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Ann Thorac Surg 2001;72:2134-2136
© 2001 The Society of Thoracic Surgeons
a Department of Thoracic and Cardiovascular Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
Accepted for publication March 23, 2001.
* Address reprint requests to Dr Cassada, Department of Thoracic and Cardiovascular Surgery, University of Virginia Health System, MR4, Room 3111, PO Box 801359, Charlottesville, VA 22908-1359, USA
e-mail: dcc3s{at}hscmail.mcc.virginia.edu
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Abstract |
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Introduction |
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A 39-year-old man was in a high-speed motor vehicle accident. Upon arrival his pulse was 115, blood pressure 130/80 mm Hg, and Glasgow Coma Score 3T (he was pharmacologically paralyzed and unresponsive on the ventilator). He had a large contusion over the left chest and shoulder, and his pulses were symmetric.
A chest radiogram revealed widened mediastinum with a right pulmonary contusion and pneumothorax. After chest tube placement, the patient underwent a computed tomographic (CT) scan of the head which was negative for injury. Chest and abdominal CT revealed a large hematoma of the soft tissues of the neck and chest with extension into the superior mediastinum, a grade I splenic laceration, a right posterior acetabular fracture, and multiple right rib fractures. A thoracic arteriogram demonstrated a bovine arch (left common carotid artery taking origin from the brachiocephalic trunk), an avulsed left vertebral artery, and a pseudoaneurysm of the proximal brachiocephalic trunk.
An initial plan of nonoperative therapy was chosen for several reasons. The pseudoaneurysm distal to the takeoff of the left common carotid combined with an occluded left vertebral artery placed his entire cerebral circulation at risk during application of a proximal clamp. Anticoagulation for a shunt to both distal common carotid arteries increased the risk of hemorrhage from the splenic laceration. Additionally, there was a risk of exacerbating brain injury given the initial uncertainty of his neurologic status, despite the normal head CT. Initial management consisted of blood pressure control to keep systolic blood pressure lower than 130 mm Hg, neurologic evaluations, and serial chest CT angiograms to follow the pseudoaneurysm.
The patient was admitted and maintained on a labetalol drip. A CT angiogram of the chest obtained 12 hours after admission demonstrated a 11 x 17 mm pseudoaneurysm along the posterior aspect of the innominate artery just distal to the takeoff of the left common carotid artery (Fig 1A). The patient regained consciousness with a normal neurologic exam and was extubated. His blood pressure was controlled on oral ß-blockers. Repeat CT scans 5 days later and then 11 days postinjury showed no contrast extravasation or change in the pseudoaneurysm. He was discharged home 12 days postinjury on aspirin and ß-blockers.
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Median sternotomy was performed, and the pericardium was opened and suspended. The midline incision was extended onto the left neck, exposing the great vessels and allowing distal control of both common carotid arteries. Proximal control was obtained at the takeoff of the bovine trunk from the aorta.
Pursestring sutures of 5-0 Prolene (Ethicon, Somerville, NJ) were placed in each common carotid artery. A pursestring pledget of 4-0 Prolene was placed in the proximal ascending aorta. Heparin was administered to achieve an activated clotting time of 250 seconds. A 10F wire-wound pediatric arterial cannula was secured in the ascending aorta. Each distal common carotid artery was cannulated with an 8F wire-wound cannula. Both were connected by a Y adapter to the aortic cannula. After careful removal of air, the clamps were released and both carotids were perfused. A vascular clamp was applied just proximal to the cannula in the left common carotid artery. On the right a clamp was placed distal to the pseudoaneurysm and proximal to the takeoff of the axillary artery to insure perfusion of the right vertebral artery by way of the right common carotid artery cannula. A partial occlusion clamp was applied to the ascending aorta to encompass just the origin of the bovine trunk.
The innominate artery was opened longitudinally along the anterior wall. The posterior wall of the artery contained a pseudoaneurysm with intimal limits within the confines of the vascular clamps, and the injured segment was excised. Deep to the mobilized innominate vein, a bifurcated 14 x 7 mm Hemashield graft was sewn end-to-end to a cuff of the bovine trunk proximally and to the left common carotid artery and brachiocephalic artery distally with continuous 3-0 and 5-0 Prolene sutures, respectively (Fig 2). The clamps were released, and the bypass shunts were clamped and removed. The incision was closed in a standard manner. After an uneventful 3-day recovery, he was discharged home on aspirin and labetalol. The left vertebral lesion remained asymptomatic, and was neither treated nor reimaged.
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Central to a successful repair are planning for optimizing cerebral perfusion and timing to minimize morbidity/mortality from associated injuries. Johnston and colleagues [5] reported that associated injuries increased the mortality rate from 8% to 30%. Most series describe immediate or prompt timing of repair during the initial hospitalization. A more recent article demonstrated the feasibility of delayed repair of blunt thoracic aortic injuries to stabilize hemodynamics and attend to other injuries [6]. Our case demonstrates the successful application of a delayed definitive treatment in a patient with increased risk due to anomalous anatomy and associated injuries.
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This article has been cited by other articles:
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  P Kaul, K Javangula, S Ganti, S Balaji, M Sivananthan, M Gough, and S Lindsay Continuous selective bilateral antegrade cerebral perfusion through anomalous innominate artery for repair of root, ascending aortic and arch aneurysm - challenges, vagaries and opportunities of bovine arch variant anatomy and review of literature Perfusion, March 1, 2009; 24(2): 121 - 133. [Abstract] [PDF]
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 M. A. Moise, V. Hsu, B. Braslow, and Y. J. Woo Innominate artery transection in the setting of a bovine arch J. Thorac. Cardiovasc. Surg., October 1, 2004; 128(4): 632 - 634. [Full Text] [PDF]
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