Penetrating Trauma Involving the Innominate Artery Thomas R. McLean, MD, and Robert P. McManus, MD Departments of Surgery, Baylor College of Medicine and Veterans Affairs Medical Center, Houston, Texas, and Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin Penetrating trauma involving the innominate artery is uncommon. Few surgeons have experience with this injury. A successfully managed case of penetrating innominate artery trauma is summarized and the literature reviewed. (Ann Thorac Surg 1991;51:113-5)
A
fter reviewing four military series and 13 civilian series, Rich observed “probably less than 20 successful repairs of acute injuries to the intrathoracic great vessels have been reported in the English literature” [l]. Reported experience with penetrating innominate artery trauma is rare. Reported here is a successful technique for the management of penetrating innominate artery trauma. A 28-year-old woman sustained a single gunshot wound to the chest. The entrance wound was located just above the sternal notch. The exit wound was located in the right back. The patient was never in shock, had no neurological deficit, and had equal pulses bilaterally. Angiography demonstrated a pseudoaneurysm of the innominate artery (Fig 1). The patient was taken to the operating room directly and explored through a sternal splitting incision. When the mediastinum was entered surprisingly little evidence of trauma was present. Observing this, we heparinized the patient. The extent of the injury necessitated proximal control of the innominate artery be obtained intrapericardially. Distal control was obtained by individually controlling the right subclavian and right carotid arteries. When the pseudoaneurysm was opened, the distal two thirds of the innominate artery was seen to be destroyed by the oblique passage of the bullet. Vascular continuity was obtained by the insertion of a properly sized Dacron bifurcation graft. The only other injury present was a through and through nonbleeding injury to the right upper lobe managed by chest tube placement. Postoperatively, the patient did well. A neurological deficit was not noted. At early follow-up blood pressure in both arms is equal.
Accepted for publication June 11, 1990. Address reprint requests to Dr McLean, Surgical Service (112). VA Medical Center, 2002 Holcombe Blvd, Houston, TX 77030.
0 1991 by The Society of Thoracic Surgeons
Comment The true incidence of innominate artery injury is unknown, as the majority of patients exsanguinate before receiving treatment [2]. Bladergroen and associates [3] reported that 6 of 10 patients died before receiving a physician’s attention. A previous compilation of the literature revealed only 13 cases of penetrating innominate artery trauma [l]. In addition to our patient we could only identify an additional 19 cases of innominate artery injuries from the literature (Table 1). Data are incomplete because innominate artery trauma was placed into larger series of thoracic vascular trauma. Laceration of the vessel is the most frequently encountered lesion [I, 21. Gunshot wounds rather than knife wounds appear to be the most frequent cause of penetrating innominate artery injury [4, 8, 91. When first seen, most patients surviving to receive medical attention appear to have, like our patient, a paucity of external changes to indicate the magnitude of the injury. In the majority of patients the diagnosis is made when an arteriogram demonstrates a contained pseudoaneurysm [3-71. Although Graham and associates [6] noted that all of their patients had associated subclavian vascular trauma, most authors fail to comment on the presence of associated injuries. Once the diagnosis is made, the patient should be taken to the operating room. Median sternotomy offers excellent exposure of the innominate artery [3-61; the safety of this incision makes it the preferred approach to the innominate artery. The patient and room should be kept as warm as possible. Intraoperative autotransfusion and use of a Cell Saver may be useful. Heparin use is controversial. Some authors [7] recommend its frequent employment. Mattox [lo] has observed that in thoracic vascular trauma heparin is probably not indicated. Cardiopulmonary bypass does not appear to have been employed in any case of penetrating innominate artery trauma in the literature. The general principles of adequate exposure with proximal and distal control of the innominate artery are followed. When the pseudoaneurysm is open, the lesion is repaired by the simplest means possible. In many instances this can be accomplished by debridement and primary repair [3, 71. In some cases a saphenous vein patch or interposition graft will suffice [9]. However, for difficult or complex cases, a Dacron prosthetic graft may be the ideal solution. In our patient, employment of a bifurcation graft allowed for a simple reconstruction of the confluence of the innominate, right subclavian, and right 0003-4975/91/$3.50
114
Ann Thorac Surg
CASE REPORT McLEAN AND McMANUS INNOMINATE ARTERY TRAUMA
1991:51:11&5
Table
I. lnnorninate Artery lnjuries
Author
Year
No. Cases
No. Survived
Years Reviewed
Lim et a1 [4]
1979 1980
2 2
...
