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Innominate artery aneurysm: Axial reconstruction via a cervical approach
CASE REPORTS
Innominate artery aneurysm: Axial reconstruction via a cervical approach Thomas J. Takach, MD, and Stephen G. Lalka, MD, Charlotte, NC True aneurysms of the innominate artery are rare. Successful axial reconstruction in the past has required a combined cervical and transthoracic approach with placement of a prosthetic graft. We describe herein the occurrence of an innominate artery aneurysm that extended to and involved the proximal common carotid artery and subclavian artery in a 63-year-old woman. The patient presented with thomboembolic sequelae in her fingertips and had a pulseless upper extremity. Successful aneurysmectomy and axial reconstruction with a bifurcated graft was achieved by using cervical exposure alone. A subsequent staged revascularization of the upper extremity was successfully accomplished with a brachial to radial artery bypass and ulnar artery transposition. ( J Vasc Surg 2007;46:1267-9.)
True aneurysms of the innominate artery (IA) occur infrequently.1-3 Axial reconstruction is believed to provide optimal long-term patency4,5 and has commonly been performed by using a combined cervical and transthoracic approach that allows optimal control and exposure for aneurysmectomy and placement of a prosthetic graft.1,2 CASE REPORT A 63-year-old woman presented with a nonhealing ulcer of her right fifth finger. Physical examination demonstrated a 15 ⫻ 6 mm ulcer at the right fifth fingertip, a normal (3⫹/3) right axillary pulse, a diminished (1⫹ to 2⫹/3) right brachial pulse, absent (0/3) right radial and ulnar pulses, and normal motor and sensory examination results. Subjectively, the patient admitted to intermittent numbness of her right fingertips and hand. The patient’s medical history was significant for hypertension; obesity; thalassemia with mild anemia; a concomitant 4.5-cm infrarenal aortic aneurysm; and a transient ischemic attack 2 years earlier that involved left upper and lower extremity weakness, that resolved spontaneously, and whose source was not diagnosed. The patient had abstained from tobacco for 4 years but previously had smoked 1 pack per day for 40 years. Noninvasive evaluation demonstrated an arm-brachial index of 0.26 and a 2.2-cm aneurysm of the distal IA that involved the proximal right subclavian artery and common carotid artery (Fig 1, A). Angiography demonstrated multiple stenotic and occlusive lesions involving the right brachial, radial, and ulnar arteries and palmar arches (Fig 2). Although the patient was prepared for a combined cervical and transthoracic approach, adequate exposure and control were achieved with the initial cervical incision alone (Fig 1, A and B), thus obviating the need for a full or partial sternotomy. After From the Department of Cardiothoracic and Vascular Surgery, Carolinas Heart Institute, Carolinas Health Care System. Competition of interest: none. Reprint requests: Thomas J. Takach, MD, Department of Cardiothoracic and Vascular Surgery, Carolinas Heart Institute, Carolinas Health Care System, 1000 Blythe Blvd, Charlotte, NC 28203 (e-mail: tjtakach@ netscape.net). 0741-5214/$32.00 Copyright © 2007 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2007.06.034
aneurysmectomy (Fig 1, B and C), a bifurcated 14 ⫻ 7 mm Dacron Hemashield graft (DuPont, Wilmington, Del) was successfully placed (Fig 1, D). The patient underwent successful right upper extremity revascularization 2 weeks later by using a reversed saphenous vein conduit for a brachial to radial artery bypass with ulnar artery transposition. After surgery, palpable (2⫹ to 3⫹/3) pulses were present in the right radial and ulnar arteries, and the finger lesion healed.
DISCUSSION True aneurysms of the IA are rare. In an experience that spanned 27 years, Kieffer and colleagues1 described 6 degenerative aneurysms involving the IA among 27 patients with diverse IA pathology that also included traumatic and iatrogenic pseudoaneurysms, dissections, mycotic processes, connective tissue arteritides, and extension of arch pathology. Bower and associates2 reported the Mayo Clinic experience that spanned a 40-year period and included four patients with true aneurysms of the IA. Although the vast majority of patients present with thomboembolic complications involving either the upper extremity or cerebral circulation,1-3 Kieffer and colleagues reported one patient with an IA aneurysm who presented after rupture.1 Bower and associates have recommended operative treatment of all symptomatic and asymptomatic IA aneurysms in medically fit patients to avoid an inevitable course leading to thrombosis, rupture, or peripheral embolization.2 Axial reconstruction is believed to provide optimal long-term patency4,5 and has commonly been performed by using a combined cervical and transthoracic approach with minimal morbidity.1-5 The most frequently documented approach for IA pathology uses a median sternotomy.1,2,5 However, several authors have more recently described the use of less invasive approaches that incorporate either a partial upper sternotomy or a right anterior minithoracotomy.4,6,7 Although less invasive approaches have been described in the reconstruction of other IA pathology, we have not found them applied to treatment of IA aneurysms. The approach described in this report that 1267
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Fig 1. Intraoperative photographs demonstrating (A) a distal innominate artery (IA) aneurysm extending to and involving the origins of the common carotid artery (CCA) and subclavian artery (SCA); note the redundant proximal CCA. B, The operative field after aneurysmectomy (the CCA stump overlies and partially obscures the SCA stump); note the normal-sized IA and CCA. C, Operative specimen. D, Reconstructed vessels after placement of the bifurcated graft.
