Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injuries in Complex Aortic Arch Vessels Anatomies

Thoracic Endovascular Aortic Repair for Blunt Thoracic Aortic Injuries in Complex Aortic Arch Vessels Anatomies

Accepted Manuscript TEVAR For Blunt Thoracic Aortic Injuries In Complex Aortic Arch Vessels Anatomies Gabriele Piffaretti, MD PhD, Gianpaolo Carrafiel...

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Accepted Manuscript TEVAR For Blunt Thoracic Aortic Injuries In Complex Aortic Arch Vessels Anatomies Gabriele Piffaretti, MD PhD, Gianpaolo Carrafiello, MD, Anna Maria Ierardi, MD, Giovanni Mariscalco, MD PhD, Edoardo Macchi, MD, Patrizio Castelli, MD FACS, Matteo Tozzi, MD, Marco Franchin, MD PII:

S0890-5096(15)00408-2

DOI:

10.1016/j.avsg.2015.03.052

Reference:

AVSG 2392

To appear in:

Annals of Vascular Surgery

Received Date: 3 February 2015 Accepted Date: 10 March 2015

Please cite this article as: Piffaretti G, Carrafiello G, Ierardi AM, Mariscalco G, Macchi E, Castelli P, Tozzi M, Franchin M, TEVAR For Blunt Thoracic Aortic Injuries In Complex Aortic Arch Vessels Anatomies, Annals of Vascular Surgery (2015), doi: 10.1016/j.avsg.2015.03.052. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

TEVAR For Blunt Thoracic Aortic Injuries

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In Complex Aortic Arch Vessels Anatomies Gabriele Piffaretti1 MD PhD, Gianpaolo Carrafiello2 MD, Anna Maria Ierardi2 MD, Giovanni Mariscalco3 MD PhD, Edoardo Macchi2 MD, Patrizio Castelli1 MD FACS, Matteo Tozzi1 MD, Marco Franchin1 MD 1*

Vascular Surgery, Cardiac Surgery2 and Interventional Rdiology3 Department of Surgery and Morphological Sciences

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University of Insubria School of Medicine Circolo University Hospital, Varese – Italy Category: original article Running head: TEVAR in arch anomalies Financial support: none

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Competitive relationships: none Conflict of interest: none

Manuscript word count: 1614 Corresponding author: Gabriele Piffaretti, MD PhD

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Abstract word count: 138

Vascular Surgery - Department of Surgery and Morphological Sciences

Circolo University Hospital - University of Insubria School of Medicine Via Guicciardini, 9

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21100 Varese - Italy Tel: +39-0332-393.259

Fax: +39-0332-278.581

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e-mail: [email protected]

Abstract

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To report the use of thoracic endovascular aortic repair (TEVAR) in blunt thoracic aortic injuries (BTAIs) presenting with complex anatomies of the aortic arch vessels.Two patients were admitted to our hospital for the management of BTAI. Anomalies were as follow: aberrant right subclavian artery (n = 1), and right-sided aortic arch with five vessels anatomy variant (n = 1). TEVAR was accomplished using parallel graft with periscope configuration in the patient with the aberrant right subclavian artery. At 12 months follow-up, computed tomography-angiographies confirmed the exclusion of the BTAI, the stability of the

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endograft, the resolution of the pseudoaneurysm and the patency of the parallel endograft. Aortic arch vessels variants and anomalies are not rare, and should be recognized and studied precisely to plan the most appropriate operative treatment. TEVAR proved to be effective even in complex anatomies.

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Key words: TEVAR; aortic arch anomalies; blunt thoracic aortic injury

Introduction

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During the past two decades, the operative management of blunt thoracic aortic injury (BTAI) has shifted to the application of thoracic endovascular aortic repair (TEVAR) with favorable outcomes if compared to open repair (OR).1 However, the presence of anomalous patterns of the aortic arch vessels may complicate TEVAR application and requires tailoring treatment to the individual patient.2 The primary goal in the treatment of BTAI is survival and, therefore, rapidity and short-term outcomes are of utmost importance: recently, parallel endografts proved to be effective and quick alternative treatment

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vessels successfully treated with TEVAR.

