Atherosclerotic aneurysm of the intrathoracic subclavian artery: a case report and review of the literature

Surgical Outcome of Proximal Isolated Subclavian Artery Aneurysms: A Single-Center Retrospective Observational Study

OBJECTIVE

The objective of this study was to introduce our institutional experience of treatment strategies (cervical subclavian artery reconstruction, thoracotomy subclavian artery reconstruction and endovascular treatment) for proximal isolated subclavian artery aneurysms (PISAAs).

METHODS

we retrospectively analyzed 15 consecutive patients with PISAAs treated by different treatment strategies (cervical reconstruction, thoracotomy reconstruction and endovascular treatment) in our institution from May 2016 to May 2022. Baseline data, surgery-related data, postoperative information and long-term follow-up were assessed.

RESULTS

A total of 17 PISAAs in 15 consecutive patients were treated in our institution. The success rates of subclavian artery reconstruction in the cervical reconstruction, the thoracotomy reconstruction and the endovascular treatment were 100%, 100 and 83.33%, respectively. About the involved vertebral artery, the reconstruction rates in the cervical reconstruction, the thoracotomy reconstruction, and the endovascular treatment were 80%, 75%, and 0, respectively. The intraoperative blood loss in the thoracotomy reconstruction was significantly higher than that in the cervical reconstruction and the endovascular treatment (p<0.05). The total operation time of the thoracotomy reconstruction was significantly longer than that of the cervical reconstruction and the endovascular treatment (p<0.05). In terms of postoperative ventilator use time, total postoperative drainage fluid, total postoperative drainage time, and ICU duration, both the thoracotomy reconstruction and the cervical reconstruction were significantly more than the endovascular treatment (p<0.05). During the follow-up, one patient in the endovascular treatment underwent re-intervention 22 months after surgery due to in-stent occlusion.

CONCLUSIONS

For patients with PISAAs, different treatment strategies are recommended depending on the size of the aneurysms and whether the involved vertebral arteries require reconstruction.

CLINICAL IMPACT

This article is the largest study on the treatment strategies of PISAAs. By comparing the prognosis and complications of endovascular treatment with those of open surgery, it provides a certain reference basis for the choice of treatment for patients with PISAAs. For patients with aneurysms' diameter of >50 mm, the thoracotomy subclavian artery reconstruction is recommended; for patients with aneurysms' diameter of <30 mm requiring reconstruction of the involved vertebral arteries, the cervical subclavian artery reconstruction is recommended; for patients with aneurysms' diameter of <30 mm not requiring reconstruction of the involved vertebral arteries, the endovascular treatment is recommended.

Iatrogenic giant subclavian artery pseudoaneurysm following clavicle fracture repair: A case report

Subclavian artery aneurysms are infrequently observed in clinical settings, and are divided into intrathoracic and extra-thoracic segments. Atherosclerosis, cystic necrosis of the tunica media, trauma, or infections are more common. Blunt trauma or piercing is more frequently the cause of pseudoaneurysms, and broken bones following surgery should be evaluated. A 78-year-old woman attended the vascular clinic with a closed mid-clavicular fracture due to plant trauma before 2 months. Physical examination revealed a well-healed wound and no palpable pain, but a massive pulsating mass with normal overlying skin in the superior side of the clavicle. Thoracic CT angiography and a neck ultrasound revealed a distal right subclavian artery pseudoaneurysm of 50 × 49 mm. Arterial injuries were repaired by a ligature and bypass. The recovery from surgery was successful, and a 6-month follow-up examination revealed a right upper limb that was symptom-free and well-perfused.

Endovascular treatment with an iliac branch endoprosthesis for a right subclavian artery aneurysm

Subclavian artery aneurysms are rare peripheral artery aneurysms, and open surgical repair is the reference standard treatment. We have reported the case a patient with a right subclavian artery aneurysm who was not indicated for open surgical repair because of comorbidities. Thus, endovascular treatment using the Gore Excluder Iliac Branch Endoprosthesis (WL Gore and Associates, Flagstaff, Ariz) was performed, leading to complete aneurysmal exclusion without perioperative complications. Although anatomic limitations exist, this technique could be alternative treatment option for right subclavian artery aneurysms.

