Combined Endovascular and Open Repair of innominate artery bifurcation pseudoaneurysm: A case report

doi:10.21203/rs.3.rs-3988180/v1

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Case Report

Combined Endovascular and Open Repair of innominate artery bifurcation pseudoaneurysm: A case report

https://doi.org/10.21203/rs.3.rs-3988180/v1

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published 17 Jul, 2024

Read the published version in BMC Cardiovascular Disorders →

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Background

Innominate artery aneurysms (IAAs) are rare. Without timely treatment, they may result in rupture, distal arterial embolization, or local compression, among which rupture is the most dangerous complication. Here, a case of innominate artery bifurcation pseudoaneurysm is reported.

Case Presentation:

The patient was a 45-year-old man who presented to the emergency department complaining of chest discomfort. Subsequent computed tomographic angiography (CTA) imaging indicated the presence of a 3.6*2.4 cm saccular aneurysm in the bifurcation of the innominate artery, involving both the right proximal subclavian and common carotid arteries. His vital signs were normal, with equal blood pressures in the upper arms, and no neurological dysfunction. Gadolinium-enhanced magnetic resonance angiography indicated that the circle of Willis was intact. The operation was performed by open surgery combined with endovascular treatment. The external carotid artery was first transposed to the right subclavian artery (RSA) and an 8-mm woven Dacron graft was inserted in the middle. The covered stent graft was then placed in the proximal part of the innominate artery to close the entrance of the aneurysm. Lastly, the occluder was implanted into the origin of the RSA. There were no procedural or postprocedural complications. A year later, the aneurysm was not visible on CTA and the right vertebral artery was patent.

Conclusions

Combined Endovascular and Open Repair is an effective option for the treatment of innominate artery bifurcation pseudoaneurysm.

innominate artery aneurysm

hybrid technique

vertebral artery

occluder-covered stent-graft

endovascular repair

Aneurysms of the aortic branch account for approximately 3% of arterial aneurysms, of which innominate artery aneurysms (IAAs) are extremely rare ¹. While IAAs are usually caused by atherosclerotic degeneration, infection, trauma, tuberculosis, arteritis, syphilis, and connective tissue disorders may also be responsible ^1–2. Rupture represents the most dangerous complication and occurs in approximately 11% of patients with untreated IAA. Other complications are secondary to thrombosis, distal embolization, or local compression ^3–4. Both open surgical techniques and endovascular repair are currently used for treating IAA, with many recent reports on the efficacy of the latter⁴. Hence, a case of innominate artery bifurcation pseudoaneurysm is reported where the patient was treated with occluder combined with covered stent graft and artery bypass.

Patient information

A 45-year-old Chinese man presented to the emergency department with chest distress. The patient had a surgical history of partial pancreatectomy due to a car accident 10 years previously. Apart from current smoking, the patient had no cardiovascular risk factors.

Clinical findings

Normal pulses were detected in the right carotid and right branchial arteries. A body temperature of 36.2°C was recorded, together with a heart rate of 92 beats/min, respiratory rate of 16 breaths/min, and an oxygen saturation of 99% at administration. The blood pressure in both upper arms was 135/80 mmHg. No indicators of infection were found on laboratory examinations. No specific genetic or family history was reported, nor any relevant employment, social, or exposure history.

Diagnostic evaluation

On physical examination, the patient was 172 cm in height with a weight of 73 kg. The pulse in the right radial artery was palpable but weaker than that of the left. The systolic brachial pressure was 110 mmHg and 125 mmHg in the right and left arms, respectively. Chest radiography showed an abnormal shadow on the upper mediastinum, while computed tomographic angiography (CTA) and three-dimensional reconstruction revealed a 3.6*2.4 cm saccular aneurysm of the innominate artery involving both the proximal right subclavian and common carotid arteries (Fig. 1). No mural thrombus was found. There were no neurological problems and the patient did not complain of arm claudication. Gadolinium-enhanced magnetic resonance angiography indicated that the circle of Willis was intact and no notable stenosis of the intracranial carotid arteries. No abnormalities were found on the coronary angiogram and echocardiogram.

Therapeutic intervention

A right supraclavicular incision was made under general anesthesia and the right common carotid artery (RCCA) and right subclavian artery (RSA) were dissected. The right external carotid artery was carefully debranched, with transposition onto the RSA and insertion of an 8-mm woven Dacron graft. A percutaneous 8Fr sheath was inserted in the right common femoral artery, with a percutaneous 5Fr sheath placed in the right brachial artery via a surgical cut down with distal clamping. After systemic heparinization (0.5 mg/kg), a pigtail was positioned in the aortic arch via the femoral access, and a pseudoaneurysm in the IA associated with the bifurcation was visible on subtraction angiography (Fig. 2A). No other aneurysms or notable stenoses were found. The right subclavian artery through a Dacron graft to the external carotid artery after contrast injection was confirmed. Percutaneous access was then obtained through the right groin, allowing the placement of a 25 cm-long 12Fr sheath proximal to the IA and a 13*100-mm covered stent graft close to the aneurysm entrance. An occluder was inserted into the right brachial sheath to block the RSA at its origin. Subtraction angiography demonstrated the patency of the stent and total exclusion of the IAA, while antegrade opacification showed that the flow in the right vertebral artery was good (Fig. 2B).

