With newly created therapy devices and cutting-edge diagnostic techniques, we successfully diagnosed and treated subclavian steal syndrome in this case report. This case report is complemented by a literature review that examines the current state of knowledge about diagnostic and treatment options. The patient reported pain and numbness in his left upper arm when raising his arm above his head. On clinical examination, he had good left radial and ulnar pulses while in a sitting position; however, he had absent left ulnar pulses when he raised his hand above his head. Angiography revealed retrograde perfusion of the left vertebral artery and nearly complete occlusion of the ostium of the left subclavian artery. The patient underwent angioplasty and stenting. Immediately after the procedure, the patient reported a reduction in the pain and numbness in his left upper limb by 50%, which completely disappeared at his routine follow-up after one month. The patient was completely asymptomatic during follow-up and had no signs of neurological deficit.

Complete and precise knowledge of the neck anatomy and its eventual anomalies is crucial while performing a safe thyroid and parathyroid surgery. Embryo-genetic malformations of the IV branchial arch can lead to an uncommon anatomical alteration known as non-recurrent inferior laryngeal nerve. Its prevalence varies between 0.7% for the dextral branch and 0.04% for the sinistral. In these cases, the inferior laryngeal nerve branches originate directly from the cervical vagus nerve, entering the larynx without hooking, on the right side around the subclavian artery or on the left around the aortic arch. The presence of a non-recurrent laryngeal nerve is challenging, due to the increased risks of iatrogenic damage to the nerve, which results in hoarseness, dysphagia, glottal obstruction, vocal cords palsy, and serious airway impairment. We present the case of a 58-year-old woman. The patient was admitted to our department for a nodule classified as Bethesda IV in the right thyroid lobe. Through the use of intraoperative neuromonitoring (IONM), surgeons detected intraoperatively a non-recurrent laryngeal nerve. A subsequent computed tomography scan confirmed an anomalous right subclavian artery branching from the left aortic arch, the Lusoria Artery. Anatomical variants represent pitfalls in this case and an accurate knowledge of the neck region is imperative while performing thyroid surgery. Devices such as IONM are useful for detecting abnormalities that may lead to iatrogenic damages.

Subclavian artery aneurysm is usually rare. We report a case of a right subclavian artery aneurysm with infective endocarditis. A 36-year-old woman was admitted at our hospital due to a cerebral embolism. The echocardiogram showed severe mitral regurgitation with vegetation, and computed tomography (CT) revealed an intrathoracic right subclavian artery aneurysm. The 59×39 mm-sized mass was located distal to the vertebral artery. Mitral valvuloplasty, tricuspid annuloplasty, and aneurysm surgery with extra-anatomical bypass were performed simultaneously. The aneurysm was resected through a median sternotomy and right supraclavicular and subclavicular incisions. Revascularization with transthoracic aorto-axillary extra-anatomical bypass was also performed. The postoperative course was uneventful with no noted complications.

OBJECTIVE: This study aimed to develop and validate a convolutional neural network (CNN) that automatically detects an aberrant right subclavian artery (ARSA) on preoperative computed tomography (CT) for thyroid cancer evaluation.
METHODS: A total of 556 CT with ARSA and 312 CT with normal aortic arch from one institution were used as the training set for model development. A deep learning model for the classification of patch images for ARSA was developed using two-dimension CNN from EfficientNet. The diagnostic performance of our model was evaluated using external test sets (112 and 126 CT) from two institutions. The performance of the model was compared with that of radiologists for detecting ARSA using an independent dataset of 1683 consecutive neck CT.
RESULTS: The performance of the model was achieved using two external datasets with an area under the curve of 0.97 and 0.99, and accuracy of 97% and 99%, respectively. In the temporal validation set, which included a total of 20 patients with ARSA and 1663 patients without ARSA, radiologists overlooked 13 ARSA cases. In contrast, the CNN model successfully detected all the 20 patients with ARSA.
CONCLUSIONS: We developed a CNN-based deep learning model that detects ARSA using CT. Our model showed high performance in the multicenter validation.

暂无摘要。

OBJECTIVE: The objective of this study was to enhance the efficiency of aortic arch replacement through the development of a novel frozen elephant trunk (FET) prosthesis with an endovascular side branch for left subclavian artery (LSA) connection. After successful pre-clinical testing, the feasibility and safety of implementing this innovative prosthesis in human subjects were investigated.
METHODS: Between September 2020 and September 2021, 4 patients (mean age 67) with conditions such as penetrating ulcer, non A-non B aortic dissection and chronic arch aneurysm underwent surgery utilizing the customized device. Surgeries were performed under high moderate hypothermia (27°C), employing bilateral selective antegrade cerebral perfusion (SACP) and distal aortic perfusion. Anastomosis of the FET prosthesis with the aortic arch occurred in zone 1, followed by separate reimplantation of the left common carotid artery and the brachiocephalic artery.
RESULTS: All patients were discharged in good clinical condition. The mean aortic cross-clamp, antegrade selective cerebral perfusion and distal aortic perfusion times were 111, 71 and 31 min, respectively. Endovascular extension of the side branch for the LSA was required in all cases to prevent endoleak formation. One patient received a stent graft extension at the end of the operation, while 2 others underwent the procedure during their hospital stay. One patient was diagnosed with an endoleak at the first follow-up after 3 months, and endoleak sealing was achieved via the brachial artery with an extension stent graft.
CONCLUSIONS: Preliminary clinical outcomes suggest that the newly designed FET prosthesis shows promise in simplifying total arch replacement. These initial findings provide a foundation for planned clinical studies to further assess the effectiveness of this modified surgical hybrid graft, with particular attention to the length and diameter of the LSA sidearm.

