Endovasculartherapyofalargetrueinnominatearteryaneurysmviaatranscervicalapproach

Abstract

True innominate artery aneurysm (IAA) is relatively rare. Compared with massively invasive open surgery, though as conventional treatment for IAA, endovascular therapy is thought to provide optimal outcomes. We described herein a large true IAA in a 64-year old Chinese man with intermittent dizziness for 1 year. Successful endovascular therapy was achieved via a transcervical approach. There were no perioperative complications and computed tomography angiography (CTA) in the follow-up 3 months later showed the IAA was completely excluded.

Keywords: innominate artery, aneurysm, stent

Introduction

Innominate artery aneurysm (IAA) is quite rare. According to Stolf,1 it makes up only 3% in all arterial aneurysms. IAA is generally secondary to atherosclerosis, besides, alternative causes include trauma, thoracic outlet syndrome, syphilis, Takayasu’s disease, connective tissue disease, Marfan syndrome, Behcet’s disease and angiosarcoma.2-4 Clinical features are commonly compressive symptoms (eg. hoarseness, dysphagia and dyspnea), ischemia secondary to thrombosis or embolism (eg. transient ischemi, cerebral infarction and upper limb oedema), tracheo-innominate artery fistula and so on.5,6 Currently, open repair is still the standard of care, but it associated with high morbidity of sternotomy with or without cardiopulmonary bypass. Endovascular therapy, with appealing results applied in other aneurysms, now begins to nd a role in the treatment of IAA. By far, there are just a few cases managed with endovascular therapy in literature.7-9 Here we first describe a large true IAA excluded with a Talent limb stent graft (Medtronic Vascular, Santa Rosa, California) via a transcervical approach.

Case Report

A 64-year-old man was referred to our vascular and endovascular center with a history of intermittent dizziness for 1 year. No syncope, dyspnea, hoarseness, or hemoptysis was noted. Magnetic resonance imaging (MRI) showed no cerebral infarction, but some ischemia lesion around the ventricles. Computed tomography angiography (CTA) revealed a large aneurysm of the innominate artery and a bulging in the descending aorta with very severe atherosclerotic plaques (Fig. 1).

Under general anesthesia, a pigtail catheter was inserted into ascending aorta through the right femoral approach to get an angiogram. Digital subtraction angiography (DSA) showed a 36-mm-diameter aneurysm involving the brachiocephalic trunk 1cm above its orifice on the aorta and extending distally to its bifurcation (Fig. 2A). Both vertebral arteries were visualized and the left one was bigger. An anterior sternocleidomastoid incision was done to expose the right common carotid artery (CCA). After systemic heparization, distal CCA was clamped and a marker catheter was inserted through the CCA approach to measure IAA length. Then A 16mm *120mm Talent limb stent graft (Medtronic Vascular, Santa Rosa, California) was deployed through the right CCA access to exclude the IAA, with 5mm of the proximal stent protruding into the aortic arch. Another multipurpose catheter was advanced into the residual aneurysm lumen through the right brachial approach, coils were inserted to promote thrombosis. After the interventional procedure, a final angiography showed that the IAA was completely excluded (Fig. 2B). Then another clamp was located proximal to the puncture hole, we extended the hole in the CCA vertically with scissor and released each of the two clamps briefly to flush both air and debris out of the arteries. The right CCA was sutured with 6-0 MAXONTM CV omonfilament ployglyconate synthetic absorbable sutures and the femoral puncture site was closed with vascular close device (Proglide, Abbott, Illinois, USA). No bleeding, hematoma, right arm ischemia, stroke, or other complications occured after operation. Although the patient presented with pulselessness in the right radial artery, he didn’t feel paresthesia or weakness in his right arm. He was maintained on a daily aspirin and favorable remodeling of the innominate artery was found in the follow-up 3 months later (Fig. 3).

Discussion

IAA is a potentially life threatening disease, of which rupture occurs in approximately 11% of all cases if untreated.10 In our case, the IAA diameter was 36mm and minor atherosclerotic plaques and mural thrombi may cause potential cerebral embolism. So the patient had indication for surgical or endovascular treatment, though we are not sure whether the symptom of dizziness was associated with the IAA.

