Di Tommaso L.

Iannelli G.

Monaco M.

Piscione F.

English

Archivio della ricerca - Università degli studi di Napoli Federico II

 2005;129:682-684 J Thorac Cardiovasc SurgGabriele Iannelli, Luigi Di Tommaso, Mario Monaco and Federico Piscione  congenitally malformed aortic archEndovascular treatment of right-sided subclavian artery aneurysm in a http://jtcs.ctsnetjournals.org/cgi/content/full/129/3/682located on the World Wide Web at: The online version of this article, along with updated information and services, is2005 American Association for Thoracic Surgery Association for Thoracic Surgery and the Western Thoracic Surgical Association. Copyright ©  is the official publication of the AmericanThe Journal of Thoracic and Cardiovascular Surgery on July 25, 2006 jtcs.ctsnetjournals.orgDownloaded from Endovascular treatment of right-sided subclavianartery aneurysm in a congenitally malformed aorticarchGabriele Iannelli, MD,a Luigi Di Tommaso, MD,a Mario Monaco, MD,a andFederico Piscione, MD,b Naples, ItalyEncouraging results obtained with endovascular treat-ment of subclavian artery aneurysms (SAAs)1 led us touse this technique as an alternative to conventionaloperation in a young female patient with an intratho-racic SAA on the right side complicated by a left-sided cervicalaortic arch and agenesis of the left common carotid and vertebralarteries.Clinical SummaryA pulsatile mass was detected in a 38-year-old woman during anechocardiographic assessment of the thyroid. Computed tomo-graphic (CT) scanning showed a 14-mm left-sided cervical aorticarch at the T2 level, a 36-mm enlargement of the ascending aorta,and a normal-sized descending aorta (25 mm). An angiographicstudy confirmed the presence of a saccular aneurysm of the rightsubclavian artery with a broadneck, agenesis of the left ca-rotid artery, and narrowing ofthe aortic arch (Figure 1). Be-cause of the complexity of thepatient’s vascular abnormalities, we elected to use an endovascularprocedure to treat the right SAA only.The size of the right subclavian artery was 7 mm, and the aneu-rysm neck was 20 mm at the CT scan: the ideal stent graft length was40 mm, considering 10 mm from the aneurysm neck to be a good seal.Otherwise, a more than desirable length could occlude the commoncarotid artery proximally or the right vertebral artery distally. Fluo-roscopic imaging was used throughout the procedure.General anesthesia was achieved, the right brachial artery wasexposed by means of a surgical procedure, and a 12F introducerwas inserted into the vessel. A 6F angiographic pigtail catheter(Cordis Corp, Miami, Fla) was inserted through the femoral arteryinto the brachiocephalic artery. A 0.035-in Radifocus guidewire M(Terumo Corp, Tokyo, Japan) was inserted through the brachialartery to cross the SAA and to position the stent graft at theproximal end of the subclavian artery. Two stent grafts (Viabahn;W. L. Gore & Associates, Inc, Flagstaff, Ariz; 8 mm wide and 25mm long) were implanted with the telescope technique, placing thesecond stent graft to overlap the first distally to obtain the foreseenlength.An angiogram obtained after insertion of the stent graftsshowed complete exclusion of the SAA and patency of the rightFrom the Departments of Cardiac Surgerya and Cardiology,b University“Federico II” of Naples, Naples, ItalyReceived for publication July 26, 2004; revisions received Aug 6, 2004;accepted for publication Aug 10, 2004.Address for reprints: Gabriele Iannelli, MD, Via Santo Strato, 8, 80121Naples, Italy (E-mail: gabrieleiannelli@libero.it).J Thorac Cardiovasc Surg 2005;129:682-40022-5223/$30.00Copyright © 2005 by The American Association for Thoracic Surgerydoi:10.1016/j.jtcvs.2004.08.010Figure 1. A, Angiogram showing subclavian artery aneurysm on the right side (rSAA) and cervical aortic arch onthe left (LCCA). B, Digital subtraction angiogram of the right-sided subclavian artery aneurysm (rSAA).Dr IannelliBrief Communications682 The Journal of Thoracic and Cardiovascular Surgery ● March 2005 on July 25, 2006 jtcs.ctsnetjournals.orgDownloaded from subclavian and vertebral arteries (Figure 2, A). The patient recov-ered uneventfully and was discharged from the hospital 3 daysafter the procedure. At 6 months’ follow-up, the patient was doingwell, and a CT scan showed aneurysm exclusion and no endoleaks(Figure 2, B).DiscussionOf the 6 pairs of embryonic aortic arches that connect the ventraland dorsal portions of the aorta, only the third, fourth, and sixtharches remain recognizable after birth (Figure 3, A). The cervicalaortic arch, first described by Reid in 1914, is a rare embryologicmalformation caused by nondevelopment of the left-sided fourthembryonic arch and persistence of the third (Figure 3, B).2An aortic arch formed from an embryologic remnant designedto regress might not have normal