BACKGROUND: Cerebral perfusion may change depending on arterial cannulation site and may affect the incidence of neurologic adverse events in post-cardiotomy extracorporeal life support (ECLS). The current study compares patients\' neurologic outcomes with three commonly used arterial cannulation strategies (aortic vs. subclavian/axillary vs. femoral artery) to evaluate if each ECLS configuration is associated with different rates of neurologic complications.
METHODS: This retrospective, multicenter (34 centers), observational study included adults requiring post-cardiotomy ECLS between January 2000 and December 2020 present in the Post-Cardiotomy Extracorporeal Life Support (PELS) Study database. Patients with Aortic, Subclavian/Axillary and Femoral cannulation were compared on the incidence of a composite neurological end-point (ischemic stroke, cerebral hemorrhage, brain edema). Secondary outcomes were overall in-hospital mortality, neurologic complications as cause of in-hospital death, and post-operative minor neurologic complications (seizures). Association between cannulation and neurological outcomes were investigated through linear mixed-effects models.
RESULTS: This study included 1897 patients comprising 26.5% Aortic (n = 503), 20.9% Subclavian/Axillary (n = 397) and 52.6% Femoral (n = 997) cannulations. The Subclavian/Axillary group featured a more frequent history of hypertension, smoking, diabetes, previous myocardial infarction, dialysis, peripheral artery disease and previous stroke. Neuro-monitoring was used infrequently in all groups. Major neurologic complications were more frequent in Subclavian/Axillary (Aortic: n = 79, 15.8%; Subclavian/Axillary: n = 78, 19.6%; Femoral: n = 118, 11.9%; p < 0.001) also after mixed-effects model adjustment (OR 1.53 [95% CI 1.02-2.31], p = 0.041). Seizures were more common in Subclavian/Axillary (n = 13, 3.4%) than Aortic (n = 9, 1.8%) and Femoral cannulation (n = 12, 1.3%, p = 0.036). In-hospital mortality was higher after Aortic cannulation (Aortic: n = 344, 68.4%, Subclavian/Axillary: n = 223, 56.2%, Femoral: n = 587, 58.9%, p < 0.001), as shown by Kaplan-Meier curves. Anyhow, neurologic cause of death (Aortic: n = 12, 3.9%, Subclavian/Axillary: n = 14, 6.6%, Femoral: n = 28, 5.0%, p = 0.433) was similar.
CONCLUSIONS: In this analysis of the PELS Study, Subclavian/Axillary cannulation was associated with higher rates of major neurologic complications and seizures. In-hospital mortality was higher after Aortic cannulation, despite no significant differences in incidence of neurological cause of death in these patients. These results encourage vigilance for neurologic complications and neuromonitoring use in patients on ECLS, especially with Subclavian/Axillary cannulation.

