Endovascular management of a ruptured mycotic aneurysm of the innominate artery

Mycotic aneurysms of the innominate artery are infrequent lesions and, as such, represent challenging surgical problems. We describe herein a case of a ruptured mycotic innominate artery aneurysm, which developed after radical neck dissection and radiation therapy for tonsillar carcinoma. The aneurysm was successfully excluded from the systemic circulation with endoluminal placement of a covered stent, with efficacy confirmed by vascular imaging at 6 months follow-up. The patient suffered no permanent neurologic sequelae. Long-term follow-up and chronic antibiotic therapy will be necessary to avoid infection of the covered stent in this high-risk surgical patient.     

A case of traumatic aneurysm of innominate artery with occlusion of right subclavian artery

A 42-year-old woman with history of chest blunt trauma from an automobile accident 250 days earlier had suffered easy fatigability of the right upper extremity. She had difference of blood pressure between upper extremities, 94/60 mmHg in the right and 126/70 mmHg in the left. Chest CT showed dilation of the innominate artery which compressed the trachea. Aortography showed an aneurysm of the innominate artery and occlusion of the right subclavian artery at its origin. The aneurysm of the innominate artery was resected and replaced with a 6 mm Dacron graft with aid of the external shunt. The right subclavian artery was also reconstructed with same graft. The aneurysm of the innominate artery should be suspected as a rare complication in blunt trauma of the chest.     

Posttraumatic innominate artery aneurysm with occlusion of the common carotid artery at its origin by an intimal flap

Blunt trauma involving the innominate and carotid arteries is a rare occurrence that can be lethal or have serious neurologic sequelae. To our knowledge this is the first reported case in the international literature describing the association of posttraumatic innominate, artery aneurysm with total occlusion and thrombosis of the common carotid artery at its origin by an intimal flap. The diagnostic problems created by this unusual injury are discussed. In this case the patency of the distal portion of the common and internal carotid arteries was demonstrated by magnetic resonance angiography (MRA), whereas color duplex and digital arteriographic studies were unsuccessful. This demonstration was crucial to patient management. Since no studies are available comparing color duplex imaging, conventional arteriography, and MRA in the evaluation of blunt carotid trauma, this case study is presented to demonstrate the utility of MRA in emergency situations. In addition, we analyze the possible pathogenesis and discuss the surgical treatment.     

Surgical treatment of ruptured aneurysms of the innominate artery

The cases of 3 patients with an aneurysm of the innominate artery treated surgically are reported. The clinical manifestations were different, and the surgical procedures employed also varied. In 1 patient, the neck of the aneurysm was isolated and clamped near the aortic arch. It was closed, and a graft was interposed between the ascending aorta and the right carotid and subclavian arteries. In the second, the aneurysm was resected under cardiopulmonary bypass, deep hypothermia, and total circulatory arrest. The neck was closed with a large Teflon patch, and a tube graft was interposed between the ascending aorta and the right carotid artery. In the third, a graft was interposed between both carotid arteries; conventional cardiopulmonary bypass was instituted, and the aorta was clamped between the innominate and the left carotid arteries. The neck of the aneurysm was closed, and a graft was interposed between the ascending aorta and the right carotid and subclavian arteries. All patients had an excellent postoperative course. Our comments regarding the clinical and surgical aspects of this condition are based on the present experience and reports in the literature.     

Rerupture mechanism of ruptured intracranial dissecting aneurysm in the vertebral artery following proximal occlusion

