Endangered Cerebral Blood Supply After Closure of Left Subclavian Artery: Postmortem and Clinical Imaging Studies Hannu Manninen, MD, PhD, Harri Tulla,

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Presentation transcript:

Endangered Cerebral Blood Supply After Closure of Left Subclavian Artery: Postmortem and Clinical Imaging Studies Hannu Manninen, MD, PhD, Harri Tulla, MD, PhD, Ritva Vanninen, MD, PhD, Antti Ronkainen, MD, PhD The Annals of Thoracic Surgery Volume 85, Issue 1, Pages 120-125 (January 2008) DOI: 10.1016/j.athoracsur.2007.08.035 Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Cast angiography; “substantial” risk for acute complication after closure of LSA. (A) Cervicocranial angiography demonstrates almost symmetrical cervical portions of vertebral arteries. (B) Cerebral cast angiography at axial view depicts missing right VA above PICA, hypoplastic right PComA, and persistent fetal left PCA. (PCA = posterior cerebral artery; PComA = posterior communicating artery; VA = vertebral artery.) The Annals of Thoracic Surgery 2008 85, 120-125DOI: (10.1016/j.athoracsur.2007.08.035) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Cerebral cast angiography. “Substantial” risk for acute complication after closure of LSA because of hypoplastic right VA, missing left PComA, and hypoplastic right PComA. (PComA = posterior communicating artery; LSA = left subclavian artery; VA = vertebral artery.) The Annals of Thoracic Surgery 2008 85, 120-125DOI: (10.1016/j.athoracsur.2007.08.035) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Clinical computed tomographic angiography of a 55-year old male demonstrates left VA ending to PICA creating an obvious risk for neurological complication in case of closure of LSA. (A) Mirrored posterior view in the three dimensional reconstruction image, arrows indicating the aplastic left VA above PICA. (B) Axial slice at V2 segment with dominating VA on the right. (C) Absent intradural portion of left VA. (BA = basilar artery; PICA = posterior inferior cerebellar artery; VA = vertebral artery.) The Annals of Thoracic Surgery 2008 85, 120-125DOI: (10.1016/j.athoracsur.2007.08.035) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Magnetic resonance angiography of a 44-year old male shows hypoplastic proximal basilar artery and the right VA is ending to PICA (A). Persistent trigeminal artery (arrow in B) connecting the right internal carotid artery to basilar artery supplies right PCA, and there is persistent fetal PCA supply on the left. After closure of LSA there arises concern whether blood supply to left PICA retrogradely through the rudimental proximal basilar artery is sufficient, especially because the left upper extremity now steals blood from the left VA. (BA = basilar artery; ICA = internal carotid artery; PCA = posterior cerebral artery; PICA = posterior inferior cerebellar artery; VA = vertebral artery.) The Annals of Thoracic Surgery 2008 85, 120-125DOI: (10.1016/j.athoracsur.2007.08.035) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Magnetic resonance angiography of a 40-year old female shows missing A1 segment of the left anterior cerebral artery (arrow in A) and severe hypoplasia of the left ICA. Blood supply to left MCA is mainly dependent on the retrograde flow through the hyperplastic posterior communicating artery (arrow in B). After closure of the left subclavian artery there arises concern whether the right vertebral artery can supply enough blood to the whole posterior circulation and left MCA territory. (BA = basilar artery; ICA = internal carotid artery; MCA = middle cerebral artery; PCA = posterior cerebral artery.) The Annals of Thoracic Surgery 2008 85, 120-125DOI: (10.1016/j.athoracsur.2007.08.035) Copyright © 2008 The Society of Thoracic Surgeons Terms and Conditions