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OBJECTIVES:
A true bovine aortic arch is a rare anatomical variant of a single common orifice off the arch branching to bicarotid and subclavian arteries. In general population, a “bovine type” arch has an incidence of 10-33%. We report a case of 72-year-old woman with a ruptured thoracic aneurysm complicated by a true bovine arch emergently treated with TEVAR (thoracic endovascular aneurysm repair) and carotid to carotid bypass.
METHODS:
The patient was brought to the ED in severe shock with complaints of chest/back pain and respiratory distress. Physical examination was significant for absent breath sounds on the left. Computed tomography of chest/abdomen/pelvis with contrast showed likely a contained rupture of descending thoracic aortic aneurysm (10cm) with a left hemothorax causing a mediastinal shift to the right. Due to the emergency nature, patient was immediately taken to the operating room.
RESULTS:
Bilateral femoral cutdowns were performed. A 7-French sheath was placed on the right side and a 5-French sheath was placed on the left. An aortogram revealed a large thoracic aneurysm with a contained rupture. It also revealed a true bovine arch, a common orifice between the left common carotid artery and left subclavian and innominate artery, with a 4mm neck between the common orfice and the beginning of the aneurysm sac. A right to left carotid to carotid bypass with a retroesophageal tunneling using 8mm ring PTFE was performed. Next, serial grafts were placed: a COOK Zenith TX2® 34mm x 127mm Endo Graft (Cook Medical, Bloomington, Ind) proximally, followed by 36mm x 152mm, then distally a 40mm x 216mm. A completion angiogram showed no endoleak. The patient was brought to the surgical intensive care unit for further care and eventually was discharged to a subacute nursing home.
CONCLUSIONS:
The mortality of ruptured thoracic aortic aneurysm (TAA) approaches nearly 100%. This rare true bovine arch resulting in a short proximal neck severely complicated this case of a ruptured TAA. An emergent carotid to carotid bypass had to be performed prior to the deployment of the endograft to preserve the flow. This hybrid treatment of extra-anatomic bypass and endovascular stenting is not only a feasible option but also improves perioperative morbidity and mortality in emergency high risk patients.