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to address acute aortic pathology.3 We report two cases of BTAIs with anomalous origins of the aortic arch

Case reports

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Case 1

He is a 64-year-old man with a with multiple co-morbidities including hypertension, obesity (BMI = 37.2), previous spontaneous cerebral hematoma, dyslipidemia, chronic obstructive pulmonary disease and obstructive sleep apnoea syndrome on positive airway pressure treatment. He was transferred to our university teaching hospital for the management of polytrauma following a road-traffic accident. At admission he was hemodinamically stable but complained for jugular tightness. Total body computed

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tomography-angiography (CT-A) revealed the presence of a grade III aortic injury1 (Fig. 1 A1-3); multiple rib fractures, left pneumothorax, pancreas head edema and adrenal hematoma were also identified. The

aortic arch had a three vessels configuration: a “bovine-type” main trunks, left subclavian artery (LSA), and an aberrant right subclavian artery (ARSA) as last branch (Fig. 1 A4,5). The aortic pseudoaneurysm involved the take-off of the ARSA, measured 52mm in diameter; the proximal neck was located 25mm

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below common main trunk and 15 mm below the LSA. Glasgow Coma Score was 15, Injury Severity

Score was 35, and the EuroSCORE was 12 (predicted morbidity/mortality: 35.98%). Informed consent

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was obtained to proceed with TEVAR and the local Institutional Review Board approved the procedure. TEVAR was performed in the operating theatre under general anaesthesia and systemic heparinization (40UI/Kg). We used a right common femoral artery cut-down to introduce the main endograft, a right axillary artery surgical exposure to catheterize the ARSA and deploy a parallel endograft in the periscope configuration and a percutaneous left transfemoral approach for the preliminary and final angiographies. We used a 60° left anterior obliquation to visualize the arch vessels anatomy. The ARSA was cannulated

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transaxillary using a 180cm guidewire (Radiofocus® – Terumo; Somerset – NJ, USA) and a diagnostic catheter (Vertebral® - Cordis Endovascular Johnson & Johnson; Miami Lakes - FL, USA) via 14-F sheath (DrySeal® – W.L. Gore & Associates Inc.; Flagstaff – AZ, USA). The guidewire was then exchanged for a superstiff guidewire (Lunderquist® – Cook Medical; Bloomington – IN; USA) and a 18mm x 14cm

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parallel endograft (Excluder® - W.L. Gore & Associates Inc.; Flagstaff - AZ, USA) was temporarily parked in the ARSA towards the descending thoracic aorta in the periscope configuration. A 37mm x 10cm thoracic endograft (C-TAG® - W.L. Gore & Associates Inc.; Flagstaff - AZ, USA) was introduced

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through a 24-F sheath (DrySeal® – W.L. Gore & Associates Inc.; Flagstaff – AZ, USA) and positioned

under fluoroscopy and angiographic control to land just beyond the LSA. After the thoracic aortic

endograft was successfully deployed at the intended position, the periscope endograft was deployed. Full

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modeling of all endografts was performed with a kissing-balloon technique. Final control angiography confirmed the complete exclusion of the aortic injury and the patency of the ARSA: invasive pressure measurement confirmed no critical residual stenoses or kinking across the periscope endograft. Delay from admission and diagnosis to intervention was 1 hour; total fluoroscopy time was 24 minutes. The left pneumothorax was drained with a chest tube, subsequently. He was extubated on day 4th postoperatively when the CT-A control confirmed the stability of the previous cerebral hematoma, the resolution of the

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visceral abdominal lesions and the chest drainage was removed; he became ambulatory on day 9th. The postoperative course was uneventful and the patient discharged home on day 15th with clopidogrel bisulfate (Plavix® – Sanofi-Aventis SpA – Milan; IT) 75mg and 100mg acetylsalicylic acid

(Cardioaspirin® – Bayer SpA; Milan – IT) ad infinitum. He was last seen 12 months later, asymptomatic

and well; follow-up CT-A confirmed the endograft was stable, the exclusion of the aortic injury with the

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complete resolution of the pseudoaneurysm with no endoleak and the patency of the periscope endograft in

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the ARSA (Fig. 1 B1-5).

