Cas clinique

DOI of or

Pr�esent�e aucular Surgical

1Division oSurgery, Harb

2Asociaci�onUruguay.

CorrespondEndovascularson Street, Tor

Ann Vasc Surghttp://dx.doi.or� Annals of V�Edit�e par ELS

Traitement endovasculaire des traumatismesaortiques ferm�es avec une art�ere sous-clavi�eredroite aberrante associ�ee : Rapport de trois cas

Tyler S. Reynolds,1 Carlos E. Donayre,1 Carmelo Gastambide Somma,2 Walter Giossa Poggio,2

Karen M. Kim,1 Tien Nguyen,1 Rodney White,1 Torrance, California, USA, et Montevideo,

Uruguay

La rupture traumatique de l’aorte dans les cas rares d’art�ere sous-clavi�ere droite aberrante(ARSA) exige une attention sp�eciale pour empecher la survenue d’un AVC post�erieurd�evastateur. Nous pr�esentons trois cas trait�es en employant une approche endovasculaire,avec un examen des donn�ees pr�eop�eratoires et op�eratoires importantes. Trois patientsimpliqu�es dans des collisions de v�ehicule �a moteur avec des l�esions multiples ont �et�e trait�esdans deux �etablissements. Le scanner montrait une transsection de l’aorte et une ARSA. Cha-cun des trois cas a �et�e trait�e avec une approche diff�erente. Un patient n’a pas eu de pontagepr�eop�eratoire parce que l’imagerie confirmait une zone d’ancrage satisfaisante distale �a l’originede l’art�ere sous-clavi�ere gauche. Deux patients ont eu un pontage pr�eop�eratoire entre la caro-tide droite et la sous-clavi�ere devant la couverture pr�evue des deux art�eres sous-clavi�eres par lestentgraft pour pr�eserver un flux dans une art�ere vert�ebrale. Chez un patient, un dispositif endo-vasculaire d’occlusion a �et�e d�eploy�e dans l’ARSA avant d�eploiement aortique d’un stentgraft.Chez l’autre, l’occlusion de l’ARSA a �et�e effectu�ee 4 jours plus tard pour une endofuite persis-tante de type II. Le patient qui a eu un pontage et l’occlusion pr�eop�eratoire de l’ARSA a fait unAVC post�erieur mortel peu de temps apr�es la chirurgie. Les deux autres patients n’ont euaucune complication proc�edurale et n’ont eu besoin d’aucune r�einterventions avec un suivi de2 et 5 ans. Un patient est toujours en r�eadaptation apr�es 5 ans de suivi pour des l�esions trau-matiques c�er�ebrales ind�ependantes de la r�eparation par stentgraft. Bien que l’incidence del’ARSA soit tr�es limit�ee, l’imagerie et l’�evaluation pr�eop�eratoire du flux sanguin c�er�ebral sont cri-tiques pour empecher un AVC p�eriop�eratoire. La revascularisation, si elle est n�ecessaire pourobtenir une zone proximale sure de largage, doit etre effectu�ee avant le d�eploiement du stent-graft. La revascularisation sous-clavi�ere bilat�erale est indiqu�ee si des anomalies de la circulationc�er�ebrale sont pr�esentes.

iginal article: 10.1016/j.avsg.2011.05.001.

28�eme Annual Meeting de la Southern California Vas-Society, 30 avril e 1er mai 2010, Carlsbad, CA, USA.

f Vascular and Endovascular Surgery, Department ofor-UCLA Medical Center, Torrance, CA, USA.

