Endovascular repair of thoracic aortic dissection associated with right-sided aortic arch：report of four cases

Aortic dissection involving a right-sided aortic arch（RAA）is extremely rare with an incidence in adults of 0.04%to 0.1%^（[1]）.Thoracic aortic dissection associated with RAA is even a more uncommon and life-threatening condition.For complicated aortic dissection,conventional open surgical repair is considered a standard therapy^（[2]）.However,

Intracranial hemangiopericytoma with right-sided aortic arch: a case report and summary of experience

Hemangiopericytoma is clinically rare and easily confused with meningioma.Right-sided aortic arch is also a rare disease of congenital cardiovascular variability.The intracranial hemangiopericytoma associated with the right-sided aortic arch has not been reported in the literature.We are here to register a case of right aortic arch concurrent with intracranial hemangiopericytoma;the patient was initially thought to be a simple meningioma,but he was eventually diagnosed as a hemangiopericytoma with right aortic arch and multiple intracranial vascular stenosis and malformation.Whether there was a genetic correlation between the two provides a potential research direction for us.Therefore,the diagnosis and treatment of some rare diseases should be a more comprehensive analysis and evaluation.Adequate examination and accurate diagnosis are crucial,which will directly affect the efficacy of surgery and the prognosis of patients.

Three-dimensional lattice Boltzmann method for simulating blood flow in aortic arch

The three-dimensional （3D） lattice Boltzmann models, 3DQ15, 3DQ19 and 3DQ27, under different wall boundary conditions and lattice resolutions have been investigated by simulating Poiseuille flow in a circular cylinder for a wide range of Reynolds numbers. The 3DQ19 model with improved Fillippova and Hanel （FH） curved boundary condition represents a good compromise between computational efficiency and reliability. Blood flow in an aortic arch is then simulated as a typical haemodynamic application. Axial and secondary fluid velocity and effective wall shear stress profiles in a 180° bend are obtained, and the results also demonstrate that the lattice Boltzmann method is suitable for simulating the flow in 3D large-curved vessels.

Diagnosis of Congenital Aortic Arch Anomalies in Chinese Children by Multi-Detector Computed Tomography Angiography

Summary： The purpose of this study was to evaluate the value of multi-detector computed tomography （MDCT） angiography for the diagnosis of congenital aortic arch anomalies and present the radiological images of congenital aortic arch anomalies in Chinese children. MDCT angiography and transthoracic echocardiography （TTE） were applied for the diagnosis of congenital aortic arch anomalies in 362 Chi- nese children between May 2006 and December 2011 （age ranges from 5 days to 12 years; mean age, 3.3 years）. Surgery and/or catheter angiography （CA） were conducted in all patients to confirm the final diagnosis. In the 362 Chinese children with congenital heart anomalies, congenital aortic arch anomalies were definitely diagnosed in 198 children and 164 children ruled out by operation and/or （CA）. Among the 198 children with anomalies, coarctation of aorta （CoA）, interruption of aortic arch （IAA）, fight aor- tic arch, aberrant right subclavian artery and double aortic arch were diagnosed in 134, 32, 20, 10 and 2 children respectively, and there were 6 cases with uncommon congenital aortic arch anomalies： 2 had double aortic arch including 1 with five branches of the aortic arch, 2 had isolation of the right sub- clavian artery with two patent ductus arteriosus （PDA）, 1 had an isolation of the common carotid artery with a PDA, and 1 had double PDA with a single ventricle and pulmonary artery atresia. Among the 32 children with IAA, 28 were of type A, and 4 were of type B. The diagnostic sensitivity, specificity and accuracy of MDCT angiography for congenital aortic arch anomaiies were 100% （198/198）, 98% （161/164） and 99% （359/362）, respectively. The diagnostic sensitivity, specificity and accuracy of TTE were 92% （182/198）, 81% （133/164） and 87% （315/362）, respectively. In conclusion, MDCT angiogra- phy is a reliable, noninvasive imaging technique for the diagnosis of congenital aortic arch anomalies in children. Sometimes, even more information can be obtained from this technique than from conven- tional angiography.