Proximal occlusion is commonly employed to prevent rebleeding of intracranial dissecting aneurysms of the vertebral artery (VA), but rebleeding sometimes occurs. To determine the cause of such rebleeding we reviewed nine cases, including eight reported in the literature and one treated at our hospital. We classified the techniques used to proximally occlude the VA into two types. In Type I, occlusion is performed immediately proximal to the aneurysm so that there are no perforating arteries or the posterior inferior cerebellar artery (PICA) between the clip and the aneurysm. In Type II, occlusion is performed proximal to the PICA so postoperative retrograde flow persists from the contralateral VA through the aneurysm into the ipsilateral PICA. Among the four Type I cases reviewed, it was found that the interval between occlusion and rebleeding was very short: three developed rebleeding within four hours of occlusion, and the fourth showed rebleeding on the fourth day. In the five Type II patients, rebleeding occurred more than four days (mean 15.2 days) after occlusion. It is thought that in Type I occlusion, retrograde flow into the aneurysm immediately after occlusion may raise the intraaneurysmal pressure enough to cause rerupture within just a few hours of occlusion. In Type II occlusion, postoperative retrograde flow through the aneurysm into the ipsilateral PICA exists, so the intraaneurysmal pressure is not likely to rise as rapidly, with the result that rebleeding occurred after more than four days probably due to recurrence of dissection. The short interval between proximal occlusion and rebleeding, especially in Type I cases, suggests that postoperative angiography is only of limited usefulness in evaluating the possibility of rebleeding. The mortality rate reported for cases with reruptured vertebral dissecting aneurysms after proximal occlusion is very high (55.6%). These data indicate that surgical trapping or endovascular intraluminal occlusion, which is difficult to perform in some patients, should be considered the most suitable procedure from the view point of preventing postoperative rebleeding.     

经导管封堵主动脉窦瘤破裂

目的探讨经导管介入封堵主动脉窦瘤破裂的临床疗效。方法7例主动脉窦瘤破裂患者,5例为主动脉无冠状动脉窦（无冠窦）破裂至右心房,2例为主动脉右冠状动脉窦（右冠窦）破裂至右心室。对5例患者经同侧的右股动、静脉建立轨道,应用PDA单盘蘑菇伞封堵器进行封堵;对2例患者经同侧右桡动脉及右股静脉建立轨道,置入“细腰大边”的室间隔封堵器。结果7例患者均封堵成功,技术成功率100％;仅2例患者出现微量残余分流,术后2天心脏超声证实完全封闭,无相关并发症。术后1、3、6个月超声心动图显示舒张末期左心室内径均较术前明显改善,封堵器形态、位置良好,无残余分流及主动脉瓣反流。结论介入封堵主动脉窦瘤破裂微创、有效,近期疗效尚满意,中远期的疗效有待进一步随访观察。对于合并心力衰竭或心功能控制不满意的患者,经桡动脉建立轨道是有益的尝试。     

Repair of mycotic aneurysm of the innominate artery with homograft tissue

The case of a 46-year-old drug addict who underwent repair of a mycotic aneurysm of the innominate artery with a 12-mm homograft is presented. The homograft was obtained from the descending thoracic position in a young child. Replacement of infected arteries with various artificial grafts risks recurrent infection and anastomotic disruption. The use of a homograft conduit in this case was successful in restoring the appropriate blood flow without infection. We suggest that the homograft conduit can be used in other areas with similar results.     

A ruptured aneurysm of the distal posterior inferior cerebellar artery associated with basilar artery occlusion: a case report]

We presented a case of a distal posterior inferior cerebellar artery (PICA) aneurysm associated with basilar artery occlusion. A 66-year-old female was found unconscious at home and transferred to our hospital in a deep coma on February 9, 1991. Emergency CT scan revealed subarachnoid hemorrhage in the posterior fossa. She was treated conservatively because of her poor neurological status. The angiograms performed on February 13 showed occlusion of the basilar artery and a saccular aneurysm at the cortical branch of the PICA. The contrast material remained in the aneurysm for a long time throughout the venous phase. The left vertebral artery was markedly hypoplastic. The patient improved remarkably after admission and became almost alert late in February, although she still presented tetraparesis, dysfunction of lower cranial nerves and other neurological signs linked with the brain stem. The unusual angiographical findings in this case prompted us to perform the examination again, expecting some angiographical changes. The angiograms taken on March 15 revealed spontaneous disappearance of the aneurysm, although the basilar artery occlusion remained unchanged. The authors discussed some problems involved in this case, including the relation between the aneurysm and the arterial occlusion, and the mechanism of spontaneous disappearance of the aneurysm.