Thoracic Endovascular Repair of Blunt Thoracic Aortic Injury in the Setting of an Aberrant Right Subclavian Artery

Thoracic Endovascular Repair of Blunt Thoracic Aortic Injury in the Setting of an Aberrant Right Subclavian Artery

Accepted Manuscript Thoracic Endovascular Repair of Blunt Thoracic Aortic Injury in the Setting of an Aberrant Right Subclavian Artery Donald G. Harri...

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Accepted Manuscript Thoracic Endovascular Repair of Blunt Thoracic Aortic Injury in the Setting of an Aberrant Right Subclavian Artery Donald G. Harris, MD, Michael E. Huffner, BS, Luqman Croal-Abrahams, BS, Laura DiChiacchio, MD, PhD, Behzad S. Farivar, MD, Joseph D. Ayers, MD, Shahab Toursavadkohi, MD, Joseph Rabin, MD, Robert S. Crawford, MD PII:

S0890-5096(17)30640-4

DOI:

10.1016/j.avsg.2016.12.012

Reference:

AVSG 3257

To appear in:

Annals of Vascular Surgery

Received Date: 13 July 2015 Revised Date:

12 December 2016

Accepted Date: 19 December 2016

Please cite this article as: Harris DG, Huffner ME, Croal-Abrahams L, DiChiacchio L, Farivar BS, Ayers JD, Toursavadkohi S, Rabin J, Crawford RS, Thoracic Endovascular Repair of Blunt Thoracic Aortic Injury in the Setting of an Aberrant Right Subclavian Artery, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2016.12.012. 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.

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Thoracic Endovascular Repair of Blunt Thoracic Aortic Injury in the Setting of an Aberrant Right Subclavian Artery. Donald G. Harris, MD;1 Michael E. Huffner, BS;1 Luqman Croal-Abrahams, BS;1 Laura

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DiChiacchio, MD, PhD;1 Behzad S. Farivar, MD;1 Joseph D. Ayers, MD;2 Shahab

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Toursavadkohi, MD;1,3 Joseph Rabin, MD;4 Robert S. Crawford, MD.1,3

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1. Division of Vascular Surgery, Department of Surgery. University of Maryland School of Medicine. Baltimore, MD. 2. Naval Medical Center San Diego, San Diego, California.

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3. Center for Aortic Disease. University of Maryland Medical Center. Baltimore, MD.

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4. R Adams Cowley Shock Trauma Center. University of Maryland School of Medicine.

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Baltimore, MD.

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Abstract.

Blunt thoracic aortic injury (BTAI) in a patient with an aberrant right subclavian artery

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(ARSA) presents unique challenges for patient management and aortic repair. Specific

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considerations include the need to treat coincidental ARSA, subclavian revascularization, and

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ARSA exclusion. Despite the rise of endovascular endovascular repair as the primary modality

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for aortic repair for BTAI, reports of this technique in the setting of ARSA are limited. Here we

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describe three patients with ARSA who underwent TEVAR for BTAI, and discuss critical

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management and technical issues in these patients.

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MANUSCRIPT

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Introduction. Blunt thoracic aortic injury (BTAI) is the second most common cause of death from blunt

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trauma, after traumatic brain injury. 1, 2 Recently, the management of patients with BTAI has

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been revolutionized by advances in computed tomographic (CT) imaging, adjunctive medical

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therapy, selective delayed repair or non-operative management, and the primary use of thoracic

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endovascular aortic repair (TEVAR) when intervention is required. 1, 3-7 Together, these have

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resulted in a better understanding of the short-term natural history of traumatic aortic lesions, and

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enabled management strategies tailored to lesion severity and risk for rupture. 8

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Management of BTAI is more complex in the setting of aberrant aortic anatomy, which

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occurs in up to 40% of patients with BTAI. 9 In particular, an aberrant right subclavian artery

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(ARSA) originating distal to the LSCA in Zone 3 or 4 may complicate TEVAR for BTAI. 10, 11

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ARSA results from abnormal involution of the right fourth aortic arch, an is the most common

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congenital aortic arch anomaly, occurring in 0.5 – 2.5% of the general population. 12 An ARSA

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may be further complicated by aneurysmal degeneration at the origin, resulting in a Kommerell

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Diverticulum (KD) that is at risk for rupture or dissection. 12, 13 Specific challenges in managing

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BTAI in the setting of an ARSA include achieving complete BTAI isolation, treatment of

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concurrent KD, and maintenance of posterior cerebral circulation. Here we describe three

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patients with ARSA and BTAI to illustrate the management of these issues.

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Case Reports.

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Among 120 patients with BTAI between 2009 – 2014 at a major Level I trauma center,

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three (2.5%) had ARSA. Institutional practice includes screening CT angiography for patients at

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risk for BTAI. Patients with BTAI are managed in consultation with a joint cardiac and vascular

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aortic injury team, and preoperative medical therapy includes β-blockade and medical adjuncts to

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achieve a systolic blood pressure ≤ 120 mmHg, a mean arterial pressure ≤ 80 mmHg, and heart

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rate between 60 – 80 beats/min. TEVAR is performed in a standard fashion. Percutaneous

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femoral catheterization is obtained for guidewire and pigtail catheter access of the aortic arch.

