A Case of Successful Surgical Management of Tracheo-Innominate Artery Fistula after Endovascular Repair / 日本心臓血管外科学会雑誌

A 15-year-old girl who had undergone a tracheostomy 4 years earlier because of holoprosencephaly and severe mental and physical disabilities had tracheo-innominate artery fistula with sudden-onset bleeding after endotracheal suctioning. Due to respiratory and circulatory instability, VIABAHN® was implanted in the brachiocephalic artery, and the patient was discharged on postoperative day 33. Three months later, rebleeding from the tracheostomy site was observed, and the patient was transported to our hospital. Although the bleeding stopped spontaneously on arrival, the patient experienced multiple bleeding episodes after admission. Therefore, transection of brachiocephalic artery was performed, after which the patient was discharged on postoperative day 20. Tracheo-innominate artery fistula is a rare complication that occurs after tracheostomy, but it is associated with a poor prognosis, and has a mortality rate of 100% if left untreated. Our case suggests that endovascular treatment using VIABAHN® for tracheo-innominate artery fistula is useful for temporary hemostasis.

Successful treatment of ischemic stroke associated with brachiocephalic artery stenosis using alteplase / Journal of Rural Medicine

Introduction: Brachiocephalic artery stenosis rarely causes right hemispheric infarction with associated left hemiparesis. To date, there have been no reported cases of stroke associated with brachiocephalic artery stenosis that were successfully treated with recombinant tissue-type plasminogen activator (rt-PA), alteplase.Case Report: An 80-year-old woman presented with left hemiparesis. Brain computed tomography showed no hemorrhage, and computed tomography angiography demonstrated brachiocephalic artery stenosis. Alteplase was administered based on a diagnosis of ischemic stroke. Brain magnetic resonance imaging showed multiple acute infarctions. Thereafter, the blood pressure of the right arm was found to be lower than that of the left arm. The patient’s neurological deficits gradually improved; she was eventually able to walk again and was thus discharged home.Conclusion: While the combination of left hemiparesis and a decrease in blood pressure in the right arm are well known in patients with stroke associated with Stanford type A aortic dissections, it may also occur in patients with stroke due to brachiocephalic artery stenosis. Unlike stroke associated with Stanford type A aortic dissections, stroke due to brachiocephalic artery stenosis may be treated with alteplase.

Transesophageal echocardiography evaluation of the aortic arch branches

Visualization of aortic arch branches by transesophageal echocardiography has been technically challenging. Visualizing these vessels helps in identifying the extent of dissection of the aorta, assessing the severity of carotid artery stenosis, presence of atheromatous plaques, patency of the left internal mammary artery graft, confirmation of subclavian artery cannulation, confirming holodiastolic flow reversal in the left subclavian artery by spectral Doppler imaging in case of severe aortic regurgitation, and confirming the optimal position of the intraaortic balloon perioperatively. The information obtained is helpful for diagnosis, monitoring, and decision-making during aortic surgery.

Treatment of acute Stanford type A aortic dissection using the Sun’s procedure with preservation of autologous brachiocephalic artery / 中国胸心血管外科临床杂志

@#Objective     To study surgical indication, technique for treating acute Stanford type A aortic dissection involving repair of the aortic arch using Sun’s procedure with preservation of autologous brachiocephalic artery. Methods     We retrospectively analyzed the clinical data of 28 consecutive patients (23 males, 5 females) who underwent operations on acute Stanford type A aortic dissection using Sun’s procedure with preservation of autologous brachiocephalic artery in our hospital between August 2011 and October 2013. The mean age was 29-62 (47±8) years. There were 26 patients with hypertension and 2 patients with Mafan syndrome. Sun’s procedure with preservation of autologous brachiocephalic artery was performed in all patients, concomitant procedure included aortic root replacement (Bentall) in 4 patients, aortic root replacement (Bentall) and mitral valve replacement (MVR) in 1 patient, aortic valsalva sinus plasty in 6 patients. Results     The cardiopulmonary bypass time was 167±37 min. The cross clamp time was 80±22 min. Selective cerebral perfusion time was 29±5 min. One patient died postoperatively from acute hepatic failure. Two patients suffered from transient neurologic deficit and recovered after treatment during follow-up. Computed tomography angiography (CTA) of aorta was performed in each patient before discharged from the hospital. The patency of the anastomotic site at brachiocephalic artery was identified. Descending aortic true lumen was significantly expanded. There was only 2 patients with endoleak and total thrombosis of false lumen was found near stent graft with 25 patients. The 27 patients were followed up for 47 (36-62) months. One patient with descending thoracic aortic dilatation underwent thoracoabdoninal aortic replacement. One combined with acute endometrial tear underwent thoracic endovascular aortic repair. Conclusion     Sun’s procedure with preservation of autologous brachiocephalic artery is safe and effective in the treatment of acute Stanford type A dissection in patients without brachiocephalic artery involved. Low mortality and complication rate are achieved, but the long-term results need the further follow-up.

