Abstract Objective To perform a preliminary investigation of a rare case of retrograde tearing of a branch artery entrapment of the head and arm into the aorta. Methods Three patients, one with idiopathic carotid artery entrapment and two with medically induced subclavian artery entrapment, were recently admitted and operated on, all of whom were operated on after conservative treatment had failed, using endoluminal treatment and surgical bypass surgery methods, respectively. The patients’ postoperative pain improved significantly, and postoperative follow-up CTA showed stable cephalobrachial artery entrapment with pseudoluminal thrombosis. Discussion Both endoluminal treatment and open surgery are possible methods for cephalobrachial artery entrapment involving the aorta.
Keywords aneurysm; entrapment; surgery; endoluminal treatment
CIG Classification Number: Literature Identifier:A Article Number:
The treatment of brachiocephelic artery dissection involving aorta
JIA Xin, GUO Wei, LIU Xiao-ping, YIN Tai, ZHANG Hong-peng, ZHANG Guo-hua, LIANG Fa-qi Department of Vascular Surgery, PLA General Hospital, Beijing 100853, China
Corresponding author: Guo Wei Email:[email protected]
Abstract Objective brachiocephlic artery dissection involving aorta is rare compared with aorta dissection. three patients of brachiocephlic artery dissection were operated in our center and the experience was presented and related literature was reviewed. methods one carotid dissection and two iatrogenic subclavicle artery dissection are included in this group. after medication therapy had failed, we tried endovascular repair and surgical bypass on these patients. results all the patients felt pain relief after the procedures, and CT scans were performed during follow-up with satisfying results. conclusion endovascular and suigical repair are both feasible approach for the treatment of brachiocephelic artery dissection involving aorta.
Key words : aneurysm; dissection; surgical procedures; endovascular repair
The majority of arterial dissections occur in the aorta, while those in the cephalic branch arteries (carotid and subclavian arteries) are relatively uncommon. In this paper, we retrospectively summarize and analyze the treatment experience of this group of cases with the aim of guiding future treatment.
Materials and methods
Case 1 Male, 65 years old, was admitted to the hospital with chronic chest and back pain with left-sided limb weakness for 3 months. CTA examination was performed, and the preliminary diagnosis was aortic coarctation involving the bifurcation of the right common carotid artery, about 80% stenosis of the right internal carotid artery, patency of the right external carotid artery, and about 90% severe stenosis at the beginning of the left internal carotid artery. The aortic entrapment tears down to the bilateral iliac arteries, and all internal arteries are supplied with true lumen.
Case 2 Female, 75 years old, admitted to the hospital with chest pain for 1 month after coronary angiography. The patient underwent coronary angiography 1 month ago and punctured the right brachial artery. During the angiography, sudden tearing-like pain in the back of the chest was observed, and aortography was performed, which revealed that the patient was a vagal right subclavian artery with its root originating from the left descending aorta, and a right subclavian artery entrapment was formed and torn retrogradely to the aorta.
Case 3 Male, 70 years old, diagnosed with left subclavian artery occlusion due to vertigo for 1 year, underwent interventional treatment with puncture from the left brachial artery, the guidewire failed to pass through the occluded segment of the subclavian artery, and the operation was terminated with sudden tear-like pain in the thoracic back during the operation. The first rupture was located at the root of the left subclavian artery and the proximal retrograde tear to the aorta.