Espa~nola Primera de Socorros Mutuos, Montevideo,

ance : Carlos E. Donayre, Division of Vascular andSurgery, Harbor-UCLA Medical Center, 1000 West Car-rance, CA 90502, USA, E-mail: cdonayre@cox.net

2011; 25: 979.e7-979.e12g/10.1016/j.acvfr.2012.10.014ascular Surgery Inc.EVIER MASSON SAS

INTRODUCTION

Aortic transection occurs in only 0.8% of motor

vehicle collisions but accounts for 16% of associated

deaths.1 Endovascularmanagement of these injuries

is rapidly evolving and may soon become first-line

treatment for select patients. Sufficient landing

zone to avoid a type I endoleak often requires

coverage of the left subclavian artery. The absolute

and relative indications for selective revasculariza-

tion of the left subclavian artery are discussed.

Aberrant right subclavian artery (ARSA), also

referred to as arteria lusoria, is the most common

1043.e7

Fig. 1. Thoracic aortic transection with aortic hematoma,

left hemothorax, and aberrant right subclavian artery

(ARSA).

Fig. 2. Postoperative computed tomographic recon-

struction showing endograft in good position with a

patent left subclavian artery and exclusion of the ARSA.

1043.e8 Cas cliniques Annales de chirurgie vasculaire

intrathoracic arterial abnormality occurring in 0.45-

2% of the population. The abnormality is often

discovered incidentally on diagnostic imaging.2,3 To

our knowledge, the endovascular management of

transection of the thoracic aorta with ARSA has not

been previously reported. In the special setting of an

ARSA and a transected aorta, endograft coverage of

both subclavian vessels mandates revascularization

of one or possibly both vessels. We report manage-

ment of three such cases over a 5-year period at two

different institutions.

Case 1

A 21-year-old female asthmatic was struck laterally

by a truck while she was in her vehicle. She was

unconscious on arrival to the emergency room and

was intubated for respiratory depression with a

stable blood pressure. She had stigmata of facial and

blunt chest trauma. Computed tomography (CT)

showed a left maxillary and frontal skull fracture

with hemorrhagic brain injury. CT of the thorax

showed aortic injury, with a mediastinal hematoma

and hemothorax (Fig. 1). AnARSAoriginating distal

to the left subclavian artery was also noted. Trans-

esophageal ultrasound confirmed an aortic intimal

disruption with an associated pseudoaneurysm.

The patient was initially stabilized in the inten-

sive care unit and underwent thoracic endovascular

aortic repair (TEVAR) the following day.

A TALENT (Medtronic, Inc., Santa Rosa, CA),

26 mm in diameter and 150 mm in length, endo-

prosthesis was successfully deployed just distal to

the origin of the left subclavian artery with exclu-

sion of the transection and the ARSA.

She subsequently underwent tracheostomy

5 days later, followed by gastrostomy, and was dis-

charged 2 months after the incident with moderate

neurologic impairment secondary to traumatic

brain injury. At that time, a repeat CT showed no

evidence of endoleak and successful endovascular

exclusion of her transected aorta. CT scan at 1 and

5 years later confirmed the lack of endoleaks and

no migration (Fig. 2). She is still undergoing neu-

rologic rehabilitation while working as a secretary.

Case 2

A 40-year-old man was driving a semi-truck when

he struck another truck. After a 90-minute extri-

cation, he was brought to a local emergency

department in a hypotensive state with a blood

pressure of 85/52 mm Hg and required intubation.

Abdominal ultrasound demonstrated fluid in Mor-

rison’s pouch. He was given 4 U of packed red blood

cells and 4 U of fresh frozen plasma, and blood

pressure was restored to normal. CT scan revealed

an open-book pelvic fracture and a possible aortic

injury. The patient was airlifted to our institution

where CT angiogram confirmed aortic transection

and ARSA. CT angiogram of the brain demonstrated

questionable filling of the right posterior commu-

nicating artery of the circle ofWillis; however, it was

believed to be patent. The vertebral arteries were of

good caliber.

The patient was taken to the endovascular suite

immediately where transesophageal ultrasound

and intravascular ultrasound confirmed transection

located just distal to the left subclavian origin. A right

carotid to right axillary bypass was performed using

an 8-mm polytetrafluoroethylene to preserve flow

Fig. 3. Fluoroscopy demonstrating axillary to right

common carotid artery bypass graft followed by Amplat-

zer vascular plug placement to exclude the ARSA.

