Endovascular repair of an innominate artery true aneurysm

Hybrid Repair of an Innominate Artery Mycotic Aneurysm with an "On-The-Table" Customized Endograft

BACKGROUND

The objective of this report is to present a challenging case of a mycotic aneurysm of the innominate artery (IA) in a patient with a bovine aortic arch.

MATERIALS AND METHODS

An 85-year-old woman presented with intermittent fever and positive blood cultures for Staphylococcus aureus. An echocardiogram and a positron emission tomography-computed tomography were performed, showing a hypermetabolic dilation of the IA compatible with a mycotic aneurysm with a type one bovine aortic arch. Conventional open arch repair and total endovascular repair with a custom-made aortic endograft were rejected given the elderly age and need for urgent repair. Treatment was achieved with a hybrid procedure, including a left carotid transposition and exclusion of the aneurysm with a modified Endurant II^® iliac limb (two stents were cut off and it was resheathed in an inverted fashion) released through a prosthetic graft sutured onto the right axillary artery, followed by coil embolization of the sac. One year after the repair, the patient is well with complete exclusion of the aneurysm.

CONCLUSIONS

Under the need for urgent repair, "on-the-table" modification of standard endograft components can be an effective solution for aneurysm exclusion when off-the-shelf endovascular stent grafts do not meet the anatomical requirements.

Blunt Injury of the Innominate Artery: What Surprises to Expect? A Case Report

Injuries of the supra-aortic trunk after blunt chest trauma are rare. This is a case report of a blunt traumatic lesion of the innominate artery (IA) origin that exhibited aortic arch involvement with a focus on imaging and treatment. A 41-year-old fisherman presented an IA injury secondary to a high-impact blunt chest trauma. Upon physical examination, vital signs were stable and upper extremity pulses were present. In addition to several bone fractures (costal ribs, clavicle, scapula, temporal, maxillary, and sphenoid), computed tomography angiography revealed dissection/pseudoaneurysm of the IA sparing the bifurcation. The patient underwent emergent angiography, which confirmed that the IA dissection was not ruptured, but it was unclear whether there was a pseudoaneurysm at the origin of the IA or aortic arch involvement. The patient was considered for open surgery. An ascending aorta-to-IA bypass was achieved by the off-pump beating heart approach. The IA stump was carefully observed, but oversewing was not possible due to the extension of the intimal-medial lesions into the artic arch. An on-pump intervention was then required for aortic angioplasty with a pericardial patch that was reinforced by Gel Seal. The postoperative course was uneventful. The patient was discharged without any complications. Conventional surgery provides good results and should remain in the armamentarium for the treatment of traumatic lesions at the IA origin, particularly if aortic arch involvement cannot be ruled out, to ensure a truly patient-tailored approach.

Endovascular repair of an innominate artery pseudoaneurysm using the Valiant Mona LSA branched graft device

A 60-year-old woman involved in a motor vehicle collision presented with a traumatic pseudoaneurysm of the innominate artery origin in addition to multiple concomitant injuries. She was classified as a high-risk candidate for open repair. An experimental thoracic branched graft device was used for coverage of the injury with the addition of a right carotid-to-left carotid-to-left subclavian artery bypass. Follow-up imaging showed resolution of the pseudoaneurysm and patency of her bypass grafts. This is the first described use of the Mona LSA Branch Thoracic Stent Graft System (Medtronic, Minneapolis, Minn) in the innominate artery.

A case of superior vena cava syndrome caused by a ruptured brachiocephalic artery aneurysm

An 84-year-old man was transferred to the emergency department for the treatment of shock. His upper body was swollen. Hematoma from the ruptured brachiocephalic artery aneurysm was compressing and obstructing the superior vena cava (SVC). A stent graft was deployed from the brachiocephalic artery to the right common carotid artery, and the proximal right subclavian artery was coil embolized. On postoperative day 5, when his neck swelling subsided and tracheal stenosis seemed resolved, the patient was extubated and the subsequent recovery was uneventful. He was discharged from the hospital on postoperative day 24. Although the stent grafting does not directly decompress the SVC by removing aneurysm and hematoma, it seems to be the treatment option for the morbid patients.

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.

Eight-year follow-up of endovascular repair of a brachiocephalic trunk aneurysm due to Takayasu's arteritis

Aneurysms of the brachiocephalic trunk are rare but their clinical outcomes are potentially devastating; they include rupture, cerebral or arm ischemia secondary to thromboembolism, and compression of the surrounding structures. Although open repair has proven successful, it is associated with significant morbidity and mortality rates. Endovascular treatment, if anatomically feasible, may offer a safer and less invasive approach to these lesions, especially in high-surgical-risk patients. We report the good long-term outcome of endovascular repair of a large innominate artery true aneurysm due to Takayasu's arteritis. A stent graft was safely and successfully deployed to exclude the aneurysm; assessment by vascular imaging at 8-year follow-up demonstrated the efficacy of the procedure.

Supra-aortic vessels aneurysms: diagnosis and prompt intervention

PURPOSE

Aneurysms involving the supra-aortic vessels are rare but carry serious risk of embolization, thrombosis, and rupture. We describe our experience with the diagnosis, treatment strategies, and outcomes in patients with extended follow-up.

