Journal of Otology & RhinologyISSN: 2324-8785

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Case Report, J Otol Rhinol Vol: 4 Issue: 3

Case Report: Stab Injuries in the Neck Involving the Innominate Artery

Ryohei Akiyoshi, Hiroaki Kanaya*, Wataru Konno, Takashi Kashiwagi, Hideki Hirabayashi and Shin-ichi Haruna
Department of Otorhinolaryngology, Head and Neck Surgery, Dokkyo Medical University, Japan
Corresponding author : Dr. Hiroaki Kanaya
Department of Otorhinolaryngology, Head and Neck Surgery Dokkyo Medical University, Japan,
Tel: +81 282-87-2164; Fax: +81 282-86-5928
E-mail: [email protected]
Received: September 26, 2014 Accepted: February 18, 2015 Published: April 29, 2015
Citation: Akiyoshi R, Kanaya H, Konno W, Kashiwagi T, Hirabayashi H, et al. (2015) Case Report: Stab Injuries in the Neck Involving the Innominate Artery. J Otol Rhinol 4:3. doi:10.4172/2324-8785.1000224

Abstract

Case Report: Stab Injuries in the Neck Involving the Innominate Artery

Isolated innominate artery injuries caused by stab wounds are uncommon, but otolaryngologists may still encounter these injuries. The present report describes the case of an 80-yearold woman with a history of rheumatoid arthritis that was referred to our department after sustaining a stab injury to the innominate artery during a suicide attempt. On admission, she was hemodynamically unstable, and injury to the great vessels was suspected. Urgent surgical exploration through anterior neck incision was performed. Thoracic surgeons were consulted, because there was extensive hematoma in the neck and extending to the thorax with continuous active bleeding. A bleeding point was found in the distal part of the innominate artery, and the defect was immediately sutured with a prosthetic patch. Seven weeks after surgery, the patient presented with continuous oozing of blood from a posttraumatic aneurysm in the proximal part of the innominate artery. Emergent surgery was performed to achieve hemostasis and to replace the aneurysmal lesion with an interposition graft. Unfortunately, she expired intraoperatively due to uncontrollable bleeding. Vascular vulnerability based on systemic rheumatoid inflammation caused the outcome to worsen. Otolaryngologists should be aware that stab injury to the neck can result in death, even if the wound appears minor externally. The importance of diagnostic modalities, and cooperation with thoracic surgeons as well as the difficulty in predicting delayed complications followed innominate artery injury are discussed.

Isolated innominate artery injuries caused by stab wounds are uncommon, but otolaryngologists may still encounter these injuries. The present report describes the case of an 80-yearold woman with a history of rheumatoid arthritis that was referred to our department after sustaining a stab injury to the innominate artery during a suicide attempt. On admission, she was hemodynamically unstable, and injury to the great vessels was suspected. Urgent surgical exploration through anterior neck incision was performed. Thoracic surgeons were consulted, because there was extensive hematoma in the neck and extending to the thorax with continuous active bleeding. A bleeding point was found in the distal part of the innominate artery, and the defect was immediately sutured with a prosthetic patch. Seven weeks after surgery, the patient presented with continuous oozing of blood from a posttraumatic aneurysm in the proximal part of the innominate artery. Emergent surgery was performed to achieve hemostasis and to replace the aneurysmal lesion with an interposition graft. Unfortunately, she expired intraoperatively due to uncontrollable bleeding. Vascular vulnerability based on systemic rheumatoid inflammation caused the outcome to worsen. Otolaryngologists should be aware that stab injury to the neck can result in death, even if the wound appears minor externally. The importance of diagnostic modalities, and cooperation with thoracic surgeons as well as the difficulty in predicting delayed complications followed innominate artery injury are discussed.

