Ann Thorac Surg 2002;74:2184-2186
© 2002 The Society of Thoracic Surgeons
Case report
Endovascular management of a ruptured mycotic aneurysm of the innominate artery
Ruth L. Bush, MD*a,
Julian E. Hurt, MDa,
Charles C. Bianco, MDa
a Cardiac and Vascular Surgery Center, Tallahassee Memorial Hospital, Tallahassee, Florida, USA
Accepted for publication July 1, 2002.
* Address reprint requests to Dr Bush, Cardiac and Vascular Surgery Center, 1405 Centerville Road, Suite 5000, Tallahassee, FL 32308, USA.
e-mail: rlbush{at}aol.com
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Abstract
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Mycotic aneurysms of the innominate artery are infrequent lesions and, as such, represent challenging surgical problems. We describe herein a case of a ruptured mycotic innominate artery aneurysm, which developed after radical neck dissection and radiation therapy for tonsillar carcinoma. The aneurysm was successfully excluded from the systemic circulation with endoluminal placement of a covered stent, with efficacy confirmed by vascular imaging at 6 months follow-up. The patient suffered no permanent neurologic sequelae. Long-term follow-up and chronic antibiotic therapy will be necessary to avoid infection of the covered stent in this high-risk surgical patient.
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Introduction
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Mycotic aneurysms of the innominate artery are exceedingly rare lesions, with only a few case reports existing in the literature. Analogous to other aneurysms, these lesions have the potential to cause considerable morbidity and mortality from distal embolization, thrombosis, or rupture. Perhaps the possibility of a devastating complication is more so with an innominate artery aneurysm because of its relative inaccessibility. The traditional treatment of these challenging surgical problems has consisted of aneurysm resection and interposition grafting, which is safe and efficacious in an elective setting. Endovascular stent-graft implantation is an alternative to open surgical repair in high-risk patients or special circumstances, albeit with inherent risks and complications.
A 56-year-old man presented with chest wall bleeding following an episode of cellulitis and subsequent drainage of a right pectoral abscess. Three years prior, he had been treated for squamous cell carcinoma of the right tonsillar fossa with modified radical neck dissection followed by radiation therapy. The treating oncologist considered the patient to be in a state of remission with no evidence of active disease and only the development of occasional low-grade peritonsillar infections.
Physical examination at this presentation was significant for a pulsatile mass at the right neck base and slow, but persistent arterial bleeding from an infraclavicular fistula tract onto his chest wall. Due to previous surgery and radiation, the consulting cardiovascular surgeon thought this patient to be an unacceptable surgical risk.
Angiography demonstrated a 3-cm aneurysm at the innominate artery bifurcation (Fig 1).
Initial endovascular therapy was with a 14-mm Palmaz XL stent (Cordis Endovascular Systems, a Johnson & Johnson Company, Warren, NJ) deployed through a 12F sheath through a right brachial artery approach (Fig 2a).
After stent placement, a 5F angled catheter was introduced through the stent interstices. Embolization coils (fibered platinum coils; Target Therapeutics, Inc/Boston Scientific Corp, Fremont, CA) were inserted into the aneurysm lumen (Fig 2b). Completion aortic arch, cervical, and cerebral angiography was performed to document aneurysm exclusion and a patent internal carotid artery.
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Fig 1. Arch aortogram demonstrating innominate artery pseudoaneurysm. Despite multiple images performed, the exact origin of the common carotid artery could not be identified.
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Fig 2. (a) A Palmaz XL stent was introduced and deployed by a transaxillary approach due to limited catheter length. An injection catheter was positioned in the ascending aorta from the femoral artery for contrast injection throughout the procedure. (b) An angled catheter was placed through the stent interstices for coil embolization. Completion arteriography showed exclusion of the pseudoaneurysm from the systemic circulation.
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Nonetheless, persistent bleeding requiring multiple blood transfusions necessitated further imaging. Indeed, confirmatory color and pulse-wave Doppler ultrasound indicated incomplete exclusion of the aneurysm. The patient was returned to the angiography suite. A 14-mm Wallgraft (Medi-tech/Boston Scientific Corp, Natick, MA), after being partially unsheathed, cut to the appropriate length as measured on the fluoroscopy screen, and recaptured within its sheath, was deployed inside of the previously placed Palmaz stent (Fig 3).
Due to the proximity of the aneurysm to the origin of the common carotid artery, this vessel was deliberately covered. Completion angiography now showed exclusion of the aneurysm and intracerebral angiography through the contralateral internal carotid artery demonstrated cross-filling of the right hemisphere through the anterior communicating artery.
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Fig 3. After placement of a Wallgraft within the Palmaz stent for continued chest wall bleeding. The common carotid artery no longer fills; however, the patient was neurologically intact.