METHODS

Data during a 17-year period (January 1990 to December 2007) was analyzed. We assessed age, gender, presenting symptoms, localization, pathologic diagnosis, type of procedures, complications, and survival.

RESULTS

A total of 74 patients were treated for supra-aortic aneurysms. Of all aneurysms treated, 63% were degenerative, 24% iatrogenic, 8% traumatic, 3% genetic, and 1% mycotic. The subclavian artery was most commonly affected (50%, 2/3 in the right side), followed by the common carotid (36%), internal carotid (10%), innominate (3%), and vertebral (1%). At the time of diagnosis, 52 patients (70%) were asymptomatic, but of those symptomatic 68% had an embolic event as a presenting symptom. Embolic episodes were more common in patients with smaller aneurysms (P < .006). Open surgery was performed in 77% of all cases, and the use of endovascular techniques became the predominant treatment modality over the last 4 years. Survival at 30 days was 100%. Five- and 10-year survival rates were 87% and 43%, respectively.

CONCLUSION

Most cases of supra-aortic aneurysm are asymptomatic and embolization as opposed to rupture represents the greatest risk to the patient. Most cases can be detected prior to symptoms. Endovascular repair is an emerging alternative of treatment and, with the current development of appropriate devices, will likely form the mainstay of therapy in the near future.

Innominate artery aneurysm: axial reconstruction via a cervical approach

True aneurysms of the innominate artery are rare. Successful axial reconstruction in the past has required a combined cervical and transthoracic approach with placement of a prosthetic graft. We describe herein the occurrence of an innominate artery aneurysm that extended to and involved the proximal common carotid artery and subclavian artery in a 63-year-old woman. The patient presented with thomboembolic sequelae in her fingertips and had a pulseless upper extremity. Successful aneurysmectomy and axial reconstruction with a bifurcated graft was achieved by using cervical exposure alone. A subsequent staged revascularization of the upper extremity was successfully accomplished with a brachial to radial artery bypass and ulnar artery transposition.

Aneurysm of an Aberrant Right Subclavian Artery Successfully Excluded by a Thoracic Aortic Stent Graft with Supra-aortic Bypass of Three Arch Vessels

An aberrant right subclavian artery (ARSA) arising from a left-sided aortic arch is the fourth most common aortic arch anomaly. Aneurysmal dilatation of the ARSA requires treatment because of the associated risk of rupture. We present a case where supra-aortic bypass of the arch vessels was performed to facilitate exclusion of the aneurysm by a thoracic aortic stent graft.

Extracranial revascularization therapy: Angioplasty and stenting

Beginning with simple balloon angioplasty, minimally invasive revascularization techniques have progressed to the use of metallic stents for improved immediate and long-term results. Stent-supported angioplasty now offers a therapeutic option for those individuals ineligible for surgical revascularization of stenotic atherosclerotic lesions and who have failed maximal medical therapy. However, the clinical equivalence, or possibly even superiority, of angioplasty of the extracranial carotid and vertebral arteries in atheromatous occlusive disease over surgical revascularization has yet to be determined in ongoing randomized controlled trials. Additionally, endovascular techniques offer treatment for a variety of nonatherosclerotic disease affecting the extracranial arteries, such as inflammatory, radiation-induced, and postsurgical strictures; acute intimal dissection; traumatic and spontaneous arteriovenous fistulas; and aneurysms or pseudoaneurysms. For certain disease entities at high risk for surgical complications, endovascular procedures have gained preference as the therapeutic modality of choice, yet lacking controlled trials providing evidence for noninferiority against surgical approach. Continued innovation and refinement of endovascular technology and techniques will further improve technical success, reduce procedure-related morbidity, and broaden the endovascular therapeutic spectrum for extracranial and intracranial cerebrovascular disease.

Traumatic Pseudoaneurysm of the Brachiocephalic Artery following Medianoscopy: Initial Endovascular Repair Followed by Open Surgery—A Case Report

Endovascular stent graft repair of traumatic vessel injuries is gaining worldwide acceptance as a minimally invasive alternative to open surgical repair. However, effective endovascular repair fails if the aneurysm is not completely excluded. Conversion to open surgery may be unavoidable in such cases. Herein we describe the case of a 45-year-old man who was referred to our hospital with a pseudoaneurysm of the proximal brachiocephalic artery caused by biopsy during diagnostic medianoscopy. The pseudoaneurysm was primarily treated by stent-graft implantation into the proximal brachiocephalic artery. As a result of the unfavorable location of the lesion exclusion of the aneurysm failed and the initial therapy had to be extended to open reconstruction of the brachiocephalic artery. A bypass procedure from the aortic arch to the right common carotid artery was performed with reinsertion of the right subclavian artery to exclude the pseudoaneurysm.

Endovascular management of a ruptured mycotic aneurysm of the innominate artery

Mycotic aneurysms of the innominate artery are infrequent lesions and, as such, represent challenging surgical problems. We describe herein a case of a ruptured mycotic innominate artery aneurysm, which developed after radical neck dissection and radiation therapy for tonsillar carcinoma. The aneurysm was successfully excluded from the systemic circulation with endoluminal placement of a covered stent, with efficacy confirmed by vascular imaging at 6 months follow-up. The patient suffered no permanent neurologic sequelae. Long-term follow-up and chronic antibiotic therapy will be necessary to avoid infection of the covered stent in this high-risk surgical patient.