the general practitioner to seek a respiratory specialist respiratory consultation with spirometry.

An anomalous spirometric pattern can initiate a diagnostic path leading to the finding of a congenital vascular malformation. The flow–volume curve may hide a nonrespiratory pathology. Spirometry is not just asthma or COPD.http://bit.ly/30iHRCp

The Mediastine's Cane: A Simple Radiograph Case

Congenital anomalies of the aorta are rare disorders that result from an abnormal development of the embryonic pharyngeal arch system. Aortic arch abnormalities occur in 1% to 2% of the population, and their clinical representation, usually in the first years of life, depend on esophageal or tracheobronchial compression or abnormal blood patterns. Such abnormalities are seldom seen in adults. (Level of Difficulty: Intermediate.).

Intraluminal fibrous cord of the aorta in the differential diagnosis of aortic dissection

A patient presented with an intraluminal fibrous cord in the distal segment of ascending aorta. On axial images, the fibrous cord had the appearance of an aortic dissection flap. Observation of continuous images and multiplanar reconstruction were critical for differential diagnosis. Volume render images showed both ends of the fibrous cord had tentiform attachments to the aorta inner wall, which indicating a congenital aorta anomaly. One possible hypothesis for the congenital variation might be the fifth primitive aortic arches remnant.

Assessment of persistent fifth aortic arch by echocardiography and computed tomography angiography

To evaluate the utility of echocardiography (echo) in the diagnosis of persistent fifth aortic arch (PFAA), a very rare congenital aortic arch anomaly, and to compare echo and computed tomography angiography (CTA) imaging findings to improve our understanding of this anomaly.Data on the clinical diagnosis, imaging findings, and clinical management of PFAA were retrospectively analyzed in 10 suspected cases of PFAA admitted to our hospital between January 2012 and February 2017. We compared echo as a first line examination modality, and CTA and surgery results as the gold standard. Weinberg's classification was used to classify the type of PFAA.All patients (100%) received echo examination, eight patients (80%) received CTA examination, and four patients (40%) received sternotomy surgery; all recovered well after surgery. According to Weinberg's classification, 2, 6, and 2 cases (20%, 60%, and 20%) were classified as Type A, B, and C, respectively. Echo was able to diagnose 5 cases of PFAA (1 Type A case and 4 Type B cases) in the first instance. The diagnostic conformance rate of echo was 62.5% after comparisons with CTA and surgery results.The clinical manifestation of PFAA was atypical, and its diagnosis depended primarily on medical imaging. Echo has a relatively high diagnostic accuracy for PFAA, which is very valuable for its early detection.

Circumflex retroesophageal left aortic arch with right ductus arteriosus: A rare complete vascular ring diagnosed on computed tomography angiography

A circumflex retroesophageal left aortic arch with a right-sided ductus is an extremely rare cause of a complete vascular ring, which may result in severe tracheobronchial compression, leading to respiratory compromise, especially in children. We present a case of a 6-month-old female child with stridor and feeding difficulties since birth with interspersed self-resolving episodes of cyanosis and apnea, secondary to the presence of the above-mentioned vascular ring.

Anomalous vasculature in the neck diagnosed by ultrasound

Anomalous vascular anatomy was detected in the neck of a 52-year-old female with a Klippel-Feil anomaly. Ultrasound identified three separate arteries in the left carotid sheath without any branching or bifurcations. The vascular waveforms were used to identify the vessels as the internal carotid artery, external carotid artery and vertebral artery. This rare vascular anomaly was confirmed with CT angiography.

Interrupted aortic arch: A case report

Interrupted aortic arch diagnosed in adult age is a rare entity, with only a few cases published in the literature. Most of them are classified as type A interrupted aortic arch and differential diagnosis is associated with severe chronic coarctation. We present a case of a 52-year-old woman accessed to the emergency department for chest and right upper limb pain that increased in the last days. She underwent a computed tomography angiogram showing interruption of the aortic arch, distal to left subclavian artery origin, large bilateral collateral vessels connecting subclavian arteries to descending aorta with multiple voluminous aneurysms, a bicuspid aortic valve, dilatated tubular segment of ascending thoracic aorta, and a suspected atrial septal defect. A nonsystematic literature review regarding these conditions has been performed.