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ACCEPTED MANUSCRIPT Case 2

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He is a 47-year-old man who was referred to our hospital because of a fall polytrauma. At

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admission he presented in shock. Emergent total body computed tomography-angiography (CT-A)

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revealed the presence of a grade III aortic injury (Fig. 2 A1);1 bilateral lung contusions, multiple rib

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fractures, right pneumothorax, and left femur fracture were also identified. We found a right aortic

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arch with five vessels configuration: the arterial branches starting from right (first branch) to left

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(last branch) were left common carotid, right common carotid, isolated right vertebral directly from

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the arch, right subclavian artery (RSA) and LSA at the distal aortic arch (Fig. 2 A2). There was no

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vertebral dominance. The aortic injury involved the take-off of the LSA, and was located just

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beyond the RSA ostium (Fig. 2 A3). Glasgow Coma Score was 9, Injury Severity Score was 42, and

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the EuroSCORE was 7 (predicted morbidity/mortality: 9.04%). He persisted hemodinamically

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unstable, hence informed consent was obtained to proceed with TEVAR, rapidly. The local

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Institutional Review Board approved the procedure. TEVAR was performed in the operating theatre

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under general anaesthesia and systemic heparinization (40UI/Kg). We used a right common femoral

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artery cut-down to introduce the main endograft and a percutaneous left transfemoral approach for

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the preliminary and final angiographies. We used a 55° left anterior obliquation to visualize the

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origin of each vessel, then we introduced a 31mm x 15cm thoracic endograft (C-TAG® - W.L. Gore

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& Associates Inc.; Flagstaff - AZ, USA); it was deployed just distal to the RSA which was

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immediately beyond the ipsilateral vertebral artery. Final control angiography confirmed the

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complete exclusion of the aortic injury with overstenting of the LSA; flow inversion refilled the left

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vertebral artery. Delay from admission and diagnosis to intervention was 1 hour; total fluoroscopy

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time was 14 minutes. The right pneumothorax was drained with a chest tube and femur fracture

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stabilized surgically. He was extubated on day 4th postoperatively and became ambulatory on day

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6th. The postoperative course was uneventful and the patient discharged home on day 21st with

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100mg acetylsalicylic acid (Cardioaspirin® – Bayer SpA; Milan – IT) ad infinitum. He was last seen

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the exclusion of the aortic injury (Fig. 2 B1).

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ACCEPTED MANUSCRIPT Discussion

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Variants or anomalies of the vessels arising from the aortic arch are not rare: they have been

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reported in the range of 15% to 34% of the cases (Tab. 1).4-9 Several different configurations have

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been described including eight to eleven different patterns, with one to six branches and any

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combination of number and origin.4-9 Although ARSA have been reported rarely in the range of

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0.4% to 1.2%, it has been commonly registered as the third most frequent anomaly of the aortic arch

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(Tab. 1).4-9 A right-sided aortic arch is even more rare: in one of its three configurations it has been

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reported in the 0.1% to 0.2%.4,6-9 To our knowledge, the anomaly detected in our second case has

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never been described so far: in fact, it combines the type Va anomaly described by Vucurevic et al.9

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with the presence of a right vertebral artery with a separate origin directly from the arch. Having

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knowledge of aortic arch anatomy is vital for planning surgical and/or endovascular interventions:

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unrecognized or misinterpreted branches may cause cerebrovascular accidents, upper limbs

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ischemia, or endoleaks.