Claviculectomy for exposure and redo repair of expanding, recurrent right subclavian aneurysm

Subclavian artery aneurysms (SAAs) are rare, and their repair can be technically complex. We have reported the redo repair of a large, expanding, right SAA after primary repair consisting of total aortic arch replacement with bilateral subclavian artery ligation and bypass. The redo repair used claviculectomy to facilitate exposure, ligation of the right deep cervical and internal thoracic arteries from within the aneurysm sac, and revision of the previous axillary artery bypass that had thrombosed owing to the mass effect of the expanding SAA. Claviculectomy can facilitate repair of large SAAs that are poorly suited to more routine exposure approaches, with acceptable risk and functional outcomes.

Isolated True Subclavian Aneurysm without Aberrant Subclavian Artery or Coarctation of Descending Aorta

OBJECTIVE

Isolated true subclavian artery aneurysm (SAA) without aberrant subclavian artery or coarctation of descending aorta is a rare peripheral aneurysm. Herein, the experience of our medical center in the treatment of this disease is presented.

METHODS

The Division operative log was queried to identify cases of SAA repair between January 2012 and September 2019 that were not associated with coarctation of the aorta or the presence of an aberrant subclavian artery. A total of 22 cases were identified. The characteristics, treatment and clinical outcomes of these cases were assessed.

RESULTS

The mean age of patients was 53.5 ± 14.3 years and 14 patients were male (63.6%). Half of the cases were attributed to atherosclerotic degeneration. The clinical symptoms of aneurysms were varied, including asymptomatic, pulsatile mass of supraclavicular fossa, local pain, upper limb embolism, Horner's syndrome and hoarseness. Aneurysms were located on the right in 17 cases, on the left in 3 cases and on both sides in 2 cases. Fifteen (68%) patients underwent an intervention, of which 11 (50%) underwent an open surgical repair, and 4 (18%) underwent endovascular repair. The mean diameter of the aneurysms was 39.5 ± 20.7 mm in the open surgery group, and 24.0 ± 4.7 mm in the endovascular group. The follow-up duration ranged from 2 months to 12 years. One patient died of cardiogenic disease in the untreated group. Patients undergoing open operative repair had 100% patency of the reconstruction. In the endovascular group, one patient had stent occlusion 2 years after the operation.

CONCLUSIONS

The most common cause of isolated subclavian aneurysm without aberrant subclavian artery or coarctation of descending aorta is atherosclerosis. The clinical symptoms of aneurysms are varied, and the aneurysms tend to occur on the right side. Based on the anatomical conditions of SAAs, open surgery and endovascular repair can be used for treatment.

[Subclavian artery aneurysms: pathogenesis, diagnosis, and therapeutic decision-making]

The article deals with the relevant literature data concerning diagnosis and treatment of subclavian artery aneurysms. This nosological entity is relatively uncommon, however its importance for modern medicine should not be underestimated. Despite a low incidence of the pathology, it should be understood that the disease's course for the patient is associated with the development of severe complications which may lead to disability or even death. The development of complications is extremely difficult to predict and stratification of risks for such patients is too complicated. It is also known that the diagnosis of a subclavian artery aneurysm is frequently an accidental finding, since the pathology may for a long time proceed symptom-free. At the same time, the subclavian artery occupies the first place by the frequency of localization of upper-limb aneurysms, thus making this problem currently important. Besides, separate attention should be paid to modern methods of correction of this disease, since implementation of high-tech interventions into vascular surgery have significantly expanded the arsenal of the operating surgeon.

