Ann Thorac Surg 2000;69:1263-1264
© 2000 The Society of Thoracic Surgeons
CASE REPORTS
Innominate arterial rupture distal to anomalous origin of left carotid artery
Charles S. Roberts, MDa,
John D. Sadoff, MDa,
David R. White, MDa
a Division of Cardiothoracic Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
Address reprint requests to Dr Roberts, Division of Cardiothoracic Surgery, University of North Carolina, 108 Burnett-Womack Bldg, CB 7065, Chapel Hill, NC 27599-7065
e-mail: charless{at}med.unc.edu
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Abstract
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Isolated innomnate arterial rupture from blunt trauma is rare. We present the case of a pregnant woman with an isolated injury to the innominate artery distal to an anomalous origin of the left common carotid artery. A safe operative technique is described.
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Introduction
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The anatomic variant in which both common carotid arteries originate from the innominate artery is present in about 27% of the population, according to Liechty and associates [1], who studied aortic arch branching in 1,000 adult autopsy patients. Herein, we present the case of a pregnant woman with isolated injury to the innominate artery distal to the anomalous origin of the left common carotid artery. Unique aspects of operative management are described.
A 24-year-old woman who was 20 weeks pregnant was an unrestrained driver in a high-speed automobile collision. She was hemodynamically stable on arrival at the hospital and complained only of posterior neck pain. She had neck tenderness posteriorly and ecchymosis of her upper sternum. The T waves in leads V1–V4 were inverted. A chest radiograph showed a widened mediastinum. An ultrasound of the abdomen and pelvis disclosed no injuries, and the fetus was active with a normal heart rate. A computer tomogram of the chest revealed a mediastinal hematoma. An aortic angiogram (Fig 1) demonstrated an anomalous left common carotid artery originating in the proximal innominate artery and a tear in the innominate artery just distal to this anomalous left carotid ostium. A dissection in the innominate artery extended from the tear to its bifurcation into the right subclavian and right common carotid arteries.
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Fig 1. Aortic arch angiogram. (A = aorta; I = innominate artery, injured segment; LCC = left common carotid artery; LSC = left subclavian artery; RCC = right common carotid artery; RSC = right subclavian artery.)
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At operation through a median sternotomy, the great arteries were delineated, and a circumferential hematoma was observed overlying the innominate artery from just distal to the origin of the left common carotid artery to its bifurcation into the right common carotid and right subclavian arteries. A medial tear could be seen through the adventitial hematoma at the proximal end. Heparin (75 U/kg) was administered, and a Javid shunt was placed from the ascending aorta to the proximal right common carotid artery. A side-biting vascular clamp was placed, occluding the innominate artery proximal to the tear, but permitting antegrade flow in the left common carotid artery. Another clamp was placed just proximal to the bifurcation (Fig 2). The innominate artery was resected and replaced with a Dacron (C.R. Bard, Haverhill, MA) interposition graft (10 mm in diameter), using continuous 4-0 polypropylene suture. The fetal heart rate was monitored throughout the operation and at intervals postoperatively, and remained normal. The patient’s postoperative convalescence was uncomplicated, and she was discharged after 8 days.
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Fig 2. Operative technique used to repair the ruptured innominate artery distal to the anomalous origin of the left common carotid artery.
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Comment
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Several series of patients with blunt injury to the innominate artery have been reported, including that of Rosenberg and colleagues [2], who used no arterial shunts. Cardiopulmonary bypass with circulatory arrest was reserved for patients with "extensive injuries that involve both the innominate and left common carotid (which can arise from a common trunk)." Johnston and associates [3] advocated "the bypass principle" for innominate arterial injury—no shunt, heparin, or cardiopulmonary bypass is used.
Reubben and associates [4] reported a patient with a "traumatic pseudoaneurysm" of the innominate artery proximal to and involving the origin of an anomalous left common carotid artery. This patient underwent operative transfer of the origin of the left common carotid artery to the left subclavian artery, followed by insertion of an endovascular stent into the innominate artery. Villegas-Cabello and Cooley [5] also reported a patient with an aneurysm of the innominate artery proximal to and involving an anomalous left carotid artery. Repair was carried out using deep hypothermic circulatory arrest. In contrast to these 2 patients, the proximal innominate artery and the left common carotid artery in our patient were uninjured.
Repair of rupture of the innominate artery in cases in which it gives rise to both common carotid arteries requires careful techniques if neurologic injury is to be avoided. Clamping the proximal innominate artery would interrupt three of the four primary arteries to the brain, ie, all antegrade flow to the brain except for the left vertebral artery. Clamping the innominate artery just distal to the origin of the left common carotid artery preserves antegrade flow through the left common carotid and left vertebral arteries, but interrupts flow through the right common carotid and right vertebral arteries. The safest operative technique, in our view, was to preserve antegrade flow through both carotid arteries and also avoid cardiopulmonary bypass in our pregnant patient. The use of a Javid shunt from the aorta to the right common carotid artery allowed safe clamping of the innominate artery at its proximal and distal ends, and cardiopulmonary bypass was unnecessary.
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References
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Liechty J.D., Shields T.W., Anson B.J. Variations pertaining to the aortic arches and their branches, with comments on surgically important types. Q Bull Northwest Univ Med School 1957;31:136-143.
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Rosenberg J.M., Bredenberg C.E., Marvasti M.A., Bucknam C., Conti C., Parker F.B., Jr Blunt injuries to the aortic arch vessels. Ann Thorac Surg 1989;48:508-513.[Abstract/Free Full Text]
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Johnston R.H., Jr, Wall M.J., Jr, Mattox K.L. Innominate artery trauma. J Vasc Surg 1993;17:134-140.[Medline]
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Reubben A., Merlo M., Verri A., et al. Combined surgical and endovascular treatment of a traumatic pseudo-aneurysm of the brachiocephalic trunk with anatomical anomaly. J Cardiovasc Surg 1997;38:173-176.[Medline]
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Villegas-Cabello O., Cooley D.A. Aneurysm of the innominate artery with aberrant origin of the left carotid artery. Tex Heart Inst J 1996;23:298-300.[Medline]
Accepted for publication September 3, 1999.
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Abstract
Introduction
