Traumatic Pseudoaneurysm of the Distal Anterior Cerebral ...
Blunt traumatic innominate pseudoaneurysm and left common carotid occlusion with an associated...
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Blunt traumatic innominate pseudoaneurysm and left common carotid occlusion with an associated bovine aortic arch Patrick Wells, MD, and Aaron Estrera, MD, Dallas, Tex W e report a case of innominate artery pseudoaneu- rysm and left common carotid occlusion with an associated bovine arch managed by bypass graft- ing followed by innominate and carotid ligation. Clinical Summary A 20-year-old man was seen after a high-speed motor vehicle collision as a restrained driver. Initial vital signs were stable, and he had an intact mental status although he had reportedly lost consciousness at the crash scene. He was noted to have a promi- nent seat belt mark extending from his right groin to his left shoulder, with depression of the sternum and ribs along this area. Radial pulses were easily palpable and symmetric, and the left carotid pulse was absent. Breath sounds were diminished on the left side. Initial chest radiograph showed a widened mediastinum, left-sided hemothorax, and elevated left hemidiaphragm. A left- sided chest tube was inserted, producing 600 mL of blood. Com- puted tomographic scans of the head, chest, abdomen, and pelvis were obtained. Chest computed tomography demonstrated a large mediastinal hematoma, with suggestion of an aortic arch injury and nonfilling of the left common carotid artery with contrast medium (Figure 1, A). An urgent arteriogram showed a proximal innomi- nate pseudoaneurysm, complete occlusion of the proximal left common carotid artery, and an occluded left vertebral artery with associated bovine arch anatomy (Figure 1, B). The patient had no other immediately life-threatening injuries, and he was taken to the operating room for mediastinal vascular repair. A median sternot- omy with right supraclavicular extension was performed, and the innominate vein was divided to expose the innominate and prox- imal right subclavian arteries. The pericardium was entered, and the ascending aorta and aortic arch were exposed, with care taken to avoid entering the proximal innominate pseudoaneurysm. The distal left common carotid artery was exposed through an incision along the anterior border of the left sternocleidomastoid muscle. Anticoagulation with 5000 units of heparin was administered, and bypass grafting was performed with a 14 7-mm bifurcated graft from the ascending aorta to the left common carotid artery and then to the proximal right subcla- vian artery (Figure 2). An inter- nal shunt was used during bypass of the left carotid artery. After successful bypass grafting, a large partial occlusion clamp was used to control the aortic arch at the innominate takeoff. The innominate and left common carotid arteries were controlled with vascular clamps, and then the hematoma was explored. The innominate artery was found to be torn circumferentially at its most proximal portion, and the left common carotid artery was lacerated and thrombosed. The innominate and carotid arteries were divided and ligated. The aortic arch was oversewn with pledget-supported sutures. The patient tolerated the procedure without complication and was neurologically intact on emergence from anesthesia. He had an uneventful postoperative course and was discharged from the hospital 6 days after admission. Discussion Innominate vascular injury is a rare entity, particularly in blunt trauma. It is estimated that 71% of patients with innominate injuries die before arrival at the hospital. 1 Bovine arch anatomy is present in 27% of the population. 2 Patients with bovine arch anatomy may account for a higher percentage of patients with blunt innominate artery injuries. It is theorized that bovine anat- omy predisposes toward injury because there are a decreased number of fixation points on the aortic arch when it is compressed suddenly between the sternum and spine while the neck is hyper- extended. The energy of this force is concentrated on the innom- inate takeoff, resulting in a tear or transection. 1 Operative repair has been approached in many different ways: interposition or bypass grafting with or without shunts, cardiopul- monary bypass with hypothermic arrest, and combined endovas- cular and open repairs. 1-5 There are advocates of each method. but in this particular case, bypass grafting followed by pseudoaneu- rysm exploration was considered the ideal method. Our patient’s entire cerebral perfusion was dependent on the injured but patent innominate artery because of the occluded left common carotid and left vertebral arteries. It was believed that cardiopulmonary bypass with hypothermic arrest was not needed and that the associated risks of systemic heparinization, hemodilution, coagu- lopathy, and neurologic complications could be avoided. An in- From the Department of Cardiovascular and Thoracic Surgery, UT South- western Dallas, Dallas, Tex. Received for publication Jan 13, 2005; accepted for publication March 2, 2005. Address for reprints: Patrick R. Wells, MD, Department of Cardiovascular and Thoracic Surgery, UT Southwestern Dallas, 5323 Harry Hines Blvd, Dallas, TX 75390 (E-mail: [email protected]). J Thorac Cardiovasc Surg 2005;130:928-9 0022-5223/$30.00 Copyright © 2005 by The American Association for Thoracic Surgery doi:10.1016/j.jtcvs.2005.03.005 Dr Wells Dr Estrera Brief Communications 928 The Journal of Thoracic and Cardiovascular Surgery ● September 2005
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Transcript of Blunt traumatic innominate pseudoaneurysm and left common carotid occlusion with an associated...
