Total endovascular repair of post-trauma ascending aortic pseudo-aneurysm and secondary superior vena cava syndrome.

Structured Abstract Introduction Clavicular fracture or sterno-clavicular luxation are observed in 10% of all polytrauma patients and are frequently associated with concomitant intra-thoracic life-threatening injuries. Posterior sterno-clavicular luxation is well known to induce underlying great vessels damage. The gold standard treatment usually is a combined orthopedic and cardiovascular surgical procedure associating vascular repair, clavicular open reduction and internal fixation. Material and methods A 59 year-old wheel-chair ridden, institutionalized woman, known for psychiatric disorder, severe scoliosis, malnutrition and chronic obstructive pulmonary disease was admitted in our hospital for chronic chest pain three months after a stairway wheelchair downfall. A thoracic CT-Scan revealed a voluminous ascending aortic pseudo-aneurysm (63x58mm, orifice 5mm) consecutive to perforation following posterior sterno-clavicular luxation. The patient refused all therapies and was lost to follow-up. Six months later, she was re-admitted for a symptomatic superior vena cava syndrome. Thoracic CT-Scan revealed pseudo-aneurysm growth with innominate vein thrombosis and superior vena cava sub occlusion. Pseudo-aneurysm orifice was stable. In the presence of symptoms with massive facial edema and inability to open her eyelids, the patient accepted an endovascular treatment. Results The procedure was performed under general anesthesia using both fluoroscopic and transesophageal echocardiographic guidance. Through a femoral arterial access, a 10mm atrial septal defect occluder device was used to seal successfully the pseudo-aneurysm orifice. The superior vena cava was then opened with a 26mm nitinol high radial force stent through a femoral venous access. Post-operative course was uneventful. At three-month follow-up the patient remains symptom free and a CT-Scan confirmed pseudo aneurysm thrombosis and superior vena cava permeability. Discussion Post traumatic sterno-clavicular posterior luxation is a cause of great vessels and ascending aorta injuries. Minimally invasive endovascular approaches can be considered to treat vascular injuries and their consequences, especially in elderly patients and those at high risk for surgery.