Synchronous arch arterial occlusion - A clinical impasse?

BACKGROUNDIntravascular lithotripsy (IVL) is a novel technique increasingly used for plaque modification and endovascular revascularization in patients with severe calcification and peripheral artery disease. However, much of the available literature on IVL is focused on its use in coronary arteries, with relatively limited data on non-coronary artery use.AIMTo analyze the safety and efficacy of current IVL use in non-coronary artery lesions, as reported in case reports and case series.METHODSWe searched EMBASE, PubMed, and Reference Citation Analysis databases for case reports and case series on IVL use in peripheral artery disease. We then extracted variables of interest and calculated the mean and proportions of these variables.RESULTSWe included 60 patients from 33 case reports/case series. Ninety-eight percent of the cases had IVL usage in only one blood vessel, while four had the IVL used in two vessels (2.0%), resulting in 64 Lesions treated with IVL. The mean age of the patients was 73.7 (SD 10.9). IVL was successfully used in severe iliofemoral artery stenosis (51.6%), severe innominate, subclavian, and carotid artery stenosis (26.7% combined), and severe mesenteric vessel stenosis (9.4%). Additionally, IVL was successfully used in severe renal (7.8%) and aortic artery (4.7%) stenosis. There were complications in 12% of the cases, with dissection being the commonest.CONCLUSIONIVL has successfully used in plaque modification and endovascular revascularization in severely calcified and challenging lesions in the iliofemoral, carotid, subclavian, aorta, renal, and mesenteric vessels. The most severe but transient complications were with IVL use in the aortic arch and neck arteries.

Purpose: To analyze aortic arch anatomy of patients who were already treated with a 2-inner-branch arch endograft (2-IBAE) in order to assess the anatomical suitability of the supra-aortic arteries as target vessels for a 3-IBAE. Materials and Methods: Three different configurations of the Cook Zenith Arch endograft were designed with distances of 110 mm (model 1), 90 mm (model 2), and 70 mm (model 3) between the orifices of the first and third inner branches. Preoperative measurements of the aortic arch anatomy from 104 consecutive patients treated electively with custom-made 2-IBAEs at 2 European centers between 2014 and 2019 were analyzed. A previously described standard methodology with a planning sheet was used. Data and measurements included the treatment indication for the aortic arch pathology, the type of landing zone, the type of arch, and the inner and outer lengths of the ascending aorta from the sinotubular junction to the innominate artery (IA). Additionally, the diameters and clock positions of the IA, left common carotid artery (LCCA), and left subclavian artery (LSA) were assessed, along with the distances between the IA and the LCCA, the IA and the LSA, and the distal landing zone. Results: Type I was the most common arch configuration (75/104, 72%). The mean clock positions were 12:30±00:28 for the IA, 12:00±00:23 for the LCCA, and 12:15±00:29 for the LSA. The mean diameters were 14.2±2.2 mm for the IA, 8.8±1.8 mm for the LCCA, and 10.5±2 mm for the LSA. The mean distances between the IA and LCCA and between the IA and LSA were 14.7±5.8 mm and 33±9.4 mm, respectively. Model 2 (branch distance 90 mm) had the highest suitability (79%), while models 1 and 3 showed suitability rates of 73% and 68%, respectively. The most frequent exclusion criterion in all models was the diameter of the LSA, followed by the IA to LSA distance. Conclusion: The suitability for a 3-IBAE among patients who had a 2-IBAE implanted is high, favoring a 90-mm distance between the retrograde LSA branch and baseline.

Takayasu arteritis is a chronic, idiopathic, inflammatory disease mainly affecting medium and large vessels with a significant rate of morbidity and mortality. The vessels most frequently affected are the aorta and its branches; branches originating from the aortic arch include right brachiocephalic trunk and its branches, left common carotid artery, left subclavian artery, coronary arteries from the ascending aorta, celiac trunk, right and left renal arteries, superior and inferior mesenteric arteries from the descending aorta, and right and left iliofemoral arteries. Local and systemic inflammation along with end organ ischemia is attributed to severe clinical manifestations associated with this condition. Although Takayasu arteritis is more commonly diagnosed in adults, this study highlights the unusual occurrence of childhood-onset Takayasu arteritis (TAK), presenting a unique set of diagnostic challenges. We present a case of a seven-year-old female patient who manifested atypical symptoms, such as absent pulses and malignant hypertension at an early age, leading to a delayed diagnosis. The patient's clinical course, including diagnostic workup and imaging studies such as CT or MR angiography, is thoroughly discussed. This study emphasizes the importance of recognizing the subtleties of Takayasu arteritis in children. The disease may initially masquerade as other common conditions, such as peripheral arterial disease, coarctation of aorta, renal artery stenosis, chronic renal disease, and increased intracranial pressure, thereby hindering timely diagnosis and appropriate intervention. This case underscores the importance of considering Takayasu arteritis as a differential diagnosis in children, presenting with unexplained constitutional symptoms or signs of systemic vasculitis, emphasizing the need for multidisciplinary collaboration and tailored therapeutic intervention to optimize the outcome in this rare and potentially debilitating condition.

