Changing Profiles of Diagnostic and Treatment Options in Subclavian Artery Aneurysms

[Endovascular treatment of intra-thoracic left subclavian artery aneurysm]

Aneurysms of the subclavian artery are rare, and remain asymptomatic until complications. We report one case of atherosclerotic aneurysm of the proximal portion of the left subclavian artery fortuitously discovered and successfully treated by endovascular stent graft. This case report aims to illustrate endovascular procedures in the management of difficult access lesions or in high-risk surgical patients.

Hybrid Repair of Proximal Subclavian Artery Aneurysm

OBJECTIVE

Conventional open repair for proximal subclavian artery aneurysms (SCAAs) requires cardiopulmonary bypass. However, patients with proximal SCAA can be treated with hybrid repair.

METHODS

Between 2007 and 2012, we performed hybrid repair to treat six consecutive patients with proximal SCAA (three left SCAAs, one right aberrant SCAA, two right SCAAs). Their median age was 73.5 [70-87] years, and the size of their aneurysm was 33.5 [30-45] mm. Thoracic endovascular aneurysm repair (TEVAR) only was used for one patient with left SCAA, TEVAR and supra-aortic bypass for two with left SCAA and one with right aberrant SCAA, and endovascular repair with reconstruction of the vertebral artery using the saphenous vein graft (SVG) for two with right SCAA.

RESULTS

The follow-up duration was 3.7 [0.2-6.8] years. There was no 30-day mortality and only one early complication consisting of a minor stroke after TEVAR for shaggy aorta. Two late deaths occurred, one caused by cerebral infarction due to occlusion of SVG to the dominant vertebral artery 2 months after the operation and the other by aortic dissection 5 years postoperatively.

CONCLUSIONS

Hybrid repair can be a less-invasive alternative for proximal SCAA. Revascularization of neck vessels and TEVAR should be performed very carefully to prevent neurologic complications.

Endovascular treatment of ruptured subclavian artery aneurysm presented with hemoptysis

Ruptured subclavian artery aneurysm (SAA) is extremely rare and it can cause a life-threatening condition. We described an elderly patient with ruptured SAA who underwent endovascular treatment successfully. Our case showed that endovascular repair may be one of the options for the treatment of ruptured SAA when surgical repair is impossible or not indicated for its difficulty. <Learning objective: How to manage ruptured subclavian artery aneurysm by endovascular therapy.>.

Long-term outcome after surgical and endovascular management of true and false subclavian artery aneurysms

Subclavian artery aneurysm is a rare but serious disease due to the risk of thrombosis, embolization, rupture and compression of adjacent structures. Treatment consists of surgical and endovascular techniques. Up to now few long-term follow-up results have been reported. In our study the results from 15 patients treated for subclavian artery aneurysms were evaluated. Eleven patients underwent open surgical reconstruction, four patients were treated endovascularly. After a mean follow-up period of 77 months (83 months for the open surgical group, 38 months for the endovascular group), 10 of 11 open surgical reconstructions and all primarily implanted stent grafts were patent. Secondary intervention was necessary in two patients. Thirty-day mortality for both treatment groups was 0%. Subclavian artery aneurysm-related symptoms disappeared in six out of 10 patients after the treatment. Long-term outcomes with good technical results, patency rates and low periprocedural morbidity could be shown in both treatment groups.

Subclavian artery aneurysm in a patient with vascular Ehlers-Danlos syndrome

We describe our experience of surgical treatment in a 28-year-old woman with vascular Ehlers-Danlos syndrome. A right subclavian artery aneurysm was detected. The right vertebral artery arose from the aneurysm. Digital subtraction angiography showed interruption of the left vertebral artery. The aneurysm was excised and the right vertebral artery was anastomosed end-to-side to the right common carotid artery under deep hypothermia and circulatory arrest. The patient remained very well 4 years after surgery, with no late vascular complication.

