[Repair of Traumatic Brachiocephalic Artery Pseudoaneurysm by Open Surgery:Report of a Case].

The patient is a 56-year-old man. He fell while playing golf and sustained a contusion on his right chest. He fell into hemorrhagic shock during surgery for a right clavicle fracture at a nearby hospital and required cardiac resuscitation. Computed tomography( CT) scan revealed left pneumothorax and right hemothorax, and a contrast-enhanced CT scan revealed a pseudoaneurysm at the brachiocephalic artery origin. He underwent surgery three weeks later. Surgery was performed through a median sternotomy and partial arch replacement (zone 2) with antegrade cerebral perfusion under moderate hypothermia. He was discharged on postoperative day 10 without significant complications.

Clinical outcomes of a balloon-expandable stent for symptomatic obstructions of the subclavian or innominate arteries.

Background: Upper-extremity peripheral arterial disease (PAD) may present with a broad spectrum of signs and symptoms. If an endovascular treatment is planned, percutaneous angioplasty and stent placement may lead to a better patency compared to percutaneous angioplasty alone. We assessed the characteristics and clinical course of patients with upper-extremity PAD who received angioplasty and a balloon-expandable stent. Patients and methods: We analyzed data from consecutive patients treated with angioplasty and placement of a balloon-expandable BeSmooth Peripheral Stent System® (Bentley, Germany) at the Angiology Department (University Hospital Zurich) between 2018 and 2022. The primary outcome was re-intervention at the target lesion within 6 months from index angioplasty and during available follow-up. The study was approved by the local ethical commission. Results: A total of 27 patients were treated. The median age was 70 (Q1-Q3: 60-74) years and 59% were men. The subclavian artery (74%) represented the most frequently treated target lesion, followed by the innominate artery (26%). The mean improvement in blood pressure in the treated arm was 21 (95%CI 7 to 35) mmHg at 24 hours and 29 (95%CI 15 to 43) mmHg at 6 months. At 6 months, 2 (8%) patients required a target lesion re-intervention. During the remaining follow-up period up to 24 months, one of these two patients required additional intervention and a total of 3 (11%) patients died due to sepsis, cancer, and unknown causes, respectively. Conclusions: Percutaneous catheter-based treatment with a balloon-expandable stent for symptomatic upper extremity PAD appeared to be effective and safe.

Complete Isolation of Left Innominate Artery in a Patient With CHARGE Syndrome: Case Presentation and Review of Reported Cases.

We report a rare case of complete isolation of the left innominate artery in a child with CHARGE (coloboma, heart defects, atresia choanae, growth retardation, genital abnormalities, and ear abnormalities) syndrome. This anatomical cluster had been undetected for a relatively large period of time and the patient was referred to us with an incomplete diagnosis even after multiple medical evaluations and a thoracic surgery during the neonatal period. In conclusion, to the best of our knowledge, this is the first case of a complete isolation of left innominate artery treated with a transcatheter approach.

Chronic respiratory disorders due to aberrant innominate artery: a case series and critical review of the literature.

BACKGROUND: Tracheal compression (TC) due to vascular anomalies is an uncommon, but potentially serious cause of chronic respiratory disease in childhood. Vascular slings are congenital malformations resulting from abnormal development of the great vessels; in this group of disorders the most prevalent entity is the aberrant innominate artery (AIA). Here we provide a report on diagnosis and treatment of AIA in nine children with unexplained chronic respiratory symptoms. We describe the cases, perform a literature review, and provide a discussion on the diagnostic workup and treatment that can help manage AIA. METHODS: Clinical history, diagnostic procedures and treatment before and after the AIA diagnosis were retrospectively reviewed in nine children (5 boys and 4 girls), who were referred for recurrent-to-chronic respiratory manifestations over 10 years (2012-2022). We performed a comprehensive report on the ongoing clinical course and treatment as well as an electronic literature search on the topic. RESULTS: Diagnoses at referral, before AIA was identified, were chronic dry barking cough associated with recurrent pneumonia (n = 8, 89%), lobar/segmental atelectasis (n = 3, 33%), atopic/non atopic asthma (n = 3, 33%); pneumomediastinum with subcutaneous emphysema complicated the clinical course in one case. When referred to our Unit, all patients had been previously treated with repeated antibiotic courses (n = 9, 100%), alone (n = 6, 67%) or combined with prolonged antiasthma medications (n = 3, 33%) and/or daily chest physiotherapy (n = 2, 22%), but reported only partial clinical benefit. Median ages at symptom onset and at AIA diagnosis were 1.5 [0.08-13] and 6 [4-14] years, respectively, with a relevant delay in the definitive diagnosis (4.5 years). Tracheal stenosis at computed tomography (CT) was ≥ 51% in 4/9 cases and ≤ 50% in the remaining 5 subjects. Airway endoscopy was performed in 4 cases with CT evidence of tracheal stenosis ≥ 51% and confirmed CT findings. In these 4 cases, the decision of surgery was made based on endoscopy and CT findings combined with persistence of clinical symptoms despite medical treatment. The remaining 5 children were managed conservatively. CONCLUSIONS: TC caused by AIA may be responsible for unexplained chronic respiratory disease in childhood. Early diagnosis of AIA can decrease the use of expensive investigations or unsuccessful treatments, reduce disease morbidity, and accelerate the path toward a proper treatment.

