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Hybrid treatment for thoracic aortic aneurysm combined with aberrant right subclavian artery.

Lee JH, Ko YG, Yoon YN, Choi D, Lee DY - Korean Circ J (2013)

Bottom Line: An aberrant right subclavian artery (ARSA) is the most common vascular abnormality of the aortic arch and is associated with development of aneurysms in 3-8% of these anomalies.In this case report, we describe an 84-year-old man with a symptomatic ARSA treated with staged hybrid procedure combining surgical replacement of the ascending aorta and bilateral carotid-to-subclavian artery bypass with implantation of a stent graft in the aortic arch and descending aorta.Our case suggests that a less invasive hybrid therapy can be performed successfully for the treatment of ARSA with aneurysmal change in patients at high surgical risk.

View Article: PubMed Central - PubMed

Affiliation: Division of Cardiology, Yonsei University College of Medicine, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea.

ABSTRACT
An aberrant right subclavian artery (ARSA) is the most common vascular abnormality of the aortic arch and is associated with development of aneurysms in 3-8% of these anomalies. In this case report, we describe an 84-year-old man with a symptomatic ARSA treated with staged hybrid procedure combining surgical replacement of the ascending aorta and bilateral carotid-to-subclavian artery bypass with implantation of a stent graft in the aortic arch and descending aorta. Our case suggests that a less invasive hybrid therapy can be performed successfully for the treatment of ARSA with aneurysmal change in patients at high surgical risk.

No MeSH data available.


Related in: MedlinePlus

One-month follow-up computed tomography images of thoracic aorta presenting a TAA completely excluded by stenting graft. A: horizontal plane image. B: three-dimensional reconstructed image. SVC: superior vena cava, RCCA: right common carotid artery, LCCA: left common carotid artery, TAA: thoracic aortic aneurysm, T: trachea, E: esophagus, ARSA: aberrant right subclavian artery, LSA: left subclavian artery, AA: ascending aorta, DA: descending aorta.
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Figure 4: One-month follow-up computed tomography images of thoracic aorta presenting a TAA completely excluded by stenting graft. A: horizontal plane image. B: three-dimensional reconstructed image. SVC: superior vena cava, RCCA: right common carotid artery, LCCA: left common carotid artery, TAA: thoracic aortic aneurysm, T: trachea, E: esophagus, ARSA: aberrant right subclavian artery, LSA: left subclavian artery, AA: ascending aorta, DA: descending aorta.

Mentions: The second procedure was performed 14 days after the first procedure. Under general anesthesia, a left neck skin incision was made. Left common carotid and left subclavian arteries were exposed. A bypass surgery connecting common carotid artery and subclavian artery was performed using an 8 mm hemashield graft. A bypass surgery connecting the right common carotid artery with the subclavian artery was performed 6 days later as a third stage procedure because of fragile patient's condition after the surgery. After the closure of the incision site, the patient was placed under a fluoroscope. Both common femoral arteries are punctured. A 5 Fr marker pigtail catheter was inserted through the left femoral artery for the angiographic guidance. The right femoral artery was prepared for the later closure using two Perclose ProGlide suture closure devices (Abbott Vascular, Redwood City, CA, USA). Amplatz Vascular Plugs II (14 mm in diameter, AGA Medical Corporation, Golden Valley, MN, USA) were implanted into the right and the left subclavian artery using a 7 Fr shuttle sheath in order to prevent retrograde endoleaks into aortic aneurysm. A 0.035 inch extra stiff wire (Lunderquist, Cook Inc., Bloomington, IN, USA) was inserted through the right femoral artery into the ascending aorta. A 34×202 mm thoracic stent graft (Zenith TX2, Cook, Bloomington, IN, USA) was inserted over the wire and deployed within the hemashield graft implanted in the aortic arch. Stent grafts of appropriate size were not available from one vendor at that time. Therefore, an additional 40×100 mm stent graft (SEAL, S & G, Seoul, Korea) was implanted distal to the first stent graft in an overlap manner. A 40 mm balloon (Coda, Cook Inc., Bloomington, IN, USA) was used to appose the stent graft the aorta wall under rapid pacing. An immediate post-implant aortography showed no significant endoleak (Fig. 3). The right femoral artery access site was closed by tightening the knots prepared by Preclose technique without complication. At a CT taken before discharge, the aneurysm was completely excluded without significant endoleak. The patient was discharged in good status 5 days after the stent graft procedure and in the subsequent 2 years has remained well with no complications (Fig. 4).


