Repair of Innominate Artery Injuries with a Modified Endovascular Graft

Innominate artery injuries, including tracheoinnominate artery fistula (TIF) are rare but associated with significant morbidity and mortality. Traditionally, these and other arch branch vessel injuries have been treated with open surgical repair via a sternotomy, which can be challenging in emergency situations, redo sternotomy, or both. Endovascular techniques are now used to treat a variety of arterial injuries. However, no stent grafts are specifically designed for repair of the arch vessels. We describe two patients in which Zenith® Iliac limb extension stent grafts were modified for repair of innominate artery injuries. The first patient is a 46-year-old man who sustained an iatrogenic injury to the innominate artery during insertion of a port for chemotherapy. The second patient is a 64-year-old woman who suffered a cerebrovascular accident complicated by locked-in syndrome. A TIF developed 6 weeks after a tracheostomy was performed. Both patients had undergone prior sternotomy and were hemodynamically unstable. Challenges included the need for a midrange diameter, short-length, and nontapered device. A Zenith® iliac leg extension (ESLE) was chosen and modified to the appropriate length by removing one of the three Z stents. The modified stent was deployed retrograde from the right common carotid artery to address delivery system length and tortuosity. In both cases a completion angiogram demonstrated exclusion of the injury and good flow to the carotid and subclavian vessels. The first patient had an uneventful postoperative course. A computed tomography (CT) angiogram on postoperative day 1 demonstrated no leak. The second patient underwent laryngoscopy, which demonstrated a tracheal ulceration distal to the vocal cords through which the stent graft was visualized. The tracheal defect was subsequently repaired with a sternocleidomastoid myocutaneous flap. The patient was ultimately discharged to a rehabilitation facility with a healed TIF and improved neurologic status. Currently, there are no covered stents designed or labeled for the treatment of innominate artery injuries. We describe the successful repair of two innominate injuries in patients at high risk for open repair with an off-label modified endovascular graft.