Case
A 38-year-old Jehovah’s Witness female with situs inversus totalis, restrictive cardiomyopathy and end stage renal failure was referred to our hospital for evaluation for heart failure therapy. She complained of progressive dyspnea on exertion, palpitations and orthopnea. Her condition was diagnosed as acute decompensated biventricular heart failure. Her hemodynamic data was as follows. Central venous pressure was 18 mmHg, mean pulmonary artery pressure was 50 mmHg, pulmonary capillary wedge pressure was 38 mmHg and her cardiac index was 1.7 L/min/m2. An axillary IABP was considered to be a good option for circulatory support, which would allow her to perform physical therapy actively during evaluation for the next phase of her care. Initially, her IABP insertion was successfully performed through her right axillary artery in a percutaneous fashion (Figure 1A). Of note, her right axillary artery is the third cervical branch from aorta(first branch; left brachiocephalic artery, second branch; right common carotid artery). However, the IABP kinked and ruptured three days later(Figure 1B). While we tried to exchange it in the operating room, she suddenly complained of acute back pain and difficulty breathing. She remained hemodynamically stable, but we were concerned about a possible aortic complication. The IABP insertion was deferred and she was taken for a computed tomography angiography(CTA). CTA demonstrated a descending thoracic aortic rupture and contrast extravasation at the take-off of the right vertebral artery from the right axillary resulting in a large hematoma behind the trachea(Figure 2A,B,3A,B). The trachea was significantly compressed by the hematoma(Figure 2A). Open descending aorta replacement was considered to be too invasive as she refused any blood transfusion and was anemic(10.5mg/dl). Therefore, thoracic endovascular aortic repair(TEVAR) was felt to be a reasonable treatment modality. Under general anesthesia, a 22×100 mm Valiant Navion Covered Seal device(Medtronic Corp,Santa Rosa,CA) was selected and deployed from just distal to the right subclavian artery. Moreover, coiling of the right vertebral artery and placement of a 7mm×50mm Viabahn covered stent(WL Gore & Associates,Flagstaff,Ariz) into the right axillary artery was successfully performed without any need for blood transfusion. Her postoperative course was stable and her heart failure improved as well.
Although her hemoglobin level decreased to 6.7mg/dl four days after the rupture, it returned to baseline one month later. A postoperative CTA demonstrated resolution of the extravasation and improvement of the hematoma behind the trachea(Figure 2C,D, 3C,D).