The fate of nonaortic arterial segments in Marfan patients

ABSTRACTA thoracic aortic aneurysm is a dilatation in the wall of the aorta. If untreated, it can rupture or tear, which is life‐threatening. A 74‐year‐old man was admitted to Sina Hospital with hoarseness and dysphonia. He was diagnosed with a thoracic aortic aneurysm (TAA) measuring 73 mm near the left subclavian artery and a 46 mm saccular ulcerous TAA in the mid‐thoracic aorta. Preoperative evaluations were normal. Due to comorbidities, open surgery was not an option, so the patient was selected for thoracic endovascular aneurysm repair (TEVAR). However, the proximity of the aneurysm to the origins of the left subclavian and common carotid arteries limited the stent's landing zone. To resolve this, an open surgery was performed to ligate the left subclavian and common carotid arteries and bypass them to their right counterparts, extending the landing zone for the stent. TEVAR was then successfully carried out from the brachiocephalic trunk, covering most of the ulcerous TAA in the mid‐aorta. The patient was discharged in good condition and has shown positive progress in follow‐up visits. This case demonstrates a novel and complex approach that combines open surgical ligation and bypass of the left subclavian and common carotid arteries with TEVAR. The technique successfully expands the proximal landing zone for thoracic aortic aneurysm repair, contributing a practical solution for high‐risk patients with complex anatomy, leading to effective stent deployment and enhanced clinical outcomes.

The frozen elephant trunk: An interesting hybrid endovascular-surgical technique to treat complex pathologies of the thoracic aorta

A novel modular inner aortic arch stent-graft for localized Stanford type A aortic dissection aneurysm with short healthy proximal ascending aorta

In this study, the aim was to investigate the anatomy of the aortic arch arteries in mole-rats (Spalax leucodon). Six adult mole-rats were used for this purpose. Coloured latex was injected into the left ventriculus of the hearts of all animals. The materials were carefully dissected and the arterial patterns of arteries originating from the aortic arch were examined. The brachiocephalic trunk, the left common carotid and the left subclavian arteries were detached from the aortic arch. The brachiocephalic trunk separated into the right subclavian and common carotid arteries. The branches separating from the subclavian arteries were on the right, the common branch giving the profund cervical, the internal thoracic, and the costocervical trunk, and on the left the internal thoracic and the costocervical trunk were in the common root and the profund cervical artery was independent and on both sides after giving the common branch of the superficial servical and the external thoracic artery. This continued as the axillary artery which was then separated into the subscapular and the brachial arteries. Thus, the arteries originating from the aortic arch and the branches of these arteries were found to be different from other rodents and domestic mammals.  

Objective To explore the value of MRI in the diagnosis of fetal aortic arch anomalies. Methods We retrospectively collected 10 fetuses with aortic arch anomalies indicated by prenatal ultrasound and underwent MR examination and were subsequently proven by autopsy or post-birth follow-up from 320 pregnant women. We focused on the observations of the location of the aortic arch and brachiocephalic artery anomalies, the locations of the liver and stomach in the abdominal cavity, and the large vessels in abdomen. The above-mentioned finding were compared with prenatal ultrasound and follow-up findings. Results Of 10 cases, right aortic arch with aberrant left subclavian artery was seen in 7 cases, right aortic arch with the mirror branch, left aortic arch with aberrant right subclavian artery, right aortic arch with aberrant left subclavian artery combined with cervical aortic arch and double aortic arch was seen in 1 case, respectively. All aortic arch anomalies detected by MRI were consistent with post-birth or autopsy findings. Ultrasound misdiagnosed aortic branch malformation in 5 places, which included right aortic arch but misdiagnosed aberrant left subclavian artery in 2 cases, right aortic arch never diagnosed mirror branch anomaly in 1 case, right aortic arch with left subclavian artery misdiagnosed cervical aortic arch in 1 case, left atrial isomerism but misdiagnosed left aortic arch with aberrant right subclavian artery in 1 case; One double aortic arch was misdiagnosed as right aortic arch with aberrant left subclavian artery in ultrasound. Conclusion Fetal cardiovascular MRI is an effective and supplementary examination to complement ultrasound in diagnosis of fetal aortic arch anomalies. Key words: Fetus; Aorta,thoracic; Vascular malformations; Magnetic resonance imaging