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In nearly 40% of BTAIs, overstenting of the LSA is required to achieve safe aortic sealing and to

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optimize the landing zone on the inner curve of the arch which is frequently characterized by a

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small radius diameter.1 In the presence of variants or anomalies, such as ARSA or right aortic arch,

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TEVAR may be more complicated or even contraindicated. On the other hand, OR is very

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challenging in these situations because of the unusual pattern of the aortic arch vessels, along with

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the presence of the mediastinal hematoma which distorts anatomies and the relationship with the

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contiguous structures. While fenestration, scalloped or branched endografts have been successfully

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attempted, they should be customized before implantation, limiting their applicability in emergent

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settings.10 TEVAR with parallel grafts have been used as an alternative method of treatment in

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emergent cases, making it possible to deploy standard off-the shelf devices to treat these lesions

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rapidly.3 Parallel grafts for BTAIs have been described already, but the periscope configuration in

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BTAI has been reported just one time in literature: Vicente et al.11 successfully treated a case with

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ACCEPTED MANUSCRIPT two parallel grafts using a combination of chimney and periscope to maintain perfusion in both the

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subclavian arteries. In contrast, TEVAR for BTAI in a right sided aortic arch has never been

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reported.12 In both our cases, TEVAR was easy and rapid despite the presence of variants and

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anomalies: we were able to treat risky patients and complex anatomies with remote accesses in less

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than two hours, avoiding challenging open aortic repairs which have been associated with high

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morbidity and mortality rates even in experienced centers (Tab. 2).13-15

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ACCEPTED MANUSCRIPT Conclusion

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Aortic arch vessels variants and anomalies are not rare, and should be recognized and studied

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precisely to plan the most appropriate operative treatment. Open aortic arch repair in case of vessels

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variants and anomalies has been burdened by high morbidity and mortality rates even in

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experienced centres, and may be even more complicated in BTAIs. Although variants and

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anomalies may complicate anatomical analysis and operative planning, TEVAR proved to be

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effective in BTAIs also in combination with the additional parallel graft technique.

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ACCEPTED MANUSCRIPT Acknowledgments

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None

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12

ACCEPTED MANUSCRIPT References

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1.Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic

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aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg

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2011;53(1):187-192

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2.Chiesa R, Melissano G, Bertoglio L, et al. Hybrid repair of an aortic arch aneurysm with complex

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anatomy: right aortic arch and anomalous origin of supra-aortic vessels. J Vasc Surg

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2007;46(1):128-130

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3.Xue Y, Sun L, Zheng J, et al. The chimney technique for preserving the left subclavian artery in

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thoracic endovascular aortic repair. Eur J Cardiothorac Surg 2014 Jul 9. pii: ezu266 . [Epub ahead

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of print]

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4.Berko NS, Jain VR, Godelman A, et al. Variants and anomalies of thoracic vasculature on

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computed tomographic angiography in adults. J Comput Assist Tomogr 2009;33(4):523-528

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5.Natsis KI, Tsitouridis IA, Didagelos MV, et al. Anatomical variations in the branches of the

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human aortic arch in 633 angiographies: clinical significance and literature review. Surg Radiol

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Anat 2009;31(5):319-323

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6.Jakanani GC, Adair W. Frequency of variations in aortic arch anatomy depicted on multidetector

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CT. Clin Radiol 2010;65(6):481-487

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7.Ergun E, Şimşek B, Koşar PN, et al. Anatomical variations in branching pattern of arcus aorta:

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64-slice CTA appearance. Surg Radiol Anat 2013;35(6):503-509

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8.Celikyay ZR, Koner AE, Celikyay F, et al. Frequency and imaging findings of variations in

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human aortic arch anatomy based on multidetector computed tomography data. Clin Imaging

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2013;37(6):1011-1019

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9.Vučurević G, Marinković S, Puškaš L, et al. Anatomy and radiology of the variations of aortic

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arch branches in 1,266 patients. Folia Morphol (Warsz) 2013;72(2):113-122

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ACCEPTED MANUSCRIPT 10.Silveira PG, Franklin RN, Cunha JR, et al. Total endovascular repair of aberrant left subclavian

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artery with Kommerell's diverticulum using a customized branched device. J Vasc Surg

