Aortic Surgery by Mike Poullis

Case 2

Unstable Angina - Previous RTA

A 50 year old gentleman presents with unstable angina. His CXR shows an obvious aneurysm at the distal aspect of the arch of the aorta. further questioning reveals a previous RTA 20 years ago, with a significant deceleration injury but no specific injuries found at the time. His coronary anatomy is unsuitable for stenting. What would you do ?

It depends how unstable his unstable angina is. A CT scan would be very helpful. The CT scan revealed that he had a classic false aneurysm at the site of the missed traumatic rupture of the aorta. In the setting of unstable angina simultaneous surgical attempts to dealing with the false aneurysm would probably be unnecessarily risky.

Surgical options include:

CABG and aortic stent or CABG and aortic surgery

CABG, but don't use the LIMA, in case the left subclavian has to be clamped or stented across while dealing with the false aneurysm at a second procedure.

Depending on the possible proximal and distal landing site lengths, at the time of CABG to increase the proximal landing site, you may need to perform an extra anatomical bypass from ascending aorta to left carotid (images "A"). The origin of the left carotid should be tied off to prevent an endoleak occurring when a stent is placed at a second procedure. The left subclavian can be embolised if it causes an endoleak after stent placement.