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Potter HA, Ziegler KR, Weaver FA, Han SM, Magee GA. Transposition of Anomalous Left Vertebral to Carotid Artery During the Management of Thoracic Aortic Dissections and Aneurysms. J Vasc Surg 2022; 76:1486-1492. [PMID: 35810951 DOI: 10.1016/j.jvs.2022.05.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 04/13/2022] [Accepted: 05/23/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Preservation of antegrade flow to the left vertebral artery is often achieved by transposition or bypass to the left subclavian artery during zone 2 thoracic endovascular aortic repair (TEVAR). An anomalous left vertebral artery (aLVA) originating directly from the aortic arch is a common arch variant with a reported incidence of 4-6%. In addition, 6-10% of vertebral arteries terminate in a posterior inferior cerebellar artery (PICA), increasing the risk of stroke if not revascularized. Few series of aLVA to carotid transposition have been reported. The aim of this study was to evaluate the outcomes of patients who underwent aLVA to carotid transposition for the management of aortic disease. METHODS A retrospective review of all aLVA-carotid transpositions performed for the management of thoracic aortic dissection or aneurysm at a single center from 2018 to 2021 was performed. The primary outcomes were postoperative stroke and patency of the transposed aLVA. Secondary outcomes were spinal cord ischemia, postoperative cranial nerve injury (CNI), and Horner's syndrome. RESULTS Seventeen patients underwent aLVA to carotid transposition as an adjunct to management of aortic disease during the study period. Most were men (14) and the mean age was 54 (±16 years). The primary indication for aortic repair was dissection in 10, aneurysm in 6, and Kommerell diverticulum in 1. Nine patients underwent zone 2 TEVAR, seven received open total arch repair and there was one attempted total endovascular arch repair which was aborted due to unfavorable anatomy. Twelve transpositions were performed prior to or concomitant with planned aortic repair due to high-risk cerebrovascular anatomy (3 PICA termination, 6 dominant aLVA, 4 intracranial left vertebral artery stenosis), and two were performed postoperatively for treatment of type II endoleak. LVA diameter ranged from 2 - 6mm (mean 3.3 mm). Mean operative time for transposition was 178 (±38) minutes, inclusive of left subclavian artery revascularization and mean estimated blood loss was 169 (±188) mL. No patients experienced 30-day postoperative spinal cord ischemia, stroke, or mortality. There were two cases of postoperative hoarseness, presumably due to recurrent laryngeal nerve palsy, both of which resolved within 4 months. There were no cases of Horner's syndrome. At follow-up (mean 306 days [6-714 days]), all transpositions were patent. CONCLUSIONS Vertebral-carotid transposition is a safe and effective adjunct in the management of aortic disease with anomalous origin of the LVA.
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Affiliation(s)
- Helen A Potter
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California.
| | - Kenneth R Ziegler
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California.
| | - Fred A Weaver
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California.
| | - Sukgu M Han
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California.
| | - Gregory A Magee
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Keck School of Medicine of USC, University of Southern California, Los Angeles, California.
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Xia Q, Cao Y, Xie B, Qiu D, Deng L, Wang M, Han H. Cannulation strategies in type A aortic dissection: a novel insight narrative review. J Thorac Dis 2021; 13:2551-2562. [PMID: 34012600 PMCID: PMC8107572 DOI: 10.21037/jtd-21-411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This review highlights vital details that can be easily overlooked and discuss how to identify and fix failed cannulation from another novel insight. Appropriate arterial cannulation strategy during cardiopulmonary bypass (CPB) in Stanford type A aortic dissection (AAD) is highly necessary to reach satisfactory perfusion effects and appreciable clinical outcomes. Despite several previously published reviews on cannulation strategies in AAD, most focus on the advantages and disadvantages by comparing various cannulation strategies. In fact, most of evidence came from retrospective studies. More importantly, however, some important details and novel approaches maybe overlooked due to variety reasons. These overlooked details also make sense in clinical practice. Papers related to cannulation refer to type AAD were retrieved and analyzed from the PubMed and Medline database. The key words such as “aortic dissection”, “cannula”, “cannulation”, “cannulation strategy”, “cerebral perfusion”, “type I aortic dissection” were conducted and analyzed. In addition, we looked at some new and very significant specific perfusion techniques such as anterograde cerebral perfusion combined with retrograde inferior vena caval perfusion (RIVP) and reperfusion via the right carotid artery before surgery. The arterial cannulation site and strategy should be determined individually. Monitoring measures are very necessary in the whole procedure.