320-slice Computed Tomography Angiography Imaging Findings and Follow-up in A Patient with Aortic Coarctation Misdiagnosed as Hypertension: A Case Report and Literature Review

In this case, we report a simple coarctation of the aortic isthmus (CoA) in a patient without intracardiac abnormalities or patent ductus arteriosus, who was misdiagnosed as essential hypertension for over 20 years. The patient underwent X-rays, echocardiography, and 320-slice CT angiography (CTA). Among them, CTA comprehensively showed the diameter of the aortic coarctation, the anatomy and morphology of the heart and aortic arch, and the collateral circulation before surgery. It also accurately evaluated the postoperative status of the bypass vessel. This article highlights the excellent performance of 320-slice CTA in the diagnosis, surgical planning, and follow-up in CoA. Moreover, when adolescents suffer from refractory hypertension, the possibility of organic cardiovascular disease should be considered.

Anatomical variations of the aortic arch branches in a sample of Chinese cadavers: embryological basis and literature review

OBJECTIVES

The aim of this study is to determine the incidence and explore the types of aortic arch branch variations found in our cadavers.

METHODS

The types and incidence of aortic branch variations in 120 cadavers were analysed after careful dissection.

RESULTS

One hundred and six of 120 cadavers had normal aortic arch branches and gave rise to usual branches, namely the brachiocephalic trunk, the left common carotid artery and the left subclavian artery. The remaining 14 cadavers had 2 basic types of branch variations, thus accounting for an incidence of 11.67%. A total of 9 aortic arches emitted 4 branches; the brachiocephalic trunk, the left common carotid artery, the left vertebral artery and the left subclavian artery (incidence 7.5%). The second subgroup of 5 cadavers also emitted 4 aortic branches: the right common carotid artery, the left common carotid artery, the left subclavian artery and the right subclavian artery (incidence 4.16%). In this group, the right subclavian artery sprung as a distal branch of the aortic arch (descending), thus making a vascular ring that takes a superoposterior course round the back of the trachea and the oesophagus to reach the right side. There was a single cadaver, different from the other 4 aortic branches of the second group which had a common origin for the common carotid arteries, while the left subclavian artery and distally placed right subclavian artery were present. We did not observe any Kommerell's aortic diverticula.

CONCLUSIONS

The variations of aortic arch branching are complex and diverse due to varied possible alterations in the embryological processes. There is an imperative need for further research on these variations to elucidate the possible relationships with clinical diagnostic or surgical events.

Case of anomalous origin of right coronary artery from pulmonary artery associated with interrupted aortic arch type A, diagnosed by multidetector computed tomography angiography

Anomalous origin of the right coronary artery from pulmonary artery (ARCAPA) is a rare congenital anomaly of the coronary circulation, which can be easily missed by echocardiography. Interrupted aortic arch (IAA) is another rare congenital cardiac abnormality that typically presents in the first few weeks of life. We present a case of ARCAPA associated with IAA diagnosed with the help of multidetector computed tomography angiography, in a 7-year-old boy.

Right-sided aortic arch with mirror image branching and situs solitus: a case of a 79 years old woman

Right aortic arch with mirror image branching (RAMI) is a rare congenital defect of the aorta. The exact incidence of RAMI in the general population is unclear. In RAMI the first branch arising from the arch is the left innominate artery, followed by the right carotid artery and right subclavian arteries. We report a case of an adult female patient with RAMI discovered as an incidental finding during radiological investigations for suspected pulmonary embolism in emergency department. No other congenital malformations were reported. It is important to recognize congenital variants of the aortic arch, as they can have relevant implications for patients’ prognosis and management. Therefore, being aware of these conditions is key to avoid any mistakes or surgical and endovascular complications.

Reduced maternal vitamin A status increases the incidence of normal aortic arch variants

While common in the general population, the developmental origins of "normal" anatomic variants of the aortic arch remain unknown. Aortic arch development begins with the establishment of the second heart field (SHF) that contributes to the pharyngeal arch arteries (PAAs). The PAAs remodel during subsequent development to form the mature aortic arch and arch vessels. Retinoic acid signaling involving the biologically active metabolite of vitamin A, plays a key role in multiple steps of this process. Recent work from our laboratory indicates that the E3 ubiquitin ligase Hectd1 is required for full activation of retinoic acid signaling during cardiac development. Furthermore, our study suggested that mild alterations in retinoic acid signaling combined with reduced gene dosage of Hectd1, results in a benign aortic arch variant where the transverse aortic arch is shortened between the brachiocephalic and left common carotid arteries. These abnormalities are preceded by hypoplasia of the fourth PAA. To further explore this interaction, we investigate whether reduced maternal dietary vitamin A intake can similarly influence aortic arch development. Our findings indicate that the incidence of hypoplastic fourth PAAs, as well as the incidence of shortened transverse arch are increased with reduced maternal vitamin A intake during pregnancy. These studies provide new insights as to the developmental origins of these benign aortic arch variants.

