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• W2000904826 abstract "An aortic neck with a nonconstant diameter represents a challenge for endovascular treatment. We report our experience in a patient with right aortic arch, aneurysmatic aberrant subclavian artery, aortic coarctation, and a precoarctation aneurysm that was treated with surgery and endoprothestic procedures in two stages. An aortic neck with a nonconstant diameter represents a challenge for endovascular treatment. We report our experience in a patient with right aortic arch, aneurysmatic aberrant subclavian artery, aortic coarctation, and a precoarctation aneurysm that was treated with surgery and endoprothestic procedures in two stages. Marty-Ane and colleagues [1Marty-Ane C. Serres-Cousine O. Laborde J.C. Costes V. Alauzen M. Mary H. Use of endovascular stents for acute aortic dissection: an experimental study.Ann Vasc Surg. 1994; 8: 434-442Abstract Full Text PDF PubMed Scopus (19) Google Scholar] reported in 1994 a study of the first experimental use of endovascular stents. In 1995, Parodi [2Parodi J.C. Endovascular repair of abdominal aortic aneurysm and other arterial lesions.J Vasc Surg. 1995; 21: 549-555Abstract Full Text Full Text PDF PubMed Scopus (450) Google Scholar] reported his first and promising experience with an endograft in a patient. This type of treatment is now very common and does not represent any novelty; however, an aortic neck with a nonconstant diameter represents a challenge for endovascular treatment because it does not allow anchorage of the endoluminal stent device. If the segment affected is long enough to present multiple dilatations or stenosis, and the diameter of the final segment, where the distal anchor should be placed, differs notably from the proximal one, the only endovascular device that should fit must be conical.A 67-year-old woman presented at admission with a right aortic arch, an aberrant left subclavian artery with aneurysmatic origin, an aortic coarctation, and a postcoarctation aneurysm.Because a surgical procedure was considered hazardous, an endovascular treatment was planned. Three different specially made conical endoprotheses, with increasing diameters of 24 to 34, 30 to 40, and 36 to 46 mm, were used to cover a 21-cm-long aortic aneurysmatic sector. The proximal neck aortic diameter was 15 mm. Aneurysm diameter postcoarctation was 61 mm, and the distal neck, close to the diaphragm, was 42 mm.The patient’s right aortic arch was partially interrupted by a coarctation. The origin of both carotids was proximal to the coarctation, and both subclavian arteries emerged afterwards. The left subclavian had an aberrant origin and a 50-mm ostium diameter.A surgical bypass from the right carotid artery to the right subclavian artery was performed to allow the endoprothesis to occlude its ostium. The left subclavian ostium was occluded without bypass (Fig 1).The procedure was started with the insertion of the distal segment and ended with the proximal segment to prevent the segments from being dislodged. Coarctation dilatation was performed after implantation. At the 4-year follow-up, the aneurysm was completely excluded and the patient was free of symptoms.CommentA combined procedure for aortic aneurysm treatment must be always considered as an alternative. Because of the anatomic properties of this patient’s aneurysm, its surgical approach was considered as extremely hazardous. The endoprothestic treatment presented the difficulty of the nonconstant diameter of the neck in the application as well as the coarctation (Fig 2). To occlude the origin of both subclavian arteries, an extraanatomic bypass from the right carotid artery to the right subclavian artery was performed as a first step. This preserved the right vertebral artery.Fig 2(A) Carotid-to-subclavian bypass. (B) Aneurysm before the implants. (C) Aneurysm after the implant.View Large Image Figure ViewerDownload (PPT)In a second step, three manufactured conical endoprotheses, especially made for this patient, were implanted in a distal-to-proximal way to avoid dislodgment (Fig 3). The endoprothesis sealed the aneurysmatic origin of the left subclavian artery, and a balloon dilatation of the coarctation was performed to finish the procedure.Fig 3Resistance of dislodgement.View Large Image Figure ViewerDownload (PPT)We think, as Criado and colleagues [3Criado F.J. Clark N.S. Barnatan M.F. Stent graft repair in the aortic arch and descending aorta experience.J Vasc Surg. 2002; 36: 1121-1128Abstract Full Text PDF PubMed Scopus (285) Google Scholar] and Nitta and colleagues [4Nitta Y. Tsuru Y. Yamaya K. Akasaka J. Oda K. Tabayashi K. Endovascular flexible stent grafting with arch vessel bypass for a case of aortic arch aneurysm.J Thorac Cardiovasc Surg. 2003; 126: 1186-1188Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar] reported, that a combination of surgical and endoprothesical procedures should be considered when dealing with such complex cases. Marty-Ane and colleagues [1Marty-Ane C. Serres-Cousine O. Laborde J.C. Costes V. Alauzen M. Mary H. Use of endovascular stents for acute aortic dissection: an experimental study.Ann Vasc Surg. 1994; 8: 434-442Abstract Full Text PDF PubMed Scopus (19) Google Scholar] reported in 1994 a study of the first experimental use of endovascular stents. In 1995, Parodi [2Parodi J.C. Endovascular repair of abdominal aortic aneurysm and other arterial lesions.J Vasc Surg. 1995; 21: 