Objective To evaluate the effect of surgical treatment on extracranial supra-aortic aneurysms and summarize the experience. Methods The clinical data of 10 patients undergoing surgical treatment of extracranial supra-aortic aneurysms from May 2019 to November 2023 in the Department of Vascular Surgery of Beijing Tiantan Hospital affiliated to Capital Medical University were collected.The 10 patients included 5 patients with internal carotid artery aneurysm,2 patients with subclavian artery aneurysm,2 patients with vertebral artery aneurysm,and 1 patient with internal carotid artery aneurysm combined with ipsilateral subclavian artery aneurysm.The surgical indications,surgical regimens,clinical efficacy,and complications were retrospectively analyzed. Results All the 10 patients underwent surgery successfully,with the surgery duration range of 60-420 min and the median surgery duration of 180.0 (121.5,307.5) min.Intraoperative bleeding volume varied within 30-400 mL,with a median of 90 (50,125) mL.The time of carotid artery blocking and vertebral artery blocking varied within the ranges of 10-20 min and 20-30 min,with the medians of 15.0 (11.5,16.3) min and 25.0 (15.0,22.5) min,respectively.No cardiac accident,cerebral infarction,or cerebral hemorrhage occurred during the perioperative period.The 10 patients were followed up for 3-58 months,with the median follow-up time of 8.5 (5.3,17.0) months.One patient with subclavian artery aneurysm developed artificial vessel occlusion 20 months after surgery.One patient with internal carotid artery aneurysm developed distal carotid artery stenosis 6 months after surgery. Conclusion Surgical treatment should be actively adopted for extracranial supra-aortic aneurysms,and individualized surgical regimens should be designed according to patient conditions.
目的 探讨手术治疗颅外段弓上动脉瘤的临床疗效并总结其治疗经验。方法 收集首都医科大学附属北京天坛医院血管外科2019年5月至2023年11月收治的10例颅外段弓上动脉瘤患者的临床资料,其中颈内动脉瘤5例、锁骨下动脉瘤2例、椎动脉瘤2例、颈内动脉瘤合并同侧锁骨下动脉瘤1例。回顾性分析颅外段弓上动脉瘤的手术指征、手术策略、临床疗效及相关并发症。结果 10例患者均顺利完成手术,手术时间60~420 min,中位手术时间180.0(121.5,307.5) min。术中出血30~400 mL,中位出血量90(50,125) mL。颈动脉阻断时间10~20 min,中位阻断时间15.0(11.5,16.3) min。椎动脉阻断时间20~30 min,中位阻断时间25.0(15.0,22.5) min。围手术期均无心脏意外、脑梗死及脑出血发生。10例患者获随访3~58个月,中位随访时间8.5(5.3,17.0)个月。1例锁骨下动脉瘤患者术后20个月出现人工血管闭塞。1例颈内动脉瘤患者术后6个月出现远端颈内动脉狭窄。结论 颅外段弓上动脉瘤应积极采取手术治疗,需根据不同的病变情况采取个体化的手术策略。.

UNASSIGNED: Stent fractures may be a risk factor for delayed restenosis, but it is difficult to diagnose asymptomatic stent fractures in the subclavian artery (SCA). We report a rare case of percutaneous transluminal angioplasty and stenting (PTAS) for SCA stenosis with asymptomatic severe stent fracture that showed progressive in-stent stenosis in the early postoperative period.
UNASSIGNED: A 70-year-old woman presented with left arm claudication. Magnetic resonance imaging at the time of admission showed SCA stenosis with severe calcification. Because of the left subclavian steal phenomenon on ultrasonography of the left vertebral artery, she underwent PTAS using a balloon-expandable stainless stent. Ultrasonography the day after treatment showed appropriate stent placement. Computed tomography angiography (CTA) 30 days after PTAS showed an asymptomatic complete spiral stent fracture at the mid-portion of the stent. The in-stent stenosis then gradually progressed on follow-up ultrasonography at the site of the stent fracture. Nine months after the first PTAS, a second PTAS using a self-expandable nitinol stent was performed because the peak systolic velocity exceeded 300 cm/s on Doppler ultrasound. Two years after the second PTAS, no neurological symptoms and no stent deformation were observed.
UNASSIGNED: PTAS with a balloon-expandable stainless stent for SCA stenosis with severe calcification may lead to stent fracture. In the case of severe stent fracture, careful follow-up may be needed for the detection of asymptomatic in-stent stenosis in the early postoperative period.

BACKGROUND: Bilateral diaphragmatic dysfunction can lead to dyspnea and recurrent respiratory failure. In rare cases, it may result from high cervical spinal cord ischemia (SCI) due to anterior spinal artery syndrome (ASAS). We present a case of a patient experiencing persistent isolated diaphragmatic paralysis after SCI at level C3/C4 following thoracic endovascular aortic repair (TEVAR) for Kommerell\'s diverticulum. This is, to our knowledge, the first documented instance of a patient fully recovering from tetraplegia due to SCI while still exhibiting ongoing bilateral diaphragmatic paralysis.
METHODS: The patient, a 67-year-old male, presented to the Vascular Surgery Department for surgical treatment of symptomatic Kommerell\'s diverticulum in an aberrant right subclavian artery. After successful surgery in two stages, the patient presented with respiratory insufficiency and flaccid tetraparesis consistent with anterior spinal artery syndrome with maintained sensibility of all extremities. A computerized tomography scan (CT) revealed a high-grade origin stenosis of the left vertebral artery, which was treated by angioplasty and balloon-expandable stenting. Consecutively, the tetraparesis immediately resolved, but weaning remained unsuccessful requiring tracheostomy. Abdominal ultrasound revealed a residual bilateral diaphragmatic paralysis. A repeated magnetic resonance imaging (MRI) 14 days after vertebral artery angioplasty confirmed SCI at level C3/C4. The patient was transferred to a pulmonary clinic with weaning center for further recovery.
CONCLUSIONS: This novel case highlights the need to consider diaphragmatic paralysis due to SCI as a cause of respiratory failure in patients following aortic surgery. Diaphragmatic paralysis may remain as an isolated residual in these patients.