High-riding innominate artery in the neck: A hazardous presentation during surgery.

Aberrant innominate artery lying high in the neck is a rare entity that can be encountered intraoperatively during midline neck surgeries such as thyroidectomy and tracheostomy. Surgeons should be mindful of this entity as injury to the artery can lead to life-threatening haemorrhage. We report a case of a 40 year old female in whom an aberrant innominate artery was identified high in the neck, while performing a total thyroidectomy.

Symptomatic Aortic Arch Floating Thrombus In A Patient With "Bovine Arch".

Bovine arch is an aortic arch variant in which the left common carotid artery and the brachiocephalic trunk share the same origin. Several vascular pathologies, as aneurysm, dissection or strokes have an increased prevalence in patients with this anatomic variant. We describe the first reported case of a young patient with a symptomatic aortic arch floating thrombus in association with a bovine arch.

[Vascular Prosthesis Perforation Caused by a Stent Graft Inserted into the Innominate Artery after Total Aortic Arch Replacement].

The patient was a 60-year-old woman who underwent thoracoabdominal aorta replacement for type B aortic dissection three years ago and aortic root replacement and total aortic arch replacement due to asymptomatic type A aortic dissection two years previously. Her clinical course was uneventful until follow-up computed tomography (CT) disclosed anastomotic insufficiency in the innominate artery and left main coronary artery stenosis owing to hematoma. Emergent percutaneous coronary intervention and stent graft insertion into the innominate artery were performed successfully. Seven months later, however, CT scan revealed a perforation in the posterior wall of the artificial graft damaged by the edge of the implanted stent graft. The patient underwent open surgery and perforation of artificial graft was sutured and redundant stent graft edge was resected. Artificial graft damage by stent graft placement is rare to date, but may increase in the future in accordance with broader application of endovascular treatment.

Preliminary experience with new generation balloon expandable stent-graft in the treatment of innominate artery obstructive disease.

BACKGROUND: The aim of this study was to describe a single center preliminary experience with the use of a specific balloon expandable stent-graft for the treatment of innominate artery (IA) obstructive lesions. METHODS: We report our experience with four male patients treated with Gore Viabahn balloon (Gore Medical, Flagstaff, AZ, USA) expandable stent-graft for different types of IA stenosis: three patients were symptomatic for vertebrobasilar insufficiency, while one patient was asymptomatic for cerebrovascular symptoms. The stent grafts were deployed using retrograde (N.=2) or antegrade approach (N.=2), aiming to cover the entire lesions length and to slightly protrude into the aortic arch. Post-dilatation was performed with a compliant balloon. One patient presented a tandem lesion (IA and right internal carotid artery) and after the stenting of the IA he was treated also with a carotid artery stenting during the same procedure. RESULTS: Technical success was achieved in all patients. No perioperative or postoperative complications had been reported and the neurological disorders disappeared for the three symptomatic patients. After a mean clinical and radiological follow-up of 24±5 months, all the stents were patent and perfectly adapted to the vessels. CONCLUSIONS: This preliminary clinical experience shows that the use of the Gore Viabahn balloon (Gore Medical) expandable stent-graft seems safe and feasible for the treatment of the IA obstructive lesions, also in presence of irregular plaques and hostile anatomies for an endovascular treatment. Larger experiences and long-term data are mandatory.

[Total Arch Replacement due to Tracheal Compression by Brachiocephalic Artery with Bovine Aortic Arch:Report of a Case].

A 78-year-old female presented to our institution with a dry cough and dyspnea. Chest computed tomography( CT) revealed tracheal stenosis caused by compression from a brachiocephalic artery with a bovine aortic arch. Subsequently, surgery was performed in which the brachiocephalic artery was resected, and a total arch replacement using a four-branched graft was completed. We paid particular attention to the graft branches, making sure to avoid contact with the trachea. Both the patient's cough and dyspnea dissipated after the surgery, and a CT revealed the tracheal stenosis had been completely relieved. The patient has remained in good condition for the past three years since the surgery showing no respiratory symptoms or thoracic aortic disease. Because the bovine aortic arch is a known risk factor for thoracic aortic disease, rather than simply reconstructing the brachiocephalic artery, we chose a more aggressive surgical treatment to prevent any possible future thoracic aortic disease.

Presentation, Diagnosis and Management of Innominate Artery Thromboembolism.