Hybrid treatment for thoracic aortic aneurysm combined with aberrant right subclavian artery.

Lee JH, Ko YG, Yoon YN, Choi D, Lee DY - Korean Circ J (2013)

One-month follow-up computed tomography images of thoracic aorta presenting a TAA completely excluded by stenting graft. A: horizontal plane image. B: three-dimensional reconstructed image. SVC: superior vena cava, RCCA: right common carotid artery, LCCA: left common carotid artery, TAA: thoracic aortic aneurysm, T: trachea, E: esophagus, ARSA: aberrant right subclavian artery, LSA: left subclavian artery, AA: ascending aorta, DA: descending aorta.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3569571&req=5

Figure 4: One-month follow-up computed tomography images of thoracic aorta presenting a TAA completely excluded by stenting graft. A: horizontal plane image. B: three-dimensional reconstructed image. SVC: superior vena cava, RCCA: right common carotid artery, LCCA: left common carotid artery, TAA: thoracic aortic aneurysm, T: trachea, E: esophagus, ARSA: aberrant right subclavian artery, LSA: left subclavian artery, AA: ascending aorta, DA: descending aorta.
Mentions: The second procedure was performed 14 days after the first procedure. Under general anesthesia, a left neck skin incision was made. Left common carotid and left subclavian arteries were exposed. A bypass surgery connecting common carotid artery and subclavian artery was performed using an 8 mm hemashield graft. A bypass surgery connecting the right common carotid artery with the subclavian artery was performed 6 days later as a third stage procedure because of fragile patient's condition after the surgery. After the closure of the incision site, the patient was placed under a fluoroscope. Both common femoral arteries are punctured. A 5 Fr marker pigtail catheter was inserted through the left femoral artery for the angiographic guidance. The right femoral artery was prepared for the later closure using two Perclose ProGlide suture closure devices (Abbott Vascular, Redwood City, CA, USA). Amplatz Vascular Plugs II (14 mm in diameter, AGA Medical Corporation, Golden Valley, MN, USA) were implanted into the right and the left subclavian artery using a 7 Fr shuttle sheath in order to prevent retrograde endoleaks into aortic aneurysm. A 0.035 inch extra stiff wire (Lunderquist, Cook Inc., Bloomington, IN, USA) was inserted through the right femoral artery into the ascending aorta. A 34×202 mm thoracic stent graft (Zenith TX2, Cook, Bloomington, IN, USA) was inserted over the wire and deployed within the hemashield graft implanted in the aortic arch. Stent grafts of appropriate size were not available from one vendor at that time. Therefore, an additional 40×100 mm stent graft (SEAL, S & G, Seoul, Korea) was implanted distal to the first stent graft in an overlap manner. A 40 mm balloon (Coda, Cook Inc., Bloomington, IN, USA) was used to appose the stent graft the aorta wall under rapid pacing. An immediate post-implant aortography showed no significant endoleak (Fig. 3). The right femoral artery access site was closed by tightening the knots prepared by Preclose technique without complication. At a CT taken before discharge, the aneurysm was completely excluded without significant endoleak. The patient was discharged in good status 5 days after the stent graft procedure and in the subsequent 2 years has remained well with no complications (Fig. 4).

Bottom Line: An aberrant right subclavian artery (ARSA) is the most common vascular abnormality of the aortic arch and is associated with development of aneurysms in 3-8% of these anomalies.In this case report, we describe an 84-year-old man with a symptomatic ARSA treated with staged hybrid procedure combining surgical replacement of the ascending aorta and bilateral carotid-to-subclavian artery bypass with implantation of a stent graft in the aortic arch and descending aorta.Our case suggests that a less invasive hybrid therapy can be performed successfully for the treatment of ARSA with aneurysmal change in patients at high surgical risk.

View Article: PubMed Central - PubMed

Affiliation: Division of Cardiology, Yonsei University College of Medicine, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Korea.

ABSTRACT
An aberrant right subclavian artery (ARSA) is the most common vascular abnormality of the aortic arch and is associated with development of aneurysms in 3-8% of these anomalies. In this case report, we describe an 84-year-old man with a symptomatic ARSA treated with staged hybrid procedure combining surgical replacement of the ascending aorta and bilateral carotid-to-subclavian artery bypass with implantation of a stent graft in the aortic arch and descending aorta. Our case suggests that a less invasive hybrid therapy can be performed successfully for the treatment of ARSA with aneurysmal change in patients at high surgical risk.

No MeSH data available.


Related in: MedlinePlus