Blunt traumatic innominate pseudoaneurysm and leftcommon carotid occlusion with an associated bovineaortic archPatrick Wells, MD, and Aaron Estrera, MD, Dallas, Tex
We report a case of innominate artery pseudoaneu-rysm and left common carotid occlusion with anassociated bovine arch managed by bypass graft-ing followed by innominate and carotid ligation.
Clinical SummaryA 20-year-old man was seen after a high-speed motor vehiclecollision as a restrained driver. Initial vital signs were stable, andhe had an intact mental status although he had reportedly lostconsciousness at the crash scene. He was noted to have a promi-nent seat belt mark extending from his right groin to his leftshoulder, with depression of the sternum and ribs along this area.Radial pulses were easily palpable and symmetric, and the leftcarotid pulse was absent. Breath sounds were diminished on theleft side. Initial chest radiograph showed a widened mediastinum,left-sided hemothorax, and elevated left hemidiaphragm. A left-sided chest tube was inserted, producing 600 mL of blood. Com-puted tomographic scans of the head, chest, abdomen, and pelviswere obtained. Chest computed tomography demonstrated a largemediastinal hematoma, with suggestion of an aortic arch injury andnonfilling of the left common carotid artery with contrast medium(Figure 1, A). An urgent arteriogram showed a proximal innomi-nate pseudoaneurysm, complete occlusion of the proximal leftcommon carotid artery, and an occluded left vertebral artery withassociated bovine arch anatomy (Figure 1, B). The patient had noother immediately life-threatening injuries, and he was taken to theoperating room for mediastinal vascular repair. A median sternot-omy with right supraclavicular extension was performed, and theinnominate vein was divided to expose the innominate and prox-imal right subclavian arteries. The pericardium was entered, andthe ascending aorta and aortic arch were exposed, with care takento avoid entering the proximal innominate pseudoaneurysm. Thedistal left common carotid artery was exposed through an incisionalong the anterior border of the left sternocleidomastoid muscle.Anticoagulation with 5000 units of heparin was administered, andbypass grafting was performed with a 14 � 7-mm bifurcated graft
from the ascending aorta to theleft common carotid artery andthen to the proximal right subcla-vian artery (Figure 2). An inter-nal shunt was used during bypassof the left carotid artery. Aftersuccessful bypass grafting, alarge partial occlusion clampwas used to control the aorticarch at the innominate takeoff.The innominate and left commoncarotid arteries were controlledwith vascular clamps, and thenthe hematoma was explored. Theinnominate artery was found tobe torn circumferentially at itsmost proximal portion, and theleft common carotid artery waslacerated and thrombosed. The innominate and carotid arterieswere divided and ligated. The aortic arch was oversewn withpledget-supported sutures. The patient tolerated the procedurewithout complication and was neurologically intact on emergencefrom anesthesia. He had an uneventful postoperative course andwas discharged from the hospital 6 days after admission.
