The isolated posttraumatic aneurysm of the brachiocephalic artery after blunt thoracic contusion

The Surgical Management of a Giant Innominate Artery Aneurysm in a Patient With Coronary Disease: A Case Report

The innominate artery aneurysm (IAA) accounts for a small percentage of all peripheral aneurysms. However, its clinical outcomes are potentially devastating, especially when it is associated with coronary disease, due to the high risk of spontaneous rupture and thromboembolic complications. Surgical repair is always recommended in such cases. The treatment of such a condition presents a surgical challenge with high morbidity and mortality rates. In this report, we discuss the case of a 56-year-old male who presented with a right cervical mass secondary to a large IAA with underlying coronary artery disease. The patient underwent a simultaneous operation for IAA and coronary bypass grafting.

Axillo-Axillary Artery Bypass With Coil Embolization of the Innominate Artery for a Traumatic Innominate Artery Aneurysm: A Case Report

BACKGROUND

Innominate artery aneurysm (IAA) is a rare cervical artery aneurysm. Although atherosclerosis is its most common cause, IAAs due to cervical injury are often reported. Operative indications for IAAs include rupture or symptomatic aneurysm, saccular aneurysm, aneurysm with a diameter of 3 cm or greater, and aneurysmal change of the origin of the innominate artery. Although the ligature of the innominate artery or open surgical repair is well described, the usefulness of endovascular repair has also recently been reported. Herein, we report a case of traumatic IAA with infection in the cervical region after tracheostomy.

CASE PRESENTATION

A 40-year-old man with cholecystolithiasis planned to undergo laparoscopic cholecystectomy at another hospital. Urgent tracheostomy was performed because of laryngeal edema at the induction of general anesthesia. Enhanced computed tomography angiography 1 week after the tracheostomy revealed a saccular IAA. The patient was deemed to be at high risk for aneurysm rupture and was referred to our hospital. Preoperative Matas test, Allcock test, and innominate arterial stump pressure measurement were performed to assess the cerebral blood flow and ischemic tolerance of the brain. These examinations showed the patency of the circle of Willis. An axillo-axillary artery bypass with coil embolization of the innominate artery was performed to avoid postoperative vascular graft infection. No postoperative complications such as infection or cerebral infarction occurred. Magnetic resonance imaging angiography performed 6 months after surgical treatment showed that the aneurysm had disappeared, and patency of the bypass graft was present. There were no postoperative complications, such as neurological deficits or graft infection, at more than 5 years after surgery.

CONCLUSIONS

We report a successfully treated case of IAA after tracheostomy. Axillo-axillary artery bypass with coil embolization of the innominate artery is an effective treatment of IAA with cervical infection.

Innominate artery aneurysm, how to solve it?

We herein describe our

*These authors contributed equally to this work.

experience with a congenital innominate artery aneurysm (IAA) that was managed with a simple surgical procedure. A 44-year-old woman was admitted for chest distress. Computed tomography angiography showed a 3.6-cm IAA arising from the aortic arch and compressing the trachea. A median sternotomy was performed with the patient under general anesthesia, and the IAA was found to involve the origin of the innominate artery and the bifurcation of the right subclavian artery and common carotid artery; however, the aorta was intact. An 8-mm Dacron graft was anastomosed to the ascending aorta and distal end of the IAA without cardiopulmonary bypass. The postoperative course was uneventful, and repeat computed tomography angiography revealed no evidence of recurrence 6 months postoperatively. We also herein present a literature review of this rare clinical condition.

Open Treatment of Blunt Injuries of Supra-Aortic Branches: Case Series

BACKGROUND

Blunt injuries of the supra-aortic branches are rare entity, and majority of patients die before arrival at the hospital. Those who arrive alive require complex and fast procedure that requires sternotomy. We report 3 successfully managed cases.

CASE REPORTS

We report 3 patients with injury of supra-aortic branches. One was treated urgently due to longitudinal rupture on the posterior wall of innominate artery after car accident, and another 2 had chronic false aneurysm located at the very orifice of the right subclavian and left common carotid artery. In first and second patient bypass grafting with a hand-made, Y-shaped, 8-mm Dacron graft from the ascending aorta to the right common carotid and proximal right subclavian artery were performed, whereas in last 1 bypass grafting from the ascending aorta to the cervical part of the left common carotid artery was performed. In our facility, there were no possibilities for any endovascular treatment.

