Hybrid surgery for a severe infectious innominate artery pseudoaneurysm compressing the main trachea

Abstract

Here, we report a case of an infectious pseudoaneurysm at the root of the innominate artery, compressing the trachea, that resulted in massive hemorrhage due to rupture of the innominate artery. The patient, a 31-year-old man, had complained of persistent fever for 40 days and severe dyspnea for 1 week. Contrast-enhanced computed tomography imaging of neck and thorax showed a pseudoaneurysm originating from the root of the innominate artery that was severely compressing the main trachea. A hybrid surgery strategy was applied. We first implanted a covered stent in the root of the innominate artery. Then, we performed a left-to-right carotid-carotid bypass with a great saphenous vein graft. Finally, we performed a median thoracotomy in which both the pseudoaneurysm and the previously implanted covered stent were successfully extracted. The patient lost strength in the right upper limb muscle on postoperative day 2 but recovered to baseline strength after 3 months. A hybrid surgical technique may represent a practical solution for such conditions.

Keywords: Infectious innominate pseudoaneurysm; anti-infection therapy; endovascular repair; extra-anatomic bypass; hybrid surgery; median thoracotomy; saphenous vein graft patency.

Figure 1.

Computed tomography images showing (a) the pseudoaneurysm originating from the root of the innominate artery (yellow arrow), and (b) the trachea that was severely compressed by the pseudoaneurysm (yellow arrow).

Figure 2.

Arteriography showing (a) the rupture of the root in the innominate artery and contrast extravasation (yellow arrow), and (b) the covered stent implantation (Viabahn, 11 × 8 mm, W. L. Gore and Associates, Newark, DE, USA ) that prevented rupture of the innominate artery (yellow arrow).

Figure 3.

Surgical views indicating (a) the saphenous vein graft (SVG) from the left-to-right carotid-carotid artery (yellow arrow), and (b) removal of the covered stent from the root of the innominate artery (yellow arrow).

Figure 4.

Computed tomography angiography showing (a, b) normal trachea diameter, good patency of the saphenous vein graft, and disappearance of the pseudoaneurysm on postoperative day 14 (yellow arrow); and (c) occlusion of the innominate and right subclavian artery (yellow arrow).

Figure 5.

Computed tomography angiography at the 1-year postoperative follow-up showing (a) good patency of the saphenous vein graft (yellow arrow), and (b) the occluded innominate artery but recanalized right subclavian artery (yellow arrow).

Figure 6.

Changes in the infectious markers white blood cell count (WBC, 10⁹/L), neutrophils (Neu%), and C-reactive protein (CRP, mg/L) on pre-, peri-, and post-operative days. POD, post-operative day.