Initial experience in the treatment of thoracic aortic aneurysmal disease with a thoracic aortic endograft at Baylor University Medical Center

Fully percutaneous treatment of an aberrant right subclavian artery and thoracic aortic aneurysm

Treatment of an aberrant right subclavian artery (arteria lusoria) aneurysm is traditionally performed surgically or via a hybrid approach. To our knowledge, a fully percutaneous approach has not yet been reported. We describe the fully endovascular exclusion of an aberrant right subclavian artery and thoracic aortic aneurysm. This approach has the potential advantage of avoiding complications of an open surgical repair, particularly in patients of advanced age and/or with multiple comorbidities.

Hybrid treatment in a patient with acute aortic syndrome and an aberrant right subclavian artery

A 57-year-old man was admitted to our department with recent onset of chest pain. Computed tomography (CT) scans revealed an acute aortic syndrome manifested by a penetrating atherosclerotic ulcer and contained rupture at the level of origin of an aberrant right subclavian artery. A combined vascular and endovascular approach was selected. The entire arch was rerouted, a reversed bifurcated Dacron prosthesis was placed, and a bypass was created between the right common carotid artery and the lusorian artery, followed by thoracic endovascular aortic repair. The clinical course was uneventful. The CT scan obtained after the procedure revealed regular supra-aortic perfusion and complete exclusion of the complex lesion.

Evaluation of cardiovascular anomalies in patients with asymptomatic turner syndrome using multidetector computed tomography

Turner syndrome is well known to be associated with significant cardiovascular abnormalities. This paper studied the incidence of cardiovascular abnormalities in asymptomatic adolescent patients with Turner syndrome using multidetector computed tomography (MDCT) instead of echocardiography. Twenty subjects diagnosed with Turner syndrome who had no cardiac symptoms were included. Blood pressure and electrocardiography (ECG) was checked. Cardiovascular abnormalities were checked by MDCT. According to the ECG results, 11 had a prolonged QTc interval, 5 had a posterior fascicular block, 3 had a ventricular conduction disorder. MDCT revealed vascular abnormalities in 13 patients (65%). Three patients had an aberrant right subclavian artery, 2 had dilatation of left subclavian artery, and others had an aortic root dilatation, aortic diverticulum, and abnormal left vertebral artery. As for venous abnormalities, 3 patients had partial anomalous pulmonary venous return and 2 had a persistent left superior vena cava. This study found cardiovascular abnormalities in 65% of asymptomatic Turner syndrome patients using MDCT. Even though, there are no cardiac symptoms in Turner syndrome patients, a complete evaluation of the heart with echocardiography or MDCT at transition period to adults must be performed.

Endovascular treatment of an aberrant right subclavian artery aneurysm with use of the Zenith iliac plug

Aberrant right subclavian artery aneurysms are rare but demonstrate a propensity toward rupture; thus, early elective repair is mandated. Novel endovascular modalities are available to offer less-invasive treatment for a patient population with increasing comorbidities. We report a case of a 65-year-old woman with an aberrant right subclavian artery aneurysm causing dysphagia lusoria. The aneurysm was excluded proximally at Kommerell's diverticulum with a Zenith iliac plug and excluded distally by surgical ligation combined with a right carotid-subclavian artery bypass to preserve extremity perfusion.

How to manage the left subclavian artery during endovascular stenting for thoracic aortic dissection? An assessment of the evidence

BACKGROUND

Despite the publication of recent guidelines for management of the left subclavian artery (LSA) during endovascular stenting procedures of the thoracic aorta, specific management for those presenting with dissection remains unclear. This systematic review attempts to address this issue.

METHODS

Systematic assessment of the published data on thoracic aorta dissection was performed identifying 46 studies, which incorporated 1,275 patients. Primary outcomes included the prevalence of left arm ischemia, stroke, spinal cord ischemia, endoleak, stent migration, and mortality. Outcomes were compared between patients with and without LSA coverage and revascularization incorporating factors such as the number of stents used, length of aorta covered, urgency of intervention, and type of dissection (acute or chronic). Statistical pooling techniques, χ(2) tests, and Fisher's exact testing were used for group comparisons.

RESULTS

As compared with other outcomes, LSA coverage without revascularization in the presence of aortic dissection is much more likely to be complicated by left arm ischemia (prevalence increased from 0.0% to 4.0% [p = 0.021]), stroke (prevalence increased from 1.4% to 9.0% [p = 0.009]), and endoleak (prevalence increased from 4.0% to 29.3% [p = 0.001]). However, revascularization was not shown to reverse these effects. Longer aortic coverage (≥ 150 mm) was associated with an increased prevalence of spinal cord ischemia (from 1.3% to 12.5% [p = 0.011]) and mortality (from 1.3% to 15.6% [p = 0.003]).

CONCLUSION

In patients undergoing endovascular stenting for thoracic aortic dissection, in cases where LSA coverage is necessary, revascularization should be considered before the procedure to avoid complications such as left arm ischemia, stroke, and endoleak, and where feasible, an appropriate preoperative assessment should be carried out.