Hybrid Approach for

Management of Penetrating

Trauma of the Innominate ArteryGautham Chitragari1, MD. Alexander Warner1. Jonathan Mckenzie1, MD. Gautam Agarwal1, MD

Manuel Ramirez1, MD. Richard Lee2, MD. Mrinal Shukla1, MD

1. Department of Surgery, Division of Vascular Surgery, Augusta University, Augusta, GA, USA

2. Department of Surgery, Division of Cardiothoracic Surgery, Augusta University, Augusta, GA, USA

Disclosure

• I have no financial disclosure or conflicts of interest

with the presented material in this presentation.

Innominate artery (IA) trauma

• Relatively rare.

• 2nd most common great vessel to get injured in the chest, only after descending thoracic aorta.

• Represent about 3-4% of all penetrating traumatic arterial injuries in the chest

• High mortality - 48 to 71% of patients die prior to reaching the hospital (1).

Symptoms/Signs

• Hemorrhagic shock

• Active external bleeding

• Zone I neck hematoma

• Decreased pulses in RUE

(2)

Diagnostic studies

• Chest x-ray - mediastinal widening

• Conventional angiogram - Gold

standard. Sensitivity of 94 to 100%

and specificity of 96%.

• Contrast enhanced CT is the initial

screening test of choice. Non-invasive

and relatively high sensitivity and

specificity

Treatment

• Open repair – standard treatment.

• Sternotomy with or without right neck

extension.

• Primary anastomosis, vein patch

angioplasty or interposition graft repair.

• May require cardiopulmonary bypass during

the procedure.

• Hybrid options - temporary balloon

occlusion or stent graft placement.

(3)

Our patient• 27 y/o M with self-inflicted penetrating trauma to the chest.

PMH:

Multiple self-inflicted penetrating wounds to the chest, self mutilation.

PSH:

- Mediastinal exploration x 2 for foreign body removal

Exam

– A linear metallic foreign body was identified in the suprasternal region.

– No bleeding, expanding hematoma, or other signs of trauma. Bilateral upper extremities had normal neuro-vascular exam.

Sagittal and axial views of CT scan of the chest demonstrating foreign body in innominate artery

Treatment Options

• Open removal - requires sternotomy,

possibility of requiring cardiac

bypass.

• Reopening of the sternotomy -

hostile surgical field.

• Decision was made to proceed with

a hybrid approach.

Operative technique

• Right Brachial access with advancement of wire/sheath into the thoracic aorta

• Direct cut down around foreign body in suprasternal region.

• Foreign body was removed and manual pressure was applied for hemostasis.

• Initial angiogram showed extravasation. Manual pressure was continued for additional 10 minutes.

• Completion angiogram confirmed hemostasis.

COMPLETION ANGIOGRAM

Proposition

• Patients with innominate artery trauma who present with hemodynamic

instability are best treated by open repair.

• On the contrary, if patient is hemodynamically stable, endovascular repair

should be attempted.

• Endovascular approach also provides access to temporary control of the

injury with balloon tamponade when conversion to open repair is required

in a hostile surgical field.

• Although current experience with endovascular management of

innominate artery injuries is limited, we can foresee increased utilization

of endovascular approach in the future

Conclusion

• For hemodynamically stable patients with an innominate

artery injury, endovascular repair can be considered.

• We encourage a collaborative approach with involvement

of CT surgery team.

• The hybrid approach involves being ready for conversion

to open surgery and potential placement on cardiac

bypass.

References

1) Du Toit DF, Odendaal W, Lambrechts A, Warren BL. Surgical and endovascular

management of penetrating innominate artery injuries. Eur J Vasc Endovasc Surg.

2008;36(1):56-62

2) Figure extracted from Newton K et. Al. Penetrating neck injuries: Initial evaluation and

management. Uptodate Jun 07, 2017.

3) Figure extracted from – Atlas of Surgical Techniques in Trauma by Demetrios Demetriades.

Chapter 16. Cambridge University Press; 1 edition (April 20, 2015)

4) C. Garcı´a-Madrid et al. Eur J Vasc Endovasc Surg 28, 365–372 (2004)

QUESTIONS?