Keywords: Stab injuries; Neck; Innominate artery; Post-traumatic aneurysm; Rheumatoid arthritis

Keywords

Stab injuries; Neck; Innominate artery; Post-traumatic aneurysm; Rheumatoid arthritis

Introduction

The innominate artery is the most frequently injured branch of the aortic arch in patients with blunt or penetrating trauma [1,2] and often occurs in association with damage to other thoracic great vessels. By contrast, isolated innominate artery injuries as a result of stab wounds are uncommon [3-6], but otolaryngologists can still encounter innominate artery injuries if wounds involve skin penetration of the neck area. Since life-threatening situations, such as massive bleeding with circulatory collapse, occur after innominate artery injuries, few patients survive long enough to receive medical attention. Survival depends on the clinical status of the patient at the time of admission, prompt and accurate diagnosis, and expeditious exposure and repair. A timely diagnosis is very important, as early diagnosis and treatment may prevent further complications. Past reports of innominate artery repair are limited [3-5]. Although the main treatment strategy relies on open surgical repair with or without prosthetic graft insertion, that strategy is a relatively high-risk procedure. Even if the patient can survive beyond the immediate acute phase, delayed complications, such as post-traumatic aneurysm, can develop [7-10]. The present report describes the case of a patient with innominate artery injury due to a stab injury who subsequently died due to post-traumatic aneurysm related to arterial vulnerability caused by rheumatoid arthritis.

Case History

An 80-year-old Japanese woman with a history of rheumatoid arthritis and mental instability attempted suicide by stabbing herself twice in the neck with a narrow gimlet. She was found lying on the floor by her daughter 7 hours later and was transported to a regional hospital via ambulance. The patient was initially seen by an Emergency Department doctor. Because of her neck swelling and respiratory distress, urgent intra-tracheal intubation was performed. The patient was subsequently referred to our department for further evaluation and treatment.
On arrival, the patient was intoxicated and hemodynamically unstable. Physical examination revealed pulse deficits and a swollen neck. Two pinholes were seen on her frontal neck adjacent to cricoid cartilage, and great vessel injury was suspected (Figure 1). Although there was no active extravasation that could be observed by external inspection, there was concern for acute rupture with massive bleeding.
Figure 1: External signs in a patient with a stab injury to the frontal neck. Two closed pinholes on a swollen neck (arrows) is seen with extensive subcutaneous hemorrhage.
Enhanced computed tomography (CT) scan images of the neck showed a large, dumbbell-shaped hematoma highly suggestive of extravasation from a penetrating injury to the great artery. She was emergently taken to the operating room for repair of a suspected injury to the great vessels. As the hematoma was present anterior and to the right of the trachea, bleeding from innominate artery was suspected (Figure 2). Emergent surgical exploration through an anterior neck incision was performed. There was extensive hematoma in the neck and extending to the thorax with continuous active bleeding.
Figure 2: Enhanced computed tomography scan demonstrates a large, dumbbell-shaped hematoma (asterisk) in front of trachea. Hematoma is present at the position corresponding to the innominate artery (horizontal view; left, coronal view; right). IA; innominate artery, CA: carotid artery, SA: subclavian artery, AA: aortic arch, JV: jugular vein.
Intraoperatively, her systolic blood pressure gradually decreased to less than 50 mmHg, and she suffered cardiac arrest. We performed cardiac resuscitation in the operating room. After her revival, the incision was extended to the thorax to clarify which artery was bleeding. There was a large amount of hematoma in the thorax. We ultimately found a hemorrhagic point at a distal portion of the innominate artery. Grossly, the vessel wall of surgically explored innominate artery was noted to be thin and friable. Vascular surgeons were consulted, and they sutured the defect in the innominate artery with a prosthetic patch. The operation was successfully completed.
Seven weeks after the operation, the patient developed continuous oozing of blood from the injury site. CT scan with three-dimensional reconstruction showed a post-traumatic aneurysm of 1 cm in diameter in the proximal part of the innominate artery (Figure 3), which was thought to be a hemorrhagic point. This finding strongly suggested that the tip of the gimlet had reached just into vascular intima and media, resulting in subclinical disruption. An emergent surgery was performed to achieve hemostasis and to replace the aneurysmal lesion with an interposition graft. Unfortunately, the patient died intraoperatively due to uncontrollable and massive bleeding while performing bypass grafting from the aorta to the distal innominate artery before entering the hemorrhagic lesion.
Figure 3: Three-dimensional computed tomography scan shows aneurysm formation of 1 cm in diameter (arrow) in the proximal part of the innominate artery. A patch was used to repair the injury of the distal part of the vessel (arrowhead).