Cardiac-MRI demonstration of the ligamentum arteriosum in a case of right aortic arch with aberrant left subclavian artery

Right-sided aortic arch with aberrant left subclavian artery (RAA/ALSC) is the second most common mediastinal complete vascular ring. Adult presentation of dysphagia lusoria due to a RAA/ALSC is uncommon with fewer than 25 cases reported in the world literature. The left lateral portion of this vascular ring is not a vessel, but an atretic ductus arteriosus, the ligamentum arteriosum, which has been identified in different cases as the major cause of tracheo-esophageal impingement. Surgical division of the ligamentum arteriosum allows the vessels to assume a less constricting pattern decreasing dysphagic symptoms. Clear visualization of the ligamentum arteriosum by diagnostic imaging has not been obtained in previously reported cases. We demonstrated, using magnetic resonance imaging, the location and the complete course of a left-sided ligamentum arteriosum in a patient with adult-onset dysphagia due to a RAA/ALSC with a small Kommerell' s diverticulum, providing, during the same session, a complete assessment of both mediastinal vascular abnormalities and esophageal impingement sites.

Acute Type A Aortic Dissection—Replacement of Ascending Aorta, Aortic Arch and Antegrade Stenting of the Descending Thoracic Aorta Using the Thoraflex™Hybrid Plexus Device (Terumo Aortic)—“Frozen Elephant Trunk”: The Plymouth Way!

Objectives: To describe our technique for the implantation of the Thoraflex Hybrid prosthesis for replacement of the aortic arch in a safe and reproducible way. Materials: Thoraflex™ Hybrid Plexus Device (Terumo Aortic). Design: Drawing on our own experience over the past 4 years in the management of acute type A aortic dissection, we have distilled the essentials of our “Frozen Elephant Trunk” technique which have led us through our own learning curve to the improved management of this taxing condition. Method/ Results: Small extension of the median sternotomy incision along the medial border of sternocleidomastoid muscle. End to side graft anastomosis near the origin of the left subclavian artery during cooling on bypass towards 20 degrees. Attention to cardiac protection and maintenance of cerebral perfusion during the shortened corporeal arrest period. Excellent results in 24 consecutive AAAD patients with just one hospital mortality. Conclusions: We believe we are entering a new phase in the treatment of AAAD, facilitated by the availability of a hybrid prosthesis which combines expanding stent technology with familiar surgical graft material. Our particular management of the left subclavian artery and of the cerebral circulation during implantation has contributed to an expeditious and reproducible method of treating dissection within the arch of the aorta and beyond.

MDCT of right aortic arch with aberrant left subclavian artery associated with kommerell diverticulum and calcified ligamentum arteriosum

We present a case of the right aortic arch with kommerell diverticulum (KD) and aberrant left subclavian artery in a symptomatic 50-year-old patient with a calcification in the presumed attachment site of the ligamentum arteriosum (LA) to the KD. In another 30-year-old male patient, the entire course of a calcified LA was demonstrated using multidetector row computed tomography.

Left recurrent laryngeal nerve palsy following aortic arch stenting: A case report

BACKGROUND Aortic arch stenting is continuously emerging as a safe and effective option to alleviate aortic arch stenosis and arterial hypertension.CASE SUMMARY We present a 15-year-old girl with aortic arch hypoplasia who had undergone implantation of an uncovered 22 mm Cheatham-Platinum stent due to severe(native)aortic arch stenosis.On follow-up seven months later,she presented a significant re-stenosis of the aortic arch.A second stent(LD Max 26 mm)was implanted and both stents were dilated up to 16 mm.After an initially unremarkable post-interventional course,the patient presented with hoarseness five days after the intervention.MRI and CT scans ruled out an intracranial pathology,as well as thoracic hematoma,arterial dissection,and aneurysm around the intervention site.Laryngoscopy confirmed left vocal fold paresis attributable to an injury to the left recurrent laryngeal nerve(LRLN)during aortic arch stenting,as the nerve loops around the aortic arch in close proximity to the area of the implanted stents.Following a non-invasive therapeutic approach entailing regular speech therapy,the patient recovered and demonstrated no residual clinical symptoms of LRLN palsy after six months.CONCLUSION Left recurrent laryngeal nerve palsy is a rare complication of aortic arch stenting not previously reported.