Fig. 4. Angiogram demonstrating site of traumatic aortic

transection with origin of associated aberrant right sub-

clavian artery (ARSA) (white arrow). RCCA, right com-

mon carotid artery; LCCA, left common carotid artery;

LSA, left subclavian artery.

Vol. 25, No. 7, 2011 Cas cliniques 1043.e9

to the right vertebral artery. A 14 mm Amplatzer

vascular plug (AGA Medical Corp., Minneapolis,

MN) was then deployed in the proximal right sub-

clavian artery (Fig. 3).

A TALENT (Medtronic, Inc.), 32 mm in diameter,

endoprosthesis was subsequently deployed exclud-

ing the right and left subclavian arteries.

Adenosine-induced temporary cardiac arrest was

performed to ensure proper placement of the

endoprosthesis, and postoperative angiogram con-

firmed good placement without endoleak.

The patient was transferred back to the intensive

care unit in stable condition; however, he began to

require increased ventilator support 6 hours later

and had decreased ocular reflexes. CT confirmed

posterior stroke with massive cerebral edema and

basilar artery thrombosis. The patient expired

shortly thereafter.

Case 3

A 47-year-old man involved in a motor vehicle

collision was found to have multiple pelvic fractu-

res, acute diaphragmatic hernia, and widened

mediastinum. He was hemodynamically stable;

however, CT confirmed aortic transection, and so

the patient was transferred to our institution. CT

angiogram revealed transection of the aorta with

incidental ARSA. It also demonstrated an intact

circle of Willis and normal vertebral arteries. The

patient was taken directly to the operating room.

Angiography revealed approximately 15 mm bet-

ween the lowermost edge of the left common

carotid and the beginning of the transaction and the

aberrant vessel could also be visualized (Fig. 4).

A right carotid to right axillary bypass using an

8-mm polytetrafluoroethylene was again per-

formed followed by device deployment. A 36-mm

Valiant endoprosthesis (Medtronic, Inc.) was selec-

ted. After full deployment of the thoracic endo-

prosthesis, IVUS interrogation and angiography

revealed full endoprosthesis expansion and good

placement just distal to the left common carotid

artery. Type II endoleak was visualized from the

ARSA, as expected (Fig. 5). Given the patient’s other

injuries, he was then taken for repair of the dia-

phragmatic injury, with a plan to return later for

occlusion of the proximal right subclavian artery.

Repeat CT the next day confirmed persistent type

II endoleak from retrograde filling of the ARSA, and

the patient was taken on postoperative day 4 for

endoluminal exclusion of the leak using a 12-mm

Amplatzer vascular plug. The patient has done

well 2 years later with no further interventions.

DISCUSSION

Endovascular repair may soon become the first-line

treatment for transection of the aorta. Traumatic

rupture of the aortic isthmus can occur with rapid

deceleration or extreme shear forces after blunt

chest trauma.4 Mechanisms include compression

and blast forces, especially in the vertical or hori-

zontal axis.5 Immediate death has been reported in

>75% of cases.4-7 In an autopsy series of all post-

mortem examinations over a 4-year period, trau-

matic rupture of the aorta was found in 16% of

automobile accidents resulting in death.6 This

patient population is younger than those with other

thoracic aortic pathology, including aneurysm and

dissection. The pathology and characteristics of the

Fig. 5. Final angiogram demonstrating type II endoleak

secondary to retrograde filling through ARSA.

1043.e10 Cas cliniques Annales de chirurgie vasculaire

aorta are quite different. Our institution has found

the aorta in these younger patients to be more

compliant than older patients (T. Reynolds et al.,

unpublished data, January 2011). This may be

related to normal aging or a physiologic change after

blunt aortic injury.

