Treatment Of Blunt Traumatic Aortic Injury With Aberrant Right Subclavian Artery
Samuel D. Leonard, MD, Regina Husman, MD, Brett Vernier, BS, Gordon Martin, MD, Naveed Saqib, MD, Shihuan Wang, MD.
McGovern Medical School at UTHealth, Houston, TX, USA.
DEMOGRAPHICS:Our understanding of the optimal management of blunt traumatic aortic injury (BTAI) and the role for thoracic endovascular aortic repair (TEVAR) is rapidly evolving. We present the case and intraoperative complication with subsequent rescue of a 30-year-old female who presented as a polytrauma with grade III BTAI and aberrant right subclavian artery originating from the pseudoaneurysm.HISTORY:30-year-old female with unknown medical history presented via LifeFlight following MVC with ejection at 70+mph. Patient intubated on scene for GCS-3 and received multiple products for hypotension and tachycardia enroute. Hemodynamics improved upon arrival with further resuscitation. Computed tomography angiography demonstrated grade III BTAI measuring with aberrant right subclavian originating near the pseudoaneurysm (figure 1), left vertebral dominance, and polytraumatic injuries including cervical spine fractures precluding manipulation of the neck.PLAN:Initial operative plan involved selective exclusion of BTAI with proximal stent graft deployed in zone 4. Utilizing intraoperative ultrasound and diagnostic angiogram we deployed a GORE cTAG successfully excluding the grade III BTAI and aberrant right subclavian; however, the patient immediately lost arterial waveform in her left upper extremity and angiogram confirmed incidental coverage of the left subclavian artery (figure 2), likely from the PTFE sleeve of the cTAG. Given new inadvertent bilateral subclavian artery coverage and existing trauma comorbidities complicating open surgical bypass, endovascular techniques were used to revascularize the left subclavian artery. After unsuccessful attempts to retract the device caudally with CODA balloons, the left upper extremity was prepped to perform brachial cutdown for retrograde access. Pulses returned in arm following parallel stent grafting via deployment of GORE VBX stent across origin of L SCA and into the aorta. Completion angiogram demonstrated patent L SCA and exclusion of BTAI without endoleak (figure 3). Postoperatively, the patient did well without any upper extremity sequalae and was discharged with antiplatelet regimen.
In this case, we report the successful endovascular treatment of a grade III BTAI in the setting of aberrant right subclavian artery arising near the pseudoaneurysm despite inadvertent coverage of the left subclavian with intraoperative rescue via parallel grafting.
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