structural integrity. This charac-teristic, together with the hemodynamic changes in the tortuouscervical aortic arch, can create conditions favorable for formationof an aneurysm.3Surgical treatment of SAAs is necessary because of the highrisk of rupture of large aneurysms and of embolization or throm-bosis in smaller aneurysms.4 Only a few cases of congenitalaneurysm of the major supraortic branches and cervical aortic archhave been reported.5The type of complex pathology found in our patient led to anin-depth analysis of the most appropriate surgical strategy, eitherconventional or endovascular, both of which required prostheticmaterial. The patient was unwilling to undergo open surgery forcosmetic reasons, and moreover, the traditional surgical approach,which would have involved a median sternotomy with a supra-clavicolar extension, would entail a considerable risk of damage tothe cerebral blood flow caused by the reduction of collateralarterial supply and the very close localization to the aneurysm ofthe carotid and vertebral right arteries.Endovascular surgery, on the other hand, was considered fea-sible for the presence of a satisfactory landing zone, measuringproximally 1.5 cm from the right common carotid artery anddistally 1.0 cm from the right vertebral artery. Use of the endo-vascular approach in our patient allowed us to comply with thepatient’s requests regarding cosmetic results. In addition, use ofendovascular treatment does not preclude subsequent use of con-ventional surgery if required because of unsatisfactory results ordeterioration of materials used.Successful use of endovascular grafts in other locations and inour experience suggests that endovascular surgery might be a safeand reliable treatment for some very rare vascular disorders.We thank Mr Lucio Riccardi for his contribution to this effort.References1. Iannelli G, Piscione F, Di Tommaso L, Monaco M, Chiariello M,Spampinato N. Thoracic aortic emergencies: impact of endovascularsurgery. Ann Thorac Surg. 2004;77:591-6.Figure 2. A, Perioperative angiogram of the right subclavian artery after implantation of a stent graft. B, A 6-month3-dimensional CT follow-up scan.Figure 3. Normal and abnormal development of the aorta. A,Normal development of the 6 pairs of embryonic aortic arches. B,Abnormal development of the aorta and side branches in ourpatient. ICA, Internal carotid artery; ECA, external carotid artery;RSA, right subclavian artery; LSA, left subclavian artery; Ao,thoracic aorta; III, third embryonic aortic arch; IV, fourth embry-onic aortic arch; VI, sixth embryonic aortic arch; PA, pulmonaryartery; CAA, cervical aortic arch.Brief CommunicationsThe Journal of Thoracic and Cardiovascular Surgery ● Volume 129, Number 3 683 on July 25, 2006 jtcs.ctsnetjournals.orgDownloaded from 2. Pearson GD, Kan JS, Neill CA, Misgley FM, Gardner TJ, Hougen TJ.Cervical aortic arch with aneurysm formation. Am J Cardiol. 1997;79:112-4.3. Farsak B, Yilmaz M, Kaplan S, Boke E. Cervical aortic arch withaneurysm formation. Eur J Cardiothorac Surg. 1998;14:437-9.4. Davidovic LB, Markovic DM, Pejkic SD, Kovacevic NS, Colic MM,Doric PM. Subclavian artery aneurysms. Asian J Surg. 2003;26:7-11.5. Tsukamoto O, Seto S, Moriya M, Yano K. Left cervical aortic archassociated with aortic aneurysm and coartation, and branch arteryaneurysm: a case report and review. Angiology. 2003;54:257-60.A successful total cavopulmonary connection conversion 13 years afteran anatomic repair for tricuspid atresia IIc with severe pulmonaryresistanceKoichi Sughimoto, MD, Hiromi Kurosawa, MD, Toshiharu Shin’oka, MD, Masayoshi Nagatsu, MD,Shigehiro Morishima, MD, and Takahiko Sakamoto, MD, Tokyo, Japan.High pulmonary artery resistance (Rp) is one of the riskfactors for Fontan completion. Although appropriate pul-monary artery banding (PAB) might decrease the pul-monary artery pressure (PAP), there are some patientswho are unable to undergo the Fontan procedure because of high Rp.Anatomic repair with pulmonary autograft for the Björk procedure isone of the options for those patients. On the other hand, total cavo-pulmonary connection (TCPC) conversion is currently performed forpatients with arrythmia or intra-atrial thrombus after atriopulmonaryconnected Fontan circulation.1-3 We recently had a successful expe-rience with extracardiac TCPC conversion after anatomic repair.Clinical SummaryA 4-year-old boy with tricuspid atresia (TA) IIc and a ventricularseptal defect had undergone an anatomic repair consisting ofJatene, Rastelli, and Björk procedures in 1989. PAB at 19 days ofage, a Blalock-Hanlon procedure at 10 months of age, and rightpulmonary artery (PA) angioplasty, digital septostomy, and re-PAB at 2 years and 4 months of age had been performed previ-ously. Preoperative catheterization data showed a high mean PAPof 20 mm