Management of blunt Innominate artery injury in the setting of multisystem trauma
Amer Homsi, M.D, Timothy Wu, M.D, Michael A. Curi, M.D., MPA, Frank Padberg, M.D., Justin Sambol, M.D., Joe Huang, M.D..
Rutgers-New Jersey Medical School, Newark, NJ, USA.
Objective:
Blunt traumatic injuries to the innominate artery are rare. The forces involved result in significant associated injuries, complex overall management, and high morbidity and mortality. We describe a case of blunt innominate artery injury in a setting of multisystem trauma and examine the literature of the incidence, treatment, and outcomes of this type of injury.
Methods:
A 21-year-old woman in a motor vehicle accident with prolonged extrication sustained a blunt innominate artery dissection and pseudoaneurysm distal to the origin of the innominate artery, with resultant occlusion of the right common carotid artery. Associated injuries included bilateral rib fractures, bilateral pneumothoraces, and right mainstem bronchus transection, requiring open thoracotomy and extracorporeal membranous oxygenation (ECMO). On hospital day 6, she subsequently underwent successful endovascular stent graft repair of the innominate artery pseudoaneurysm via brachial cutdown. A review was performed of the incidence, treatment, and outcomes of blunt innominate artery injuries.
Results:
Only 5% of blunt force trauma vascular injuries are to the thoracic outlet vessels. The Innominate artery is the most commonly injured vessel, but remains an extremely rare injury. Up to 70% of these injuries prove lethal at the scene with an associated in hospital mortality ranging from 10%-70%. The most commonly associated vascular and thoracic injuries are the carotid arteries (22%); pneumothorax (30%); rib fractures (26%); and bronchotrachial injuries (8%). Open surgical repair has been the mainstay of therapy with 98.5% of cases reported up to 2004 being treated in this manner. With advancements in endovascular therapies, there has been a steady increase in the numbers of endovascular interventions in these patients, currently in approximately 10% of cases. Recent short-term data comparing open and endovascular approaches have shown endovascular repair to be favorable to open surgery in terms of operative time, blood loss, and length of stay. No difference was detected with regards to graft patency and extremity ischemia.
Conclusions:
Blunt traumatic injuries to the innominate artery are rare, with endovascular repair feasible in multisystem trauma patients.
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