Prevalence and Types of Aortic Arch Variants and Anomalies in Congenital Heart Diseases

RATIONALE AND OBJECTIVES

Aortic arch (AA) variants and anomalies are important to recognize in patients with congenital heart disease (CHD) before surgery or intervention. The aim was to study the prevalence of AA anomalies and variants in patients with CHD compared to a control group. The secondary outcome was to report the associations between common variations of AA and specific types of CHD.

MATERIALS AND METHODS

After institutional review board approval, computed tomography studies of 352 CHD patients and control group of 400 consecutive computed tomography scans of the thorax were evaluated. The AA was assigned to one of seven common types, and their distribution was compared between CHD and control. The distribution of the AA anomalies and variants was evaluated as regard specific types of CHD and the visceroatrial situs.

RESULTS

Normal three-vessel branching pattern was the commonest in both groups, but was present in only 50.5% in the CHD compared to 68.5% in the control group, p < 0.00001. Right AA and aberrant right subclavian artery were significantly more common in CHD than control group (18.1% versus 0.25%, p < 0.00001) and (4.5% versus 0.25%, p = 0.0001), respectively. Direct aortic origin of left vertebral artery was insignificantly more common in CHD group (4.2% versus 2.7%, p = 0.258). Brachiobicephalic trunk was significantly more common in control than CHD group (27.7% versus 19.3%, p = 0.007).

CONCLUSION

Normal three-vessel AA was significantly less common in CHD. AA anomalies (right arch and aberrant right subclavian) were more common in CHD than control, while AA variants (brachiobicephalic trunk and direct aortic origin of left vertebral artery) were not.

Ductus arteriosus location in relation to aortic arch position, branching pattern, and viscero-atrial situs

AIM

To investigate ductus arteriosus (DA) location in relation to viscero-atrial situs and branching pattern of the right aortic arch (RAA).

MATERIALS AND METHODS

Computed tomography (CT) images of paediatric patients (May 2015 to July 2017, n=352) referred for evaluation of cardiovascular malformations were reviewed retrospectively. Patients with RAA were identified and images were analysed for documentation of the viscero-atrial situs, the branching pattern, DA location, and associated malformations.

RESULTS

The study included 64 RAA patients, 45 situs solitus, 11 situs ambiguous, and eight situs inversus. Mirror-image branching was observed in 34 situs solitus, 11 situs ambiguous, and seven situs inversus patients. Aberrant left subclavian artery (ALSCA) was present in 10 situs solitus and one situs inversus patient. One patient with situs solitus had isolated left subclavian artery. The location of the DA was identifiable in 32 patients (19 left and 13 right). In situs solitus with mirror-image branching, the DA was left in 10, right in four patients. In situs inversus and ambiguous with mirror-image branching, the DA was right in eight and left in two patients. In patients with ALSCA, the DA was left in seven and right in one patient. The location of the DA was identifiable in 85 patients with left aortic arch (left-sided in 84, right-sided in only one patient).

CONCLUSION

The location of DA in RAA varies according to viscero-atrial situs and branching pattern. In mirror-image branching, the DA is more commonly left-sided with situs solitus and more right-sided with abnormal viscero-atrial situs.

Right aortic arch with an aberrant left subclavian artery and aortic coarctation including a descending aortic aneurysm

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.

Atretic anomalous left subclavian artery as part of an unusual vascular ring

In this report, a unique case of a symptomatic vascular ring formed by right aortic arch, aberrant left subclavian artery, and left ligamentum arteriosus in which there is atresia of the proximal left subclavian artery is described. Imaging modalities were non-diagnostic and the patient was sent to surgery based on strong clinical suspicion. Her anatomy was delineated in the operating room and the ring was successfully repaired.