Fig 2. Angiography of right upper extremity runoff. Note the multiple stenotic and occlusive lesions involving the brachial, ulnar, and radial arteries and palmar arches.
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chest should also be prepared to facilitate completion of a median sternotomy for emergency proximal control of the IA if the aneurysm is inadvertently entered before cervical control of that vessel is attained. Puech-Leao and Orra8 reported a combined open surgical and endovascular intervention in a patient with a true IA aneurysm and an occluded right subclavian artery. They successfully inserted a stent graft directly into the IA via the right common carotid artery and anchored the graft via sutures to the common carotid artery. Endovascular intervention for other disease involving the IA has been reported and should be considered as an option for aneurysms if anatomically feasible.9 We conclude that true IA aneurysms should be considered for early intervention on the basis of the potential for the development of complications. Minimally invasive repair techniques should be considered if anatomically feasible. REFERENCES Fig 3. Computed tomography scan three-dimensional reconstruction (posterior/right lateral view) of the aortic arch and innominate artery. Note the distal innominate artery aneurysm involving the origins of the common carotid and subclavian arteries and the normal proximal innominate artery. IA, Innominate artery; Ao, aortic.
uses a cervical incision alone provides another even less invasive approach that should be considered according to anatomy. It is especially suited for distal IA disease that involves the proximal common carotid artery and subclavian artery. Although two reconstructive procedures were required and staged in the patient in this report, we do not believe that staging will be necessary for future patients. Most IA aneurysms that have been described in the literature involve the proximal or entire IA.1-3 An approach such as that described in this article would not be suitable for such lesions, and this reinforces the need for preoperative imaging both to define the limits of the aneurysm and to confirm the presence of a normal, proximal IA at the arch (Fig 3). It may not be possible to assess the adequacy of exposure and control until intraoperative visualization. The
1. Kieffer E, Chiche L, Koskas F, Bahnini A. Aneurysms of the innominate artery: surgical treatment of 27 patients. J Vasc Surg 2001;34:222-8. 2. Bower TC, Pairolero PC, Hallett JW Jr, Toomey BJ, Glowitzki P, Cherry KJ Jr. Brachiocephalic aneurysm: the case for early recognition and repair. Ann Vasc Surg 1991;5:125-32. 3. Bower TC. Aneurysms of the great vessels and their branches. Semin Vasc Surg 1996;9:134-46. 4. Berguer R, Morasch MD, Kline RA. Transthoracic repair of innominate and common carotid artery disease: immediate and long-term outcome for 100 consecutive surgical reconstructions. J Vasc Surg 1998;27:34-41. 5. Takach TJ, Reul GJ, Cooley DA, Duncan JM, Livesay JJ, Gregoric ID, et al. Brachiocephalic reconstruction. I. Operative and long-term results for complex disease. J Vasc Surg 2005;42:47-54. 6. Takach TJ, Reul GJ, Cooley DA. Transthoracic reconstruction of the great vessels using minimally invasive technique. Tex Heart Inst J 1996; 23:284-8. 7. Sakopoulos AG, Ballard JL, Gundry SR. Minimally invasive approach for aortic branch vessel reconstruction. J Vasc Surg 2000;31:200-2. 8. Puech-Leao P, Orra HA. Endovascular repair of an innominate artery true aneurysm. J Endovasc Ther 2001;8:429-32. 9. Sullivan TM, Gray BH, Bacharach JM, Perl J II, Childs MB, Modzelewski L, et al. Angioplasty and primary stenting of the subclavian, innominate, and common carotid arteries in 83 patients. J Vasc Surg 1998;28:1059-65. Submitted Apr 3, 2007; accepted Jun 14, 2007.