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2013;57(4):1123-1125

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11.Vicente S, Glenck M, Mayer D, et al. Chimney and periscope grafts to facilitate endovascular

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treatment of aortic transection in a patient with aberrant right subclavian artery. J Endovasc Ther

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2014;21(1):123-126

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12.Taif S, Al Kalbani J. A case of acute traumatic aortic injury of a right-sided aortic arch with

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rupture of an aberrant left subclavian artery. J Radiol Case Rep 20131;7(12):1-9

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13.Kieffer E, Bahnini A, Koskas F. Aberrant subclavian artery: surgical treatment in thirty-three

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adult patients. J Vasc Surg 1994;19(1):100-109

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14.Kamiya H, Knobloch K, Lotz J, et al. Surgical treatment of aberrant right subclavian artery

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(arteria lusoria) aneurysm using three different methods. Ann Thorac Surg 2006;82(1):187-190

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15.Kouchoukos NT, Masetti P. Aberrant subclavian artery and Kommerell aneurysm: surgical

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treatment with a standard approach. J Thorac Cardiovasc Surg 2007;133(4):888-892

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Table 1

Literature review of aortic arch vessels variants and anomalies

Most frequent variant patterns (type) Cases

(year)

(years)

(number)

2009

1

1005

2009

Jakanani, et al.

Ergun, et al.

2010

2013

Celikyay, et al.

Vucurevic, et al.

2013

20113

5

4

5

1.5

n.r.

633

945

101

1361

1265

Rx method

CT-A

DSA

CT-A

CT-A

Normal arch

I

II

III

ARSA

RAA

(%)

(%)

(%)

(%)

(%)

(%)

65.9

"bovine type"

LVA

ARSA

27.4

6.6

1.2

1.2

0.1

"bovine type"

LVA

Bicarotidus

15

0.79%

0.16

0.16

n.r.

"bovine type"

LVA

ARSA

20

6

0.4

"bovine type"

LVA

ARSA

7.8

5.1

0.7

"bovine type"

LVA

ARSA

21.1

3.7

0.8

"bovine type"

LVA

ThIMA

15.6

3.6

2.2

83

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Natsis, et al.

Inclusion period

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Berko, et al.

Publication

74

85

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Author

CT-A

CT-A, DSA

74.4

74.7

Rx, radiologic; ARSA, aberrant right subclavian artery; RAA, right sided aortic arch; CT-A, computed tomography-angiography;

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DSA, digital subtraction angiography; LVA, left vertebral artery; n.r., not reported; ThIMA, thyroideal inferior IMA artery.

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0.2

0.1

0.2

0.5

0.3

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Open repair for ARSA: minimum > 10 cases

Author

Publication (year)

Inclusion period (years)

Cases (number)

Morbidity (%)

Mortality (%)

Kieffer, et al.

1994

16

33

6

12

Kamiya, et al.

2006

10

8

12

12

Kouchoukos, et al.

2006

10

10

20

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0*

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Legends

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Figure 1

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the take-off of the ARSA (A2, arrow). Volume rendering analysis confirmed the location of the

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aortic injury and pseudoaneurysm (A4,5; arrows) and the close origin of the ARSA (A4, asterisk).

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LS = left subclavian. Follow-up CT-A confirmed the exclusion of the aortic injury and the patency

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of the parallel endograft with no residual kinking (B1-5, arrows).

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Figure 2

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which highlighted the aortic pseudoaneurysm on the postero-inferior aspect of the inner curve in the

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close proximity of the RSA (A3, arrow). Follow-up CT-A confirmed the exclusion of the aortic

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injury and the patency of all vessels except the LSA which was intentionally covered (B1). LC = left

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carotid, RC = right carotid, RV = right vertebral, RS = right subclavian, LS = left subclavian).

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Preoperative CT-A showing the presence of the aortic tear (A1,3; arrow) involving

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Preoperative CT-A of the aortic injury (A1, arrow) in a right-sided aortic arch (A1-3)

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