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Affiliation(s)
- Qingping Xia
- Department of Science and Education, The People's Hospital of Gaozhou, Gaozhou, China
| | - Yong Cao
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Baodong Xie
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dongyun Qiu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Li Deng
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China.,Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Maosheng Wang
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Hongguang Han
- Department of Cardiovascular Surgery, The General Hospital of Northern Theater Command, Shenyang, China
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Sato K, Emura S, Tomiyoshi H, Morita S. Endovascular Repair of an Aortic Arch Aneurysm in a Patient with a Hypoplastic Left Vertebral Artery Terminating into the Posterior Inferior Cerebellar Artery. Ann Vasc Dis 2019; 12:555-558. [PMID: 31942220 PMCID: PMC6957897 DOI: 10.3400/avd.cr.19-00078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
We present a 76-year-old male with an aortic arch aneurysm and a hypoplastic left vertebral artery (VA). Endovascular repair with left subclavian artery (SCA) closure was planned. The right VA was dominant, while the left VA was hypoplastic, barely connected to the basilar artery, and appeared to terminate at the posterior inferior cerebellar artery (PICA). The VA sizes and flow patterns during ultrasonography confirmed these findings. Therefore, we performed endovascular repair with left SCA reconstruction to prevent ischemia of the PICA perfusion area. After the operation, he experienced no difficulty with brain perfusion.
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Affiliation(s)
- Katsutoshi Sato
- Department of Cardiovascular Surgery, National Hospital Organization, Higashihiroshima Medical Center, Higashihiroshima, Hiroshima, Japan
| | - Shogo Emura
- Department of Cardiovascular Surgery, National Hospital Organization, Higashihiroshima Medical Center, Higashihiroshima, Hiroshima, Japan
| | - Hideki Tomiyoshi
- Department of Radiology, National Hospital Organization, Higashihiroshima Medical Center, Higashihiroshima, Hiroshima, Japan
| | - Satoru Morita
- Department of Cardiovascular Surgery, National Hospital Organization, Higashihiroshima Medical Center, Higashihiroshima, Hiroshima, Japan
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Piffaretti G, Gelpi G, Tadiello M, Ferrarese S, Socrate AM, Tozzi M, Bellosta R. Transposition of the left vertebral artery during endovascular stent-graft repair of the aortic arch. J Thorac Cardiovasc Surg 2019; 159:2189-2198.e1. [PMID: 31301891 DOI: 10.1016/j.jtcvs.2019.06.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/29/2019] [Accepted: 06/04/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of this study was to present our experience with the management of isolated left vertebral artery during hybrid aortic arch repairs with thoracic endovascular aortic repair completion. METHODS This is a single-center, observational, cohort study. Between January 2007 and December 2018, 9 patients (4.5%) of 200 who underwent thoracic endovascular aortic repair were identified with isolated left vertebral artery. The isolated left vertebral artery was the dominant vertebral artery in 4 cases and entered the Circle of Willis to form the basilar artery in all cases. Isolated left vertebral artery transposition was performed in 2 patients during open ascending/arch repair before thoracic endovascular aortic repair completion. In 4 patients, isolated left vertebral artery transposition was performed concomitant with carotid-subclavian bypass during thoracic endovascular aortic repair completion ("zone 2" thoracic endovascular aortic repair). Primary outcomes were early (<30 days) and late survival, freedom from aortic-related mortality, and isolated left vertebral artery patency. RESULTS Primary technical success was achieved in all cases. Isolated left vertebral artery-related complication occurred in 1 patient (Horner syndrome). Immediate thrombosis, vagus/recurrent laryngeal nerve palsy, lymphocele, and chylothorax were never observed. Postoperative cerebrovascular accident or spinal cord injury was not observed. Median follow-up was 15 months (range, 3-72). We did not observe aortic-related mortality during the follow-up. Aortic-related intervention was never required. Both isolated left vertebral artery and carotid-subclavian bypass are still patent in all patients with no sign of anastomotic pseudoaneurysm or stenosis. CONCLUSIONS Although isolated left vertebral artery is not a frequent occurrence, it is not so rare. It may pose additional difficulties during hybrid aortic arch surgical repairs, but isolated left vertebral artery transposition was feasible, safe, and a durable reconstruction.