2
5 25
1980
7
...B
23
1989
4
. . .a
12
1989
4
4
10
Pate and Casini [5] Graham et a1 [61
Bladergroen et a1 [4] Weaver et a1 [71 a
Insufficient data to determine survival.
References
Fig 1 . This subtraction arteriogram demonstrates how subtle a pseudoaneurysm of the innominate artery may be.
common carotid arteries without tension, stenosis, or kinking. This technique has previously been reported
D11.
The postoperative morbidity and mortality of innominate artery injury cannot be accurately determined from the literature. However, there have been no reports of postoperative neurological deficits. In conclusion, review of the literature reveals only 33 explorations for penetrating injuries to the innominate artery. The majority of patients with this injury die before reaching medical attention. Those surviving generally have an acute pseudoaneurysm of the innominate artery and minimal external signs of trauma. Usually repair is accomplished primarily or with saphenous vein graft. In difficult situations use of a Dacron bifurcation graft may be warranted.
INVITED COMMENTARY It is increasingly important that the thoracic surgeon remain current in the management of thoracic trauma. The development of trauma systems with rapid communication, triage, and transportation presents the surgeon with the responsibility to manage patients who would have died before arrival at the hospital in years past. Although penetrating injury to the innominate artery is unusual, our Trauma Center has managed 4 such patients
1. Rich NM. Inominate artery trauma. In: Rich NM, Spencer FC, eds. Vascular trauma. Philadelphia: W.B. Saunders, 1978: 287-306. 2. Rich NM, Baugh JB, Hughes CW. Acute arterial injuries in Vietnam, 1,OOO cases. Trauma 1970;18:359-69. 3. Bladergroen M, Brockman R, Luna G, Kohler T, Johnsen K. A twelve year survey of cardiothoracic vascular injuries. Am J Surg 1989;157483-6. 4. Lim LT, Saletta JD, Flanigan DP. Subclavian and innominate artery trauma. Surgery 1979;86890-7. 5. Pate JW, Casini M. Penetrating wounds of the neck: explore or not? Am J Surg 1980;80:38-43. 6. Graham JM, Feliciano GV, Mattox KL, Beall AC, DeBakey ME. Management of subclavian vascular trauma. J Trauma 1980;2053744. 7. Weaver FA, Suda RW, Stiles GM, Yellin AE. Injuries to the
ascending aorta, aortic arch and great vessels. Surg Gynecol Obstet 1989;169:27-31. 8. Symbas PN, Kourias E, Tyras DH, Hatcher CR. Penetrating wounds of the great vessels. Ann Surg 1974;179:757-69. 9. Monson DO, Saletta JD, Freeark RJ. Carotid-vertebral
trauma. J Trauma 1969;9:987-95. 10. Mattox KL. Thoracic vascular trauma. J Vasc Surg 1988;7: 725-9. 11. Symbas PN. In: Cardiothoracic trauma. Philadelphia: W.B. Saunders, 1989:212-20.
from among 15,936 major trauma admissions within the last 5 years. The risk of cerebral ischemia and major neurological deficit is present in all injuries of aortic arch branches, and raises additional legal problems. This report well summarizes the present knowledge of penetrating injury to the innominate artery. The authors’ recommendations for immediate arteriography, emergency median sternotomy, proximal and distal vascular control before entering the hematoma, and encouragement for the use of prosthetic grafts delineate the major
Ann Thorac Surg
19!31;51:11b5
principles involved. We routinely open the pericardium for a proximal bypass graft and expose the common carotid in mid-neck for the distal graft end before we disturb the hematoma and area of injury. Both Dacron and Gore-Tex have been used; the only major difficulty with either has been in preventing kinking. I think a saphenous vein graft is too small and prone to late aneurysm formation in this location; therefore, we always use a prosthesis when primary repair is impractical. The advisability of heparin administration is unproven. We do
CASE REPORT McLEAN AND McMANUS INNOMINATE ARTERY TRAUMA
115
use heparin for penetrating injuries of the carotid and innominate arteries, although usually not in blunt trauma to major systems.
James W. Pate, M D Division of Cardiovascular Surgery University of Tennessee Memphis, TN 38263
Notice From the American Board of Thoracic Surgery The part 1 (written) examination will be held at the HyattRegency, Dallas Fort Worth Airport, Dallas TX,on February 16, 1992. The closing date for registration is August 1, 1991. To be admissible for the part I1 (oral) examination, a candidate must have successfully completed the part I (written) examination.