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Contralateral open or percutaneous femoral access is obtained for cannulation with an introducer

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sheath, arch access with a Lunderquist wire, and endograft deployment. Routine preoperative

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subclavian revascularization is not performed in patients who may require LSCA coverage. 5

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A 57 year old woman was admitted in 2009 after a motorvehicle collision, having

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sustained blunt thoracic and spinal injuries. An admission CT angiogram demonstrated a

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common arch origin of the right and left carotid arteries, and a 5 mm ARSA with a 13 mm KD

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located 10 mm distal from the LSCA. A further 20 mm distal from the ARSA was a 38 mm

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traumatic pseudoaneurysm with moderate mediastinal hematoma (Figure 1). TEVAR was

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performed on hospital day two using three Gore Excluder aortic cuffs deployed in the descending

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thoracic aorta starting just distal to the ARSA (Figure 2); given the urgent nature of the

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procedure and the limited size of the KD, further intervention to address the ARSA was not

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pursued. The patient was discharged on hospital day 49 after recovering from concurrent

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injuries. A CT angiogram obtained six months after repair demonstrated exclusion of the

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pseudoaneurysm and stable KD. At latest follow-up five years after surgery the patient was

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doing well.

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Patient 2. A 27 year old man was admitted with thoracic and extremity injuries in 2012 after a

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motorvehicle collision. On admission CT angiogram, the patient had a 29 mm traumatic

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pseudoaneurysm arising 18 mm from the LSCA. Just proximal to the injury was a 7 mm ARSA

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that neither involved the pseudoaneurysm nor had a diverticulum (Figures 3, and 4a & b). The

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left vertebral artery was dominant and arose from the LSCA, while the right vertebral artery

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arose from the right carotid artery. The patient underwent TEVAR on hospital day two, with

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deployment of a Gore TAG endograft just distal from the LSCA, covering the ARSA origin in

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order to achieve a sufficient proximal landing zone (Figure 4c). Because the ARSA had no

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aneurysmal degeneration and did not communicate with the aortic injury, embolization was not

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performed.

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Afterwards, the patient lost his right radial and ulnar pulses, but had biphasic Doppler

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waveforms and no symptoms of arm ischemia. A postoperative CT angiogram demonstrated

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exclusion of the traumatic pseudoaneurysm and collateral filling of the ARSA (Figure 4d). He

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was discharged on hospital day 5, and upon follow-up one month after injury had regained his

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right radial and ulnar pulses.

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Patient 3.

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In 2014 a 27 year old man presented after a motorcycle crash with extensive leg and chest

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injuries. On CT angiography he had a symmetric vertebral arteries arising from the ARSA and

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LSCA, and an 11 mm wide ARSA with a diverticulum arising 18 mm distal from the LSCA.

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Near the ARSA origin arose a complex, 27 mm traumatic pseudoaneurysm (Figure 5). On

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hospital day two he underwent TEVAR with deployment of a Medtronic Valiant thoracic graft

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distal to the LSCA, covering the ARSA and pseudoaneurysm. Because the wide origin of the

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ARSA communicated with the pseudoaneurysm, the proximal ARSA was embolized via

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retrograde right brachial access with with Amplatzer vascular plugs at the origin of the ARSA

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and the distal ARSA to the right of the esophagus(Figure 6). Postoperatively the patient had right

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finger digital pressures of 65 mmHg versus 135 on the left, but had no symptoms of extremity or

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vertebrobasilar ischemia.

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101 Discussion.

Aberrant aortic anatomy is common among patients with BTAI, and may be a risk factor

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for aortic injury. 9, 14 Further, ARSA may complicate otherwise frequently routine endovascular

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treatment of BTAI. The three patients described in this report illustrate several important

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concepts for managing patients with ARSA and BTAI, particularly the role for ARSA

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intervention, revacularization, and exclusion.

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Aberrant right subclavian artery is usually clinically occult, and an incidental finding

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during thoracic imaging studies. Indeed, as illustrated by Patient 1, in certain situations of ARSA

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and BTAI, the ARSA may not complicate aortic intervention. This patient had a sufficient

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landing zone between her ARSA and traumatic pseudoaneurysm to enable a proximal seal

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without covering the ARSA. Although a KD was present, it was much smaller than the 3 cm

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recommended as a threshold for intervention, 15 and could be treated on an elective basis should

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it enlarge. As such, if there is no significant KD and TEVAR can be performed without ARSA

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coverage, the ARSA requires no further immediate management.

