Blunt Trauma of the Innominate Artery: a Unique Presentation

Abstract

Radiology, Rambam Medical Center and The Bruce Rappaport Faculty ofMedicine, Technion – Israel Institute of Technology, Haifa, IsraelIntroductionTrauma to the great vessels in the chest most com-monly affects the aorta and the innominate artery.Although well described series are small and includemainly penetrating trauma. Blunt injuries of theinnominate artery typically involve the origin of theartery. Two rare cases of blunt trauma to the distalinnominate artery are reported herein. CTA andselective angiography were obtained for accuratediagnosis. Treatment was achieved via thoracotomyand placement of a synthetic interposition graft with-out the use of a temporary shunt. Endovascular treat-ment option is discussed. Review of the literature wasdone and a possible cause for this rare trauma issuggested.Case ReportsCase 1A 21-year-old motorcyclist, was involved in a roadaccident and transferred to our medical center intu-bated and in hypovolemic shock (Hemoglobin 7.8g%,Hct 24%). Peripheral pulses were intact. Chest x-rayrevealed a widened mediastinum at the thoracic outletwithout pneumothorax. His injuries included: skullfracture without brain hemorrhage, fracture of thesternum and the first rib on the right side, bilaterallung contusion and fractures of the pubis andextremities.CTA demonstrated an irregular innominate arterialoutline (Fig. 1). Angiography was obtained showing alarge pseudoaneurysm in the distal innominate arterynear its bifurcation (Fig. 2). Upper median sternotomywith a lateral extension was carried out. The dissec-tion revealed a 3-cm pseudoaneurysm in the distalinnominate artery. Proximal control was in the prox-imal part of the innominate artery while distal controlwas in the proximal part of the carotid and subclavianarteries. The innominate artery was disrupted withintimal flap reaching almost to the origin of the carotidartery. After debridement a small rim just at the originof the right carotid artery enabeled the insertion of an8mm PTFE as an interposition graft. The procedurewas done without a temporary shunt. Sequentially, allthe fractures were managed by external fixation. Thepostoperative recovery, albeit long, was unremarkableand without severe complications. CTA was per-formed a week later and demonstrated preservedblood flow. On follow up 13 months later the patientis well.Case 2A 26-year-old male was injured in MVA. On admis-sion he was comatose and in shock. His blood pres-sure 80/50mmHg with heart rate of 130beats/min.No peripheral pulses could be found in the right armwith normally palpated axillary and brachial pulses inthe left. His injuries included subdural and subarach-noid hemorrhage without cerebral herniation, left