Brachiocephalic Artery Cannulation for Patients with Diseased Ascending Aorta / 日本心臓血管外科学会雑誌

<p><b>Objective</b> : The ascending aortic cannulation (Ao-C) is the routine procedure for cardiopulmonary bypass (CPB) in our hospital. However, for patients with diseased ascending aorta, such as severely calcified aorta, dissected or aneurysmal aorta, we used brachiocephalic artery (BCA) cannulation. The effectiveness and simplicity of BCA cannulation was evaluated. <b>Methods</b> : For patients with diseased ascending aorta, BCA was cannulated when the diameter of BCA is larger than 10 mm and is free from calcification, since January 2013. There were 62 patients who underwent aortic valve replacement (AVR) for aortic valve stenosis and BCA cannulation was applied for 11 patients. Standard Ao-C was used for remaining 51 patients. There were 44 patients with dissected or aneurysmal ascending aorta and BCA cannulation was applied for 7 patients, axillary artery perfusion was used for 15 patients and standard Ao-C was used for 22 patients. Consciousness level at the time of awaking from general anesthesia and any complication related with BCA cannulation was evaluated for the effectiveness. Simplicity was evaluated by the time required to establish CPB after skin incision. <b>Results</b> : In AVR patients, there was 1 patient with delayed consciousness level recovery with BCA cannulation and this patient was found to have cerebral infarction by CT. Intraoperative aortic dissection, probably due to BCA cannulation was observed in 1 patient, very old fragile and long period steroid user. In diseased ascending aorta patients, no patient suffered neurological accident nor any complication due to cannulation. In AVR patients, the time required to establish CPB after skin incision was 51+/-9 min in BCA cannulation and 47+/-10 min in Ao-C patients (<i>p</i>=0.34). In diseased ascending aorta patients, the time required to establish CPB after skin incision was 49+/-49 min in BCA cannulation and 51+/-16 min (<i>p</i>=0.82). <b>Conclusion</b> : BCA cannulation is a very simple and safe technique to establish CPB for patients with diseased ascending aorta. However great care should be taken, and BCA cannulation should be avoided for the long term steroid users or patients with connective tissue disease.</p>

Origin of the Left Common Carotid Artery from the Brachiocephalic Artery.

Anatomical variations in the origin of the branches of the arch of the aorta are frequent. In this case report the left common carotid artery arose as a branch from the brachiocephalic artery. The left common carotid artery arose at a distance 11mm from the arch of the aorta and had an internal diameter of 9mm.

A Case of Endovascular Stent Grafting for Dissecting Brachiocephalic Artery Aneurysm Deriving from Anastomotic Leakage after Surgery for Acute Type A Aortic Dissection / 日本心臓血管外科学会雑誌

We report a case of a dissecting brachiocephalic artery aneurysm that developed at the anastomotic site following surgery for acute aortic dissection ; and which was successfully treated by stent grafting. The patient, a 62-year-old man, had undergone total arch replacement for an acute Stanford type A aortic dissection that accompanied dissection of the brachiocephalic artery. In the early postoperative period, he complained of dull pain in the right arm and fatigue on exertion. The blood pressure in the patient's right arm was found to be significantly lower than in the left. Enhanced computed tomography (CT) performed 1 month postoperatively revealed leakage at the anastomotic site of the brachiocephalic artery, leading to the formation of a false lumen and the creation of a dissecting aneurysm with a maximum short diameter of 30 mm. No re-entry was seen, and the greatly expanded false lumen was exerting pressure on the true lumen, causing ischemia of the arm. Enhanced CT performed 3 months postoperatively showed that the maximum short diameter of the aneurysm had increased to 35 mm. Because ischemic symptoms of the arm were also present, surgery was considered to be indicated, and stent grafting was performed. A stent graft was inserted via the right axillary artery and positioned to close the entry to the false lumen of the dissecting aneurysm. Symptoms resolved without any complications, and the patient was discharged 7 days after the surgery. The false lumen of the dissecting aneurysm completely disappeared, and no complications have developed during the 3-year interval since stent grafting. In this patient, stent grafting enabled minimally invasive closure of the entry to the dissecting aneurysm that had developed at the anastomosis site. We conclude that stent grafting is very useful for treating dissecting aneurysms caused by anastomotic leakage and without re-entry, as seen in this case.

Multiple Pseudoaneurysms of the Brachiocephalic Artery Following Penetrating Arrow Injury in the Neck.

