A rare case of a blunt thoracic aortic injury in a patient with an aberrant right subclavian artery: A case report and literature review (original) (raw)
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Left Subclavian Artery - Does It Need Attention During TEVAR For Blunt Traumatic Aortic Injury
2020
Introduction: Endovascular treatment for Blunt Thoracic Aortic Injury is currently an emerging alternative as compared to traditional open repair due to superior outcomes in terms of mortality and morbidity. However, the decision to revascularize the left subclavian artery remains controversial in cases requiring the coverage of the left subclavian artery. We report our experience with endovascular stent-graft repair for blunt traumatic thoracic aorta injury. Methods: Medical records from 11 patients who underwent Thoracic Endovascular Aortic Repair (TEVAR) for Blunt Thoracic Aortic Injury (BTAI) between January 2017 to April 2019 were analysed Results: Among the 11 patients who sustained BTAI, 10 of them have been caused by motor vehicle accidents with the exception of 1 patient who sustained a fall from height. The mean Injury Severity Score is 32.72. Time elapsed between injury and TEVAR ranged between 13 hours and 321.17 hours with a mean of 73.47 hours and a median of 31.5 hour...
Journal of Endovascular Therapy, 2014
P urpose: To report the use of parallel grafts to extend the proximal landing zone for stentgraft repair of aortic transection involving an aberrant right subclavian artery (ARSA). Case Report: A 28-year-old patient was referred for treatment of traumatic aortic transection with contained rupture at the level of an ARSA. Immediate thoracic endovascular aortic repair (TEVAR) was planned because of hemodynamic instability. To achieve rapid sealing and maintain perfusion to both subclavian arteries, a chimney stent to the left subclavian artery (LSA) and a periscope stent-graft to the ARSA were deployed successfully. After surgical repair of all fractures, the patient was discharged 1 month after the initial injury in good condition. Imaging follow-up at 10 months showed a stable repair, patent parallel grafts, and no complications. Conclusion: TEVAR with chimney and periscope grafts proved to be a safe and quick treatment for a patient requiring ARSA repair in acute aortic transection. This technique maintained blood flow to the ARSA and LSA in a totally endovascular approach, which could be very valuable in transection cases where bypass surgery to supra-aortic branches is compromised or deemed challenging due to thoracic wall and/or neck trauma. Parallel grafting can be a valuable tool to address any acute aortic pathology as it can be performed with off-the-shelf devices.
Journal of Vascular Surgery, 2013
This single-center, prospective study aimed to investigate the technical success and outcome of intentional coverage of the left subclavian artery (LSA) in patients undergoing thoracic endovascular aortic repair (TEVAR) for traumatic rupture of the aortic isthmus at a tertiary care medical center. Methods: From January 2005 to June 2011, patients who presented with traumatic aortic transection underwent TEVAR with coverage of the LSA when the distance between the artery and the rupture was <2 cm. At 12, 24, and 72 hours postoperatively, clinical and neurologic evaluation including transcranial Doppler insonation of the brachial artery was performed. A decrease in peak systolic velocity (PSV) >60% with respect to the contralateral one was considered relevant. Functional status of the left arm was evaluated using a provocative test. Thoracoabdominal computerized tomographic angiography was performed postoperatively at 3-, 6-, and 12-month follow-up. Results: Thirty-one patients (mean age 35 years) underwent emergency TEVAR for traumatic aortic transection with intentional LSA coverage during the study period. In four cases (12.9%) coverage was partial. Two patients (6.4%) died during the postoperative period due to associated lesions. No signs of vertebrobasilar insufficiency, stroke, or paraplegia were observed in any of the patients. Nine patients (36%) had severe arm claudication (ischemic pain within 60 seconds of beginning arm exercise and decrease of PSV between 50% and 60%). Risk factors for the condition were left vertebral artery diameter <3 mm (P < .0001). A significant correlation was found between the degree of PSV reduction and left arm symptoms (P < .0001). There was an improvement in ischemic arm symptoms (P < .0001) during mean follow-up of 36 months (range, 6-65 months), with only one patient (4.2%) presenting with severe claudication. Freedom from reintervention at 48 months was 93.5%. No signs of endoleaks or graft migrations were detected on computerized tomographic angiography control scans. Conclusions: Coverage of the LSA during TEVAR for traumatic aortic injuries appears to be a feasible, safe method for extending the endograft landing zone without increasing the risk of paraplegia, stroke, or left arm ischemia. Left vertebral artery diameter can be used to identify patients at risk for postoperative left arm ischemia.