Successful Balloon-assisted Coil Embolization of Right Subclavian Artery Aneurysm: A Case Report

Objective

Subclavian artery aneurysms are relatively rare, and have been treated by open surgery and/or endovascular treatment using a stent graft. In this article, we report a case of unruptured right subclavian artery aneurysm successfully treated using balloon-assisted coil embolization.

Case Presentation

A 77-year-old man was diagnosed with an asymptomatic unruptured right subclavian artery aneurysm of 8 mm in diameter by follow-up CTA after surgery for thoracoabdominal aortic aneurysms. He also had a history of cerebral infarction and clipping of an unruptured cerebral aneurysm. The subclavian artery aneurysm was treated by balloon-assisted coil embolization because its diameter increased to 17.6 mm in 2 years. Balloon assistance was mainly used to prevent protrusion of the framing coil into the parent artery, and satisfactory framing was achieved. Subsequently, the aneurysm was obliterated using filling and finishing coils. The postoperative course was uneventful, and the follow-up MRI at 18 months after treatment revealed no recanalization of the aneurysm.

Conclusion

Balloon-assisted coil embolization may be an effective treatment for subclavian artery aneurysms, but further long-term follow-up and case accumulation are needed.

Minimally Invasive Repair of Left Subclavian Artery Aneurysm

A 79 year-old gentleman with a history of trauma resulting in paraplegia was being evaluated for vascular access for hemodialysis. Cardiac catheterization revealed a large, asymptomatic left subclavian artery aneurysm. The patient was taken to the hybrid vascular intervention suite. A small incision was made in the left arm to gain access to the left brachial artery into which a sheath was inserted. The aneurysm was crossed with a wire through which two, overlapping covered stents were deployed completely excluding the aneurysm. The patient was discharged to home the following day. Endovascular exclusion has become the treatment of choice for aneurysms of the subclavian artery.

Single center experience in the management of a case series of subclavian artery aneurysms

OBJECTIVE

Subclavian artery aneurysms (SAAs) are rare, but they may cause life- and limb-threatening complications.

METHODS

Retrospective review was performed of all SAA patients that underwent treatment at the Clinic for Vascular and Endovascular Surgery, Clinical Center of Serbia, Belgrade between January 1st 2006 and January 1st 2018. The paper includes analysis of etiology and therapeutic options based on the experience from our institution.

RESULTS

Twenty (80%) of SAAs involved extrathoracic (ET), while five (20%) intrathoracic (IT) segment. Out of total five IT SAAs, two were asymptomatic (40%), one had dyspnea (20%), while two (40%) had hematothorax due to rupture. Seven (35%) patients with ET SAA had shoulder pain and pulsatile mass, five (25%) acute, seven (35%) had chronic limb ischemia, while one was asymptomatic (5%). Two IT SAAs were treated with open surgery (OS). Other three cases underwent hybrid procedure. One case with ET SAA was treated endovascularly due to hostile anatomy, while in all other 19 cases of ET SAAs open repair was performed, which included: graft interposition in 10 (52.63%), end-to-end anastomosis in 7 (36.84%) cases, while bypass procedure in 2 (10.52%) patients. One of our patients (4%) died during the first 30 postoperative days.

CONCLUSIONS

SAAs are rare, however because of their natural history they have huge clinical significance. OS is the method of choice in cases of ET SAAs caused by TOS. Endovascular and hybrid treatment decrease significantly perioperative morbidity and mortality rates in cases of intrathoracic SAAs and thus should be the first option.

Endovascular Repair for Ruptured Axillary Artery Aneurysm Proximal to Hemodialysis Access

Axillary artery aneurysms are uncommon and potentially high-risk lesions threatening the upper extremities. In hemodialysis patients, arteriovenous fistulae creation rarely triggers aneurysmal degeneration and arterial aneurysms in inflow arteries. These aneurysms are usually treated by surgical repair. However, this may lead to complications because of the anatomical complexity surrounding aneurysms of axillary arteries. We report a patient undergoing hemodialysis who had a ruptured ipsilateral axillary artery aneurysm proximal to vascular access. We successfully treated it by endovascular repair with the GORE Excluder AAA contralateral leg endoprosthesis, approaching from the left brachial artery proximal to the shunt. No complications occurred during 15 months after the endovascular repair.

