Case 1 «symptomatic subclavian steal syndrome»
47-year-old, male, Asian
Clinical history
- For 2 years, dizziness at postural movements and by using left upper limb.
- Different upper limbs arterial pressure: R=130/90mmHg; L=100/90mmHg (differential systolic: 30mmHg)
Imaging:
- DUS:reverse flow in left vertebral artery -> LSA: PSV 80cm/sec; RSA: PSV 180 cm/sec
- Transcranic Doppler: vertebro-basilar flow is sustained by right vertebral artery
- CT imaging findings: Kommerell’s diverticulum (Type II) with punctuate opening of aberrant left subclavian artery (Fig.5). KD size = 45x28 mm
- Angiography findings: Left subclavian artery stenosis sustained reverse left vertebral artery flux confirming a subclavian steal syndrome (Fig.6).
√ Treatment:
1. 8x29 mm balloon-expandable over-the-wire stent was placed on 014’’ wire at the origin of the left subclavian artery (Fig.7 A).
2.Stenosis dilatation with complete subclavian artery reperfusion and correction of reverse vertebral artery flux was achieved (Fig.7 B).
♦ CT performed after 7 months showed an optimal left subclavian and vertebral artery perfusion (Fig.7 C).
Teaching Point:
• Symptomatic -> subclavian steal syndrome ->aortic and KD diameter did not exceed any thresholds therefore ⇒Only stenotic LSA was treated using a balloon expandable stent.
Case 2 «symptomatic dysphagia lusoria »
61-year-old, female, Caucasian
Clinical history:
- Fainting episodes and severe dysphagia lusoria.
Imaging:
- CT imaging findings: Kommerell's Diverticulum (type I) with a diameter of 50 mm and bovine arch presenting with an aberrant right subclavian artery crossing behind the esophagus (Fig.8). KD size= 52 x 21 mm
- Fluoroscopy imaging findings: KD is compressing the esophagus posteriorly and is leading to a severe obstruction to the contrast transition (Fig.9)
√ Treatment:
1.Surgical aberrant right subclavian artery translocation with vascular graft.
♦Imaging Follow-up: Angio-CT images performed 12-months after the procedure, shows a satisfactory outcome that lead to a full resolution of the symptoms (Fig.10).
Teaching point
• Symptomatic. -> severe dysphagia lusoria -> KD diameter >50mm therefore ⇒ surgical RSA reconstruction with a vascular graft.
Case 3 «asymptomatic»
76-year-old, male, Caucasian
Clinical history:
- Diabetes, Hypertension, severe aortic valve stenosis and dyspnea.
Imaging:
- CT imaging findings: Kommerell's diverticulum in right aortic arch (type II) presenting a diameter of 20,5 mm with punctate aberrant left subclavian artery (Fig.11). At 2 years follow-up the KD showed a slightly increase in size, in particular the KD diameter itself reached 25 mm. KD size: at baseline 47 x20 mm and at 2-years- follow-up= 49x25 mm.
Teaching point: The KD at 2-years follow-up scan showed a minimum increase to 25 mm, it still did not exceed any threshold ->asymptomatic , therefore ⇒conservative approach and close imaging follow-up at 6 months.
Case 4 «asymptomatic»
52-year-old, female, Caucasian.
Clinical history:
- Hypertension, multiple aneurism syndrome, subarachnoid hemorrhage (SAH).
Imaging:
- CT imaging findings: Thorax:KD in a right aortic arch (type II) with aberrant left subclavian artery that crossed the esophagus posteriorly. Moreover, an isolated origin of right subclavian artery and of the right common carotid artery (Fig 12 A, B). KD size= 32x17 mm. Abdomen:aneurism of splenic artery (Fig 12D).
- Angiography: confirmed right aortic arch and aberrant left subclavian artery. Moreover, an aneurism of posterior communicant artery was found and treated with coils (Fig.13).
Teaching point: KD in the range -> asymptomatic therefore ⇒conservative approach and close imaging f-u.
Case 5 «growing in size in short time»
65-year-old, female, Caucasian.
Clinical history:
- AF on oral anticoagulant medication.
Imaging:
- CT imaging findings: KD in a left aortic arch (Type I) presenting substantial growing in size in short time.
√ Treatment:
1. PTFE left Subclavian-Carotid bypass.
2. An endoprostheses (stent graft) on aortic arch and descending thoracic aorta was placed (Fig.14).
♦ At two years follow-up an increasing in size of the diverticulum and of both aneurysms of the arch and descending aorta (7,5 mm vs 10,5 mm) was noted due to a type I endo-leak.
Teaching point: KD exceeding the threshold -> asymptomatic -> growing in size in short time, therefore⇒ treated with endoprostheses.