Hybrid Approach for Repair or Traumatic Pseudoaneurysm of the Innominate Artery in a Pediatric Patient

Adeola Titilayo Odugbesi; Megan E. Parrott; Maen Aboul Hosn

doi:10.1016/j.jvs.2024.06.126

Demographics A 17-year-old male with no significant medical history who presented after sustaining a motor vehicle collision resulting in extensive injuries including an innominate artery pseudoaneurysm. History The patient was transferred from an outside hospital where he had coded, but ROSC was achieved. His injuries included multiple bony fractures, bilateral rib fractures with right hydropneumothorax, solid organ lacerations (liver, spleen, and pancreas), bilateral IVH, and bilateral pulmonary contusions resulting in ARDS. CTA neck showed a 1.9-cm innominate artery pseudoaneurysm (Fig). He underwent an exploratory laparotomy, which showed no active bleeding from the liver or spleen. Cardiac surgery was consulted for management of the pseudoaneurysm. Due to progression of his ARDS, ECMO initiation was considered. The patient was deemed too high risk for open surgery so vascular surgery was consulted. Plan The patient's mother was consented for right brachial artery cutdown, and exclusion of the pseudoaneurysm, followed by coil embolization of the pseudoaneurysm. A right transverse antecubital incision was made for brachial artery exposure followed by left percutaneous femoral access. A small heparin bolus was administered due to the IVH. An 8Fr sheath was inserted via the brachial access and a long 5Fr sheath inserted in the left femoral artery. After obtaining an angiogram demonstrating the pseudoaneurysm, a 2.4Fr Progreat was advanced via the left groin and parked within the sac. A 10 mm × 29 mm VBX stent graft was advanced via the brachial artery sheath with protrusion into the aortic lumen and deployed. Through the microcatheter, multiple Azur coils were deployed within the pseudoaneurysm sac to achieve optimal packing. The stent graft was post-dilated with a 14-mm balloon, which resulted in loss of proximal seal, so an 11-mm × 29-mm VBX stent graft was deployed and profiled. Repeat angiogram showed a widely patent stent with no filling of the pseudoaneurysm. Postoperative CTA showed complete thrombosis of the pseudoaneurysm with a widely patent stent graft. Discussion Traumatic injury of the innominate artery is usually managed with open surgery with either primary repair or bypass exclusion. We present a case of successful endovascular repair of an innominate artery pseudoaneurysm using a hybrid approach.

Hybrid Approach for Repair or Traumatic Pseudoaneurysm of the Innominate Artery in a Pediatric Patient

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