Interesting case of left subclavian pseudoaneurysm in a child managed successfully

Subclavian artery aneurysm is extremely rare, and further aneurysm in a 3-year-old child is more exceptional. Most common causes of subclavian artery aneurysms are atherosclerosis, poststenotic thoracic outlet syndrome, infectious, trauma, and inflammatory arteritis, and connective tissue disorders. Pseudoaneurysms may be due to trauma or any iatrogenic injury to subclavian artery. We present a case report of a 3-year-old male child presented to us with recurrent cough without expectoration for 4-months duration due to compression by a large subclavian artery aneurysm. Patient was successfully managed surgically through left thoracotomy approach. After operation, the patient improved symptomatically. Child was asymptomatic at 3-month follow-up.

Surgical Treatment of a Left Axillary Arterial Aneurysm with Marfan Syndrome by Combining Two Skin Incisions

An axillary arterial aneurysm is a rare disorder, with few surgical cases reported to date. Here we report the case of a left axillary arterial aneurysm associated with Marfan syndrome. A 44-year-old female with Marfan syndrome presented with numbness of the left upper limb and a pulsatile mass on the left chest. A computed tomography scan revealed a highly enlarged and tortuous left axillary arterial aneurysm. We performed a graft replacement and resection of the aneurysm with two skin incisions. After the surgery, the blood flow to the patient’s left upper limb was confirmed, and the neurological symptoms improved significantly.

Open Repair of a 12-cm Posttraumatic Aneurysm of Right Subclavian Artery

Purpose

To present a rare case of a patient with a 12-cm posttraumatic right subclavian artery aneurysm successfully treated with aneurysmectomy and innominate-axillary bypass.

Case report

A 54-year-old man presented to the emergency department due to progressive dyspnea and hoarseness of voice. His medical record was unremarkable except that he had right-sided pneumothorax and multiple rib fractures from a car accident 16 years ago. A chest X-ray showed a mass in the upper lobe of the right lung, and the patient was hospitalized for further investigation. A computed tomography (CT) with intravenous contrast of the thorax was performed, which depicted a giant aneurysm of the right subclavian artery. Vascular and cardiothoracic surgeons were consulted immediately, and the operation was scheduled. Aneurysmectomy and innominate-axillary bypass were performed. The patient had an uncomplicated progress and was discharged on 5 days followed by a single antiplatelet therapy and symptom-free.

Conclusion

Posttraumatic subclavian artery aneurysm is a rare entity. Imaging of the thorax is essential for the diagnosis and surgical preparation of the patient. Open repair remains the gold standard therapy for subclavian artery aneurysm despite the improvements in endovascular surgery in such huge aneurysms.

Successful Treatment of Giant Left Subclavian Artery Pseudoaneurysm Abutting the Arch of the Aorta and Descending Aorta

A 28-year-old woman presented with 3-month history of fever of unknown origin and progressively increasing cough. She was diagnosed with pulmonary tuberculosis on bronchial lavage cultures. A chest X-ray performed on follow-up showed a new opacity in the left apical area of the chest. Computed tomography scan of chest showed a large 10 cm pseudoaneurysm of the left subclavian artery 1 cm from its take off from the arch of the aorta. The pseudoaneurysm was approached through a left posterolateral thoracotomy and opened following a proximal and distal control. A 3 cm longitudinal defect was identified in the subclavian artery within its intrathoracic portion. This was debrided and repaired with an autologous pericardial patch. The patient had an uneventful recovery and remained well on follow-up.