In a prospective study of blunt aortic injury by the

American Association for the Surgery of Trauma in

1996, the average time to open operative repair for

transection was just over 16 hours.8 However, the

average time taken to perform an endovascular

repair at our institution is less than 16 hours. In the

same study, reportedmortality rate with open repair

is 14.9-15.1%, depending on technique.

In an analysis by Tang et al. in 2008, endovascu-

lar repair was compared with open surgery.9 Mor-

tality rate is lower with endovascular repair at 7.6

versus 15.2%. Paraplegia rate was reported to be 0%

with endovascular repair and 5.6% for open repair.

Stroke is also lower at 0.8 versus 5.6%. A later study

by the American Association for the Surgery of

Trauma in 2008 showed similar rates of paraplegia

in both groups, and additionally reported device-

related complications, including vascular access

(4.8%) and endoleak (13.6%).10

Endovascular management of aortic transection

has been shown to be safe and effective in clinical

trials. The evolution of management of blunt aortic

injury is well summarized by Neschis et al. in

2008.11 Several advantages of endovascular repair

include decreased blood loss, operative time, hos-

pital stay, and most importantly, aortic clamping is

not necessary; therefore, risks associated with

shunting and bypass are avoided. Perioperative

mortality is decreased with endovascular repair at

6.8% compared with 16-31% for open repair.

Stroke and paraplegia rates have been shown to be

lower with endovascular repair when compared

with open repair.11

Anticoagulants are routinely administered dur-

ing stent-graft deployment. Systemic hepariniza-

tion is avoided in the setting of complex solid organ

injury, concern for head trauma/brain injury, or

significant pelvic fractures. In such cases, we con-

nect only access sheaths to a heparin solution to

prevent formation of thrombus within the sheaths.

The previously published data are limited in

regard to the timing of repair of aortic transection.

Patients without pseudoaneurysm formation and

minimal intimal disruptionmay be able to be mana-

ged with delayed treatment or nonoperative mana-

gement. However, if the transection is complex

(pseudoaneurysm, intra-aortic thrombus, or

hemothorax), then it should be treated emergently.

At this time, delayed repair may be a reasonable

alternative in carefully selected patients with long-

term follow-up and imaging.12,13 Serial radio-

graphic examinations during the first week are

necessary because of the potential for rapid pro-

gression of the aortic injury.14

Subclavian artery revascularization

Controversy exists regarding routine or selective

revascularization with the coverage of one subcla-

vian (left) artery during TEVAR without ARSA.

Selective revascularization, through carotid-to-

subclavian bypass or transposition of the sub-

clavian artery, for patients with unfavorable

anatomy has been shown to be safe. Reece et al.

reported on 27 patients who underwent TEVAR

requiring coverage of the left subclavian artery

(LSA) among 64 patients in the series.15 Seven

patients underwent selective preoperative revascu-

larization based on vascular anatomy. The indica-

tions for TEVAR for these patients were not

mentioned; however, indications for preemptive

revascularization included dominant left vertebral

artery (one patient), incomplete Circle ofWillis (two

patients), ARSA (three patients), and left internal

mammary artery-to-left anterior descending artery

bypass (one patient). The three patients with ARSA

underwent revascularization 1-3 days before

TEVAR. Among the 20 patients who were not

revascularized, three developed left arm claudica-

tion and one developed postoperative retrograde

aortic dissection and subclavian steal syndrome. All

four patients subsequently underwent post-

operative LSA revascularization with no further

symptoms. There was no perioperative mortality or

paraplegia in the series and no significant posterior

circulation strokes or permanent left arm deficits.