549-555Abstract Full Text Full Text PDF PubMed Scopus (450) Google Scholar] reported his first and promising experience with an endograft in a patient. This type of treatment is now very common and does not represent any novelty; however, an aortic neck with a nonconstant diameter represents a challenge for endovascular treatment because it does not allow anchorage of the endoluminal stent device. If the segment affected is long enough to present multiple dilatations or stenosis, and the diameter of the final segment, where the distal anchor should be placed, differs notably from the proximal one, the only endovascular device that should fit must be conical. A 67-year-old woman presented at admission with a right aortic arch, an aberrant left subclavian artery with aneurysmatic origin, an aortic coarctation, and a postcoarctation aneurysm. Because a surgical procedure was considered hazardous, an endovascular treatment was planned. Three different specially made conical endoprotheses, with increasing diameters of 24 to 34, 30 to 40, and 36 to 46 mm, were used to cover a 21-cm-long aortic aneurysmatic sector. The proximal neck aortic diameter was 15 mm. Aneurysm diameter postcoarctation was 61 mm, and the distal neck, close to the diaphragm, was 42 mm. The patient’s right aortic arch was partially interrupted by a coarctation. The origin of both carotids was proximal to the coarctation, and both subclavian arteries emerged afterwards. The left subclavian had an aberrant origin and a 50-mm ostium diameter. A surgical bypass from the right carotid artery to the right subclavian artery was performed to allow the endoprothesis to occlude its ostium. The left subclavian ostium was occluded without bypass (Fig 1). The procedure was started with the insertion of the distal segment and ended with the proximal segment to prevent the segments from being dislodged. Coarctation dilatation was performed after implantation. At the 4-year follow-up, the aneurysm was completely excluded and the patient was free of symptoms. CommentA combined procedure for aortic aneurysm treatment must be always considered as an alternative. Because of the anatomic properties of this patient’s aneurysm, its surgical approach was considered as extremely hazardous. The endoprothestic treatment presented the difficulty of the nonconstant diameter of the neck in the application as well as the coarctation (Fig 2). To occlude the origin of both subclavian arteries, an extraanatomic bypass from the right carotid artery to the right subclavian artery was performed as a first step. This preserved the right vertebral artery.In a second step, three manufactured conical endoprotheses, especially made for this patient, were implanted in a distal-to-proximal way to avoid dislodgment (Fig 3). The endoprothesis sealed the aneurysmatic origin of the left subclavian artery, and a balloon dilatation of the coarctation was performed to finish the procedure.Fig 3Resistance of dislodgement.View Large Image Figure ViewerDownload (PPT)We think, as Criado and colleagues [3Criado F.J. Clark N.S. Barnatan M.F. Stent graft repair in the aortic arch and descending aorta experience.J Vasc Surg. 2002; 36: 1121-1128Abstract Full Text PDF PubMed Scopus (285) Google Scholar] and Nitta and colleagues [4Nitta Y. Tsuru Y. Yamaya K. Akasaka J. Oda K. Tabayashi K. Endovascular flexible stent grafting with arch vessel bypass for a case of aortic arch aneurysm.J Thorac Cardiovasc Surg. 2003; 126: 1186-1188Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar] reported, that a combination of surgical and endoprothesical procedures should be considered when dealing with such complex cases. A combined procedure for aortic aneurysm treatment must be always considered as an alternative. Because of the anatomic properties of this patient’s aneurysm, its surgical approach was considered as extremely hazardous. The endoprothestic treatment presented the difficulty of the nonconstant diameter of the neck in the application as well as the coarctation (Fig 2). To occlude the origin of both subclavian arteries, an extraanatomic bypass from the right carotid artery to the right subclavian artery was performed as a first step. This preserved the right vertebral artery. In a second step, three manufactured conical endoprotheses, especially made for this patient, were implanted in a distal-to-proximal way to avoid dislodgment (Fig 3). The endoprothesis sealed the aneurysmatic origin of the left subclavian artery, and a balloon dilatation of the coarctation was performed to finish the procedure. We think, as Criado and colleagues [3Criado F.J. Clark N.S. Barnatan M.F. Stent graft repair in the aortic arch and descending aorta experience.J Vasc Surg. 2002; 36: 1121-1128Abstract Full Text PDF PubMed Scopus (285) Google Scholar] and Nitta and colleagues [4Nitta Y. Tsuru Y. Yamaya K. Akasaka J. Oda K. Tabayashi K. Endovascular flexible stent grafting with arch vessel bypass for a case of aortic arch aneurysm.J Thorac Cardiovasc Surg. 2003; 126: 1186-1188Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar] reported, that a combination of surgical and endoprothesical procedures should be considered when dealing with such complex cases." @default.
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• W2000904826 title "Multiple Overlapped Conical Endoprostheses in a Patient With Aneurysmatic Right Aortic Arch and Aortic Coarctation" @default.
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