Innominate truncal dissection and rupture into right pleural cavity following acute type A dissection of the aorta with right coronary ostial avulsion and inferior STEMI

Kaul, Pankaj; George, Robert S.; Paniagua, Rodolfo; Petsa, Afroditi; Congiu, Stefano

doi:10.1177/0267659111408997

Cited by 8 publications

(7 citation statements)

References 28 publications

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“…4) Innominate artery dissection in acute type A aortic dissection is associated with neurological complication, but hardly ever complicated by rupture. Kaul P. et al 5) reported an innominate truncal dissection and rupture into the right pleural cavity following acute type A aortic dissection as a previously undescribed instance.…”

Section: Discussionmentioning

confidence: 99%

A Case of Dissection and Rupture of the Innominate Artery in Acute Type A Aortic Dissection

Tamura¹,

Kihara²,

Chikazawa³

et al. 2016

Annals of Vascular Diseases

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We report the case of a 59-year-old male presenting with dissection and rupture of the innominate artery with acute type A aortic dissection. We performed total arch replacement via median sternotomy with extension into the right side of the neck. The innominate artery was reconstructed just proximal to the bifurcation of the right subclavian artery and common carotid artery using the 1st limb of a 4-branched graft. This case illustrates an unusual aspect of an isolated innominate artery rupture in the absence of aortic rupture in acute type A aortic dissection. Keywords: aortic dissection, aneurysminnominate artery and hematoma of the mediastinum (Fig. 1). There were no clinical signs of cerebral malperfusion. An emergency operation was performed under the diagnosis of acute type A aortic dissection complicated with dissection and rupture of the bottom of the innominate artery. Under general anesthesia, midline sternotomy with an extended incision along the medial border of the right sternocleidomastoid muscle was performed. Following systemic heparinization, cardiopulmonary bypass (CPB) was established by double direct cannulations of the right axillary artery and the femoral artery with bicaval drainage. Under the circulatory arrest at a bladder temperature of 22°C, the ascending aorta and the innominate artery was opened. The false lumen of the innominate artery was dilated and ruptured. Although the dissection extended to the proximal portion of the bifurcation between the right common carotid artery and the right subclavian artery, we judged isolated reconstruction of the innominate artery was possible at the level proximal to its bifurcation. A large and latitudinal intimal tear was identified between the orifice of the innominate artery and that of the left common carotid artery in the aortic arch. Selective antegrade cerebral perfusion was established by clamping the innominate artery just proximal to its bifurcation and inserting the balloon catheters into the left common carotid artery and left subclavian artery, individually. Following the elephant trunk technique to reconstruct the distal stump of the aorta, distal anastomosis was performed using a 4-branched graft (J graft, Japan Lifeline, Tokyo, Japan). The left subclavian artery and the left common carotid artery were individually reconstructed. And then, the innominate artery was reconstructed proximal to its bifurcation under the cross-clamps of the right common carotid artery and right axillary artery. The postoperative CT demonstrated that the innominate artery was successfully reconstructed just proximal to the bifurcation between the right common carotid artery and the right axillary artery (Fig. 2). Histological findings of the ascending aorta showed neither cystic medial necrosis nor nonspecific inflammation as in Takayasu's aortitis. The patient's postoperative course was uneventful and he was discharged home on the 23rd postoperative day.

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Section: Discussionmentioning

confidence: 99%

A Case of Dissection and Rupture of the Innominate Artery in Acute Type A Aortic Dissection

Tamura¹,

Kihara²,

Chikazawa³

et al. 2016

Annals of Vascular Diseases

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“…On the other hand, 30% of patients with ascending aortic dissection died within 24 hours and a further 50% within 48 hours, mostly due to ascending aortic rupture into pericardial or pleural cavities or mediastinum [23]. This difference, in frequency of rupture between aorta and innominate artery, is explained by Laplace’s law as well as the extrapericardial location of the innominate artery, and the support provided by the supraaortic tissues making it resistant to rupture, despite high incidence of innominate involvement in type A dissection [24]. Post traumatic innominate artery rupture has been reported after repair of type A dissection [25], as has been a rupture of innominate artery associated with a localised acute dissection, repaired with a bifurcated prosthetic graft without cerebral complications [26].…”

