Ann Thorac Surg 1997;63:238-240
© 1997 The Society of Thoracic Surgeons
Case Report
Dual-Inflow Great Vessel Aneurysm: Delayed Presentation After Penetrating Trauma
Mario M. Rossbach, MD,
Reginald C. Baptiste, MD,
Mellick T. Sykes, MD,
Edward Y. Sako, MD, PhD,
John H. Calhoon, MD,
O. Lawayne Miller, MD,
Scott B. Johnson, MD
Divisions of Cardiothoracic Surgery and Vascular Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas
Accepted for publication July 24, 1996.
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Abstract
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Aneurysms constitute uncommon sequelae of injuries to the thoracic outlet. Most such aneurysms are secondary to blunt trauma and usually involve the great vessels at their take-off from the aortic arch. Penetrating injuries are more often identified in the more distal vessels and only very rarely present as pseudoaneurysms. Reported here is a single case of a chronic posttraumatic pseudoaneurysm arising from both the right common carotid artery and the right subclavian artery. The workup and surgical approach provide practical lessons, complemented with illustrations that aid in the understanding of the case. It is an unusual case because of the dual-inflow nature of the aneurysm.
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Introduction
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Injury to the great vessels at the thoracic outlet can be one of the most challenging surgical problems that will be seen by a surgeon [1]. Failure to recognize the arterial injury immediately after trauma can lead to the late development of pseudoaneurysms [2, 3]. This is a single case report of a delayed presentation of a chronic pseudoaneurysm with an unusual dual inflow from both the right common carotid artery (CCA) and the right subclavian artery (SCA) after a gunshot wound to the neck.
A 45-year-old woman was referred to the Cardiothoracic Surgery Service with a 3-month history of a painful mass above the right sternoclavicular junction. Past medical history was significant for a gunshot wound to the right side of her neck 11 years earlier. Physical examination revealed a 4-cm pulsatile mass above the right sternoclavicular junction with palpable thrill. Carotid and upper extremity pulses were normal and equal bilaterally. Chest computed tomographic scan with intravenous contrast showed a 3.5 x 5-cm right supraclavicular cystic mass with a focal area of calcification along the medial wall. The mass extended inferiorly to the confluence of the right SCA and the right CCA (Fig 1
). A transfemoral arteriogram demonstrated a large pseudoaneurysm above the bifurcation of the innominate artery (IA) with inflow from both the right SCA and the right CCA (Fig 2).
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Fig 1. . Chest computed tomographic scan with intravenous contrast shows a 3.5 x 5-cm supraclavicular cystic lesion enhanced by the contrast medium (arrow) with a focal area of thin calcification along the medial wall. The trachea is slightly deviated to the left. The hypodense area inside the mass (top) suggests the presence of old material within the lesion.
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Fig 2. . Transfemoral angiography of the aortic arch shows the innominate artery with extravasation of contrast at the origin of both the right subclavian artery and the right common carotid artery (A). The previously noted "extravasation" of contrast delineates a vascular structure with dual inflow from the right subclavian artery and the right common carotid artery (B). The intravenous contrast defines the pseudoaneurysm as a "bridge" between the right subclavian artery and the right common carotid artery (C). (RAO = right anterior oblique.)
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A midline sternotomy with extension of the incision to the right neck was performed. The pericardium was opened and proximal control of the IA was established. A 5 x 4-cm pulsatile mass involving the lower border of the right CCA as well as the origin of the right SCA was identified. Distal control of the CCA was obtained with vascular clamps after 3 minutes of intravenous heparinization. The IA and CCA were clamped, and the false aneurysm was opened with balloon occlusion of the distal SCA. An end-to-end repair of the CCA was achieved using 4-0 Prolene (Ethicon, Somerville, NJ), and cerebral flow was reestablished after proximal control of the SCA was obtained. The aneurysm was then opened in its entirety after proximal and distal control of the SCA was obtained with vascular clamps. The SCA was then repaired primarily with 4-0 Prolene. The chest and neck were closed in a routine fashion over drainage tubes.
The patient was electively ventilated postoperatively, and extubated 12 hours after the operation. She had no neurologic dysfunction, and her distal upper extremity pulses were strong and equal. She was discharged home on the fourth postoperative day. A color-flow duplex scan of the carotid and subclavian arteries 3 months after repair showed no evidence of recurrence or stenosis.
