Traumatic rupture of the innominate artery--a seat-belt injury

Endovascular Repair of Acute Innominate Artery Injury Due to Blunt Trauma

The utility of endovascular techniques has expanded greatly over the past decade. Physicians now have choices regarding the treatment of many injuries that have traditionally required open surgical repair. Technological advances in materials as well as improved training and expertise among practitioners has led to increased availability of endovascular procedures that can often provide an effective and less invasive means of management. The following case report describes the successful treatment of a traumatic blunt injury to the innominate artery using endovascular techniques. Also provided is a review of the physical and radiographic findings associated with innominate artery rupture as well as a discussion on the diagnosis and treatment of such an injury. Isolated injuries of the innominate artery are exceedingly rare, and very little has been published about the endovascular repair of this specific injury. An extensive MEDLINE search was conducted to investigate whether or not endovascular repair of this particular injury had yet been described, and we found no published reports in the American medical literature. Although the technical aspects of this case are not particularly unique this case report demonstrates yet another successful application of endovascular intervention in the acute setting of blunt injury.

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.

Seat-belt-related injuries to the supra-aortic arteries

Five seat-belt-related injuries occurring in four adults are reported. One injury involved the common carotid artery, two the internal carotid and two the subclavian arteries. Three of the four injured persons were asymptomatic and one had delayed-onset symptoms; none suffered stroke. There was no operative mortality or morbidity. Overall, the functional results of arterial reconstruction were good, with satisfactory patency at follow-up averaging 15 months.

Vertebral column injuries and lap-shoulder belts

OBJECTIVE

To present cases of vertebral column fractures or fracture dislocations that occur to restrained front seat occupants where there is no evidence of body contact with interior car components based on both medical records and car inspection.

MATERIALS AND METHODS

Reviewed were car crash injury cases investigated at the University of Michigan Transportation Research Institute and at the University of Birmingham (England) as well as the National Accident Severity Study files of the National Highway Traffic Safety Administration. Medical records and car inspections in the cases presented did not indicate any evidence of body contact with interior car structures.

MAIN RESULTS

Vertebral fractures or fracture dislocations sustained by front seat occupants who were wearing lap-shoulder belts are rare, as evidenced by the relatively few cases identified in the literature and in the crash injury files reviewed.

CONCLUSIONS

Infrequently, in frontal crashes, vertebral fractures or fracture dislocations can occur to lap-shoulder belted front seat car occupants without head or torso impacts with interior car structures. Cervical spine injuries are due to neck flexion over the shoulder portion of the restraint. Thoracolumbar fractures can occur in the frontal crash even at low crash velocity.

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

Most supra-aortic aneurysms are localized in the extracranial carotid and subclavian artery. Aneurysms of the brachiocephalic artery (BCA) represent a rather rare finding. Chronic arteriosclerotic changes are responsible for the majority of cases. Posttraumatic BCA damage is only occasionally encountered, complete vascular dissection by perforating injuries being the dominant causative mechanism. Although isolated BCA trauma after blunt thoracic contusion is rare, brachiocephalic injury in association with aortic lesions seems to be the second most common site of vascular injury after the aorta. Cases of isolated blunt BCA trauma documented in the literature to date usually involved a complete avulsion of the artery from the aortic arch or complete rupture near the aortic origin. We present an isolated case of posttraumatic BCA aneurysm in a woman involved in a car accident who suffered blunt chest trauma with a subtotal, near circumferential vessel wall dissection of only the intima and media. Clinical features, diagnostic procedure, surgical treatment, and trauma mechanisms of postcontusional BCA lesions are described and discussed in reference to the literature.

Approaches to trauma involving the major vessels of the thorax

Thoracic great vessel injury accounts for a significant amount of the acute mortality rate from trauma. Early recognition permits early repair, usually best accomplished by the simplest yet most effective technique. Use of prosthetic material is encouraged. Cardiopulmonary bypass, hypothermia, and shunts are rarely required.

Traumatic disruption of the brachiocephalic artery

We report the case of a patient presenting with blunt chest and head injuries. Initial emergency department evaluation revealed a pulmonary contusion and suspected closed head injuries. Computed tomographic scan of the head was unremarkable. An angiogram performed to further investigate the nature of his head injuries revealed a disruption of the brachiocephalic artery. The lesion was surgically repaired in the operating room and the patient was moved to the intensive care unit, where he remained comatose and died from complications of his head and chest injuries on the seventh post-operative day. The pathophysiology and clinical manifestations of injuries to the brachiocephalic artery are discussed.

Subclavian artery rupture (an unusual seat-belt injury)

A case of blunt injury to the subclavian artery in the absence of bony injury or dislocation sustained while wearing a seat belt is described. Its rarity and diagnostic pitfalls are discussed. The mechanism of the injury is analysed. The value of angiography is emphazided. It is suggested that, even in the presence of collateral circulation, exploration and repair should be undertaken.