Isolated Type C Interrupted Aortic Arch in Adult:Extra-anatomic Repair Using Circulatory Arrest

INTERRUPTED aortic arch （IAA） is a rare congenital malformation that occurs in 5.8 per million live births. 1 IAA was thought to be incompatible with life once the ductus arteriosus closed. However, ifextensive collateral circulation is p possible. We report treated successfully an unusual resent at case of with extra-anatomic under deep hypothermia drculatory arrest birth survival is IAA, who was aortic repair

Aortic arch calcification on chest X-ray combined with coronary calcium score show additional benefit for diagnosis and outcome in patients with angina

Background The coronary artery calcium （CAC） and aortic arch calcification （AoAC） are individually associated with cardiovascular disease and outcome. This study investigated the predictive value of AoAC combined with CAC for cardiovascular diagnosis and outcome in patients with angina. Methods A total of 2018 stable angina patients who underwent chest X-ray and cardiac multi-detector computed tomography were followed up for four years to assess adverse events, which were categorized as cardiac death, stroke, myocardial infarction, or repeated revascularization. The extent of AoAC on chest X-ray was graded on a scale from 0 to 3. Results During the four years of fol- low-up, 620 patients were treated by coronary stenting and 153 （7%） adverse events occurred. A higher grade of AoAC was associated with a higher CAC score. Cox regression showed that the CAC score, but not AoAC, were associated with adverse events. In patients with CAC score 〈 400, AoAC showed an additive predictive value in detecting significant coronary artery disease （CAD）. A gradual increases in the risk of adverse events were noted if AoAC was present in patients with similar CAC score. Conclusions As AoAC is strongly correlated with the CAC score regardless of age or gender, careful evaluation of CAD would be required in patients with AoAC on conventional chest X-rays.

Cervical aortic arch with aneurysm formation and an anomalous right subclavian artery and left vertebral artery:A case report

BACKGROUND A cervical aortic arch(CAA)refers to a high-riding aortic arch(AA)that often extends above the level of the clavicle.This condition is very rare,with an incidence of less than 1/10000.CASE SUMMARY A 29-year-old woman was admitted to the otolaryngology department of our hospital for repeated bilateral purulent nasal discharge for the prior 3 mo.The patient was diagnosed with chronic sinusitis and chronic rhinitis at admission.A preoperative noncontrast chest computed tomography scan showed a high-riding,tortuous AA extending to the mid-upper level of the first thoracic vertebra with local cystic dilatation.A further computed tomography angiography examination showed that the brachiocephalic trunk,left common carotid artery,left vertebral artery(LVA)(slender),and left subclavian artery sequentially branched off of the aorta from the proximal end to the distal end of the AA.The proximal end of the right subclavian artery(RSCA)was tortuous and dilated.The AA showed tumorlike local expansion,with a maximum diameter of approximately 4 cm.After consultation with the department of cardiac macrovascular surgery,the patient was diagnosed with left CAA with aneurysm formation and an anomalous RSCA and LVA and was transferred to that department.The patient underwent AA aneurysm resection and artificial blood vessel replacement under general anesthesia and cardiopulmonary bypass.No abnormality was found during the 2-mo follow-up after discharge.CONCLUSION A CAA is a rare congenital anomaly of vascular development.The present unique case of CAA with aneurysm formation and an anomalous RSCA and LVA enriches existing CAA data.

Double aortic arch and nasogastric tubes: A fatal combination

Double aortic arch is a common form of complete vascular ring that encircles both the trachea and the esophagus, and presents with various respiratory and esophageal symptoms, usually in the pediatric population. We present a case of double aortic arch in an adult patient that manifested as massive upper gastrointestinal bleeding after prolonged nasogastric intubation.

