One-stage supraclavicular hybrid procedure for type B aortic dissection involving three rare anatomical anomalies: a case report and literature review

Figures

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  Figure 1.. CTA findings confirming type B aortic dissection involving three rare anatomical anomalies. (a) 3D image showing type B aortic dissection involving anatomical anomalies, namely KD (red arrow), ARSA (white arrow), and ILVA (yellow arrow). (b) 3D image showing the ARSA and KD (red arrow), with a maximum KD diameter of 21.3 × 32.8 mm. (c) 3D image showing the ILVA (yellow arrow). (d) 2D image showing the ILVA directly arising from the aortic arch (yellow arrow). (e) The KD and ARSA were involved owing to dissection. (f) The distance between the entry tear and the LSA ostium (green arrow) on 2D imaging is 3.0 mm. This image shows the four supra-arch branches: RCCA (pink arrow), LCCA (blue arrow), ILVA (yellow arrow), and LSA (green arrow). (g) The distance between the entry tear and the ILVA ostium on 2D imaging is 13.0 mm CTA, computed tomography angiography; 3D, three-dimensional; KD, Kommerell’s diverticulum; ARSA, aberrant right subclavian artery; ILVA, isolated left vertebral artery; 2D, two-dimensional; LSA, left subclavian artery; RCCA, right common carotid artery; LCCA, left common carotid artery.

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  Figure 2.. Intraoperative images. (a) Angiography before constructing the artificial bypass showing the ARSA (red arrow) and ILVA (yellow arrow) directly originating from the aortic arch. (b) Completion angiogram demonstrating that the artificial bypass (white arrow), ILVA-LCCA transposition (yellow arrow), and LSA-LCCA transposition (green arrow) were patent, with the initial part of the ARSA not developed. (c) Intraoperative photograph of the ARSA (green dotted arrow) and RCCA (blue dotted arrow). (d) The side-to-side artificial bypass established between the distal RSA (dotted green arrow) and RCCA (dotted blue arrow). (e) Intraoperative photograph of the ILVA (yellow arrow), LCCA (blue arrow), and LSA (green arrow). (f) End-to-side transposition of the LSA (green arrow) to the LCCA (blue arrow) ARSA, aberrant right subclavian artery; ILVA, isolated left vertebral artery; LCCA, left common carotid artery; LSA, left subclavian artery; RSA, right subclavian artery; RCCA, right common carotid artery.

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  Figure 3.. CTA on postoperative day 7. (a) ARSA-RCCA artificial bypass (white arrow). The ILVA (yellow arrow) and LSA (green arrow) were patent, and a small amount of blood flowed back from the distal RSA (red arrow) on 3D imaging, with the false lumen of the aortic arch completely excluded. (b) ILVA-LCCA transposition (yellow arrow) on 2D imaging. (c) ARSA-RCCA artificial bypass (white arrow) on 2D imaging. (d) LSA-LCCA transposition (green arrow) on 2D imaging. (e) No contrast agent was found in the proximal ARSA (blue arrow) on 2D imaging. (f) No contrast agent was found in the KD (purple arrow) on 2D imaging. (g) General view of the aorta under 3D reconstruction. CTA, computed tomography angiography; ARSA, aberrant right subclavian artery; ILVA, isolated left vertebral artery; LSA, left subclavian artery; RSA, right subclavian artery; LCCA, left common carotid artery; RCCA, right common carotid artery; KD, Kommerell’s diverticulum; 2D, two-dimensional; 3D, three-dimensional.

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  Figure 4.. CTA findings 1 year postoperatively. (a) Aortic arch on 3D imaging showing that the ILVA-LCCA transposition (yellow arrow) was patent. (b) The ILVA-LCCA transposition (yellow arrow), distal LSA (green arrow), and distal RSA (red arrow) were patent on 2D imaging. CTA, computed tomography angiography; 3D, three-dimensional; ILVA, isolated left vertebral artery; LCCA, left common carotid artery; LSA, left subclavian artery; RSA, right subclavian artery; 2D, two-dimensional.