Axillary Lymph Node Metastasis in Gallbladder Carcinoma with Incidentally Detected Coexistence of Aberrant Right Subclavian Artery with Left-Sided Superior Vena Cava

The sequential development of port site recurrence, followed by recurrence in the axillary lymph node in gallbladder carcinoma is very infrequently reported in the literature. The representing 18F-fluorodeoxyglucose positron emission tomography-computed tomography image shows a metastatic right axillary lymph node in a case of gallbladder cancer developed following surgical removal of port site recurrence and six cycles of chemotherapy. The image also shows coexistence of two incidentally detected vascular anomalies, i.e., aberrant right subclavian artery and left-sided superior vena cava. Coexistence of both the vascular anomalies is rare among the general population and have their own clinical implications as described.

Esophagectomy in a patient with double aortic arch and right descending aorta

We herein report the case of a 57-year-old man with esophageal cancer who was found to have a double aortic arch and right-sided descending aorta. Traditional approaches such as the Ivor Lewis and McKeown were excluded because the descending aorta would obscure the surgical field, and a neck anastomosis with the conduit through the ring could result in compression. We therefore opted for a left thoracoabdominal incision, allowing excellent exposure while reserving the possibility of placing the conduit substernally.

Right or left thoracotomy for esophageal atresia and right aortic arch? Systematic review and surgicoanatomic justification

INTRODUCTION

The optimal thoracotomy approach for the management of esophageal atresia and tracheoesophageal fistula (EA/TEF) with a right aortic arch (RAA) remains controversial.

METHODS

Systematic review of complications and death rates between right- and left-sided repairs, including all studies on EA/TEF and RAA, apart from studies focusing on long-gap EA and thoracoscopic repairs. Review of right- and left-sided surgical anatomy in relation to reported complications.

RESULTS

Although no significant differences were elicited between right- and left-sided repairs in complications (9/29 vs. 1/6, p = 0.64) and death rates (2/29 vs. 0/6, p = 0.57), unique anatomic complications - such as injury to the RAA covering the esophagus and intractable bleeding - associated with mortality were revealed in the right thoracotomy group. Left-sided repairs following failed repair through the right showed higher complications rate (3/3) than straightforward right- (9/29) or left-sided repairs (1/6) (p = 0.024). Right thoracotomies converted to left thoracotomies led to staged repairs more frequently (4/9) than straightforward right (5/38) or left thoracotomies (0/6) (p = 0.03).

CONCLUSIONS

There is not enough evidence to support that right thoracotomy, characterized by unique surgicoanatomic difficulties, is equivalent to left thoracotomy for EA/TEF with RAA. Both approaches might be required, and, therefore, surgeons should be familiarized with surgical anatomy of mediastinum approached from right and left. Systematic review, Level of Evidence III.

Strategies for Accurate Diagnosis of Fetal Aortic Arch Anomalies: Benefits of Three-Dimensional Sonography With Spatiotemporal Image Correlation and a Novel Algorithm for Volume Analysis

BACKGROUND

Obtaining an accurate diagnosis of fetal aortic arch anomalies is often difficult with traditional two-dimensional (2D) sonography. Thus, the aim of this study was to assess the value of three-dimensional (3D) sonography with spatiotemporal image correlation for diagnosing fetal aortic arch anomalies using a novel algorithm for 3D volume analysis.

METHODS

Two-dimensional and 3D echocardiographic image data from 300 normal fetuses and 30 fetuses with aortic arch anomalies were retrospectively reviewed. Grayscale and high-definition flow imaging data were available for 2D echocardiography. Three-dimensional volumes were acquired in parasagittal views with high-definition flow imaging information. Volume postprocessing was performed using a novel algorithm to obtain 3D tomographic ultrasound imaging slices and color-rendered images. Detection of aortic arch positions, aberrant brachiocephalic patterns, and aortic arch anomalies was compared for 2D and 3D modalities. Postnatal echocardiography was used as the truth standard in assessing aortic anatomy.

RESULTS

In total, four cases of double aortic arch, 21 cases of right aortic arch, one case of retroesophageal aortic arch, and four cases of left aortic arch with aberrant right subclavian arteries were included. Inter- and intraobserver agreement were excellent for 2D and 3D modalities. The 3D modality offered better sensitivity and accuracy compared with 2D imaging for the detection of brachiocephalic anomalies (P < .01) and arch anomalies (P < .01) but comparable sensitivity for arch position. There was no difference in specificity for both modalities.

CONCLUSIONS

The proposed novel algorithm for volume postprocessing ensures that 3D reconstructed images are obtained with high repeatability. The addition of 3D spatiotemporal image correlation to fetal echocardiography may offer a more accurate diagnosis for arch anomalies.