Repair of Isolated Innominate Artery Pathology with a Modified Endovascular Graft

Research output: Contribution to journalArticle

Abstract

Innominate artery pathology is traditionally treated with open surgical repair and is associated with significant morbidity. No dedicated endovascular solution exists for this anatomic location. We report a series of 3 cases of successful management of innominate artery injuries using an off-label, modified Zenith ESLE stent graft (Cook Medical, Bloomington, IN). Two patients presented with pseudoaneurysms after attempted central venous catheterization, and 1 patient developed a tracheo-innominate fistula. Access was obtained in a retrograde fashion via the right common carotid artery in 2 cases, and via the right axillary artery in the other. Additional anatomic considerations included a prior sternotomy in 2 cases and a bovine arch in 2 cases. Due to the emergent nature of the cases, no cerebral protection maneuvers were taken. The ESLE limbs are of uniform diameter with 3 Z-stent wireforms and measure 55 mm in length. Removal of the distal stent reduces the length to 38 mm. Fourteen- to 18-mm diameter grafts were used. All 3 cases resulted in technical success with complete exclusion of the defect. There were no new neurologic deficits and all patients recovered uneventfully. This approach represents an effective off-label solution for what frequently presents as an emergent problem. In 2 cases, it obviated the need for a complicated redo sternotomy and facilitated endovascular repair in a vessel for which there was no indicated off-the-shelf conduit. Modification of existing devices successfully addressed the need for a nontapered graft of short length and moderate vessel diameter and allowed for minimally invasive treatment of anatomically complex pathology.

Original languageEnglish (US)
JournalAnnals of Vascular Surgery
DOIs
StatePublished - Jan 1 2019
Externally publishedYes

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Brachiocephalic Trunk
Stents
Sternotomy
Pathology
Transplants
Central Venous Catheterization
Axillary Artery
Common Carotid Artery
False Aneurysm
Case Management
Neurologic Manifestations
Fistula
Extremities
Morbidity
Equipment and Supplies
Wounds and Injuries
Therapeutics

ASJC Scopus subject areas

  • Surgery
  • Cardiology and Cardiovascular Medicine

Cite this

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title = "Repair of Isolated Innominate Artery Pathology with a Modified Endovascular Graft",
abstract = "Innominate artery pathology is traditionally treated with open surgical repair and is associated with significant morbidity. No dedicated endovascular solution exists for this anatomic location. We report a series of 3 cases of successful management of innominate artery injuries using an off-label, modified Zenith ESLE stent graft (Cook Medical, Bloomington, IN). Two patients presented with pseudoaneurysms after attempted central venous catheterization, and 1 patient developed a tracheo-innominate fistula. Access was obtained in a retrograde fashion via the right common carotid artery in 2 cases, and via the right axillary artery in the other. Additional anatomic considerations included a prior sternotomy in 2 cases and a bovine arch in 2 cases. Due to the emergent nature of the cases, no cerebral protection maneuvers were taken. The ESLE limbs are of uniform diameter with 3 Z-stent wireforms and measure 55 mm in length. Removal of the distal stent reduces the length to 38 mm. Fourteen- to 18-mm diameter grafts were used. All 3 cases resulted in technical success with complete exclusion of the defect. There were no new neurologic deficits and all patients recovered uneventfully. This approach represents an effective off-label solution for what frequently presents as an emergent problem. In 2 cases, it obviated the need for a complicated redo sternotomy and facilitated endovascular repair in a vessel for which there was no indicated off-the-shelf conduit. Modification of existing devices successfully addressed the need for a nontapered graft of short length and moderate vessel diameter and allowed for minimally invasive treatment of anatomically complex pathology.",
author = "Brent Safran and Karan Garg and Scher, {Larry A.} and Saadat Shariff and Lipsitz, {Evan C.}",
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AU - Lipsitz, Evan C.

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N2 - Innominate artery pathology is traditionally treated with open surgical repair and is associated with significant morbidity. No dedicated endovascular solution exists for this anatomic location. We report a series of 3 cases of successful management of innominate artery injuries using an off-label, modified Zenith ESLE stent graft (Cook Medical, Bloomington, IN). Two patients presented with pseudoaneurysms after attempted central venous catheterization, and 1 patient developed a tracheo-innominate fistula. Access was obtained in a retrograde fashion via the right common carotid artery in 2 cases, and via the right axillary artery in the other. Additional anatomic considerations included a prior sternotomy in 2 cases and a bovine arch in 2 cases. Due to the emergent nature of the cases, no cerebral protection maneuvers were taken. The ESLE limbs are of uniform diameter with 3 Z-stent wireforms and measure 55 mm in length. Removal of the distal stent reduces the length to 38 mm. Fourteen- to 18-mm diameter grafts were used. All 3 cases resulted in technical success with complete exclusion of the defect. There were no new neurologic deficits and all patients recovered uneventfully. This approach represents an effective off-label solution for what frequently presents as an emergent problem. In 2 cases, it obviated the need for a complicated redo sternotomy and facilitated endovascular repair in a vessel for which there was no indicated off-the-shelf conduit. Modification of existing devices successfully addressed the need for a nontapered graft of short length and moderate vessel diameter and allowed for minimally invasive treatment of anatomically complex pathology.

AB - Innominate artery pathology is traditionally treated with open surgical repair and is associated with significant morbidity. No dedicated endovascular solution exists for this anatomic location. We report a series of 3 cases of successful management of innominate artery injuries using an off-label, modified Zenith ESLE stent graft (Cook Medical, Bloomington, IN). Two patients presented with pseudoaneurysms after attempted central venous catheterization, and 1 patient developed a tracheo-innominate fistula. Access was obtained in a retrograde fashion via the right common carotid artery in 2 cases, and via the right axillary artery in the other. Additional anatomic considerations included a prior sternotomy in 2 cases and a bovine arch in 2 cases. Due to the emergent nature of the cases, no cerebral protection maneuvers were taken. The ESLE limbs are of uniform diameter with 3 Z-stent wireforms and measure 55 mm in length. Removal of the distal stent reduces the length to 38 mm. Fourteen- to 18-mm diameter grafts were used. All 3 cases resulted in technical success with complete exclusion of the defect. There were no new neurologic deficits and all patients recovered uneventfully. This approach represents an effective off-label solution for what frequently presents as an emergent problem. In 2 cases, it obviated the need for a complicated redo sternotomy and facilitated endovascular repair in a vessel for which there was no indicated off-the-shelf conduit. Modification of existing devices successfully addressed the need for a nontapered graft of short length and moderate vessel diameter and allowed for minimally invasive treatment of anatomically complex pathology.

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