2. Treatment strategy selection Case 1 was admitted to the hospital with a diagnosis of aortic coarctation involving the right carotid artery, but intraoperative imaging failed to detect the first rupture of the aortic coarctation. Later, the contrast catheter was guided to the bifurcation of the right common carotid artery for low-pressure imaging, and it was found that the contrast agent entered the false lumen and rapidly flowed into the aorta, which should be a retrograde tear of the coarctation of the common carotid artery into the aorta. The patient’s right internal carotid artery was completely occluded while the external carotid artery was open, the left internal carotid artery was severely stenosed at the beginning, and the right cerebral hemisphere was supplied by the left cerebral artery. Therefore, one 7/4 self-expanding stent (Precise) was placed in the left internal carotid artery first to ensure blood supply to the brain, and then one 8/4 stent-type vessel (Wallgraft) was placed in the right common carotid artery, distal to the right external carotid artery, to completely close the first breach of the entrapment. See Figure 1
Case 2 was a medically induced entrapment caused by coronary angiography, and the first breach was located at the beginning of the vagal right subclavian artery. A right brachial artery puncture angiogram was used to localize the site, and then one 8/4 stent type vessel (Wallgraft) was applied by femoral artery puncture and released at the root of the right subclavian artery to successfully close the breach. See Figure 2
Case 3 was also a medically induced entrapment, with the first breach located in the occluded left subclavian artery. An open procedure was performed with an axillary-axillary artery artificial vessel bypass, and the left subclavian artery was ligated proximally to the vertebral artery to close the clamping rupture.
Results
The immediate intraoperative angiography showed good closure of the false lumen with no contrast development in this group of cases, and the patients complained of significant pain relief after surgery and were discharged from the hospital. The follow-up was 24, 36 and 42 months, respectively. The follow-up CTA showed that two stent-type vessels and one artificial vessel graft were open, the true lumen of the cephalic brachial artery entrapment was well shaped, and the thrombosis in the false lumen of the aorta and cephalic brachial artery was formed.
Discussion
The etiology of cephalobrachial artery entrapment is still unclear. Part of it is spontaneous and may be related to the weakness of the vessel wall caused by atherosclerosis or inflammation; and part of it is caused by external factors, including the breakage of the vessel wall caused by medical factors. Case 1 in this group was a common carotid artery entrapment with no clear history of trauma, which may have been spontaneous. Case 2 and case 3 are both cases of subclavian artery entrapment caused by medical origin factors, and both occurred during retrograde puncture intervention from the brachial artery, with the entrapment retrograde tear reaching the aorta. Once cephalobrachial artery entrapment occurs, it should first be treated conservatively with strict control of blood pressure and heart rate, and standardized application of anticoagulation and antiplatelet drugs to prevent true intracavitary thrombosis. After regular conservative treatment, most cases can not continue to develop and the prognosis is good. If anticoagulation is contraindicated and anticoagulation and antiplatelet therapy cannot be performed, or if conservative treatment is ineffective for further development of the entrapment, surgical treatment should be performed.
There are two options for treatment of head and arm branch artery entrapment: open surgery and endoluminal treatment. The main purpose of endoluminal treatment for aortic coarctation is to close the first breach, reduce the pressure in the false lumen, and promote true lumen remodeling and thrombus formation in the false lumen, and the same treatment idea can be applied to cephalobrachial artery coarctation. Case 1 in this group of patients was an idiopathic carotid artery entrapment with complete occlusion of the internal carotid artery, and the ipsilateral cerebral blood supply was supplied by the external carotid artery through a collateral branch. If open surgery is used to repair the entrapment, the carotid artery will have to be blocked and the ipsilateral cerebral blood supply will be affected, and the risk of stroke will increase accordingly. In contrast, endoluminal treatment requires only one stent-type vessel to cover the interstitial rupture, which is more convenient and does not require blocking the carotid artery, and the risk of surgery is greatly reduced. In case 2, the lesion is a vagus artery with a root from the descending aorta, so if open surgery is used, it requires open-heart surgery and extracorporeal circulation, which is very traumatic. If open surgery is used, open thoracotomy and extracorporeal circulation will be required, which is very traumatic, but the endoluminal treatment can be done under local anesthesia with only one stent type vessel. Case 3 was a complication caused by the failure of endoluminal treatment. Although interventional embolization of the subclavian artery could also be used to treat the entrapment, the problem of vertebral artery blood theft could not be solved at the same time.
The most reliable method is to rotate the angles of the angiogram intraoperatively so that the angle of projection is tangential to the incision, which can clearly show the location of the incision and the direction of blood flow. A contrast catheter can also be placed near the rupture and a low-pressure contrast can be performed to determine the direction of blood flow from the flow direction of the contrast agent, thus distinguishing the entrance and exit of the false lumen.