In a single-institution study by Botta et al. in

2008, management of the left subclavian artery was

Vol. 25, No. 7, 2011 Cas cliniques 1043.e11

addressed.7 Of 27 patients who underwent endo-

vascular repair for acute traumatic transection of the

descending aorta, eight had an aorta with a short

proximal neck (<5 mm), and four of these patients

underwent endovascular complete or partial LSA

coverage. The other four patients had pseudo-

aneurysm of the left subclavian or left carotid artery

and were treated with conventional open inter-

vention. A single patientwith LSA coverage suffered

a large cerebellar stroke despite the absence of any

alteration of the circle ofWillis. The properties of the

vertebral arteries on preoperative imaging, namely

dominance, are not reported.

Riesenman et al. reported outcomes of 28 of 112

patients who underwent complete or partial cove-

rage of the left subclavian artery.16 Debranching

was performed for zone 0 or 1 coverage. Three of

these patients underwent carotid-to-carotid bypass

and one of these underwent left carotid-to-

subclavian bypass for right vertebral artery

stenosis. One patient who did not undergo revas-

cularization developed positional claudication of the

left hand while turning his head. Fourteen of 24

patients who underwent zone 2 placement had

complete coverage of the left subclavian artery.

Three patients developed left upper extremity

symptoms but did not require intervention. One

patient who had been treated emergently for a

ruptured mycotic aneurysm developed rest pain

requiring revascularization was found to have

aberrant insertion and coverage of a left vertebral

artery. Three embolic strokes were reported

(12.5%), but none were attributed to vertebral-

basilar insufficiency ischemia. The authors conclu-

ded that prophylactic revascularization is not

necessary.

Options for maintaining subclavian artery

patency during TEVAR include carotid-to-

subclavian bypass or transposition, as well as

endovascular techniques including fenestrated and

branched grafts, and the ‘‘chimney procedure.’’17

The ‘‘chimney (snorkel) procedure’’ may be performed

to improve forward flow through the subclavian

artery with the placement of a subclavian stent at

the orifice of the subclavian artery. This allows

extension of the aortic endograft over a portion of

the subclavian artery. The anatomy must be favo-

rable, including an adequate neck distal to the left

subclavian to minimize risk of a type I endoleak

around the subclavian stent.

Aberrant right subclavian artery

The ARSA results from a developmental abnorma-

lity likely related to regression of the right fourth

aortic arch and persistence of the distal right dorsal

aorta. It usually travels posterior to the esophagus

and is usually asymptomatic. Less than 10% of

patients develop dysphagia lusoria and the origin

can become aneurysmal in 8% of patients (Komme-

rell’s Diverticulum).3,18 Other abnormalities com-

monly seen with this anomaly include a

nonrecurrent right inferior laryngeal nerve, a com-

mon origin of the common carotid arteries, a

replaced right or left vertebral artery, coarctation of

the aorta, a right-sided thoracic duct, and a dex-

troposed aortic arch.18 Symptoms of progressive

dysphagia or aneurysmal disease prompt surgical

intervention.

There are several case reports in the previously

published data describing surgical repair of sympto-

matic ARSA as well as special considerations in the

repair of type B dissection.19-22 Traumatic rupture

of an ARSA has also been reported.23 Bednarkiewicz

et al. emphasized the importance of preoperative

diagnosis of ARSA in a patient with blunt aortic

injury treated by open surgical approach.24 Clamp-

ing of the aorta proximal to both subclavian arteries

with inadvertent exclusion of both vertebral arteries

may lead to posterior circulation ischemia. Revas-

cularization is the mainstay of therapy.

We prefer right carotid-to-axillary bypass initially

because it eliminates the risk of aneurysm formation

later in the ARSA, similar to what happens with the

persistent sciatic artery. However, if the left verte-

bral artery is dominant, a left carotid-to-subclavian/

axillary bypass is indicated.

CONCLUSION

The devastating complications emphasize the

importance of careful preoperative planning. The

CT angiogram is essential in all patients not only to

characterize the nature of the aortic injury and asso-

ciated injuries in the stable trauma patient, but also

to detect any pertinent anomaly such as the ARSA.