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In patients in whom ARSA coverage is required, revascularization of the right subclavian

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needs to be considered and depends on several factors. First, a dominant right vertebral artery

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arising from the ARSA warrants revascularization, preferably preoperatively unless the BTAI is

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unstable. 5, 10 If the right vertebral artery has a variant origin or is non-dominant, the ARSA can

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be covered if needed to achieve a proximal seal during BTAI exclusion. In this scenario, similar

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to coverage of the LSCA in patients with BTAI and normal arch anatomy, which is frequently

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covered without consequence, 3, 16 subsequent revascularization can be selective. 10, 17 As Patients

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2 and 3 demonstrated, and consistent with LSCA experience and other ARSA reports, ARSA

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coverage can be well tolerated without revascularization.

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insufficient distance between the LSCA and BTAI for a proximal seal, coverage of both the

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ARSA and LSCA may be required. 10 Depending on vertebral artery anatomy and dominance,

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this warrants revascularization of at least one and potentially both subclavian arteries. 10, 18

However, in patients with

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Endovascular coverage and exclusion of the origin is the most complete treatment of

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ARSA in patients undergoing TEVAR for concurrent BTAI. ARSA exclusion via retrograde

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right subclavian access and embolization is indicated for two potential scenarios. First, in

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patients with a large KD that warrants repair (≥ 3 cm), 15 TEVAR and exclusion definitively

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treats the KD. Similarly, this may be considered for patients with a moderate KD and potentially

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poor follow-up. Second, as for Patient 3, an ARSA origin that is involved by a traumatic

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pseudoaneurysm requires embolization to completely exclude the aortic injury. Given that the

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ARSA origin is more prone to degeneration than normal aortic branch arteries, coverage and

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exclusion could also be considered for lower aortic grade injuries that may otherwise be safely

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managed non-operatively. To treat or prevent esophageal symptoms or complications,

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embolization of the ARSA is performed at its origin and to the right of the esophagus,

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decompressing the segment that is in apposition to the esophagus.

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Conclusion. The presence of ARSA in the setting of BTAI complicates routine aortic repair.

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Depending on the location of the ARSA, vertebral artery anatomy, presence of a KD, and

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involvement with the aortic injury itself, ARSA coverage, exclusion, and distal revascularization

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need to be considered. ARSA coverage without revascularization is tolerated in appropriately

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selected patients.

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1. Neschis DG, Scalea TM, Flinn WR, Griffith BP. Blunt aortic injury. N Engl J Med.

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4. Demetriades D, Velmahos GC, Scalea TM, et al. Operative repair or endovascular stent graft

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FIGURE CAPTIONS.

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Figure I. Admission CT of Patient 1.

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202 A & B: Retroesophageal ARSA (block arrow) with it’s origin from the distal arch with a

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Kommerell diverticulum. A common origin of the right and left carotid arteries are

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coincidentally noted. C & D: Traumatic pseudoaneurysm (asterix) of the proximal descending

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thoracic aorta with moderate mediastinal hematoma. E: Sagittal reconstruction of the arch and

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thoracic aorta demonstrating a common carotid origin, LSCA, Kommerell diverticulum at the

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ARSA origin, and aortic injury.

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Figure II. Intraoperative angiography and postoperative CT of Patient 1.

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A: Initial arch angiogram demonstrating a common origin of the right and left carotid arteries,

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LSCA, and ARSA arising and coursing posterior to the arch (block arrow). The traumatic

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pseudoaneurysm is 2 cm distal from the ARSA (asterix). B: Completion angiogram after

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endograft deployment demonstrating a patent ARSA and excluded pseudoaneurysm. C: Sagittal

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reconstruction of the postoperative CT demonstrating the arch vessels, ARSA, and endograft.

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Figure III. Admission CT of Patient 2.

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A – C: Retroesophageal ARSA (block arrow) arising from the distal arch near, but not involving

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the traumatic pseudoaneurysm (asterix). D & E: Sagittal reconstruction demonstrating the

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relationships of the LSCA, ARSA, and pseudoaneurysm.

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Figure IV. Intraoperative angiography and postoperative CT of Patient 2.

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(block arrow) arising from the posterior aortic arch opposite the traumatic pseudoaneurysm. C:

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Postoperative CT demonstrating proximal endograft landing just distal from the LSCA. D:

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Postoperative CT demonstrating opacification of the excluded ARSA.

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Figure V. Admission CT of Patient 3.

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A & B: Demonstration of the wide ARSA with 18 mm Kommerell diverticulum (block arrows).

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C & D: Communicating with the distal aspect of the diverticulum was a complex, moderately

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sized traumatic pseudoaneurysm (asterix). E – H: Coronal and sagittal reconstructions

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demonstrating the proximity of the ARSA and diverticulum to the aortic injury.

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Figure VI. Intraoperative angiography and postoperative CT of Patient 2.

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A: Exclusion of the ARSA origin and traumatic pseudoaneurysm after deployment of Amplatzer

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vascular plugs in the proximal ARSA. B – D: Postoperative CT images and 3-D reconstruction

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demonstrating the TEVAR and vascular plugs with ARSA and traumatic pseudoaneurysm

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exclusion.

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