A candidate applying for admission to the certifying examination must fulfill all the requirements of the board in force at the time the application is received. Please address all communications to the American Board of Thoracic Surgery, One Rotary Center, Suite 803, Evanston, IL 60201.
A
fter reviewing four military series and 13 civilian series, Rich observed “probably less than 20 successful repairs of acute injuries to the intrathoracic great vessels have been reported in the English literature” [l]. Reported experience with penetrating innominate artery trauma is rare. Reported here is a successful technique for the management of penetrating innominate artery trauma. A 28-year-old woman sustained a single gunshot wound to the chest. The entrance wound was located just above the sternal notch. The exit wound was located in the right back. The patient was never in shock, had no neurological deficit, and had equal pulses bilaterally. Angiography demonstrated a pseudoaneurysm of the innominate artery (Fig 1). The patient was taken to the operating room directly and explored through a sternal splitting incision. When the mediastinum was entered surprisingly little evidence of trauma was present. Observing this, we heparinized the patient. The extent of the injury necessitated proximal control of the innominate artery be obtained intrapericardially. Distal control was obtained by individually controlling the right subclavian and right carotid arteries. When the pseudoaneurysm was opened, the distal two thirds of the innominate artery was seen to be destroyed by the oblique passage of the bullet. Vascular continuity was obtained by the insertion of a properly sized Dacron bifurcation graft. The only other injury present was a through and through nonbleeding injury to the right upper lobe managed by chest tube placement. Postoperatively, the patient did well. A neurological deficit was not noted. At early follow-up blood pressure in both arms is equal.
Accepted for publication June 11, 1990. Address reprint requests to Dr McLean, Surgical Service (112). VA Medical Center, 2002 Holcombe Blvd, Houston, TX 77030.
0 1991 by The Society of Thoracic Surgeons
Comment The true incidence of innominate artery injury is unknown, as the majority of patients exsanguinate before receiving treatment [2]. Bladergroen and associates [3] reported that 6 of 10 patients died before receiving a physician’s attention. A previous compilation of the literature revealed only 13 cases of penetrating innominate artery trauma [l]. In addition to our patient we could only identify an additional 19 cases of innominate artery injuries from the literature (Table 1). Data are incomplete because innominate artery trauma was placed into larger series of thoracic vascular trauma. Laceration of the vessel is the most frequently encountered lesion [I, 21. Gunshot wounds rather than knife wounds appear to be the most frequent cause of penetrating innominate artery injury [4, 8, 91. When first seen, most patients surviving to receive medical attention appear to have, like our patient, a paucity of external changes to indicate the magnitude of the injury. In the majority of patients the diagnosis is made when an arteriogram demonstrates a contained pseudoaneurysm [3-71. Although Graham and associates [6] noted that all of their patients had associated subclavian vascular trauma, most authors fail to comment on the presence of associated injuries. Once the diagnosis is made, the patient should be taken to the operating room. Median sternotomy offers excellent exposure of the innominate artery [3-61; the safety of this incision makes it the preferred approach to the innominate artery. The patient and room should be kept as warm as possible. Intraoperative autotransfusion and use of a Cell Saver may be useful. Heparin use is controversial. Some authors [7] recommend its frequent employment. Mattox [lo] has observed that in thoracic vascular trauma heparin is probably not indicated. Cardiopulmonary bypass does not appear to have been employed in any case of penetrating innominate artery trauma in the literature. The general principles of adequate exposure with proximal and distal control of the innominate artery are followed. When the pseudoaneurysm is open, the lesion is repaired by the simplest means possible. In many instances this can be accomplished by debridement and primary repair [3, 71. In some cases a saphenous vein patch or interposition graft will suffice [9]. However, for difficult or complex cases, a Dacron prosthetic graft may be the ideal solution. In our patient, employment of a bifurcation graft allowed for a simple reconstruction of the confluence of the innominate, right subclavian, and right 0003-4975/91/$3.50
114
Ann Thorac Surg
CASE REPORT McLEAN AND McMANUS INNOMINATE ARTERY TRAUMA
1991:51:11&5
Table
I. lnnorninate Artery lnjuries
Author
Year
No. Cases
No. Survived
Years Reviewed
Lim et a1 [4]
1979 1980
2 2
...
2
5 25
1980
7
...B
23
1989
4
. . .a
12
1989
4
4
10
Pate and Casini [5] Graham et a1 [61
Bladergroen et a1 [4] Weaver et a1 [71 a
Insufficient data to determine survival.