This study had the aim of investigating the anatomy of the aortic arch in squirrels (Sciurus vulgaris). Ten squirrels were studied. The materials were carefully dissected and the arterial patterns of arteries originating from the aortic arch were examined. The brachiocephalic trunk and the left subclavian artery were detached from the aortic arch. The brachiocephalic trunk first gave the left common carotid artery, and then detached to the right subclavian and common carotid artery. In all the examined materials, the left and right subclavian arteries gave branches that were similar after leaving the thoracic cavity from the cranial thoracic entrance. But while the whole branches of the the right subclavian artery were arising from almost the same point the left subclavian artery gave these branches in a definite order, and the branches that separated were the following: the internal thoracic artery, the intercostal suprema artery, the ramus spinalis, the vertebral artery and the descending scapular artery. It also gave the common branch formed by the junction of three of the cervical superficial, the cevical profund and the suprascapular arteries. After the separation of these branches, continuation of the artery gave the external thoracic artery on the external face of the thoracic cavity and then formed the axillar artery. The axillary artery separated into the subscapular and the brachial arteries. Thus, the arteries originating from the aortic arch and the branches of these arteries are different from other rodents and from domestic mammals.

The purpose of this study was to determine the safety and efficacy of angioplasty and stenting for symptomatic innominate-subclavian lesions by review of records of symptomatic patients undergoing angioplasty and stenting of high-grade lesions (>80%) of the innominate and subclavian arteries. Follow-up consisted of history (symptoms) and physical examination (pulses and blood pressures) at 1, 3, 6, and then every 12 months plus an annual duplex ultrasound examination. Between 1998 to 2003, 25 patients (27 lesions) were treated. Ages ranged from 48 to 89 years. Symptoms included vertebrobasilar/steal (15), claudication (6), ischemia (4), and coronary artery bypass grafting/left internal mammary artery (2). There were 7 occlusions and 20 high-grade stenoses. Access was attempted via brachial cutdown (19) or percutaneous puncture of the brachial (2) or femoral arteries (10). Twenty-two lesions were stented with either self-expanding (13) or balloon-expandable (9) stents. Technical success was 89%; 3 occluded lesions could not be crossed owing to complete occlusion. The remaining 4 occlusions were all crossed via a retrograde approach. The mean difference in systolic blood pressure between upper limbs decreased from 36 mm Hg (preprocedure) to 10 mm Hg (postprocedure). There were no procedure-related complications. Mean follow-up was 18 months (range 1-62 months). One patient died 4 months after the procedure secondary to complications from pulmonary surgery unrelated to the percutaneous transluminal angioplasty/stent. Of the 4 successfully treated occlusions, 2 were followed up to 3 years with continued patency. Three patients developed recurrent stenoses documented by duplex examination. However, these patients remained asymptomatic and were not treated. Endovascular management of high-grade lesions of the subclavian or innominate arteries is safe and efficacious and may be considered as a first line of therapy. Continued follow-up is needed to assess long-term patency.

Endovascular therapy is an accepted treatment strategy in occlusive disease of the subclavian artery. The purpose of this study was to evaluate the technical and clinical long-term outcome following either balloon angioplasty (plain balloon angioplasty (PTA)) or stenting. The authors retrospectively analyzed 108 interventions of atherosclerotic lesions of subclavian arteries or the brachiocephalic trunk (107 patients; mean age of 66 +/- 9 years; 90% symptomatic) representing 92% of the patients treated with subclavian artery obstructive disease during a 10-year period. Primary endpoint of the study was the 1-year primary patency rate. Follow-up was based on oscillometry, Doppler blood pressure measurements, and duplex ultrasound. The primary success rate was 97% (100% for stenoses (78/78) and 87% for total occlusions (26/30)). Treatment modalities included PTA alone (13%; n = 14) or stenting (87%; n = 90) with balloon-expandable (n = 61), self-expanding (n = 17), or both types of devices (n = 12). The 1-year primary patency rate of the 97 patients eligible for follow-up was 88%, for the subgroups 79% (PTA) and 89% (stenting; P = 0.2). The blood pressure difference between both limbs at baseline was 45 +/- 26 mm Hg and dropped to 10 +/- 14 mm Hg (P < 0.001) after the intervention and 15 +/- 19 mm Hg at 1 year (P < 0.01). Endovascular therapy of atherosclerotic subclavian artery obstructions result in excellent acute success rates even in total occlusions. Results evince good durability of endovascular therapy for atherosclerotic occlusive disease of subclavian arteries and with a trend towards better outcome with stenting compared to PTA.