Follow-up and outcomes

The operation went smoothly without any complications, and postoperative transverse computed tomography showed patency of the prosthetic graft with no significant displacement of the stent. There was no endoleak, and both the right vertebral and graft arteries were patent. (Fig. 2C). The patient was discharged seven days after surgery and was prescribed 100 mg of Bay aspirin enteric-coated tablets and 10 mg of Rivaroxaban daily after discharge. The follow-up CTA one year later showed no contrast within the aneurysm and no sign of endoleak in the prosthetic graft and stent (Fig. 2D). There were no other signs of endoleak and no neurological complications or limb ischemia.

Innominate artery aneurysm (IAA) is very rare, accounting for an estimated 1% of peripheral aneurysms, and is usually caused by atherosclerosis^5–6. Most patients usually do not have obvious clinical manifestations, and thus, if not diagnosed at an early stage, the aneurysm will gradually enlarge to compress the surrounding nerves, blood vessels, and trachea, and in severe cases, serious life-threatening complications, such as rupture embolism, may occur⁷. Therefor to avoid these serious consequences, aneurysms should be treated early. Traditional open aneurysm repair involves resection of the aneurysm via median sternotomy or posterolateral thoracotomy. Reconstruction of the subclavian artery is then undertaken by the implantation of a prosthesis from the ascending aorta. Currently, open aneurysm repair remains the preferred treatment for IAA². However, an 11% incidence of perioperative death following IAA repair has been reported, with 18% of patients requiring prolonged ventilation⁸. Studies have shown that vascular surgery combined with preoperative angiography and meticulous surgical planning by dedicated teams can improve surgical success. Especially in stable patients, the use of endovascular and hybrid procedures may be preferred⁹.

The patient was hospitalized with chest discomfort and subsequent examination revealed a 3.6*2.4cm aneurysm at the bifurcation of the innominate artery. Traditional open surgery would likely have been difficult in this patient, with a high probability of postoperative complications. The use of endovascular treatment alone also presented a challenge as for endovascular treatment of peripheral aneurysms, the necks of the aneurysms on both sides should be no less than 10 mm to ensure stable anchorage and the complete block of aneurysm blood flow. As the aneurysm was situated in the bifurcation of the innominate artery with an inadequate anchoring zone, it was considered that a hybrid operation would be most beneficial in this patient. This necessitated the deployment of the stent graft from the right CCA to the innominate artery, over the subclavian artery. A major concern with this procedure was the possibility of acute ischemia in the upper right arm as well as possible ischemia in the vertebral artery following stent grafting. Hence, we decided to complete the external carotid artery to subclavian artery diversion in the general operating room before moving the patient to the digital subtraction angiography room. Before deployment of the stent graft, CTA was used to confirm that the basilar circulation was intact and the visibility of the RSA following contrast injection from the left vertebral artery. This also confirmed the use of the bypass surgery for preventing ischemia of the right arm. The covered stent graft (Viabahn 13*100mm) was positioned to release the proximal part of the innominate artery, resulting in the location of the stent-graft in the right common carotid artery, thus ensuring blood flow to the right subclavian and vertebral arteries. In addition, to prevent the occurrence of a type I endoleak resulting from blood flow on the covered stent-graft at the innominate artery bifurcation, an occluder (Abbott 14 mm) was used to block the subclavian artery at its origin.

The vertebral artery is an important part of the cerebral blood supply, providing blood to the brain through the vertebrobasilar artery system, which supplies about 40% of the brain's posterior circulation. Vertebral artery dominance (VAD) describes the dominance of one vertebral artery in terms of diameter, rate of blood flow, or blood supply capacity. This is usually caused by stenosis or hypoplasia of the contralateral vertebral artery, resulting in the dominant artery supplying more blood to the brain. There is no consensus on which vertebral artery tends to be dominant in the overall population. Based on the above considerations, we believe that preserving the right vertebral artery in patients is a more appropriate option for surgery without evaluation of the superior vertebral artery to minimize the risk of postoperative stroke.

In summary, a hybrid surgical approach was used to treat the patient in this case. This involved an artificial vessel bypass of the subclavian artery followed by placement of a covered stent and occluder, thus replacing the traditional open surgery, greatly reducing the surgical risk, and ensuring blood flow of the patient's right subclavian and vertebral arteries. This reduced the risk of postoperative ischemia of the right upper limb and stroke. This type of surgery has obvious benefits for the patient, and is especially suitable for patients with general systemic conditions and aneurysms located at arterial bifurcations. However, the sample size of this case report is small, and a large multicenter sample with a longer follow-up period is needed to further demonstrate the safety and efficacy of this procedure.

Ethics approval and consent to participate

The study protocols were approved by the Ethical Committee of the Quzhou Affiliated Hospital of Wenzhou Medical University. Written consent to participate was obtained.

Consent for publication

Written Informed Consent was obtained from the patient for the publication of Case report and accompanying images.

Availability of data and materials

The datasets used and/or analyzed in the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

None.

Authors' contributions

YYX and XYL were major contributor in the conception and design of the work and in reviewing the manuscript. TZ, GBC and SYW were major contributors in reviewing and analyzing of medical records. YYX, TZ and GBC were major contributors in writing the article. TZ was a major contributor in critical revision of the article. All authors have read and approved the final manuscript.

Acknowledgements

Not applicable.

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No competing interests reported.

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Journal Publication

published 17 Jul, 2024

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You are reading this latest preprint version

Combined Endovascular and Open Repair of innominate artery bifurcation pseudoaneurysm: A case report

Status:

Journal Publication

Version 1

Abstract

Background

Case Presentation:

Conclusions

Figures

Background

Case presentation

Patient information

Clinical findings

Diagnostic evaluation

Therapeutic intervention

Follow-up and outcomes

Discussion

Conclusion

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1