Application of cerebral-myocardial perfusion combined with lower body circulatory arrest in pediatric complex aortic arch surgery

Background Adjunct RCP to DHCA ensures some extent uninterrupted cerebral perfusion and that promotes one-stage repair of complex aortic arch anomaly.One-stage repair may induce longer myocardial ischemic time.So there evolved cerebral-myocardial perfusion to reduce myocardial ischemic time.Methods We reviewed 78 patients from January 2010 to July 2017 in our center.

Hybrid Aortic Arch Replacement: A Novel Surgical Technique for a Difficult Problem

Aneurysms of the aortic arch and descending aorta are invariably fatal if left to expand, but also represent considerable surgical challenges. The development of endovascular stent grafts in combination with aortic debranching has produced results at least comparable to the more traditional surgical approach, but with considerably less comorbidity. We describe a technique for debranching of the aortic arch without the use of circulatory support, and in doing so creating a landing zone for thoracic endovascular aneurysm repair (TE-VAR). Although this procedure has been described, innovative features of our technique include transection of the left hemisternum to produce excellent surgical exposure, and ligation of the debranched arch vessels to prevent Type II endoleaks following TEVAR. Additionally, by not using mechanical circulatory support, we remove the associated pathophysiological insult, inflammatory response, and coagulopathy that is synonymous with cardiopulmonary bypass. There is also no need for circulatory arrest, with its associated perils.

Difference and similarity between type A interrupted aortic arch and aortic coarctation in adults:Two case reports

BACKGROUND Aortic coarctation(CoA)is usually confused with interrupted aortic arch(IAA),especially adult type A interrupted aortic arch,due to their similar anatomical location.Although the main difference between them is whether arterial lumen exhibits continuity or not,the clinical manifestations are similar and connection exists between them.Adult type A IAA is considered as an extreme form of CoA,which is complete discontinuity of aortic function and lumen caused by degenerative arterial coarctation.This paper reports two cases(interrupted aortic arch and severe aortic coarctation)to analyze the difference and similarity between them.CASE SUMMARY The two cases of patients presented with hypertension for many years.Computed tomography angiography showed that the aortic arch and descending aorta were discontinuous or significantly narrowed with extensive collateral flow.The IAA patient refused surgical treatment and blood pressure could be controlled with drugs.While the CoA patient underwent stent implantation because of uncontrollable hypertension,the blood flow recovered smoothly and the blood pressures at both ends of the stenosis returned to normal after surgery.CONCLUSION Adult type A IAA and CoA have difference and similarity,and type A IAA is associated with CoA to a certain extent.The treatment method should be chosen based on the patient's clinical symptoms rather than the severity of the lesion.

Double Aortic Arch in Adolescence: A Case Report

Introduction: Double aortic arch (DAA) is the most frequently encountered vascular ring malformation characterized by a complete encirclement of the trachea and esophagus by the aortic arch with a wide clinical spectrum. Objective: The aim of this study is to describe a case of DAA in adolesecents. Case Presentation: An 11-year-old boy was admitted for chronic productive cough which initially was diagnosed with pulmonary arterial hypertension. The final diagnosis was DAA which was established after chest computed tomography (CT) scan. Conclusion: Establishing a diagnosis of DAA in adolescents requires thorough understanding and clinical skills in performing diagnostic steps. The management of heart failure symptoms and other comorbidities is essential while preparing for its definite therapy.