BackgroundVascular aging is a key driver of age-related diseases, especially cardiovascular disease, significantly impacting morbidity and mortality. However, aging rates and disease susceptibility vary widely across organs and vascular regions, reflecting substantial heterogeneity. A universally accepted definition of vascular aging remains elusive.PurposeThis study aims to identify timely, non-invasive organ-specific imaging markers to facilitate the accurate estimation of vascular age (represented by arterial age) and enhance the prediction of future cardiovascular disease risk.MethodsA total of 669 patients (aged 46 to 90 years) from a biobank were included in the present study. All patients had undergone a computed tomography (CT) angiography prior to carotid endarterectomy and the CT images were used to segment the aorta, the left and right common carotid arteries, the left and right subclavian arteries, as well as the brachiocephalic trunk. Radiomic features describing the segmented arteries were generated. Arterial ages for the six arteries were estimated using radiomic features and elastic net regression in a nested cross-validation setting. Associations between the constructed arterial ages, clinical factors, circulating proteins quantified using a Proseek Multiplex cardiovascular disease panel, cerebrovascular symptoms at baseline, and postoperative cardiovascular events over a 10-year follow-up period, were examined.ResultsAmong the arterial ages derived from six arterial territories, the aorta showed the strongest correlation with the chronological age. Hypertension and creatinine levels correlated with arterial ages across all six vascular territories, whereas CRP was only associated with an increased arterial age derived from the right subclavian artery. Eighteen circulating proteins, including growth/differentiation factor 15 and osteoprotegerin, were linked to either chronological age or arterial age. The arterial ages from the aorta, the left and right subclavian arteries, and the combined six arteries were associated with postoperative cardiovascular events. Among them, patients with the highest tertile of right subclavian arterial age had a 4.6-fold higher risk (95% CI 1.8–12.0) of developing postoperative cardiovascular events. No significant association was observed between chronological age and postoperative cardiovascular events. Incorporating arterial age from the right subclavian artery significantly improved postoperative cardiovascular risk prediction, increasing the Concordance-index by 0.05 compared to using chronological age in the model.ConclusionArterial age from six major arteries were associated with clinical risk factors and improved the prediction of postoperative events. This suggests that incorporating arterial age into risk prediction enhances the ability to identify individuals at high cardiovascular risk, particularly among those undergoing carotid endarterectomy surgery.

The purpose of our study was to describe patterns of airway compression identified on cross-sectional imaging in infants and children with either right aortic arch and aberrant left subclavian artery or left aortic arch with aberrant right subclavian artery. Data from MR imaging and CT performed to evaluate pediatric patients for extrinsic airway compression were reviewed for cases that revealed an aberrant right or left subclavian artery. Clinical, endoscopic, and imaging findings in identified cases were reviewed. Recurrent patterns of extrinsic compression were reviewed among cases. Twelve patients with right aortic arch with aberrant left subclavian artery and nine patients with left aortic arch and aberrant right subclavian artery were identified. All 12 with right aortic arch with aberrant left subclavian artery had airway compression shown, with multiple sites or diffuse compression in six. Of these 12 patients, nine had compression at the level of the arch and aberrant subclavian artery (10 had Kommerell's diverticulum), and nine had compression of the distal airway in association with a midline descending aorta. Five of the nine patients with left aortic arch and aberrant right subclavian artery had airway compression shown, all at the level of the arch and aberrant subclavian artery. None of these compressions was associated with either Kommerell's diverticulum or midline descending aorta. Both right and left aberrant subclavian arteries can be associated with symptomatic airway compression, but the patterns of compression are different. The airway compression in right aortic arch with aberrant left subclavian artery is often associated with either Kommerell's diverticulum or midline descending aorta, whereas compression associated with left aortic arch and aberrant right subclavian artery is not.

Long-term patency of surgical left subclavian artery revascularization