Innominate artery lesions: problems encountered and lessons learned

Although unusual, innominate artery lesions may present challenging problems. To classify the wide spectrum of problems requiring operation and elucidate certain principles of management, a series of 71 patients undergoing operation for innominate artery problems over a 20-year period was reviewed retrospectively. Occlusive disease (37 patients) was most common, usually presenting with neurologic or ocular symptoms. Other lesions included innominate aneurysm (three), aortic dissection involving the innominate artery (three), traumatic injuries (five), tracheoinnominate fistula (10), anomalous origin or tortuosity causing tracheal compression (six), involvement in mediastinal tumor or scar (six), and thromboembolus (one). The type of operative repair and mortality rate varied with the nature of the lesion. Overall 38 patients underwent transsternal repair, whereas 12 had extrathoracic bypass, 16 resection and oversewing, and five a pexy procedure. For occlusive disease, direct repair via median sternotomy gave best long-term results with an acceptable mortality rate (3.4%). Shunting was not required. Extrathoracic grafting proved safe but less durable and should be reserved for high-risk patients or special circumstances.