A widened mediastinum on plain chest film and

transesophageal echocardiogram alone are not

sensitive for detection of ARSA. Failure to recognize

the surgical and clinical ramifications can have

drastic consequences. Carotid-to-subclavian arte-

rial bypass before endograft exclusion of the verte-

bral arteries has been shown to successfully

maintain posterior circulatory flow through the

vertebral artery.

The following principles are emphasized from the

cases discussed. First, preoperative CT angiography

or aortography is vital to assess aortic anatomy,

vertebral-basilar system, and cerebral vasculature.

1043.e12 Cas cliniques Annales de chirurgie vasculaire

Second, forward flow must be maintained through

the vertebral-basilar system to maintain posterior

cerebral perfusion. Indications for revascularization

include incomplete circle of Willis, exclusion of a

dominant vertebral artery, presence of internal

mammary coronary artery bypass, and ipsilateral

functioning hemodialysis access. Relative indica-

tions also include extensive aortic coverage, pre-

vious abdominal aortic aneurysm repair, and

aberrant left vertebral artery.

The landing zone is often proximal to both sub-

clavian arteries in the patient with ARSA. In this

setting, a unilateral revascularization procedure is

absolutely necessary to maintain perfusion of the

posterior circulation of the brain. Selective bilateral

revascularization in the setting of ARSA is then indi-

cated in the special settings discussed.

Bilateral revascularization is recommended in the

setting of incomplete Circle of Willis. In case 2, flow

in the right posterior communicating artery of the

circle of Willis was questionable. A left carotid-to-

subclavian or axillary bypass, subclavian-carotid

transposition, or endovascular technique, includ-

ing the ‘‘Chimney procedure,’’ are options for

revascularization.17 If both vertebral arteries need to

be revascularized, we prefer right carotid-to-

subclavian/axillary artery bypass and a ‘‘chimney’’

procedure to maintain perfusion of the left vertebral

artery.

Third, if revascularization is necessary, it must be

performed before endoluminal exclusion to pre-

serve flow through the vertebral-basilar system.

Carotid artery to axillary bypass is a rapid revascu-

larization procedure and is preferred by some sur-

geons in the setting of aortic transection. Finally, the

need for occlusion of the native ARSA in the setting

of type II endoleak is not urgent because associated

morbidity is low. In fact, acute changes in perfusion

through the vertebral arteries may be detrimental.

The anticipated type II endoleak in case 3 was

occluded 4 days later with no complications.

In conclusion, traumatic rupture of the aorta

with ARSA can be managed successfully with an

endovascular approach. As endovascular repair

continues to replace open repair as first-line treat-

ment for most patients, thorough preoperative

planning will improve outcomes and assist in the

development of innovative techniques for compli-

cated patients.

REFERENCES

1. Jahromi A, Kazemi K, Safar H, Doobay B, Cina C. Traumatic

rupture of the thoracic aorta: cohort study and systematic

review. J Vasc Surg 2001;34:1029-1034.

2. Felson B, Cohen S, Courter S, McGuire J. Anomalous right

subclavian artery. Radiology 1950;54:340-349.

3. Freed K, Low V. The aberrant subclavian artery. Am J

Roentgenol 1997;166:481-484.

4. Sevitt S. The mechanism of traumatic rupture of the thoracic

aorta. Br J Surg 1977;64:166-173.

5. Parmley LF, Mattingly TW, Mariom WC, Jahnke EJ. Non-

penetrating traumatic injury of the aorta. Circulation

1958;17:1086-1101.

6. Greendyke RM. Traumatic rupture of aorta. Special refe-

rence to automobile accidents. JAMA 1996;195:119-122.

7. Botta L, Russo V, Savini C, et coll. Endovascular treatment

for acute traumatic transaction of the descending aorta:

focus on operative timing and left subclavian artery

management. J Thorac Cardiovasc Surg 2008;136:

1558-1563.

