A Technique for Safe Redo Sternotomy in Patients with Aortic Proximity to the Sternum

The risk of redo sternotomy is greatly elevated in the setting of aortic proximity to the sternum. Current strategies to avoid catastrophic neurologic injury upon sternal reentry include establishment of peripheral bypass with the use of deep hypothermia and low-flow bypass, both of which may increase risk of neurologic complications. Here, we describe a technique for safe sternal reentry and illustrate its successful use in a patient with close proximity of the aorta to the sternum. With this technique, peripheral cardiopulmonary bypass is established prior to sternal reentry via cannulation of the right axillary artery and femoral vein, and the patient is cooled as the innominate artery is dissected, mobilized, and controlled. This permits the rapid institution of selective antegrade cerebral perfusion (SACP) in the event of aortic injury during sternal reentry. Once the innominate artery is isolated and SACP is initiated, one can safely complete the redo sternotomy, dissection, and distal ascending aortic cross-clamping to continue the operation without interruption in cerebral blood flow. This technique offers a safe approach in select patients and should be utilized in similar high-risk cases.

Blunt Trauma to Brachiocephalic Artery: Presentation and Management

Isolated innominate artery injury is very rare and accounts for less than 3% of recognized arterial injuries. Surgical exploration of the artery, especially at the origin of the artery from the arch of the aorta, is surgically challenging. Due to its rarity, any 1 surgeon’s experience in dealing with innominate artery injury is bound to be limited. We report 2 cases of innominate artery injury post-blunt chest trauma. Both patients underwent thoracotomy and innominate artery Dacron graft repair and both had an uneventful postoperative course.

Subclavian Steal Syndrome Secondary to Atherosclerosis: A Case Report and Review of Literature

Subclavian Steal Syndrome (SSS) is a rare vascular syndrome caused due to proximal occlusion or stenosis of subclavian or innominate artery. It is usually asymptomatic but occasionally may present with vertebrobasilar insufficiency and/or upper limb ischemia. Atherosclerosis is the most common cause.

Partial upper median sternotomy for anterior aortopexy for innominate artery compression syndrome: Our preferred technique.

Objectives: Innominate artery compression syndrome (IAS) is caused by an anterior compression of the trachea by an abnormally originating innominate artery. One option to relieve such a compression is an anterior aortopexy (AA). In this paper we describe our technique of an AA via a partial upper median sternotomy. Methods: A retrospective review of a prospectively maintained database of patients with IAS (July 2017 to November 2020) treated with AA via a partial upper median sternotomy at University teaching hospitals in the US was done. Results: Nine consecutive patients underwent AA for IAS during the study period. The median age was 9 months (IQR 3- 16.5). The male to female ratio was 1.25. All patients had > 70% compression by flexible bronchoscopy. 2 patients had previous surgeries. The follow-up was a median of 6 (IQR 4- 8.5) months. The indications for the operation were: reflex apnea (4/9 patients), recurrent intubation (4/9 patients), and severe stridor (1/9). IAS was a technical success (defined as ≤ 20 % residual stenosis) in 78 % (7/9) of the patients. Complete symptom resolution after an AA was seen in 71% (5/7) of the patients. 2 patients had an unsuccessful AA, requiring a tracheal resection and an innominate artery reimplantation, respectively. Conclusion: An upper partial sternotomy approach provides a very versatile approach to an AA for IAS. Besides facilitating an adequate AA, it provides options for direct tracheal surgery or an innominate artery reimplantation in case an optimal result is not obtained by an AA.

Endovascular Treatment of Innominate Artery Bifurcation Injury with Balloon-Expandable Covered Stents Utilizing Kissing Stent Technique

Major injury of the innominate artery is traditionally treated with an open repair which is technically challenging, associated with large volumes of blood loss and prolonged operative times. Endovascular treatment with covered stent placement across the injury is an attractive alternative. However, placement of a single covered stent across the innominate artery bifurcation into one of its distal branches will not prevent bleeding because of retrograde perfusion from the unstented branch distal to the bifurcation. Here, we report a case of successful endovascular repair of one such injury involving the innominate artery bifurcation with ongoing extravasation into the mediastinum. The injury was successfully treated by utilizing 2 balloon-expandable covered stents placed in kissing fashion from the innominate artery into both of its distal branches. This technique of parallel covered stent placement across a bifurcation could effectively repair bifurcation injuries while maintaining patency of both distal branches.