Compared against open surgery for IAA, endovascular therapy affords a much less invasive option, with lower morbidity. In this case, the left vertebral artery is preponderant, occlusion of the right subclavian artery, therefore, would be tolerated. Since the proximal IAA neck was not long enough, limb stent graft was deployed with 5mm of protrusion into the aortic arch, which had little effect on the hemodynamic. Besides, as the distal landing zone, the right CCA is ideal and can prevent the stent graft distal migration.

Various stents are currently available, however, there is no special device approved in the treatment of IAAs. Puech-Leão7 reported a case treated with a tapered endograft made from polyester graft attached to a Palmaz stent. In the same period of time, Park8 treated an IAA caused by Behcer’s disease with a balloon-expandable stent (Jostent-graft, Jomed, Rangendingen, Germany). Additionally, a Gore Excluder endoprosthesis (W. L. Gore and Associates, Flagstaff, Ariz)9 was positioned to exclude IAA due to Takayasu’s disease, and it showed a good long-term outcome. We first used the Talent limb stent graft, which was mainly placed in the common iliac artery as a limb in endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA). In our opinion, choosing appropriate stent graft should be individualized according to anatomical and pathological characteristic.

Transcervical approach is preferred for this patient due to the reasons below: First, the aortic arch of this patient is type III arch, transfemoral approach is not easy for advancing a stent graft to this target site, but is easy with transcervical approach. Second, this patient had diffuse atherosclerotic plaques in the aortic arch, so transfemoral approach has a high risk of plaques shedding into the left CCA during the procedure, furtherly, leading cerebral embolization. Transcervical approach can effectively prevent the potential risk for stroke. Third, it can prevent cerebral infarction by clamping the distal CCA during the procedure and flushing both air and debris at the end of the procedure.

Conclusion

This case demonstrated a successful outcome of individualized endovascular therapy in treating a large complicated IAA. Ultimately, long-term follow-up will be necessary to confirm the technique.

Figures

Figure 1 Preoperative CTA showed a large Innominate artery aneurysm.

Figure 2 DSA was conducted in operation. A, it revealed an innominate artery aneurysm involving the brachiocephalic trunk just above its orifice on the aorta and extending distally to its bifurcation. B, a final angiography showed that the innominate artery aneurysm was totally excluded.

Figure 3 CTA showed a favorable remodeling of the innominate artery 3 months later.

Reference

1. Stolf NA, Bittencourt D, Verginelli G, Zerbini EJ. Surgical treatment of ruptured aneurysms of the innominate artery. Ann Thorac Surg 1983;35(4):394-9.

2. Bush RL, Hurt JE, Bianco CC. Endovascular management of a ruptured mycotic aneurysm of the innominate artery. Ann Thorac Surg. 2002;74(6): 2184-6.

3. Park JH, Chung JW, Joh JH, Song SY, Shin SJ, Chung KS, et al. Aortic and arterial aneurysms in behcet disease: management with stent- grafts-initial experience. Radiology. 2001;220(3):745-50.

4. Lu CY, Lu MS, Huang YK, Tsai FC, Lin PJ. Innominate artery aneurysm as presentation of angiosarcoma. Surgery. 2011;149(4): 593-4.

5. Soylu E, Harling L, Ashrafian H, Anagnostakou V, Tassopoulos D, Charitos C, et al. Surgical treatment of innominate artery and aortic aneurysm: a case report and review of the literature. J Cardiothorac Surg. 2013. [Epub ahead of print]. doi: 10.1186/1749-8090-8-141.

6. Nakai M, Sato H, Sato M, Ikoma A, Sanda H, Nakata K, et al. Tracheo-innominate artery fistula successfully treated by endovascular stent-graft repair. Jpn J Radiol. 2013;31(1):65-70.

7. Puech-Leão P, Orra HA. Endovascular repair of an innominate artery true aneurysm. J Endovasc Ther. 2001 Aug;8(4):429-32.

8. Park JH, Chung JW, Joh JH, Song SY, Shin SJ, Chung KS, et al. Aortic and arterial aneurysms in behcet disease: management with stent-grafts -- initial experience. Radiology. 2001;220(3):745-50.

9. Angiletta D, Marinazzo D, Guido G, Fullone M, Pulli R, Regina G. Eight-year follow-up of endovascular repair of a brachiocephalic trunk aneurysm due to Takayasu´s arteritis. J Vasc Surg. 2012;56(2):504-7.

10.Kieffer E, Chiche L, Koskas F, Bahnini A. Aneurysms of the innominate artery: surgical treatment of 27 patients. J Vasc Surg. 2001;34(2):222–8.


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