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The patient remained neurologically intact throughout the procedure and postoperatively. Duplex scanning and conventional angiography at 6-month follow-up demonstrated continued aneurysm exclusion and antegrade flow in the right (ipsilateral) internal carotid artery due to flow reversal in the external carotid artery. The systolic brachial pressures remained equal. The patient continues on long-term suppression antibiotic therapy with a well-healed chest wall.
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Comment
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Innominate artery aneurysms are rare entities, representing 3% of all arterial aneurysms [1, 2]. Distal embolization or thrombosis leading to limb-threatening ischemia, rupture, or compression of adjacent structures may occur as clinical manifestations [2]. This case describes a mycotic aneurysm of the innominate artery, which developed as a result of a prior operation and chest wall irradiation. The aneurysm eroded through the patient’s chest wall instead of rupturing freely into his pleural cavity, which would have been an undoubtedly fatal complication.
Current elective surgical treatment involves both resection of the aneurysm and reconstruction with an interposition bypass graft, most often prosthetic due to size mismatch with vein conduit. To gain exposure and vascular control, median sternotomy with or without a supraclavicular extension of the incision is requisite for proximal right innominate artery aneurysms. Prosthetic replacements of the innominate artery or ascending aorta-to-innominate artery prosthetic bypass are two described methods of surgical management. In the case of an infected aneurysm, Kieffer and colleagues [3] treated by means of resection of the aneurysm, proximal ligation of the innominate artery, and transposition of the right into the left common carotid artery. Indeed, others have reported the use of complex surgical techniques, such as complete aortic arch reconstruction using grafts to the right carotid and subclavian arteries after proximal aneurysm ligation with a separate carotid–carotid bypass. In a series spanning 20 years, Brewster and colleagues [4] described their experience with 71 surgical cases of various innominate artery lesions, only 3 of which were aneurysms. Nonetheless, 2 of the 3 patients did not survive. In the present case, endoluminal therapy was chosen as the treatment modality because of the patient’s recognized high-surgical risk and presumed unacceptable operative mortality.
Endovascular treatment of innominate artery aneurysms, both true and false, has been mainly described as individual case reports [1, 5]. Various authors have demonstrated the feasibility of endovascular correction and have emphasized the avoidance of a major thoracic operation. The follow-up times ,vary with 2 years being the longest reported [5]. Homemade stent-grafts have been used for the larger caliber innominate artery, as commercial devices are currently limited in size availability and deployment catheter length. However, in this patient, we did not have complete aneurysm exclusion when using an uncovered stent combined with coil embolization; subsequently we had to place a second, albeit covered, stent. This method of stent-supported coil embolization has been used successfully in aneurysms that are not amenable to unsupported coil embolization.
The use of covered stents has been expanded to include control of hemorrhage from arterial disruption, treatment of hemodynamically significant vascular stenosis, and aneurysm exclusion [6]. In the setting of a mycotic aneurysm, the repair outcome may be complicated by delayed infection. In this report, we chose to continue suppression antibiotic therapy long-term as the mycotic aneurysm had eroded through to the chest wall. If infection of the covered stent recurs, this situation may be unsalvageable. Surgical reconstruction with homograft cryopreserved tissue may represent a reparative conduit; however, the patient’s high surgical risk status may preclude operative intervention as it did in this circumstance.
This case demonstrates the successful outcome of advanced endovascular skills in treating a ruptured mycotic innominate artery aneurysm, which, in general, represents a fatal lesion. These endovascular alternatives, albeit with uncertain long-term efficacy, avoided an operation in a hostile field and achieved complete and permanent reconstruction of the arterial wall by excluding the aneurysm. Long-term follow-up and chronic antibiotic therapy will be necessary to avoid infection of the vascular prostheses and further validate this technique.
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References
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- Ruebben 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]
- Stolf N., Bittencourt D., Verginelli G., Zerbini E. Surgical treatment of ruptured aneurysm of the innominate artery. Ann Thorac Surg 1983;35:394-399.[Abstract/Free Full Text]
- Kieffer E., Chiche L., Koskas F., Bahnini A. Aneurysms of the innominate artery: surgical treatment of 27 patients. J Vasc Surg 2001;34:222-228.[Medline]
- Brewster D., Moncure A., Darling R., Ambrosino J., Abbott W. Innominate artery lesions: problems encountered and lessons learned. J Vasc Surg 1985;2:99-112.[Medline]
- Puech-Laeo P., Orra H. Endovascular repair of an innominate artery true aneurysm. J Endovasc Ther 2001;8:429-432.[Medline]
- Parodi J., Schonholz C., Ferreira L., Bergan J. Endovascular stent-graft treatment of traumatic arterial lesions. Ann Vasc Surg 1999;13:121-129.[Medline]
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Abstract
Introduction