Proximal Left Subclavian Artery Aneurysms: A Case Report and Review of the Literature

Aneurysms of the proximal subclavian artery are extremely rare. A 39-year-old female with an incidental finding of a small proximal left subclavian artery aneurysm at its origin from the aortic arch is described. This was an incidental finding during workup for chest pain. No other vascular abnormalities were found and no obvious etiology was identified. The workup, plan for conservative treatment, and close follow-up are described. Although larger aneurysms and those in the middle and distal subclavian arteries, symptomatic or asymptomatic, are generally considered for surgical treatment, very little is known about the natural history of small proximal subclavian aneurysms.

Left Subclavian Artery Aneurysm: Surgical Repair Via a Sternal Incision

For trauma, the traditional approach to the proximal left subclavian artery is through a posterolateral thoracotomy. The purpose of this study was to evaluate the feasibility of accessing the proximal left subclavian artery through a partial sternotomy approach. Anatomical review of 52 subclavian arteries was performed on 52 randomly picked computed tomography (CT) scans of the thorax. The depth of the origin of the subclavian artery was measured from the lateral thoracic wall and from the sternum. It was noted that the distance from the sternum to the origin of the left subclavian artery was 4.71 cm as compared to the posterolateral wall, which was 8.87 cm. This is in contrast to the belief that the left subclavian artery is a posterior structure in the mediastinum. A subclavian artery aneurysm was repaired through the sternal approach and was noted to have an adequate exposure required for the procedure. This approach was necessitated owing to the fact that the patient had significant chronic obstructive pulmonary disease. From these data, the authors conclude that in elective circumstances it is easier and appropriate to use the partial sternotomy approach to access the proximal left subclavian artery, especially in patients who have reduced pulmonary function.

Surgical Repair of a Left Subclavian Artery Aneurysm Causing Stenosis of a Left Internal Mammary Graft A Case Report

Subclavian artery aneurysms are extremely rare, accounting for approximately 0.1% of peripheral artery aneurysms. We present a case of a proximal left subclavian arterial aneurysm in a patient status post previous coronary artery bypass grafting; the aneurysm was complicated by involvement of the left internal mammary artery that had been previously utilized to revascularize the left anterior descending artery. Ostial stenosis of the internal mammary artery secondary to the aneurysm was present. Simultaneous reoperative coronary bypass surgery and repair of the left subclavian aneurysm was performed, with a good result. This is the second case reported in the literature of concomitant subclavian artery aneurysm repair and coronary revascularization.

Abnormalities Associated with Aberrant Right Subclavian Arteries

An aberrant right subclavian artery (ARSA) is an anomaly with a reported incidence of 0.5% to 2%. Usually the aberrant artery follows a retroesophageal course; rarely it takes a course anterior to the esophagus or the trachea. Most patients with an ARSA remain asymptomatic; however, progressive dysphagia develops occasionally. The choice of approach depends on the presence or absence of aneurysmal disease, the urgency of the operation, and the surgeon's experience. A case is reported of a 33-year-old white male patient who had a 3-year history of progressive dysphagia to the point that he was only able to swallow liquids. A barium swallow demonstrated a posterior extrinsic compression of the esophagus. Angiography was performed, which demonstrated an ARSA with a common origin of the right and left common carotid arteries. Surgical correction was performed via a right supraclavicular neck incision. The proximal aberrant artery was mobilized behind the esophagus. The distal, right subclavian artery was exposed, transected, and transposed with reimplantation into the right common carotid artery. An aberrant right thoracic duct was encountered and ligated. The English language literature from 1960 to present was reviewed via a Medline search. Reported anomalies associated with ARSAs include a nonrecurrent right inferior laryngeal nerve, a common origin of the common carotid arteries, a replaced right or left vertebral artery, coarctation of the aorta, a right-sided thoracic duct, and a right-sided aortic arch. It is important to be aware of these associated anomalies and how they impact the operative approach involved in the correction of dysphagia lusoria.

