Innominate truncal and arch blowout with left hemiparesis and right hemothorax followed by delayed cheese-wire perforation of innominate graft

We present the case of a 68 year old Caucasian woman, in extremis, with left hemiparesis and right hemothorax, in hypovolemic shock, secondary to a blow-out of a large penetrating ulcer at the junction of innominate trunk and aortic arch. She underwent interposition graft replacement of innominate trunk and repair of aortic arch, on cardiopulmonary bypass, employing total circulatory arrest and selective antegrade cerebral perfusion and had total resolution of hemiparesis. She, however, represented, 6 months later, with threatened exsanguination after a sternal wire cheese-wired through the sternum and perforated the anteriorly lying innominate graft. Following successful repair, she was found to have an old intramural hematoma of distal arch and descending thoracic aorta and changes suggestive of chronic dissection of the whole of abdominal aorta. This was managed conservatively. We believe this patient’s presentation initially with a spontaneous innominate blow-out, cardiogenic shock, hemothorax and hemiparesis, and later with cheese-wire perforation of the innominate graft is unique. Her surgical rescue at both presentations was equally unusual, and without surgical precedent to the best of our knowledge. Was the initial innominate blow-out the result of localised innominate dissection, or more unusually, part of retrograde descending thoracic dissection with skip penetration of innominate artery and sparing of the intervening arch? Was it secondary to the minor fall she had sustained 1 week prior to the event, resulting in a false aneurysm or a contained hematoma next to the innominate artery? More intriguingly, did diffuse aortopathy underpin these diverse etiologies and result in penetrating intimal ulcer with blow out in the innominate artery, intramural hematoma in the arch and descending thoracic aorta and dissection in abdominal aorta at different points in time? We review the current literature for these unusual afflictions of innominate trunk and its origin from the arch of aorta.