DiscussionInnominate vascular injury is a rare entity, particularly in blunttrauma. It is estimated that 71% of patients with innominateinjuries die before arrival at the hospital.1 Bovine arch anatomy ispresent in 27% of the population.2 Patients with bovine archanatomy may account for a higher percentage of patients withblunt innominate artery injuries. It is theorized that bovine anat-omy predisposes toward injury because there are a decreasednumber of fixation points on the aortic arch when it is compressedsuddenly between the sternum and spine while the neck is hyper-extended. The energy of this force is concentrated on the innom-inate takeoff, resulting in a tear or transection.1
Operative repair has been approached in many different ways:interposition or bypass grafting with or without shunts, cardiopul-monary bypass with hypothermic arrest, and combined endovas-cular and open repairs.1-5 There are advocates of each method. butin this particular case, bypass grafting followed by pseudoaneu-rysm exploration was considered the ideal method. Our patient’sentire cerebral perfusion was dependent on the injured but patentinnominate artery because of the occluded left common carotidand left vertebral arteries. It was believed that cardiopulmonarybypass with hypothermic arrest was not needed and that theassociated risks of systemic heparinization, hemodilution, coagu-lopathy, and neurologic complications could be avoided. An in-
From the Department of Cardiovascular and Thoracic Surgery, UT South-western Dallas, Dallas, Tex.
Received for publication Jan 13, 2005; accepted for publication March 2,2005.
Address for reprints: Patrick R. Wells, MD, Department of Cardiovascularand Thoracic Surgery, UT Southwestern Dallas, 5323 Harry Hines Blvd,Dallas, TX 75390 (E-mail: [email protected]).
J Thorac Cardiovasc Surg 2005;130:928-9
0022-5223/$30.00
Copyright © 2005 by The American Association for Thoracic Surgery
doi:10.1016/j.jtcvs.2005.03.005
Dr Wells
Dr Estrera
Brief Communications
928 The Journal of Thoracic and Cardiovascular Surgery ● September 2005
ternal shunt was used during bypass grafting to the distal leftcommon carotid artery, and this was placed empirically withoutmeasurement of distal carotid stump pressures. We believe that forthis injury bypass grafting followed by dissection of the pseudo-
aneurysm is the preferred method of repair. Cardiopulmonarybypass with hypothermic arrest is unnecessary unless injury of theaortic arch is extensive or bypass grafting cannot be safely per-formed before entrance of the pseudoaneurysm.
References1. Graham JM, Feliciano DV, Mattox KL, Beall AC. Innominate vascular
injury. J Trauma. 1982; 22:647-55.2. Roberts CS, Sadoff JD, White DR. Innominate arterial rupture distal to
anomalous origin of left carotid artery. Ann Thorac Surg. 2000;69:1263-4.
3. Moise MA, Hsu V, Braslow B, Woo YJ. Innominate artery transectionin the setting of bovine arch. J Thorac Cardiovasc Surg. 2004;128:632-4.
4. Mauney MM, Casada DC, Kaza AK, Merlotti G. Management ofinnominate artery associated with a bovine arch. J Trauma. 2002;52:1002-4.
5. Ruebben A, Merlo M, Verri A, Rossato D, Savio D, Muratore P, et al.Combined surgical and endovascular treatment of traumatic pseudoan-eurysm of the brachiocephalic trunk with anatomical anomaly. J Car-diovasc Surg (Torino). 1997;38:173-6.
Figure 1. A, Computed tomographic scan of chest. B, Archaortogram.
Figure 2. Operative repair diagram. RCCA, Right common carotidartery; LCCA, left common carotid artery; RSCA, right subclavianartery; IA, innominate artery; LSCA, left subclavian artery.
Brief Communications
The Journal of Thoracic and Cardiovascular Surgery ● Volume 130, Number 3 929
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