PURPOSE: Acute thromboembolic disease of the innominate artery (IA) poses a unique set of therapeutic challenges, owing to its contribution to both the cerebral and upper extremity circulation, and risks of distal embolization via the carotid and subclavian arteries, respectively. Herein, we present a 74-year-old female who presents with acute IA thrombus treated successfully with right axillary and common carotid exposure and aspiration catheter-directed mechanical thrombectomy (CDT). Furthermore, an emerging use of CDT and its application in acute thromboembolism are outlined. CASE REPORT: A 74-year-old female with history of right lung transplant for pulmonary fibrosis with severe pulmonary hypertension, and stage IIIA left lung adenocarcinoma status post left lower lobectomy undergoing adjuvant chemotherapy presented with acute IA thrombus and right-sided stroke. She was treated successfully with right axillary and common carotid exposure and aspiration CDT. Computed tomography angiography performed 1 month postoperatively confirmed patent IA with no evidence of residual or recurrent thrombus. CONCLUSION: There are currently no standard guidelines on the management of acute IA thromboembolism, with mostly individual cases reported in the literature describing this rare entity. Nevertheless, this unique clinical entity mandates expeditious diagnostic and therapeutic approaches in order to avoid permanent neurologic deficits from distal embolization. Our case demonstrates that aspiration CDT may be an effective treatment modality for patients with acute IA thrombus.

A randomized trial comparing axillary versus innominate artery cannulation for aortic arch surgery.

BACKGROUND: Cerebral protection remains the cornerstone of successful aortic surgery; however, there is no consensus as to the optimal strategy. OBJECTIVE: To compare the safety and efficacy of innominate to axillary artery cannulation for delivering antegrade cerebral protection during proximal aortic arch surgery. METHODS: This randomized controlled trial (The Aortic Surgery Cerebral Protection Evaluation CardioLink-3 Trial, ClinicalTrials.gov Identifier: NCT02554032), conducted across 6 Canadian centers between January 2015 and June 2018, allocated 111 individuals to innominate or axillary artery cannulation. The primary safety outcome was neuroprotection per the appearance of new severe ischemic lesions on the postoperative diffusion-weighted-magnetic resonance imaging. The primary efficacy outcome was the difference in total operative time. Secondary outcomes included 30-day all-cause mortality and postoperative stroke. RESULTS: One hundred two individuals (mean age, 63 ± 11 years) were in the primary safety per-protocol analysis. Baseline characteristics between the groups were similar. New severe ischemic lesions occurred in 19 participants (38.8%) in the axillary versus 18 (34%) in the innominate group (P for noninferiority = .0009). Total operative times were comparable (median, 293 minutes; interquartile range, 222-411 minutes) for axillary versus (298 minutes; interquartile range, 231-368 minutes) for innominate (P for superiority = .47). Stroke/transient ischemic attack occurred in 4 (7.1%) participants in the axillary versus 2 (3.6%) in the innominate group (P = .43). Thirty-day mortality, seizures, delirium, and duration of mechanical ventilation were similar in both groups. CONCLUSIONS: diffusion-weighted magnetic resonance imaging assessments indicate that antegrade cerebral protection with innominate cannulation is safe and affords similar neuroprotection to axillary cannulation during aortic surgery, although the burden of new neurological lesions is high in both groups.

Pseudoaneurysm of Innominate Artery Graft Stump in an Infant.

Innominate artery grafts are often utilized in pediatric cardiac surgery and very rarely lead to complications, including infection. Here, we present a unique case of an infant who underwent repair of coarctation of the aorta and hypoplastic arch using a GORE-TEX graft (W. L. Gore and Associates, Newark, DE) for antegrade cerebral perfusion. The graft subsequently became infected with Pseudomonas and formed a pseudoaneurysm with resultant tracheal compression. The presentation, diagnosis, and management of this mycotic pseudoaneurysm are described.

Anesthetic management of right brachiocephalic artery aneurysm causing tracheal compression.

The airway compression poses a challenge for the anesthesiologist in airway management during aneurysm repair surgery.

Factors associated with success following transcervical innominate artery suspension.

OBJECTIVE: Aortopexy including innominate artery suspension is a well-established treatment of anterior vascular compression and associated tracheomalacia. We report the results of our case series of cervical approach to innominate artery suspension and hypothesize that increased distance from the innominate to the sternum is predictive of superior symptomatic outcome. STUDY DESIGN: Retrospective Case Series. METHODS: All cases of cervical innominate artery suspension at our institution over the last 10 years were reviewed. CT scans of the neck and chest were reviewed to obtain anatomical measurements including anterior-posterior thoracic outlet distance, thymic thickness, and sternum-innominate artery distance. Measurements were compared with surgical outcomes as verified by follow up bronchoscopy and clinical course to determine factors predictive of success. RESULTS: Ten cases of cervical innominate artery suspension were performed by the otolaryngology service at our institution over the last 10 years. Six patients had improvement in their symptoms. The average sternum-innominate artery distance (SID) was larger (14.4 mm (95% CI 9.1-19.7)) in patients who had improvement in clinical symptoms following innominate suspension compared to those that did not improve (6.3 mm (95% CI 2.5-10.1)) (p value = 0.02). Similarly, the anterior-posterior distance of the thoracic outlet was larger (34.9 mm (95% CI 27.4-42.4)) in patients who had improvement post-op compared to those that did not improve (22.6 mm (95% CI 18.2-27.2) (p value = 0.01). Two patients required spine surgery to achieve improvement in their symptoms. CONCLUSION: Cervical innominate artery suspension is successful in carefully selected patients. More space in the thoracic outlet and larger distance from the innominate artery to the sternum is associated with symptomatic improvement.