Ann Thorac Surg 2002;74:237-239
© 2002 The Society of Thoracic Surgeons
Case report
Combined endovascular and open repair of a penetrating innominate artery and tracheal injury
Seth B. Blattman, MD*a,
Gregg S. Landis, MDb,
Mark Knight, MDa,
Thomas F. Panetta, MDb,
Salvatore J.A. Sclafani, MDc,
Joshua H. Burack, MDd
a Department of Surgery, Downstate Medical Center, Brooklyn, New York, USA
b Department of Vascular Surgery, Downstate Medical Center, Brooklyn, New York, USA
c Department of Radiology, Downstate Medical Center, Brooklyn, New York, USA
d Department of Cardiothoracic Surgery, Downstate Medical Center, Brooklyn, New York, USA
Accepted for publication February 17, 2002.
* Address reprint requests to Dr Blattman, Department of Surgery, Downstate Medical Center, 450 Clarkson Ave, Brooklyn, NY 11203 USA
e-mail: sethblattman{at}doctor.com
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Abstract
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Endovascular therapy affords the opportunity to decrease surgical morbidity and improve operative planning in complex penetrating injuries of the chest. In this case report we describe a hemodynamically stable patient with a single gunshot wound to the base of the neck (zone I), with combined vascular and tracheal injuries. We present a novel approach to the repair of this type of injury using combined endovascular and open techniques.
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Introduction
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The anterior approach to mediastinal vascular injuries through a median sternotomy often makes exposure and repair of thoracic aerodigestive injuries problematic [1, 2]. The posterolateral thoracotomy is typically the preferred approach for repair of complex thoracic tracheobronchial injuries [3]. Various authors have shown that penetrating vascular injuries can be effectively managed with the placement of covered stents [4]. In the stable patient, the mediastinal vascular injury may be treated through endovascular exclusion, and then a posterolateral approach to the aerodigestive injuries can be undertaken. With the advent of covered stents, many centrally located pseudoaneurysms can be excluded with minimal invasiveness and in an expeditious time frame.
A 19-year-old man presented with a single gunshot wound to the neck (zone I). He was in respiratory distress, with air leaking from the neck wound and massive subcutaneous emphysema. He was immediately fiber-optically intubated. His blood pressure was 140/76 with a pulse of 124. There was an entrance wound approximately 1.5 cm above the sternal notch and an exit wound on the back, medial to the right scapula at T6. The pulse exam was normal, but auscultation of the chest revealed diminished right breath sounds. Chest roentgenograms revealed a right pneumothorax and a widened mediastinum. A right thoracostomy tube drained approximately 250 mL of blood, and a brisk air leak was noted. The remainder of the examination’s findings were within normal limits, and no neurologic deficit was noted. After the administration of 2 L of crystalloid solution and 1 unit of packed red blood cells, the patient’s pulse decreased to 70, and blood pressure remained stable at 150/86. Fiber-optic bronchoscopy revealed a through-and-through tracheal injury approximately 1 cm above the carina. Results of both esophagoscopy and esophagogram were normal. Angiography revealed a pseudoaneurysm of the innominate artery approximately 1.5 cm distal to the aortic arch and 1 cm proximal to the carotid-subclavian bifurcation (Fig 1).
A 40 mm x 18 mm Wallgraft covered stent was trimmed to a length of 22 mm to prevent encroachment on the common carotid orifice and was then deployed. Completion angiography revealed complete exclusion of the innominate pseudoaneurysm (Fig 2).
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Fig 2. Aortic arch angiogram after covered stent deployment showing complete exclusion of innominate artery pseudoaneurysm.
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Subsequently, the patient was explored through a right posterolateral thoracotomy to gain optimal exposure of the tracheal injury. A stellate laceration on the anterior trachea and a 2-cm rent through the membranous trachea were found. Initially, primary repair was attempted and was unsuccessful. In addition to the entrance and exit wounds, the blast injury had avulsed the adjacent membranous trachea from its rings. The five involved rings were resected, the remaining trachea was mobilized, and a primary anastomosis was performed. After an uneventful recovery, the patient was discharged home on postoperative day 14.
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Comment
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Combined injuries of the innominate artery and trachea represent a diagnostic and therapeutic challenge to the trauma surgeon. Each of these injuries alone carries significant mortality. It is estimated that 30% to 80% of patients with tracheal or bronchial injuries and 71% of patients with major vascular injuries of the thoracic outlet expire before reaching the hospital [1, 5]. Although rare, the description of complex traumatic innominate artery and tracheal injuries resulting from penetrating zone I cervical injuries is well documented in the trauma literature [2, 5]. The approach for innominate artery injuries has been operative repair through a median sternotomy with synthetic conduit bypass, primary repair, or ligation. Using this approach, the surgeon is often faced with entering an uncontrolled mediastinal hematoma, with the potential for massive hemorrhage. Additionally, optimal exposure for distal tracheal, carinal, or bronchial injuries is argued by most authors to be a posterolateral incision in the fourth interspace [3].
Arteriography and endovascular stenting have proved valuable in the diagnosis and treatment of traumatic arterial injuries. Various authors have reported success in the repair of penetrating injuries to large vessels including the subclavian and carotid arteries [4]. Covered stents have been used for the repair of blunt injuries to the innominate artery [6], but a review of the literature identified no citations regarding penetrating injuries to this vessel. Although promising, questions regarding the long-term placement of covered stents in young trauma victims still need to be addressed.
Clearly, the unstable patient is not an acceptable candidate for angiographic intervention, and direct operative repair is indicated. However, we propose that in the hemodynamically stable patient with combined aerodigestive and vascular trauma to the chest, endovascular exclusion can be used to treat traumatic pseudoaneurysms and can afford the surgeon several operative approaches.
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References
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- Johnston R.H., Wall M.J., Mattox K.L. Innominate artery trauma. A thirty-year experience. J Vasc Surg 1993;17:134-140.[Medline]
- Richardson J.D., Flint L.M., Snow N.J., Gray L.A., Trinkle J.K. Management of transmediastinal gunshot wounds. Surgery 1981;90:671-676.[Medline]
- Mathisen D.J., Grillo H. Laryngotracheal trauma. Ann Thorac Surg 1987;43:254-262.[Abstract]
- Marin M.L., Veith F.J., Panetta T.F., et al. Transluminally placed endovascular stented graft repair for arterial trauma. J Vasc Surg 1994;20:466-473.[Medline]
- Rossbach M.M., Johnson S.B., Gomez M.A., Sako E.Y., Miller O.L., Calhoon J.H. Management of major tracheobronchial injuries: a 28-year experience. Ann Thorac Surg 1998;65:182-186.[Abstract/Free Full Text]
- Axisa B.M., Loftus I.M., Fishwick G., Spyt T., Bell P.R.F. Endovascular repair of an innominate artery false aneurysm following blunt trauma. J Endovasc Ther 2000;7:245-250.[Medline]
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