Ann Thorac Surg 2008;85:653-654. doi:10.1016/j.athoracsur.2007.08.044
© 2008 The Society of Thoracic Surgeons
Case Reports
Beware of the Aberrant Innominate Artery
Prashant K. Upadhyaya, MD*,
Robert Bertellotti, MD,
Ambreen Laeeq, MD,
Jeffrey Sugimoto, MD
Department of Surgery and Cardiothoracic Surgery, Creighton University, Omaha, Nebraska
Accepted for publication August 21, 2007.
* Address correspondence to Dr Upadhyaya, Department of Surgery and Cardiothoracic Surgery, Creighton University, 601 N 30th St, Omaha, NE 68131 (Email: kpupadhyaya{at}gmail.com).
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Abstract
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The anatomy of aortic great vessels is relevant in surgeries of the anterior neck, especially with a tracheostomy, thyroidectomy, or mediastinoscopy. Variations in their anatomy could lead to severe complications if not recognized. An aberrant high-riding innominate artery incidentally encountered during mediastinoscopy is presented.
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Introduction
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The innominate artery normally arises as the first and largest branch of the arch of the aorta and courses superiorly to the right to divide into the right common carotid and subclavian arteries behind the right sternoclavicular joint. The anatomy is relevant in surgery of the anterior neck, especially in a tracheostomy, thyroid dissection, or mediastinoscopy. Although not common, variations in the anatomy must be anticipated as the complications can be catastrophic. A case of an abnormally high-riding innominate artery incidentally encountered during a mediastinoscopy is presented.
A 47-year-old obese woman in workup of atypical chest pain was noted to have mediastinal adenopathy on a computed tomographic scan of the chest. Mediastinoscopy was performed to obtain tissue for diagnosis. In the operating room with the patient positioned with the neck slightly extended, prominent pulsations were noticed midway between the suprasternal notch and the thyroid cartilage. The computed tomographic scan was re-reviewed in the operating room, suggesting a high-riding innominate artery. A 4-cm transverse incision was placed approximately 2 cm above the suprasternal notch. The innominate artery (measuring 1.2 cm in diameter) was found coursing horizontally across the trachea between the thyroid cartilage and the first tracheal ring, beneath the strap muscles (Fig 1). A plane was developed superior to the artery down to the trachea and the mediastinoscope was inserted. Right paratracheal nodes were sampled and revealed noncaseating granulomas. The patient was discharged home immediately after the procedure.
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Fig 1. Intraoperative photograph illustrating the high-riding innominate artery coursing across the operative field. (1) Strap muscles, (2) innominate artery, (3) clavicle, and (4) jugular notch.
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Comment
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A high-riding innominate artery is rarely reported in the English literature. A high bifurcation of the innominate artery at the level of the second tracheal ring has been described [1]. The patient was a 62-year-old woman who underwent parathyroid adenoma excision. Similar to our case, the abnormal anatomy of the innominate was suspected in the operating room after extension of the neck. A case of a high-riding innominate artery at the level of the third tracheal ring and coursing horizontally has been reported in a patient with laryngeal carcinoma [2]. Our case was similar in that the innominate was coursing horizontally between the thyroid cartilage and the first tracheal ring. A high located aberrant innominate artery crossing the fourth and fifth tracheal rings was described in an autopsy after a percutaneous tracheostomy [3].
One should suspect a high-riding innominate artery in the neck when a pulsatile mass is observed or palpated at the suprasternal notch. In this case, the diagnosis was made intraoperatively after noticing prominent pulsations in the neck. The patient was obese and had a short neck, making preoperative diagnosis difficult. This finding was missed in the preoperative computed tomographic scan of the chest. Subsequent review of the scan revealed a high-riding innominate artery (Fig 2).
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Fig 2. Three-dimensional reconstruction of computed tomographic scan of chest illustrating great vessels of the chest with the innominate artery coursing superior to the jugular notch. (1) Right subclavian artery, (2) right common carotid artery, (3) thyroid cartilage, and (4) high-riding innominate artery.
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In addition, the left common carotid artery, which normally arises separately from the aortic arch, was found to be arising from the innominate artery. This pattern (ie, a Bovine arch) can be found in as much as 7% to 27% of aortic vasculatures [4–6].
Surgeries of the lower anterior neck, especially mediastinoscopy, involve maximal neck extension. This tends to elevate the innominate artery, especially in a young patient to just below the jugular notch. Thus, even with a normal anatomy, this vessel is at risk for injury during mediastinoscopy. It should be a routine to palpate below the jugular notch to ascertain the level of the innominate artery before dividing the midline to obtain access to the pretracheal fascia.
Our case illustrates the possibility of asymptomatic aberrations of the great vessels of the neck. They should be anticipated in surgeries of the anterior neck as the consequences of injuries can be severe.
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References
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- Racic G, Matulic J, Roje Z, et al. Abnormally high bifurcation of the brachiocephalic trunk as a potential operative hazard: case report Otolaryngol Head Neck Surg 2005;133:811-813.[Medline]
- Ozlugedik S, Ozcan M, Unal A, et al. Surgical importance of highly located innominate artery in neck surgery Am J Otolaryngol 2005;26:330-332.[Medline]
- Comert A, Comert E, Ozlugedik S, et al. I. High-located aberrant innominate artery: an unusual cause of serious hemorrhage of percutaneous tracheotomy Am J Otolaryngol 2004;25:368-369.[Medline]
- Williams PL, Warwick R, Dyson M, et al. Gray’s AnatomyLondon, United Kingdom: Churchill Livingstone; 1995. pp. 1513.
- Liechty JD, Shields TW, Anson BJ. Variations pertaining to the aortic arches and their branches; with comments on surgically important types Q Bull Northwest Univ Med Sch 1957;31:136-143.[Medline]
- Al-Khaldi A, Robbins RC. Successful repair of blunt injury of aortic arch branches in the setting of bovine arch J Vasc Surg 2006;43:396-398.[Medline]
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Abstract
Introduction