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Affiliation(s)
- Gabriele Piffaretti
- Vascular Surgery, Department of Medicine and Surgery, ASST Settelaghi University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy.
| | - Guido Gelpi
- Cardiac Surgery-Sacco University Teaching Hospital, Milan, Italy
| | - Marco Tadiello
- Vascular Surgery, Department of Medicine and Surgery, ASST Settelaghi University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Sandro Ferrarese
- Cardiac Surgery, Department of Medicine and Surgery, ASST Settelaghi University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | | | - Matteo Tozzi
- Vascular Surgery, Department of Medicine and Surgery, ASST Settelaghi University Teaching Hospital, University of Insubria School of Medicine, Varese, Italy
| | - Raffaello Bellosta
- Vascular Surgery, Department of Cardiovascular Surgery, Poliambulanza Foundation, Brescia, Italy
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Impact of Isolated Cerebral Perfusion Technique for Aortic Arch Aneurysm Repair in Elderly Patients. Ann Thorac Surg 2019; 107:533-538. [DOI: 10.1016/j.athoracsur.2018.08.049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 07/13/2018] [Accepted: 08/20/2018] [Indexed: 11/23/2022]
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Choi JS, Oh SJ, Sung YW, Moon HJ, Lee JS. Early Experiences with the Endovascular Repair of Ruptured Descending Thoracic Aortic Aneurysm. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2016; 49:73-9. [PMID: 27064672 PMCID: PMC4825906 DOI: 10.5090/kjtcs.2016.49.2.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/12/2016] [Accepted: 02/12/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND The aim of this study was to report our early experiences with the endovascular repair of ruptured descending thoracic aortic aneurysms (rDTAAs), which are a rare and life-threatening condition. METHODS Among 42 patients who underwent thoracic endovascular aortic repair (TEVAR) between October 2010 and September 2015, five patients (11.9%) suffered an rDTAA. RESULTS The mean age was 72.4±5.1 years, and all patients were male. Hemoptysis and hemothorax were present in three (60%) and two (40%) patients, respectively. Hypovolemic shock was noted in three patients who underwent emergency operations. A hybrid operation was performed in three patients. The mean operative time was 269.8±72.3 minutes. The mean total length of aortic coverage was 186.0±49.2 mm. No 30-day mortality occurred. Stroke, delirium, and atrial fibrillation were observed in one patient each. Paraplegia did not occur. Endoleak was found in two patients (40%), one of whom underwent an early and successful reintervention. During the mean follow-up period of 16.8±14.8 months, two patients died; one cause of death was a persistent type 1 endoleak and the other cause was unknown. CONCLUSION TEVAR for rDTAA was associated with favorable early mortality and morbidity outcomes. However, early reintervention should be considered if persistent endoleak occurs.
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Affiliation(s)
- Jae-Sung Choi
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Se Jin Oh
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Yong Won Sung
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Hyun Jong Moon
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
| | - Jung Sang Lee
- Department of Thoracic and Cardiovascular Surgery, SMG-SNU Boramae Medical Center
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Minami T, Imoto K, Uchida K, Karube N, Yasuda S, Choh T, Suzuki S, Masuda M. Thoracic Endovascular Aortic Repair for Ruptured Descending Thoracic Aortic Aneurysm. J Card Surg 2014; 30:163-9. [DOI: 10.1111/jocs.12499] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Tomoyuki Minami
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
- Cardiovascular Surgery; Yokohama Municipal Citizen's Hospital; Yokohama Kanagawa Japan
| | - Kiyotaka Imoto
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Keiji Uchida
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Norihisa Karube
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Shota Yasuda
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Tomoki Choh
- Cardiovascular Center; Yokohama City University Medical Center; Yokohama Kanagawa Japan
| | - Shinichi Suzuki
- Department of Surgery; Yokohama City University Hospital; Yokohama Kanagawa Japan
| | - Munetaka Masuda
- Department of Surgery; Yokohama City University Hospital; Yokohama Kanagawa Japan