CONCLUSIONS

When endovascular technology is not available, open surgical repair of blunt injuries of supra-aortic vessels can be performed without complications. No matter to that, endovascular and hybrid procedures should be considered whenever possible.

Early Diagnosis and Treatment of a Posttraumatic Pseudoaneurysm/Dissection of the Innominate Artery

A 25-year-old male developed a traumatic intimo-medial dissection and saccular pseudoaneurysm at the origin of the innominate artery following a motorcycle accident. On physical examination there was no perceivable trauma to the chest. In addition, there were no clinical symptoms that suggested this serious injury. The patient was managed with successful stent-graft placement on an elective basis.

AzarconF, GhalebM. Early diagnosis and treatment of a posttraumatic pseudoaneurysm/dissection of the innominate artery. Prehosp Disaster Med. 2014;29(1):1-3.

Surgical treatment of innominate artery and aortic aneurysm: a case report and review of the literature

Innominate artery (IA) aneurysms represent 3% of all arterial aneurysms. Due to the risk of thromboembolic complications and spontaneous rupture, surgical repair is usually recommended on an early elective basis. We present the case of 81-year-old Caucasian male presenting with atypical anterior chest pain secondary to a large innominate artery aneurysm who underwent successful open surgical repair at our institution. In our experience, open correction via median sternotomy with extension into the right neck provides excellent exposure and facilitates rapid reconstruction with good short and long-term outcomes. Minimally invasive and endovascular approaches provide emerging alternatives to open IA aneurysm repair, however further research is required to better define optimal patient selection criteria and determine the long-term outcomes of these novel therapies.

Innominate artery aneurysm with hemoptysis and airway compression in a patient with bovine aortic arch

We present the case of a 63-year-old man with a bovine aortic arch variation, who presented episodes of mild hemoptysis secondary to a 4.5-cm (diameter) aneurysm of the innominate artery that compressed the trachea and obliterated the right subclavian artery. Surgery, performed through a median sternotomy, consisted of a bypass from the ascending aorta to both common carotid arteries using a Dacron graft, and exclusion of the aneurysm by ligature and direct thrombin injection. Computed tomography angiography at 30 days showed a patent bypass, successful aneurysm exclusion, and improvement of the tracheal compression. The patient is currently asymptomatic at 12 months following the procedure.

Aneurysms in the arteries of the upper extremity in a Kenyan population

BACKGROUND

Aneurysms in the arteries of the upper extremity are rare but important in predicting aortic aneurysms and their potential to thromboembolize and cause limb loss. Their localization, age, and gender distribution vary between countries depending on ethnic background and cause. These data are valuable in the management of aneurysms, but are largely lacking from the Kenyan population.

OBJECTIVE

This study aimed at examining the pattern of these aneurysms in a Kenyan population.

STUDY DESIGN

Retrospective.

SETTING

Kenyatta National Hospital, Kenya.

PATIENTS AND METHODS

Hospital records of aneurysms in upper limb arteries over 10 years from January 1998 to December 2007 were examined. Ethical approval was given by the Kenyatta National Hospital Ethics and Research Committee. Site, age, gender, and risk factors were recorded. Unconfirmed diagnoses were excluded. Results were analyzed using SPSS 11.50 and presented using tables.

RESULTS

Aneurysms of the upper extremity arteries comprise 34 (35.4%) out of 96 peripheral aneurysms. Of these, brachial artery was the most common site (35.3%), followed by brachiocephalic (11, 32.4%), subclavian (9, 26.5%), radial (1, 2.9%), and anterior interosseous (1, 2.9%). Trauma was the commonest predisposing factor (41.2%), followed by atherosclerosis and related comorbidities (32.4%), infection (11.8%), and autoimmune disease (8.8%). The mean age was 39.5 years (range: 13-79) with a variable gender distribution.

CONCLUSION

Aneurysms of the upper extremity arteries are not uncommon in the Kenyan population. They occur more commonly in individuals aged 50 years and less, and although most of them are traumatic, atherosclerosis constitutes a significant proportion. Prudent management of risk factors is recommended.