Discussion

Isolated innominate artery stab injury is uncommon, and few surgeons have experience with this injury. The majority of arterial injuries involving the innominate artery are gunshot wounds during military action, and, in civilian cases, have accounted for only up to 3.2% of recognized arterial trauma [3]. Johnston et al. [4] reviewed 43 patients with innominate artery injuries over a 30-year period and reported that penetrating injuries were from stab wounds in seven patients, which was associated with a 42% mortality rate. Penetrating injury involving the innominate artery secondary to neck trauma is a challenging clinical problem for any otolaryngologist if wounds only involve skin penetration of the neck area. The neck is an area of complex anatomy that contains many vital structures (e.g., great vessels, the trachea and the cranial nerves) within millimeters of one another, and the initial treatment and stabilization of the patient with neck injury is of maximum priority. Our patient had two pinholes on the frontal neck below the cricoid cartilage line. Three zones have been classified for evaluation of penetrating neck trauma. Thal et al. [11] stressed that the location of organ damage (e.g., to the great vessels of the neck and chest) can be anticipated based on the position of the injury. Zone I extends between the clavicles and the cricoid cartilage, and injuries to this zone carry the highest mortality because of vascular injury, including injury to the innominate artery. Therefore, cases of neck injury such as ours, whereby a patient presented with two small stab pinholes in the neck, are considered high risk and have a mortality rate.
A rapid diagnosis should be made based on detailed description of the mechanism of injury, and the diagnosis should be confirmed by imaging. Hemodynamically stable patients usually should undergo expedient digital subtraction angiography. The use of contrastenhanced CT angiography in the evaluation of penetrating neck injuries has obvious advantages and is being more frequently used by many medical institutions. Du Toit et al. [12] reviewed diagnostic modalities to assess the innominate artery and stated that they were not yet convinced that CT angiography can replace conventional digital subtraction angiography as the optimal diagnostic method. They pointed out that digital subtraction angiography can reliably diagnose clinically silent injuries. On the other hand, Offiah et al. [13] stated that multi-slice CT angiography is the first-line imaging modality for penetrating neck trauma, because that modality accurately demonstrates the various vascular injuries (e.g., pseudoaneurysm formation, intimal injury, dissociation and active bleeding). We used CT angiography for diagnosis because our patient was hemodynamically unstable and required immediate surgery. As a result, the possibility of post-traumatic aneurysm followed by small intimal or medial disruption was not appreciated.
Vascular repair techniques [3-6,12] can consist of endovascular repair, patch angioplasty, primary end-to-end anastomosis or placement of a prosthetic graft. Ligation is usually reserved for situations in which other maneuvers are not possible. Du Toit et al. [13] analyzed 39 cases of innominate artery injuries that were treated surgically; the survival rate was 79% (31 cases). In our case, initial repair of a penetrating lesion in the distal part of the innominate artery was successfully done using surgical suture with a prosthetic patch, but post-traumatic proximal aneurysm was observed after the initial surgery.
Delayed complications, such as post-traumatic aneurysm due to maturation of pseudoaneurysm, can occur a few weeks after injury [8,9]. In fact, post-traumatic innominate artery aneurysms need to be surgically corrected to prevent rupture, embolism, thrombosis, and compression of vital structures. In many instances this can be accomplished by saphenous vein patch or interposition graft, and for complex cases, a prosthetic graft may be ideal [6]. Patients with rheumatoid arthritis have an increased risk of morbidity and mortality due to cardiovascular disease [14,15]. This may be due to complex interactions between systemic rheumatoid inflammation in blood vessels and the vasculature. Increased vascular stiffness due to intimal and medial thickening and accelerated atherosclerotic development in endothelium result in vascular vulnerability in patients with rheumatoid arthritis. We were unfortunately not able to save our patient from the delayed complication arising from subclinical damage. Otolaryngologists should be aware that the severity of stab injuries to the neck varies by the depth of the wound and may result in death even if the wound appears minor externally. To reduce the risk of death related to delayed complications, cooperation with thoracic surgeons is vital.

Ethical Approval

Due to severe clinical course, it was impossible to obtain written informed consent from the patient and her kin. The author obtained approval for publication of this case report by ethics committee of our institution.

Acknowledgments

The authors thank Dr. Ikuko Shibasaki (Department of Thoracic Surgery) for her precise and confident decision for therapeutic planning in this case.

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