Hybrid endovascular exclusion of a bleeding innominate artery pseudoaneurysm in a patient with no open surgical options

Abstract

Mycotic pseudoaneurysms (MPs) rarely affect the aortic arch vessels and usually require surgical resection for definitive treatment. In this case, a 58-year-old woman developed a bleeding innominate artery MP after primary lung cancer resection complicated by an infected chest wound. Because of her previous surgery, irradiation, and chest wall reconstruction, she was not a candidate for open resection. A hybrid endovascular approach successfully excluded her innominate artery MP through placement of an aortic arch stent graft. Cerebral circulation was maintained through a periscoped left common carotid artery stent graft to the descending thoracic aorta graft, which supplied a left-to-right carotid-carotid bypass.

Fig 1

A, Image of chest showing wound dehiscence of surgical site 2 weeks after primary resection of the lung cancer. B, Image of chest wound during follow-up after the wound was débrided and closed with a myocutaneous rotational flap and skin graft. The top left corner of the wound continues to demonstrate an unhealed portion with ongoing bleeding.

Fig 2

A, Computed tomography angiography (CTA) of the thorax (median sagittal view) demonstrating the mycotic pseudoaneurysm (MP). The arrow shows a small focus of contrast extravasation from the proximal innominate artery. B, The same CTA image (axial view) demonstrating contrast extravasation from the aortic arch consistent with an MP.

Fig 3

Completion aortogram showing placement of two stent grafts (iCAST 9 × 38 mm; Atrium, Hudson, NH) into the proximal innominate artery. The stents are apposed to the arterial wall, with no evidence of contrast material extravasation from the aortic arch or innominate artery.

Fig 4

Computed tomography angiography (CTA) of the thorax. The arrow shows a focus of contrast extravasation from the innominate artery despite placement of previous iCAST stent grafts in the innominate artery.

Fig 5

A, Completion aortogram demonstrating placement of an innominate artery occlusive plug and proximal thoracic aortic stent graft for exclusion of the proximal arch with preservation of cerebral blood flow through a snorkeled left common carotid to descending thoracic aorta with a left-to-right carotid-carotid retropharyngeal bypass. No additional bleeding is demonstrated from the previous site of the innominate artery takeoff from the aortic arch. B, Computed tomography angiography (CTA) reconstruction showing the excluded aortic arch and snorkeled left common carotid to descending thoracic aorta stent graft.