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Aortic Surgery
Published in Theo Kofidis, Minimally Invasive Cardiac Surgery, 2021
Cem Alhan, Sahin Senay, Julian Wong, Andrew MTL Choong
Zone 3 pathologies involve the diseases of the proximal portion of descending aorta. A hybrid approach for this group of patients may require debranching of the left subclavian artery, and zone 2 (or partially zone 3) is used as a landing zone for stent graft implantation (Figure 14.2.9 and Figure 14.2.10). One of the most common pathologies at this region is type B dissection. The entry tear of the dissection is usually located in the immediate vicinity of the orifice of the left subclavian artery. Treatment in selected cases may require debranching of the left subclavian artery. In some patients the dissected segments may extend proximally to the arch. In such cases zone 1 or 2 repair may be needed to secure a safe proximal landing zone according to the extent of the dissected segment [14,15].
Technical aspects of treating aortic aneurysms
Published in Peter A. Schneider, Endovascular Skills: Guidewire and Catheter Skills for Endovascular Surgery, 2019
The most common of these procedures is the left carotid-to-subclavian artery bypass (Figure 28.16). This is because type B aortic dissection is increasingly being treated with stent–graft coverage to manage short-term complications, enhance long-term remodeling, and prevent aneurysm degeneration. Because the pathology of type B aortic dissection usually initiates at the level of the left subclavian artery, it is common for this area to require coverage in order to have graft sealing in healthy aorta proximal to the dissection site. The left carotid-to-subclavian artery bypass is best performed by using a transverse supraclavicular incision. The proximal left common carotid artery is exposed. The anterior scalene muscle is divided. The phrenic nerve is located on the anterior surface of the muscle and must be preserved. Just posterior to the muscle is the left subclavian artery. The jugular vein is located slightly anterior and lateral to the common carotid artery. The graft is usually tunneled posterior to the jugular vein. Either anastomosis may be performed first. After the carotid-to-subclavian bypass has been carried out, the aortic stent–graft is placed. Lastly, a plug is placed in the proximal left subclavian artery. The proximal left subclavian artery can also be ligated, but it must be ligated proximal to the origin of the left vertebral artery. This can be difficult when the origin of the vertebral artery is quite proximal.
Cardiac surgery
Published in Brian J Pollard, Gareth Kitchen, Handbook of Clinical Anaesthesia, 2017
This involves the use of stents specifically designed for each patient on the basis of spiral CT scans. Not all patients are suitable for this form of surgery. A stent is passed through the femoral route and placed in the aorta under X-ray control. It avoids the need for bypass or one-lung anaesthesia. It has minimal effect on the cardiovascular system because cross-clamping of the aorta is avoided. These are often performed in theatre under general anaesthesia but can be performed under local anaesthesia with sedation. Purpose-built hybrid theatres are now available in most major cardiovascular centres and allow for better facilities for the management of these patients. These patients require direct arterial monitoring but central venous monitoring may not always be necessary. Occasionally the left subclavian artery is occluded. This may, on rare occasions, necessitate carotid to axillary artery bypass surgery. Patients can be sent to the critical care unit for postoperative monitoring.
Dysphagia lusoria in a young woman with chest pain
Published in Baylor University Medical Center Proceedings, 2022
Busara Songtanin, Roy Jacob, Neha Mittal
An electrocardiogram and troponin T level were unremarkable. A barium esophagogram showed extrinsic indentation on the posterior aspect of the esophagus at thoracic vertebrae level 3 to 4 (T3–T4) without contrast retention (Figure 1). CT of the chest showed an aberrant right subclavian artery that caused slight flattening of the proximal esophagus consistent with the level of T3–T4 compression on the barium esophagogram (Figure 2). On follow-up, the patient reported worsening dysphagia and chest pain and was referred to a cardiothoracic surgeon. A cardiac angiogram showed an aberrant right subclavian artery just beyond the origin of the left subclavian artery without significant stenoses. She underwent thoracic endovascular aortic repair for exclusion of the aberrant right subclavian artery along with a carotid to subclavian bypass. At 1-year follow-up, her dysphagia had improved.
Systolic murmur in disguise: subclavian artery stenosis as an overlooked cause of missed case of hypertension
Published in Blood Pressure, 2021
Jana Brguljan-Hitij, Giuseppe Ambrosio, Tadej Žlahtič
Subclavian artery stenosis is typically asymptomatic, due to its slow progression and development of collateral circulation. On the other hand, hemodynamically significant stenosis associated with more than 70% obstruction can be presented with ischaemic claudication of ipsilateral arm, distal embolisation and vertebro-basilar insufficiency due to subclavian steal syndrome [1,2]. It is usually caused caused by atherosclerotic plaques.Other possible causes include gigantocellular arteritis, Takayasu arteritis, post-radiation injury, trauma, thoracic outlet syndrome, fibromuscular dysplasia, neurofibromatosis, and congenital malformations [1–3]. Left subclavian artery stenosis is four times more common than that the right artery (Figure 1). Incidence of subclavian artery stenosis is around 2% in the general population, but it may be substantially greater in patients with usual atherosclerosis risk factors [2]. In this report, we present a case of asymptomatic, hemodynamically significant, subclavian stenosis where diagnose of hypertension was missed because of described stenosis.
The Safety and Efficacy of a Minimalist Approach for Percutaneous Transaxillary Transcatheter Aortic Valve Replacement (TAVR)
Published in Structural Heart, 2020
Yumiko Kanei, Waqas Qureshi, Nirmal Kaur, Jennifer Walker, Nikolaos Kakouros
Procedural characteristics are described in Table 2. Device implantation was successful in 100% of patients. All but one patient underwent the procedure with MAC and PEC-1 nerve block. One patient had multiple comorbidities and general anesthesia was chosen based on clinical judgment by the anesthesiologist. The SAPIEN3 balloon-expandable valve (Edwards LifeSciences, Irvine, CA) was used in most patients using 14Fr or 16Fr sheath according to valve size. Fifty-six percent of patients had the left axillary artery approach. Median fluoroscopy time was 20.1 minutes, which was longer than the TF control arm (15.5 minutes, P = 0.0004). Axillary access was closed with 2 Perclose Proglide™ closure devices with proximal balloon occlusion of the subclavian, and based on the subclavian angiogram result, an additional closure device (Angio-Seal™, St. Jude Medical, Austin, TX) was used in 5 patients (22%), with successful hemostasis in all patients. Two patients required balloon angioplasty of the arteriotomy site, and one patient had significant left subclavian artery stenosis requiring subsequent surgical repair. Overall procedure time decreased over time. After excluding the patient who had surgical intervention for subclavian stenosis (case 2) and combined PCI/TAVR procedure (case 16), the median procedure time of the second half of cases was significantly shorter than for the first half of cases (113 minutes vs 87 minutes, P = 0.04).