8. Fabian T, Richardson J, Croce M, et coll. Prospective study of

blunt aortic injury: multicenter trial of the American Asso-

ciation for the Surgery of Trauma. J Trauma 1997;42:

374-383.

9. Tang G, Tehrani H, Usman A, Katariya K, Otero C, Perez E,

Eskandari M. Reduced mortality, paraplegia, and stroke with

stent graft repair of blunt aortic transections: a modern

meta-analysis. J Vasc Surg 2008;47:671-675.

10. Demetriades D, Velmahos G, Scalea T, et coll. Diagnosis and

treatment of blunt thoracic aortic injuries: changing per-

spectives. J Trauma 2008;64:1415-1419.

11. Neschis D, Scalea T, Flinn W, Griffith B. Blunt aortic injury.

N Engl J Med 2008;359:1708-1716.

12. Cafarelli A, Mallidi H, Maggio P, Spain D, Miller D,

Mitchell S. Early outcomes of deliberate nonoperative

management for blunt thoracic aortic injury in trauma.

J Thorac Cardiovasc Surg 2010;140:598-605.

13. Symbas P, Sherman A, Silver J, Symbas J, Lackey J. Trau-

matic rupture of the aorta: immediate or delayed repair?

Ann Vasc 2002;235:796-802.

14. Holmes J, Bloch R, Hall A, Carter Y, Karmy-Jones R. Natural

history of traumatic rupture of the thoracic aorta managed

nonoperatively: a longitudinal analysis. Ann Thorac Surg

2002;73:1149-1154.

15. Reece B, Gazoni L, Cherry K, et coll. Re-evaluating the need

for left subclavian artery revascularization with thoracic

endovascular aortic repair. Ann Thorac Surg 2007;84:

1201-1205.

16. Riesenman P, Farber M, Mendes R, Marston W, Fulton J,

Keagy B. Coverage of the left subclavian artery during

thoracic endovascular aortic repair. J Vasc Surg 2007;45:

90-95.

17. Criado F. A percutaneous technique for preservation of arch

branch patency during thoracic endovascular aortic repair

(TEVAR): retrograde catheterization and stenting. J Enco-

vasc Ther 2007;14:54-58.

18. Epstein D, Debord J. Abnormalities associated with aberrant

right subclavian arteries-a case report. Vasc Endovascular

Surg 2002;36:297-303.

19. Weinberger G, Randall A, Parker B, Kiefer A. Involvement

of an aberrant right subclavian artery in dissection of the

thoracic aorta: diagnostic and therapeutic implication. Am J

Roentgenol 1977;129:653-655.

20. Mosquera V, Marini M, Rodriguez F, Cao I, Juffe A. Com-

plicated acute type B aortic dissection with involvement of

an aberrant right subclavian artery and rupture of a thora-

coabdominal aortic aneurysm, Crawford type I: successful

emergency endovascular treatment. J Thorac Cardiovasc

Surg 2007;134:1055-1057.

Vol. 25, No. 7, 2011 Cas cliniques 1043.e13

21. Baccin C, Montegegro M, Mour~ao G. Thoracic aorta dis-

section associated with aberrant right subclavian artery:

treatment with endovascular stent-graft placement. Yale J

Biol Med 2004;77:59-62.

22. Syme J. Aortic dissection involving an aberrant right sub-

clavian artery studied by aortography. Aust Radiol 1973;17:

174-179.

23. Alcocer J, Spier L, Dyke C, Griffith B, Gammie J. Traumatic

rupture of an aberrant right subclavian artery. Ann Thorac

Surg 2000;69:621-623.

24. Bednarkiewicz M, Robert J, Khatchatourian G, Genin G,

IrmayF, Faidutti B. Traumatic rupture of the aortic isthmus in

a patientwith an aberrant right subclavian artery: therapeutic

implications. J Thorac Cardiovasc Surg 1999;118:1112-1113.