Emergency Endovascular Deployment of Stent Graft in the Ascending Aorta for Contained Rupture of Innominate Artery Pseudoaneurysm in a Pediatric Patient

Endovascular approaches to treat aortic diseases have become an important alternative to open surgical intervention in aortic pathologies. We report a case of an emergency placement of a stent graft in a 16-year-old boy with a contained rupture of an innominate artery pseudoaneurysm. This patient had been previously treated for a mediastinal T-cell lymphoma and underwent mediastinal chemoradiation. He developed tracheal stenosis, requiring multiple tracheal reconstructive surgical procedures, and subsequently emergency ligation of a tracheal-innominate fistula. A pseudoaneurysm of the previously ligated innominate artery developed. Despite coil embolization, it continued to enlarge, requiring emergency endovascular intervention. A pseudoaneurysm of the previously ligated innominate artery subsequently developed, and despite coil embolization, it continued to enlarge, which required emergency endovascular intervention.

[Innominate artery war injury]

AIM

A case is reported of successfully surgically treated explosive war injury to the innominate artery.

CASE REPORT

A 26-year-old soldier was injured in combat by a fragment of mortar shell. In the field hospital, the wound gauze packing was applied, followed by orotracheal intubation and thoracic drainage. The soldier was admitted to MMA six hours later. Physical examination, on admission, revealed huge swelling of the neck, the absence of pulse in the right arm and the right common carotid artery. Chest x-ray revealed hemopneumothorax of the right side and the foreign metal body in the projection of the right sternoclavicular joint. Due to the suspicion of large vessel injury, a median sternotomy was immediately performed. Surgery revealed disrupted bifurcation of the right innominate artery, so the ligation was performed. Aortography was performed postoperatively, followed by the reconstruction of innominate bifurcation with synthetic grafts. Control aortography showed good graft patency, and the patient was discharged from the hospital in good general condition with palpable pulses and mild anisocoria as a sole neurological sequela.

CONCLUSION

A rare and life-threatening injury was successfully managed, mainly due to the rational treatment carried out in the field hospital that helped the injured to survive and arrive to the institution capable of performing the most sophisticated diagnostic and therapeutic procedures.

Blunt Innominate Artery Injury

Traumatic injury to the innominate artery is a rare occurrence. A literature review reveals that penetrating wounds account for the overwhelming majority of these injuries. Fewer than 90 cases of innominate artery injury caused by blunt trauma have been documented. Over the past 12 months the trauma service successfully treated two patients with blunt injury to the innominate artery. Both cases involved high-speed motor vehicle crashes with sudden deceleration. Both patients were wearing lap and shoulder restraints and had similar associated bruising following the line of the shoulder harness. The first patient presented with a wide mediastinum on chest X-ray. Angiography revealed an innominate artery injury at the aortic arch. The second patient had a normal chest X-ray. Given the extent of soft tissue bruising from the shoulder harness he underwent a magnetic resonance angiography, which was suspicious for an innominate artery injury. Arch aortography confirmed a disruption of the innominate artery midway between its origin and its bifurcation. Both were repaired through a median sternotomy with cervical extension as necessary. Given the present technology of safety restraint devices this injury may occur with greater frequency. A “shoulder strap sign” should prompt a search for more extensive injuries.

Endovascular repair of an innominate artery false aneurysm following blunt trauma

PURPOSE

To describe a case of endovascular graft exclusion of an innominate artery pseudoaneurysm arising from blunt trauma.

METHODS AND RESULTS

A 21-year-old patient was admitted following a major road accident. Computed tomography (CT) and aortography on admission disclosed an isolated innominate artery pseudoaneurysm. The lesion was stable, so an elective endoluminal repair was undertaken once the patient was treated for his other injuries. The right carotid artery was exposed and controlled, and the aneurysm was excluded by transluminal implantation of a customized stent-graft consisting of predilated polytetrafluoroethylene graft material covering a balloon-expandable Palmaz stent. A CT scan at 1 month and duplex scans at 6-month intervals documented good stent-graft positioning and aneurysm exclusion over a period of 18 months.

CONCLUSIONS

This case illustrates the potential durability of endoluminal repair of innominate artery lesions and highlights the potential role of this minimally invasive alternative to surgery in these clinical situations.

Dual-inflow great vessel aneurysm: delayed presentation after penetrating trauma

Aneurysms constitute uncommon sequelae of injuries to the thoracic outlet. Most such aneurysms are secondary to blunt trauma and usually involve the great vessels at their take-off from the aortic arch. Penetrating injuries are more often identified in the more distal vessels and only very rarely present as pseudoaneurysms. Reported here is a single case of a chronic posttraumatic pseudoaneurysm arising from both the right common carotid artery and the right subclavian artery. The workup and surgical approach provide practical lessons, complemented with illustrations that aid in the understanding of the case. It is an unusual case because of the dual-inflow nature of the aneurysm.