Successful treatment of a ruptured subclavian artery aneurysm presenting as hemoptysis with a covered stent

An aneurysm of the subclavian artery is rare. Recently, we experienced a case of a ruptured subclavian artery aneurysm presenting as hemoptysis. The patient had experienced atypical chest discomfort, and computed tomography (CT) revealed a small aneurysm of the left subclavian artery (SCA). Hemoptysis occurred 2 weeks later. Follow-up CT showed a ruptured aneurysm at the proximal left SCA. Endovascular treatment with a graft stent was performed by bilateral arterial access with a 12-Fr introducer sheath placed via cutdown of the left axillary artery and an 8-Fr sheath in the right femoral artery. A self-expandable Viabahn covered stent measuring 13×5 mm was introduced retrogradely via the left axillary sheath and was positioned under contrast guidance with an 8-Fr JR4 guide through the femoral sheath. After the procedure, hemoptysis was not found, and the 3-month follow-up CT showed luminal patency of the left proximal SCA and considerable reduction of the hematoma.

Peripheral arterial aneurysms: open or endovascular surgery?

Peripheral arterial aneurysms are uncommon; for some aneurysm types, data are limited to case reports and small case series. There is no Level A evidence in most cases to determine the choice between open or endovascular intervention. The evolution of endovascular technology has vastly improved the armamentarium available to the vascular surgeon and interventionalists in the management of these rare and unusual aneurysms. The choice of operative approach will ultimately be determined on an individual basis, dependent on the patient risk factors, and aneurysm anatomy. After consideration, some aneurysms (femoral, subclavian, carotid and ECAA) fare better with an open first approach; renal, splenic and some visceral artery aneurysms do better with an endovascular first approach. In our practice PAAs are treated with an endovascular first approach. For these rare conditions, both open and endovascular therapy will continue to work in harmony to enhance and extend the capabilities of modern surgical management.

Subclavian artery aneurysms: management implications in a resource-limited setting

Subclavian artery (SA) aneurysms (SCAA) are relatively uncommon but carry a significant risk of rupture, thrombosis and embolism if left untreated. We describe the etiology, mode of presentation and outcome of surgical management of 10 patients presenting with SCAA between January 1990 and December 2010. The mean age was 43.7 years. There were seven men and three women. Five patients had aneurysms due to trauma, four had it due to thoracic outlet syndrome and one had it secondary to atherosclerosis. Five patients presented with ischemic symptoms of the distal upper extremity, while the rest presented with a pulsatile neck mass. All patients were treated surgically. Six patients were approached with combined supra- and infraclavicular incisions. Aneurysm resection with reconstruction using saphenous vein or synthetic grafts was done in eight patients. There was no perioperative mortality. The early patency rate was 100%. Surgical treatment is effective and recommended for most patients with SCAA.

Surgical reconstruction for intrathoracic aneurysm originating from proximal part of the right subclavian artery

Subclavian artery aneurysms are comparatively rare in peripheral aneurysms. We experienced a case of intrathoracic aneurysm originating from the proximal part of the right subclavian artery. A 78 year-old man was referred to our hospital with the diagnosis of a right subclavian artery aneurysm. Enhanced computed tomography demonstrated an intrathoracic aneurysm, originating from the right subclavian artery just proximal of its origin. Through a median sternotomy and supra-infraclavicular incision, we reconstructed the brachiocephalic and right common carotid arteries and bypassed to the distal part of the right subclavian artery by using a T-shaped vascular graft and the aneurysm was excluded.

A case of atherosclerotic aneurysm of the right subclavian artery with the right axillary arterial stenosis and enlargement of the ascending aorta

A 54-year-old man presented with neck pain and hoarseness. Angiography showed a rare right subclavian artery aneurysm, enlargement of the ascending aortic aneurysm, and axillary artery stenosis. These aneurysms would normally be treated with end-to-end anastomosis, but due to the complexity of the lesion in this case, we performed more extensive surgery. This consisted of successful reconstruction of the subclavian artery and replacement of the ascending aorta and aortic arch.