A case of spontaneous innominate artery perforation with pericardial tamponade

Innominate truncal dissection and rupture into right pleural cavity following acute type A dissection of the aorta with right coronary ostial avulsion and inferior STEMI

An innominate truncal dissection and rupture into the right pleural cavity with massive hemothorax is the initial presentation in this 66-year-old lady with type A dissection of the aorta complicated by right coronary ostial avulsion and inferior STEMI. She underwent supracoronary interposition graft replacement of the ascending aorta and hemiarch, interposition graft replacement of the innominate trunk and saphenous vein bypass grafting of the right coronary artery successfully. Innominate truncal rupture following aortic dissection is practically unknown and has not been described before in the absence of aortic rupture. Innominate truncal rupture secondary to other pathologies presents with supraaortic and mediastinal hematomas, but almost never with right hemothorax. On the backdrop of this unusual presentation with no neurological injury, we review the literature for innominate truncal dissection and rupture, other etiologies for innominate truncal rupture, the complex interplay of factors determining neurological injury and discuss the changes in the strategies and conduct of arterial return during cardiopulmonary bypass and selective antegrade perfusion imposed by this previously undescribed instance of innominate truncal rupture due to dissection.

Spontaneous innominate artery perforation presenting as hemoptysis

An 86-year-old man with a history of asthma and hypertension suddenly developed hemoptysis. A computed tomographic (CT) scan demonstrated a right-sided paratracheal mass adjacent to the aortic arch that had not been recognized on a CT scan 5 months before. Angiography revealed extravasation of the contrast agent from the innominate artery. These findings suggested innominate artery perforation resulting in a pseudoaneurysm. At the time of operation, an approximately 3-cm defect was noted at the right side of the innominate artery. The aneurysmal cavity was inspected through the tear of the innominate artery, and there was no purulent fluid or thrombus. A prosthetic graft interposition between the origin of the innominate artery and the bifurcation of the common carotid artery and subclavian artery was performed under cardiopulmonary bypass. Histologic study of the innominate artery revealed only atherosclerotic changes. There was no evidence of infection or malignancy. The hemoptysis disappeared postoperatively.