Delayed Traumatic Aortic Arch Pseudoaneurysm with Aorto-Innominate Fistula: A Hybrid Repair

Introduction: Pseudoaneurysms of the aortic arch with aorto-innominate fistulas are very rare, especially when they present long after the initial trauma. We report a case of a silent traumatic fragmentation injury that manifested 4 years later as a high-flow fistula. Case Report: The 33-year-old active-duty soldier presented with complaints of dyspnea during exertion, as well as finding of a palpable thrill located in the left infra-clavicular area. He sustained a shrapnel wound to the chest approximately four years ago. A large pseudoaneurysm was found located at the aortic arch and originated from just distal to the left subclavian artery (LSA). A pseudoaneurysm was also identified that created a fistulous communication between the aortic arch pseudoaneurysm and the left brachiocephalic vein. Due to the complex nature of this case a hybrid surgical technique was used. The patient underwent a left carotid-subclavian bypass and a left subclavian artery (LSA) ligation. The patient then underwent TEVAR. During the TEVAR procedure, a stent-graft was placed in Zone 2. The postoperative images confirmed that there was no further blood flow into the excluded pseudoaneurysm and ceased the fistulous flow. Conclusion: Low velocity fragmentation injuries can result in containable vascular damage that may remain asymptomatic for many years. One of the most important clues to diagnose these types of injuries is the presence of a palpable "thrill." Hybrid supra-aortic debranching using TEVAR provides a safe and durable solution to complex arch pathology, thereby eliminating the morbidity associated with open repair.