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Comment
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Twenty percent of vascular injuries are in the chest, and of that group 71% of the patients with major vascular injuries of the thoracic outlet or base of the neck die before arrival to the emergency room [1]. After a clinical diagnosis is made, the overall mortality is still as high as 30% [1, 4]. Thoracic great vessel injury may be secondary to blunt, penetrating, blast, or iatrogenic trauma. Among patients who reach the hospital alive, a similar distribution has been observed between blunt and penetrating injuries [5]. Innominate artery injuries are infrequent, with fewer than 75 cases reported during the last 50 years [1, 6]. The proximal IA is most commonly injured secondary to blunt trauma, whereas the distal IA and distal vessels are usually involved with penetrating injuries [2].
Angiography and digital subtraction angiography are the gold standard for diagnosis for both penetrating and blunt injuries of the thoracic outlet vessels [1, 7]. However, the vast majority of the patients who present to the emergency room with these injuries have associated massive hemorrhage and shock that precludes the use of the test [1], and therefore other modalities, such as preoperative two-dimensional echocardiography and intraoperative transesophageal echocardiography, may be useful in these situations [8]. Echography and computed tomographic scanning have some diagnostic value in both acute [8] and chronic cases [7, 8].
In a recent literature review, Hoff and associates found some sporadic reports of cases of late development of traumatic aneurysms of the SCA [2] and a few cases of traumatic aneurysms of the IA [2, 4, 6]. Late pseudoaneurysm development is uncommon, and usually presents within the first year after blunt trauma. False aneurysms after penetrating trauma are very rare, especially presenting so late after the initial injury. In this report, the pseudoaneurysm presented more than 10 years after a gunshot wound to the cervical zone I. The pseudoaneurysm that resulted from a gunshot wound to the neck had a dual inflow from both the CCA and the SCA.
Therapeutic approaches for posttraumatic thoracic outlet aneurysms described in the literature include ligation of the artery, insertion of a prosthetic graft to bridge the defect after resection of the traumatized vessel segments, direct repair by oversewing of the lesion, and end-to-end anastomoses with or without excision of the traumatized vessel segments [4]. A median sternotomy with extension into the right side of the neck provides excellent exposure for surgical repair of the IA, proximal right SCA, and right CCA [1–3]. The advisability of the use of a shunt while repairing the IA injury remains unsettled. Some recent publications report excellent results without using shunts [1, 4] that indicate that many patients tolerate temporary occlusion of the IA and right CCA because of the vast collateral circulation. Continuous somatosensory evoked potentials monitoring while performing the repair without a shunt is advised by some authors [4] but has not gained widespread use.
In conclusion, traumatic great vessel pseudoaneurysms are rare and usually associated with blunt trauma. Delayed presentation is unusual because the vast majority of the patients either die or are repaired acutely. For late pseudoaneurysms, angiography remains the most helpful mode of diagnosis and also provides an excellent delineation of the anatomic structures involved.
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Footnotes
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Address reprint requests to Dr Johnson, Division of Cardiothoracic Surgery, Department of Surgery, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Dr, San Antonio, TX 78284-7842.
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References
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- Johnston RH Jr, Wall MJ Jr, Mattox KL. Innominate artery trauma: a thirty-year experience. J Vasc Surg 1993;17:134–40.[Medline]
- Hoff SJ, Reilly MK, Merrill WH, Stewart J, Frist WH, Morris JA Jr. Analysis of blunt and penetrating injury of the innominate and subclavian arteries. Am Surg 1994;60:151–4.[Medline]
- Marvasti MA, Parker FB Jr, Bredenberg CE. Injuries to arterial branches of the aortic arch. Thorac Cardiovasc Surg 1984;32:293–8.[Medline]
- Kraus TW, Paetz B, Richter GM, Allenberg JR. The isolated posttraumatic aneurysm of the brachiocephalic artery after blunt thoracic contusion. Ann Vasc Surg 1993;7:275–81.[Medline]
- Mattox KL. Thoracic great vessel injury. Vascular trauma. Surg Clin North Am 1988;68:693–703.[Medline]
- McLean TR, McManus RP. Penetrating trauma involving the innominate artery. Ann Thorac Surg 1991;51:113–5.[Abstract/Free Full Text]
- Vosloo SM, Reichart BA. Inflow occlusion in the surgical management of a penetrating aortic arch injury: case report. J Trauma 1990;30:514–5.[Medline]
- Bolton JWR, Bynoe RP, Lazar HL, Almond CH. Two-dimensional echocardiography in the evaluation of penetrating intrapericardial injuries. Ann Thorac Surg 1993;56:506–9.[Abstract/Free Full Text]
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Abstract
Introduction