Innominate artery aneurysm: Axial reconstruction via a cervical approach Thomas J. Takach, MD, and Stephen G. Lalka, MD, Charlotte, NC True aneurysms of the innominate artery are rare. Successful axial reconstruction in the past has required a combined cervical and transthoracic approach with placement of a prosthetic graft. We describe herein the occurrence of an innominate artery aneurysm that extended to and involved the proximal common carotid artery and subclavian artery in a 63-year-old woman. The patient presented with thomboembolic sequelae in her fingertips and had a pulseless upper extremity. Successful aneurysmectomy and axial reconstruction with a bifurcated graft was achieved by using cervical exposure alone. A subsequent staged revascularization of the upper extremity was successfully accomplished with a brachial to radial artery bypass and ulnar artery transposition. ( J Vasc Surg 2007;46:1267-9.)
True aneurysms of the innominate artery (IA) occur infrequently.1-3 Axial reconstruction is believed to provide optimal long-term patency4,5 and has commonly been performed by using a combined cervical and transthoracic approach that allows optimal control and exposure for aneurysmectomy and placement of a prosthetic graft.1,2 CASE REPORT A 63-year-old woman presented with a nonhealing ulcer of her right fifth finger. Physical examination demonstrated a 15 ⫻ 6 mm ulcer at the right fifth fingertip, a normal (3⫹/3) right axillary pulse, a diminished (1⫹ to 2⫹/3) right brachial pulse, absent (0/3) right radial and ulnar pulses, and normal motor and sensory examination results. Subjectively, the patient admitted to intermittent numbness of her right fingertips and hand. The patient’s medical history was significant for hypertension; obesity; thalassemia with mild anemia; a concomitant 4.5-cm infrarenal aortic aneurysm; and a transient ischemic attack 2 years earlier that involved left upper and lower extremity weakness, that resolved spontaneously, and whose source was not diagnosed. The patient had abstained from tobacco for 4 years but previously had smoked 1 pack per day for 40 years. Noninvasive evaluation demonstrated an arm-brachial index of 0.26 and a 2.2-cm aneurysm of the distal IA that involved the proximal right subclavian artery and common carotid artery (Fig 1, A). Angiography demonstrated multiple stenotic and occlusive lesions involving the right brachial, radial, and ulnar arteries and palmar arches (Fig 2). Although the patient was prepared for a combined cervical and transthoracic approach, adequate exposure and control were achieved with the initial cervical incision alone (Fig 1, A and B), thus obviating the need for a full or partial sternotomy. After From the Department of Cardiothoracic and Vascular Surgery, Carolinas Heart Institute, Carolinas Health Care System. Competition of interest: none. Reprint requests: Thomas J. Takach, MD, Department of Cardiothoracic and Vascular Surgery, Carolinas Heart Institute, Carolinas Health Care System, 1000 Blythe Blvd, Charlotte, NC 28203 (e-mail: tjtakach@ netscape.net). 0741-5214/$32.00 Copyright © 2007 by The Society for Vascular Surgery. doi:10.1016/j.jvs.2007.06.034
aneurysmectomy (Fig 1, B and C), a bifurcated 14 ⫻ 7 mm Dacron Hemashield graft (DuPont, Wilmington, Del) was successfully placed (Fig 1, D). The patient underwent successful right upper extremity revascularization 2 weeks later by using a reversed saphenous vein conduit for a brachial to radial artery bypass with ulnar artery transposition. After surgery, palpable (2⫹ to 3⫹/3) pulses were present in the right radial and ulnar arteries, and the finger lesion healed.
DISCUSSION True aneurysms of the IA are rare. In an experience that spanned 27 years, Kieffer and colleagues1 described 6 degenerative aneurysms involving the IA among 27 patients with diverse IA pathology that also included traumatic and iatrogenic pseudoaneurysms, dissections, mycotic processes, connective tissue arteritides, and extension of arch pathology. Bower and associates2 reported the Mayo Clinic experience that spanned a 40-year period and included four patients with true aneurysms of the IA. Although the vast majority of patients present with thomboembolic complications involving either the upper extremity or cerebral circulation,1-3 Kieffer and colleagues reported one patient with an IA aneurysm who presented after rupture.1 Bower and associates have recommended operative treatment of all symptomatic and asymptomatic IA aneurysms in medically fit patients to avoid an inevitable course leading to thrombosis, rupture, or peripheral embolization.2 Axial reconstruction is believed to provide optimal long-term patency4,5 and has commonly been performed by using a combined cervical and transthoracic approach with minimal morbidity.1-5 The most frequently documented approach for IA pathology uses a median sternotomy.1,2,5 However, several authors have more recently described the use of less invasive approaches that incorporate either a partial upper sternotomy or a right anterior minithoracotomy.4,6,7 Although less invasive approaches have been described in the reconstruction of other IA pathology, we have not found them applied to treatment of IA aneurysms. The approach described in this report that 1267
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Fig 1. Intraoperative photographs demonstrating (A) a distal innominate artery (IA) aneurysm extending to and involving the origins of the common carotid artery (CCA) and subclavian artery (SCA); note the redundant proximal CCA. B, The operative field after aneurysmectomy (the CCA stump overlies and partially obscures the SCA stump); note the normal-sized IA and CCA. C, Operative specimen. D, Reconstructed vessels after placement of the bifurcated graft.