Section: Discussionmentioning

confidence: 99%

Innominate truncal and arch blowout with left hemiparesis and right hemothorax followed by delayed cheese-wire perforation of innominate graft

Kaul

Paniagua

2013

J Cardiothorac Surg

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We present the case of a 68 year old Caucasian woman, in extremis, with left hemiparesis and right hemothorax, in hypovolemic shock, secondary to a blow-out of a large penetrating ulcer at the junction of innominate trunk and aortic arch. She underwent interposition graft replacement of innominate trunk and repair of aortic arch, on cardiopulmonary bypass, employing total circulatory arrest and selective antegrade cerebral perfusion and had total resolution of hemiparesis. She, however, represented, 6 months later, with threatened exsanguination after a sternal wire cheese-wired through the sternum and perforated the anteriorly lying innominate graft. Following successful repair, she was found to have an old intramural hematoma of distal arch and descending thoracic aorta and changes suggestive of chronic dissection of the whole of abdominal aorta. This was managed conservatively.We believe this patient’s presentation initially with a spontaneous innominate blow-out, cardiogenic shock, hemothorax and hemiparesis, and later with cheese-wire perforation of the innominate graft is unique. Her surgical rescue at both presentations was equally unusual, and without surgical precedent to the best of our knowledge. Was the initial innominate blow-out the result of localised innominate dissection, or more unusually, part of retrograde descending thoracic dissection with skip penetration of innominate artery and sparing of the intervening arch? Was it secondary to the minor fall she had sustained 1 week prior to the event, resulting in a false aneurysm or a contained hematoma next to the innominate artery? More intriguingly, did diffuse aortopathy underpin these diverse etiologies and result in penetrating intimal ulcer with blow out in the innominate artery, intramural hematoma in the arch and descending thoracic aorta and dissection in abdominal aorta at different points in time?We review the current literature for these unusual afflictions of innominate trunk and its origin from the arch of aorta.

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“…On the other hand, if right axillary cannulation is used, an innominate dissection might first declare itself as malperfusion at institution of cardiopulmonary bypass [16]. Alternately, innominate artery dissection [17] or dissection and rupture [15] presenting as right hemispherical malperfusion might be salvageable by composite femoral and innominate artery perfusion if distal IA is intact [17] or femoral and right common carotid artery perfusion when distal IA is ruptured [15]. …”

Section: Discussionmentioning

confidence: 99%

“…All our patients, in whom sole innominate cannulation was used have required ascending aortic with or without hemiarch replacement. We have used composite innominate cannulation (with additional femoral arterial cannulation) in patients who had retrograde dissection from a descending aortic intimal tear into ascending aorta [12] and composite right common carotid artery cannulation (with additional femoral arterial cannulation) in a patient with innominate artery dissection and rupture into right pleural cavity [15]. However, the remaining description outlines the procedure we follow when the intimal tear is in ascending aorta or the inferior surface of the arch.…”

Section: Introductionmentioning

confidence: 99%

How I do it – sole innominate cannulation for acute type A aortic dissection

Kaul

2012

J Cardiothorac Surg

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We describe sole direct innominate cannulation for arterial return for establishing both cardiopulmonary bypass and selective antegrade cerebral perfusion in the repair of acute type A dissection and compare it with femoral, axillary, direct aortic and apical cannulations. We believe innominate cannulation has all the advantages of right axillary cannulation and none of its disadvantages. It can be used in all patients in whom innominate artery is not dissected, obstructed, calcified or otherwise diseased.

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Innominate truncal dissection and rupture into right pleural cavity following acute type A dissection of the aorta with right coronary ostial avulsion and inferior STEMI

Cited by 8 publications

References 28 publications

A Case of Dissection and Rupture of the Innominate Artery in Acute Type A Aortic Dissection

A Case of Dissection and Rupture of the Innominate Artery in Acute Type A Aortic Dissection

Innominate truncal and arch blowout with left hemiparesis and right hemothorax followed by delayed cheese-wire perforation of innominate graft

How I do it – sole innominate cannulation for acute type A aortic dissection

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