The Heart Surgery Forum
Association of elective debranching and endovascular thoracic aortic repair (TEVAR) with aberrant left vertebral artery (AVA) revascularization and supra-aortic left carotid-subclavian bypass in post-traumatic pseudoaneurysm of the distal aortic arch are extremely rare procedures that can minimize unnecessary neurologic complications. The patient was a 42-year-old man, stable, with a post-traumatic transection of the aortic isthmus, with origin of the AVA between the left common carotid artery (LCCA) and left subclavian artery (LSA). Preoperative planning and proper sizing of the stent-grafts were evaluated by means of computed tomography angiography (CT scan) images. The patient underwent a hybrid procedure that included TEVAR with landing zone 2, covering the origin of both the AVA and LSA and concomitant supra-aortic reimplantation of the AVA in the LCCA and left carotid-subclavian bypass combined with both ligation of the AVA and LSA proximally. Postoperative arteriography image...
Journal of Vascular Surgery Cases and Innovative Techniques, 2019
Aberrant origin of the left vertebral artery (LVA) can pose a challenge during thoracic endovascular aortic repair. We encountered such a patient who was involved in a motor vehicle accident in whom computed tomography angiography revealed a grade IIIB blunt aortic injury with an anomalous origin of the LVA distal to the origin of the left subclavian artery. On-table aortography confirmed dominance of the LVA. Hence, an open left carotidvertebral and then left carotid-subclavian artery bypass was performed, followed by thoracic endovascular aortic repair. The patient recovered well and was discharged home 3 days later.
Texas Heart Institute Journal
Aberrant right subclavian artery is a common aortic arch anomaly that can cause dysphagia as a result of compression by the aberrant artery. For patients with an aneurysm associated with an aberrant right subclavian artery, surgical or endovascular intervention is a well-described treatment. However, for patients with a nonaneurysmal aberrant right subclavian artery, treatment with thoracic endovascular aortic repair has been limited. We describe the use of thoracic endovascular aortic repair and subclavian revascularization to treat esophageal stricture in a patient with a symptomatic nonaneurysmal aberrant right subclavian artery. The patient's dysphagia was successfully relieved after the operation.
Journal of Vascular Surgery, 2009
The Society for Vascular Surgery pursued development of clinical practice guidelines for the management of the left subclavian artery with thoracic endovascular aortic repair (TEVAR). In formulating clinical practice guidelines, the society selected a panel of experts and conducted a systematic review and meta-analysis of the literature. They used the grading of recommendations assessment, development, and evaluation (GRADE) method to develop and present their recommendations. The overall quality of evidence was very low. The committee issued three recommendations. Recommendation 1: In patients who need elective TEVAR where achievement of a proximal seal necessitates coverage of the left subclavian artery, we suggest routine preoperative revascularization, despite the very low-quality evidence (GRADE 2, level C). Recommendation 2: In selected patients who have an anatomy that compromises perfusion to critical organs, routine preoperative LSA revascularization is strongly recommended, despite the very low-quality evidence (GRADE 1, level C). Recommendation 3: In patients who need urgent TEVAR for life-threatening acute aortic syndromes where achievement of a proximal seal necessitates coverage of the left subclavian artery, we suggest that revascularization should be individualized and addressed expectantly on the basis of anatomy, urgency, and availability of surgical expertise (GRADE 2, level C).