Fig 2. Angiography of right upper extremity runoff. Note the multiple stenotic and occlusive lesions involving the brachial, ulnar, and radial arteries and palmar arches.
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chest should also be prepared to facilitate completion of a median sternotomy for emergency proximal control of the IA if the aneurysm is inadvertently entered before cervical control of that vessel is attained. Puech-Leao and Orra8 reported a combined open surgical and endovascular intervention in a patient with a true IA aneurysm and an occluded right subclavian artery. They successfully inserted a stent graft directly into the IA via the right common carotid artery and anchored the graft via sutures to the common carotid artery. Endovascular intervention for other disease involving the IA has been reported and should be considered as an option for aneurysms if anatomically feasible.9 We conclude that true IA aneurysms should be considered for early intervention on the basis of the potential for the development of complications. Minimally invasive repair techniques should be considered if anatomically feasible. REFERENCES Fig 3. Computed tomography scan three-dimensional reconstruction (posterior/right lateral view) of the aortic arch and innominate artery. Note the distal innominate artery aneurysm involving the origins of the common carotid and subclavian arteries and the normal proximal innominate artery. IA, Innominate artery; Ao, aortic.
uses a cervical incision alone provides another even less invasive approach that should be considered according to anatomy. It is especially suited for distal IA disease that involves the proximal common carotid artery and subclavian artery. Although two reconstructive procedures were required and staged in the patient in this report, we do not believe that staging will be necessary for future patients. Most IA aneurysms that have been described in the literature involve the proximal or entire IA.1-3 An approach such as that described in this article would not be suitable for such lesions, and this reinforces the need for preoperative imaging both to define the limits of the aneurysm and to confirm the presence of a normal, proximal IA at the arch (Fig 3). It may not be possible to assess the adequacy of exposure and control until intraoperative visualization. The
1. Kieffer E, Chiche L, Koskas F, Bahnini A. Aneurysms of the innominate artery: surgical treatment of 27 patients. J Vasc Surg 2001;34:222-8. 2. Bower TC, Pairolero PC, Hallett JW Jr, Toomey BJ, Glowitzki P, Cherry KJ Jr. Brachiocephalic aneurysm: the case for early recognition and repair. Ann Vasc Surg 1991;5:125-32. 3. Bower TC. Aneurysms of the great vessels and their branches. Semin Vasc Surg 1996;9:134-46. 4. Berguer R, Morasch MD, Kline RA. Transthoracic repair of innominate and common carotid artery disease: immediate and long-term outcome for 100 consecutive surgical reconstructions. J Vasc Surg 1998;27:34-41. 5. Takach TJ, Reul GJ, Cooley DA, Duncan JM, Livesay JJ, Gregoric ID, et al. Brachiocephalic reconstruction. I. Operative and long-term results for complex disease. J Vasc Surg 2005;42:47-54. 6. Takach TJ, Reul GJ, Cooley DA. Transthoracic reconstruction of the great vessels using minimally invasive technique. Tex Heart Inst J 1996; 23:284-8. 7. Sakopoulos AG, Ballard JL, Gundry SR. Minimally invasive approach for aortic branch vessel reconstruction. J Vasc Surg 2000;31:200-2. 8. Puech-Leao P, Orra HA. Endovascular repair of an innominate artery true aneurysm. J Endovasc Ther 2001;8:429-32. 9. Sullivan TM, Gray BH, Bacharach JM, Perl J II, Childs MB, Modzelewski L, et al. Angioplasty and primary stenting of the subclavian, innominate, and common carotid arteries in 83 patients. J Vasc Surg 1998;28:1059-65. Submitted Apr 3, 2007; accepted Jun 14, 2007.