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.

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.

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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.

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.

BACKGROUND: Subclavian arterial injury due to blunt trauma is rare but can have devastating outcomes. Massive hemorrhage or limb ischemia might develop depending on the extent of damage, and open repair might be necessary to salvage the limb. However, life-saving treatments should be prioritized in critically unstable patients.
METHODS: A 21-year-old male patient who was transferred to our trauma center following a motorcycle accident. Abdominal and chest computed tomography (CT) revealed right renal injury and massive hemothorax with several rib fractures in the right chest.
METHODS: Right renal injury with multiple extravasations and right 8th intercostal arterial injury were detected during angiography. Emergent exploration with lateral thoracotomy was performed to manage right hemothorax. Pulsating bleeding from the thoracic roof observed in the operative field suggested a subclavian arterial injury. The unstable vital signs did not recover despite massive transfusion, and his right arm had already stiffened. Therefore, endovascular approach was adopted and the second portion of the right subclavian artery was embolized using microcoils and thrombin.
RESULTS: Postoperative intensive care unit management performed to resuscitate patient from multiorgan failure included continuous renal replacement therapy (CRRT). After confirming the demarcation lines, transhumeral amputation of the right arm was performed on admission day 12. The patient recovered from multiorgan failure for more than 3 weeks after the accident; however, the patient survived.
CONCLUSIONS: Limb salvage, albeit critical for quality of life, is not possible in some cases where life-saving measures require its sacrifice. In these cases, quick decision-making by the surgeon is paramount for patient survival. As illustrated in this case, endovascular approaches should be considered less invasive measures to save the patient\'s life.

BACKGROUND: Subclavian artery (SCA) injuries, though rare, carry significant morbidity and mortality risks due to significant blood loss causing hypovolemic shock. Early diagnosis and adequate treatment are crucial to minimize bleeding and associated morbidity. Recent advances in endovascular techniques offer faster and more accurate treatment options compared to traditional open surgical repair. This study demonstrates the efficacy of endovascular treatment in 2 cases of SCA injury and reviews its indications, limitations, and precautions.
METHODS: A 69-year-old man presented with a penetrating SCA injury from a steel bar, and a 38-year-old woman presented with a blunt SCA injury caused by a fall. Both patients were hemodynamically unstable upon presentation.
METHODS: Both patients were diagnosed with SCA injuries. The man had a penetrating injury, while the woman had a blunt injury, both resulting in hemodynamic instability and significant risk of hypovolemic shock.
METHODS: Endovascular techniques, including the use of covered stent grafts, were employed to manage the injuries. These techniques allowed for rapid and efficient treatment, reducing the need for open surgical intervention.
RESULTS: Both patients were successfully treated using endovascular methods and were discharged without any complications. The endovascular approach minimized blood loss, transfusion needs, and hospital stay.
CONCLUSIONS: This study demonstrates the effectiveness of endovascular techniques in rapidly diagnosing, bridging, and definitively treating SCA injuries, suggesting their use as a first-line therapy.