Hybrid repair of an innominate artery pseudoaneurysm after blunt traumatic injury in a bovine arch

Abstract

Innominate artery injury is an uncommon consequence of blunt trauma to the neck due to its protected position behind the thorax. A 38-year-old male presented as a trauma with a right-sided pseudoaneurysm emanating from the distal innominate artery after falling from a three-story building. On imaging, he also had a bovine arch. He underwent hybrid repair with covered stent placement from the common carotid into the innominate artery, carotid-subclavian bypass, and plugging of the subclavian artery. The patient recovered with no cerebral insult, neurological deficits, or rupture. Post-traumatic innominate artery pseudoaneurysms can successfully be repaired via a hybrid surgical approach.

Keywords: Amplatzer plug; Blunt traumatic injury; Hybrid surgery; Innominate artery; Pseudoaneurysm; Stent.

Fig 1

Computed tomography angiography (CTA) showing pseudoaneurysm (yellow arrow) of the distal innominate artery at the bifurcation of the right common carotid and subclavian artery in axial (A), coronal (B), and sagittal (C) views. A small dissection flap extends into the common carotid artery. There is no evidence of thrombosis or rupture. The pseudoaneurysm measures 2.5 cm at its widest point.

Fig 2

Illustrations and angiograms of the first stage of the procedure. A, Initial angiogram shows distal innominate artery pseudoaneurysm with filling of both the common carotid artery and right subclavian artery. The left common carotid artery can be seen taking off the proximal portion of the innominate, classifying this patient as having a bovine arch. B, After placement of an 8L × 59 mm VBX across the lesion from carotid to the normal brachiocephalic trunk and post dilation to 10 mm, the stent appeared to have migrated distally. The pseudoaneurysm can be seen filling. C, After extension with a 10 × 39 mm VBX and post-dilation to 12 mm, angiogram shows suitable coverage of the lesion with no filling of the pseudoaneurysm and exclusion of the right subclavian artery from the brachiocephalic. A, Artery.

Fig 3

Illustrations and angiograms of the third stage of the procedure. A, Retrograde angiogram from the right subclavian artery shows filling of the vertebral, right internal mammary artery (RIMA), and carotid-subclavian bypass graft with contrast seen in the pseudoaneurysm. B, After placement of an Amplatzer-2 12 × 9 mm plug distal to the injury and proximal to the RIMA and vertebral artery angiogram shows filling of the vertebral, RIMA, and carotid-subclavian bypass graft with exclusion of the pseudoaneurysm. A, Artery.