Hg, a PA index of 366, a pulmonary artery resistance(Rp) of 5.7 units, and a right ventricular end-diastolic volume of49% of the normal value (Table 1). These data suggested that theFontan procedure was unfavorable at that time, and thereforeanatomic repair was planned. The original aorta was implantedbetween the right atrium (RA) and the right ventricle (RV). Thecoronary arteries (Shaher 1) were translocated to the original PAtrunk. After repositioning of the PA as the neoaorta with theLecompte modification, the RV outflow tract was repaired with atricuspid Xenomedica conduit (22 mm; Xenomedica AG, Luzern,Switzerland) and connected to the main PA. Jatene, Rastelli, andBjörk procedures were completed (Figures 1 and 2). The finalcentral venous pressure (CVP) in the intensive care unit was 19mm Hg.The postoperative course was uneventful. However, repeatedatrial flutter and ascites have been recognized since the patient was14 years old, 10 years after the operation. An unsuccessful catheterablation, the markedly enlarged RA, and an increased CVP indi-cated the need for TCPC conversion at 18 years of age, 13 yearsafter the anatomic repair.After establishment of cardiopulmonary bypass, a bidirectionalGlenn (BDG) anastomosis was performed initially. Afterward, theaortic autograft was removed, and the RA-RV route was recon-structed with an enlarged RA wall so that only the coronary venousblood passed through the RV to the PA. Subsequently, the extra-cardiac TCPC conversion was completed with an interposition ofthe expanded polytetrafluoroethylene graft (24 mm) between theright PA and the inferior vena cava. The maze procedure was notperformed because of extremely dense epicardial adhesion. TheCVP decreased gradually to 13 mm Hg in the intensive care unit,and the atrial flutter disappeared entirely at the time of discharge.From the Department of Cardiovascular Surgery, The Heart Institute ofJapan, Tokyo Women’s Medical University, Tokyo, Japan.Received for publication May 8, 2004; revisions received June 23, 2004;accepted for publication June 28, 2004.Address for reprints: Hiromi Kurosawa, MD, Department of CardiovascularSurgery, The Heart Institute of Japan, Tokyo Women’s Medical University,Tokyo, Japan, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan(E-mail: kurosawa@hij.twmu.ac.jp).J Thorac Cardiovasc Surg 2005;129:684-50022-5223/$30.00Copyright © 2005 by The American Association for Thoracic Surgerydoi:10.1016/j.jtcvs.2004.06.047TABLE 1. Cardiac catheterization dataPAP(mm Hg)PAindexRp (dyne · s· cm5)RVEDV(% ofnormal)LVEDV(% ofnormal)Before AP (20) 366 5.7 49 229After AP 20/13 (15) 1.4 45 196BeforeTCPC-c18/10 (14) 138 1.8 73 113PAP, Pulmonary artery pressure; PA, pulmonary artery; Rp, pulmonaryartery resistance; RVEDV, right ventricular end-diastolic volume; LVEDV,left ventricular end-diastolic volume; AP, anatomic repair; TCPC-c, totalcavopulmonary connection conversion.Brief Communications684 The Journal of Thoracic and Cardiovascular Surgery ● March 2005 on July 25, 2006 jtcs.ctsnetjournals.orgDownloaded from  2005;129:682-684 J Thorac Cardiovasc SurgGabriele Iannelli, Luigi Di Tommaso, Mario Monaco and Federico Piscione  congenitally malformed aortic archEndovascular treatment of right-sided subclavian artery aneurysm in a Continuing Medical Education Activities http://cme.ctsnetjournals.org/cgi/hierarchy/ctsnetcme_node;JTCSSubscribers to the Journal can earn continuing medical education credits via the Web at  Subscription Information http://jtcs.ctsnetjournals.org/cgi/content/full/129/3/682#BIBLThis article cites 5 articles, 1 of which you can access for free at:  Subspecialty Collections http://jtcs.ctsnetjournals.org/cgi/collection/peripheral_vascular Peripheral vascular http://jtcs.ctsnetjournals.org/cgi/collection/great_vessels Great vesselsThis article, along with others on similar topics, appears in the following collection(s):  Permissions and Licensing http://www.elsevier.com/wps/find/obtainpermissionform.cws_home/obtainpermissionformreceipt, is available at: An on-line permission request form, which should be fulfilled within 10 working days of. http://www.elsevier.com/wps/find/supportfaq.cws_home/permissionusematerialcan be found online at: General information about reproducing this article in parts (figures, tables) or in its entirety on July 25, 2006 jtcs.ctsnetjournals.orgDownloaded from 

Endovascular treatment of right-sided subclavian artery aneurysm in a congenitally malformed aortic arch

https://www.iris.unina.it/bitstream/11588/818190/1/Endovascular%20treatment%20of%20right-sided%20subclavian.pdf

Endovascular treatment of right-sided subclavian artery aneurysm in a congenitally malformed aortic arch

Abstract

Similar works

Full text

Available Versions

Archivio della ricerca - Università degli studi di Napoli Federico II