Arrow injury in the neck with subsequent pseudoaneurysm formation of the brachiocephalic artery is an uncommon type of injury in our country. Initially it was a punctured wound in the neck which was simply repaired. About 13 days after the initial injury patient came back to hospital with severe respiratory distress and backache for which emergency tracheostomy was needed. This simple puncture wound subsequently developed haematoma in the neck and two pseudoaneurysms at distal brachiocephalic artery. CT angiogram was very helpful to confirm the diagnosis. Correct referral to tertiary hospital like National Institute Cardiovascular Diseases (NICVD) ,prompt diagnosis, definitive treatment of the injury and subsequent aggressive postoperative management saved the life of this young tailor.

Successful Replacement of the Dissecting Aneurysm of the Brachiocephalic Artery / 日本心臓血管外科学会雑誌

A brachiocepharic artery aneurysm is relatively rare in comparison with other peripheral artery aneurysms. A 62-year-old woman who had had a sudden chest pain 1 year previously was referred to our hospital because of a right upper mediastinal mass on a chest roentgenogram. Computed tomography demonstrated the dissection and dilatation of the innominate artery. The dissection extended to the right carotid artery and right subclavian artery. Furthermore, the ascending aorta was dilated. We performed reconstruction of the innominate artery with a Y-shaped composite graft and replacement of the ascending aorta and total aortic arch. Her postoperative course was uneventful with no neurological event. We describe our surgical strategy in this report with a review of the literature because operative methods and plans are various according to the shape and extent of the aneurysm of the brachiocepharic artery.

Estudo descritioo das variações anatômicas dos ramos do arco aórtico / Descriptivestudyy of anatomical variations of aortic arch brancess

O arco aórtico é o segundo segmento da aorta que se curva súpero posteriormente e para esquerda, sobre a face anterior da traqueia. originando três vasos: o primeiro ramo é a artéria tronco braquiocefálico que se ramifica em artéria subclávia direita e artéria carótida comum direita; o segundo é a artéria carótida comum esquerda e o terceiro é a artéria subclávia esquerda. As variações anatômicas dos ramos do arco aórtico são frequentes e podem surgir de diversos tipos (Tipo A, B, C, D e E). A trajetória desses vasos tem uma grande importância clínica e cirúrgica para profissionais e estudantes, podendo contribuir para realizar procedimentos na região anterior do pescoço minimizando lesões dessas estruturas. Este trabalho trata-se de um estudo descritivo macroscópico com abordagem quantitativa mediante análise de dezenove arcos aórtico provenientes de cadáveres humanos indigentes e formolizados a 10% pertencentes ao Laboratório de Anatomia Humana da Universidade de Rio Verde. A proposta deste estudo foi identificar, descrever e verificar o índice das variações anatômicas dos ramos do arco aórtico. Observou-se que quinze dos arcos (78,9%) apresentaram o padrão comum tipo A, e em quatro arcos (21,1%) eram variações anatômicas. Dentre essas variações, duas eram do tipo B (10,5%), uma do tipo C (5,3%) e uma do tipo D (5,3%).

The aortic arch is the second segment of the aorta that curves upper posteriorly and left on the anterior surface of the trachea. This, originate three vases: the first branch is the brachiocephalic trunk artery that branches into the right subclavian artery and right common carotid artery; the second is the left common carotid artery and the third is the left subclavian artery. Anatomical variations of the aortic arch branches are frequent and may arise from different types (Type A, B, C, D and E). The trajectory of these vessels has a great clinical and surgical importance for professionals and students can contribute to perform the procedure in the anterior neck injuries minimizing these structures. This work is in a macroscopic descriptive study with a quantitative approach through the analysis of nineteen aortic arches from indigent embalmed human cadavers and 10% belonging to the Laboratory of Human Anatomy, University of Rio Verde. The purpose of this study was to identify, describe and check the index of anatomical variations of the aortic arch branches. It was observed that fifteen of the arches (78.9%) showed type A common pattern, and four arches (21.1%) were anatomical variations. Among these variations, two were type B (10.5%), one of type C (5.3%) and type D (5.3%).

Duplex Sonographic Findings of Isolated Left Brachiocephalic Artery / 대한뇌졸중학회지

Isolated left brachiocephalic artery with right aortic arch is extremely rare congenital anormaly. This malformation can cause subclavian steal phenomenon. We report the duplex sonographic and conventional angiographic findings of isolated left brachiocephalic artery in a 22-year-old female presented with dizziness.

Innominate Artery Injury by Blunt Chest Trauma: A case report / 대한흉부외과학회지

Innominate artery injury by blunt chest trauma is rarely reported. This report describes a 40-year-old male who had innominate artery dissection and pseudoaneurysm caused by blunt chest trauma and was treated successfully by ascending aorta to innominate artery bypass graft. The patient recovered without any complications and was discharged one week after the operation.