A canine model of aortic arch aneurysm created with autologous pericardium

Background:To establish a canine model of aortic arch aneurysm that is suitable for research on new devices and techniques applied to the aortic arch.Materials and methods:Fifteen mongrel dogs underwent surgery.The autologous pericardial patch was sewn on the aortotomy site in the anterior wall of the aortic arch.The animals were followed up for 3 months postoperatively.Computed tomography angiography was used to visualize and measure the aneurysm model.Hematoxylin and eosin staining was used to observe the histological characteristics of the aneurysm model.Changes in aneurysm diameter over time were analyzed using analysis of variance.Results:One dog died of hemorrhage during surgery.Fourteen dogs survived the surgical procedure.Two of them died on the first postoperative day because of ruptures at the suturing margin.The diameter of the aneurysm model was twice as large as that of the aortic arch.There was no significant change in the maximum diameter of the aneurysm model during the follow-up period.Conclusions:We established a controllable and stable aortic arch aneurysm model created with an autologous pericardium patch.The aneurysm model can be used to research endoleaks after thoracic endovascular aortic repair and new endovascular techniques can be applied to the aortic arch.

Perioperative anesthetic management of interrupted aortic arch associated with severe pulmonary hypertension in a young adult: case report and review of the literature

The interrupted aortic arch (IAA) is rare congential heart defect and entails a very poor prognosis without surgical treatment. We describe a young adult patient with IAA associated with severe pulmonary hypertension and discuss the perioperative anesthetic management of single-stage surgical correction in this patient. Preoperative anesthetic preparation with better understanding of the malformation, intraoperative hemodynamic monitoring, and adequate alveolar ventilation in the perioperative period were all important factors contributing to a successful outcome.

Minimally Invasive Surgical Technique in Double Aortic Arch with Distal Atretic Left-Side in Infant:From a Single-Surgeon Clinical Experience

Background:Double aortic arch(DAA)with distal left-sided aortic arch atresia(LAAA)can form complete vascular ring by ligamentum connection.We aimed to introduce an uncommon DAA-LAAA diagnosis and treatment by the minimally invasive surgical technique(MIST).Methods:We retrospectively reviewed 7 cases of DAA-LAAA that were treated from January 2017 to July 2021.All infant patients underwent surgical repair by minimally invasive surgical technique.Mean follow-up was 14.43 months(range,5–21 months).Results:There were seven patients with DAA-LAAA,including six males and one female.Median age was 19.29 months(range,9.0–29.0 months).Median weight was 11.30 kg(range,9.6–13.0 kg).Three patients were found severe tracheal compression by cardiac computed tomography angiography(cCTA).Six patients with isolated DAA-LAAA were performed operations through left subaxillary minithoracotomy,and one patient with ventricular septal defect(VSD)was performed operation concurrently under the cardiopulmonary bypass(CPB)through right subaxillary minithoracotomy.All patients had symptom improvement in the postoperative period and discharged successfully.Follow-up data showed good results in short-term.Conclusions:We introduce a new surgical pathway for DAA-LAAA treatment with good symptomatic relief in short-term.MIST is a safe,feasible and economical approach for infant patients.

Isolated interrupted aortic arch in an adult:A case report

BACKGROUND Interrupted aortic arch(IAA)is a rare congenital heart disease defined by an interruption of the lumen and anatomical continuity between the ascending and descending major arteries.It is usually found within a few hours or days of birth.Without surgery,the chances of survival are low.If IAA patients have an effective collateral circulation established,they can survive into adulthood.However,IAA in adults is extremely rare,with few reported cases.CASE SUMMARY A 27-year-old woman presented with a 6-year history of progressively worsening shortness of breath and chest tightness on exertion.She had cyanotic lips and clubbing of the fingers.A transthoracic echocardiogram revealed an enlarged heart and dilation of the main pulmonary artery.There was an abnormal 9 mm passage between the descending aorta and pulmonary artery.The ventricular septal outflow tract had a 14 mm defect.Doppler ultrasound suggested a patent ductus arteriosus and computed tomographic angiography showed the absence of the aortic arch.The diagnoses were ventricular septal defect,patent ductus arteriosus,and definite interruption of the aortic arch.Although surgical correction was recommended,the patient declined due to the surgical risks and was treated with medications to reduce pulmonary artery pressure and treat heart failure.Her condition has been stable for 12 mo of follow-up.CONCLUSION Although rare,IAA should be considered in adults with refractory hypertension or unexplained congestive heart failure.