Thorax
David Heylings, Stephen Carmichael, Samuel Leinster, Janak Saada, Bari M. Logan, Ralph T. Hutchings in McMinn’s Concise Human Anatomy, 2017
A 49-year-old man presents with ptosis (drooping) of the right eyelid. Physical examination reveals that the pupil of the right eye is constricted. It is also noted that there is no sweating on the right side of his face. Radiological examination reveals a tumour near the apex of his right lung. Which of the following structures has most likely been compromised by the tumour?Thoracic duct.Right vagus nerve.Right phrenic nerve.Right sympathetic trunk.Right subclavian artery.
Technical aspects of treating aortic aneurysms
Peter A. Schneider in 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.
Angiographie Anatomy of the Peripheral Vasculature and the Non-invasive Assessment of Peripheral Vascular Disease
Richard R Heuser, Giancarlo Biamino in Peripheral Vascular Stenting, 1999
After the vertebral artery, the subclavian artery gives rise to four major branches: internal mammary, thyrocervical trunk, dorsal scapular artery, and suprascapular artery (Fig. 2.4). Next, the subclavian artery heads inferiorly and crosses the first rib. At this landmark, it becomes the axillary artery and gives rise to the following branches: superior thoracic artery, thoracoacromial artery, lateral thoracic artery, subscapular artery, and the circumflex humeral branches (Fig. 2.5). Next the axillary artery crosses the lower border of the tendon of the teres major where it becomes the brachial artery. The main branches of the brachial artery are the profunda brachial and the superior ulnar collateral arteries, both of which form a collateralization network around the brachial artery. The brachial artery bifurcates into the ulnar and radial arteries below the elbow.
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
Due to significant inter-arm blood pressure difference clinical suspicion of subclavian artery stenosis was thus advanced. CTA examination (Figure 2) of aortocervical vasculature confirmed hemodynamically significant stenotic lesion (70 to 80%) and minimal post-stenotic dilatation of left subclavian artery after branching off aortic arch. There was also hemodynamically insignificant stenosis at the beginning of left internal carotid artery. Based on lack of symptoms we decided that there was no need for further invasive therapy. Due to apparently normal pressure on her affected arm, she had not been treated for hypertension previously. The patient was prescribed antihypertensive therapy, antilipemic therapy with statins, and antiplatelet agents. She will have regular follow-ups to evaluate efficacy of the therapy, possible other manifestations of atherosclerosis, and to early recognise possible indications for further invasive therapy. We instructed her, that blood pressure measurement should be done on her right arm.
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).