References
Fig 1 . This subtraction arteriogram demonstrates how subtle a pseudoaneurysm of the innominate artery may be.
common carotid arteries without tension, stenosis, or kinking. This technique has previously been reported
D11.
The postoperative morbidity and mortality of innominate artery injury cannot be accurately determined from the literature. However, there have been no reports of postoperative neurological deficits. In conclusion, review of the literature reveals only 33 explorations for penetrating injuries to the innominate artery. The majority of patients with this injury die before reaching medical attention. Those surviving generally have an acute pseudoaneurysm of the innominate artery and minimal external signs of trauma. Usually repair is accomplished primarily or with saphenous vein graft. In difficult situations use of a Dacron bifurcation graft may be warranted.
INVITED COMMENTARY It is increasingly important that the thoracic surgeon remain current in the management of thoracic trauma. The development of trauma systems with rapid communication, triage, and transportation presents the surgeon with the responsibility to manage patients who would have died before arrival at the hospital in years past. Although penetrating injury to the innominate artery is unusual, our Trauma Center has managed 4 such patients
1. Rich NM. Inominate artery trauma. In: Rich NM, Spencer FC, eds. Vascular trauma. Philadelphia: W.B. Saunders, 1978: 287-306. 2. Rich NM, Baugh JB, Hughes CW. Acute arterial injuries in Vietnam, 1,OOO cases. Trauma 1970;18:359-69. 3. Bladergroen M, Brockman R, Luna G, Kohler T, Johnsen K. A twelve year survey of cardiothoracic vascular injuries. Am J Surg 1989;157483-6. 4. Lim LT, Saletta JD, Flanigan DP. Subclavian and innominate artery trauma. Surgery 1979;86890-7. 5. Pate JW, Casini M. Penetrating wounds of the neck: explore or not? Am J Surg 1980;80:38-43. 6. Graham JM, Feliciano GV, Mattox KL, Beall AC, DeBakey ME. Management of subclavian vascular trauma. J Trauma 1980;2053744. 7. Weaver FA, Suda RW, Stiles GM, Yellin AE. Injuries to the
ascending aorta, aortic arch and great vessels. Surg Gynecol Obstet 1989;169:27-31. 8. Symbas PN, Kourias E, Tyras DH, Hatcher CR. Penetrating wounds of the great vessels. Ann Surg 1974;179:757-69. 9. Monson DO, Saletta JD, Freeark RJ. Carotid-vertebral
trauma. J Trauma 1969;9:987-95. 10. Mattox KL. Thoracic vascular trauma. J Vasc Surg 1988;7: 725-9. 11. Symbas PN. In: Cardiothoracic trauma. Philadelphia: W.B. Saunders, 1989:212-20.
from among 15,936 major trauma admissions within the last 5 years. The risk of cerebral ischemia and major neurological deficit is present in all injuries of aortic arch branches, and raises additional legal problems. This report well summarizes the present knowledge of penetrating injury to the innominate artery. The authors’ recommendations for immediate arteriography, emergency median sternotomy, proximal and distal vascular control before entering the hematoma, and encouragement for the use of prosthetic grafts delineate the major
Ann Thorac Surg
19!31;51:11b5
principles involved. We routinely open the pericardium for a proximal bypass graft and expose the common carotid in mid-neck for the distal graft end before we disturb the hematoma and area of injury. Both Dacron and Gore-Tex have been used; the only major difficulty with either has been in preventing kinking. I think a saphenous vein graft is too small and prone to late aneurysm formation in this location; therefore, we always use a prosthesis when primary repair is impractical. The advisability of heparin administration is unproven. We do
CASE REPORT McLEAN AND McMANUS INNOMINATE ARTERY TRAUMA
115
use heparin for penetrating injuries of the carotid and innominate arteries, although usually not in blunt trauma to major systems.
James W. Pate, M D Division of Cardiovascular Surgery University of Tennessee Memphis, TN 38263
Notice From the American Board of Thoracic Surgery The part 1 (written) examination will be held at the HyattRegency, Dallas Fort Worth Airport, Dallas TX,on February 16, 1992. The closing date for registration is August 1, 1991. To be admissible for the part I1 (oral) examination, a candidate must have successfully completed the part I (written) examination.
A candidate applying for admission to the certifying examination must fulfill all the requirements of the board in force at the time the application is received. Please address all communications to the American Board of Thoracic Surgery, One Rotary Center, Suite 803, Evanston, IL 60201.