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Ohkura K, Shiiya N, Washiyama N, Yamashita K, Takahashi D, Tsuda K, Kando Y. Vertebral artery variations in thoracic aortic patients. Eur J Cardiothorac Surg 2014; 46:27-31. [PMID: 24446475 DOI: 10.1093/ejcts/ezt609] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Arterial variation is common in the vertebral artery, and simple occlusion of the left subclavian artery may result in brain infarction, especially when it terminates in the posterior inferior cerebellar artery (PICA). We report the results of preoperative vertebral artery evaluation by magnetic resonance angiography (MRA) and its impact upon operative strategy. METHODS Among the 214 patients who underwent thoracic aortic surgery from 2009 through 2012, 159 patients with preoperative MRA were retrospectively analysed. Patients' age ranged from 35 to 88 (median 72), 122 were male and 115 had degenerative aneurysms. Prevalence rates of vertebral artery variations and occlusive lesions were reported, together with operative strategies and outcomes. RESULTS There were 19 hypoplasia (12%), 10 PICA termination (6%) and 12 occlusive lesion (8%) on the right vertebral artery and 10 hypoplasia (6%), 5 PICA termination (3%), 7 direct arch origin (4%) and 3 occlusive lesion (2%) on the left. Two of the seven arch-originated arteries terminated in the PICA. In aortic arch replacement, these were reconstructed together with the left subclavian artery while hypothermia was maintained. During thoracic endovascular aortic repair with Zone-2 proximal landing, debranching bypass was employed to preserve left subclavian perfusion when there was PICA termination, hypoplasia or occlusive lesion. In 1 patient with hypoplasia between the basilar artery and the left PICA, bypass was added immediately after deployment because radial pressure dropped critically. No brain infarction occurred with this strategy. CONCLUSIONS PICA termination and right side hypoplasia/occlusive lesion, where left subclavian perfusion is important for brain protection, is present in ∼ 30%. Left vertebral artery that originated from the arch should be managed with care, because PICA termination is highly prevalent.
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Affiliation(s)
- Kazuhiro Ohkura
- The First Department of Surgery, Hamamatsu University School of Medicine, Higashi-ku, Hamamatsu, Japan
| | - Norihiko Shiiya
- The First Department of Surgery, Hamamatsu University School of Medicine, Higashi-ku, Hamamatsu, Japan
| | - Naoki Washiyama
- The First Department of Surgery, Hamamatsu University School of Medicine, Higashi-ku, Hamamatsu, Japan
| | - Katsushi Yamashita
- The First Department of Surgery, Hamamatsu University School of Medicine, Higashi-ku, Hamamatsu, Japan
| | - Daisuke Takahashi
- The First Department of Surgery, Hamamatsu University School of Medicine, Higashi-ku, Hamamatsu, Japan
| | - Kazumasa Tsuda
- The First Department of Surgery, Hamamatsu University School of Medicine, Higashi-ku, Hamamatsu, Japan
| | - Yumi Kando
- The First Department of Surgery, Hamamatsu University School of Medicine, Higashi-ku, Hamamatsu, Japan
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Minami T, Imoto K, Uchida K, Yasuda S, Sugiura T, Karube N, Suzuki S, Masuda M. Clinical outcomes of emergency surgery for acute type B aortic dissection with rupture. Eur J Cardiothorac Surg 2013; 44:360-4; discussion 364-5. [DOI: 10.1093/ejcts/ezs703] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ito H, Shimono T, Hojo R, Muto A, Hirano K, Kondo Y, Kanemitsu S, Shimpo H. Total arch replacement in a patient with an unusual vascular anatomy. Ann Thorac Surg 2012. [PMID: 23176957 DOI: 10.1016/j.athoracsur.2012.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 69-year-old man with a history of infectious abdominal aortic aneurysm, which had resulted in removal of the infrarenal abdominal aorta and bilateral axillofemoral bypass 9 years previously, underwent total arch replacement for an aortic arch aneurysm. The patient had the interrupted abdominal aorta and highly atherosclerotic proximal aorta, which precluded the possibility of endovascular stent grafting in combination with arch vessel debranching technique. Therefore, open arch repair was the only treatment option. The operation was successful with his axillofemoral bypass graft being exposed and used for arterial inflow during cardiopulmonary bypass, including integrated selective antegrade cerebral perfusion.
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Affiliation(s)
- Hisato Ito
- Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, Mie, Japan.
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