Giant Subclavian Artery Aneurysm

We report the case of a 37-year-old construction executive presenting with chest pain, shortness of breath, and dizziness on exertion secondary to a giant left subclavian artery aneurysm and aortic valvular disease.

Staged Hybrid Repair of an Intrathoracic Subclavian Artery Aneurysm Associated with a Long Segment Dissection

Intrathoracic subclavian artery aneurysms (ISAAs) are infrequently seen in clinical practice. We report the repair of a left ISAA associated with a long segment dissection from the ostia extending to the axillary artery. A hybrid approach was used. Carotid-to-axillary bypass using a reversed greater saphenous vein was first performed, followed by coverage of the origin of the subclavian artery using a thoracic stent graft. Finally, percutaneous access of the radial artery with coil embolization was performed to successfully thrombose the ISAA.

[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.

Bilateral axillary arterial aneurysms in siblings with Marfan syndrome

Axillary arterial aneurysm associated with Marfan syndrome is an extremely rare and dangerous disease because of its potential risk for rupture and impairment of neurologic function in the upper extremities. Treatment of large axillary aneurysms can be surgically challenging because the axillary artery is anatomically located under the clavicle bones and the brachial plexus runs dorsal to the aneurysm. We report 2 cases of bilateral axillary arterial aneurysms in brothers with Marfan syndrome. Revival of a novel approach and cautious attempts during the procedures are described in both cases.

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 aneurysm in Marfan syndrome

We present a case of a left subclavian artery aneurysm in a 48-year-old man with Marfan syndrome. Aneurysms of the subclavian artery are rare in patients with Marfan syndrome. Resection of the aneurysm and interposition with a synthetic graft were performed through a supra- and infraclavicular incision, without resecting the clavicle. Histological findings were compatible with Marfan syndrome. In patients with Marfan syndrome, regular follow-up is important because of the occurrence of peripheral aneurysms other than the aorta.

A hybrid operation in a patient with complex right subclavian artery aneurysm

We report a hybrid surgery including endovascular aneurysm repair and debranching procedures to treat a patient with a complex right subclavian artery aneurysm. The patient was a 70-year-old woman who presented with dry cough and hoarseness. The aneurysm was characterized by the absence of a proximal neck, and involvement of the origin of the right vertebral artery. She underwent carotid-vertebral artery bypass, stent graft from the innomiate artery to the common carotid artery and carotid-axillary artery bypass. Great saphenous vein was used for the carotid-vertebral artery bypass and 7 mm reinforced polytetrafluoroethylene graft was used for the carotid-axillary artery bypass. The postoperative course was uneventful.

Giant aneurysm of the right intra thoracic sub-clavian artery presenting as a dysphonia

Aneurysms of the intra-thoracic subclavian artery (SCA) are rare. They are often revealed by complications. Surgical treatment is always indicated. Endovascular treatment is a less invasive alternative. We report a case of a 60 years-old woman admitted for right chest pain and dysphonia. Laryngoscopy noted a right vocal cord palsy. Chest computed tomography and angiography showed a giant aneurysm of the intra-thoracic right SCA. A resection-ligation of the aneurysm was performed by a supra-clavicular approach. Postoperative course was uneventful. The histology defined an atherosclerotic aneurysm. The patient underwent voice reeducation with partial improvement after six months.

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.

Intrathoracic left subclavian artery aneurysm: report of a case

Aneurysms of the intrathoracic subclavian artery are extremely rare. A 74 year-old man was referred to our hospital with an abnormal chest X-ray film. Contrast computed tomography revealed an intrathoracic left subclavian artery aneurysm. Via left 4th posterolateral thoracotomy, the aneurysm was exposed under systemic deep hypothermia and circulatory arrest. The distal arch was replaced with a 26 mm single-branched graft and the left subclavian artery was reconstructed with a 10 mm graft.

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.

Successful surgical treatment of right subclavian artery aneurysm with a hypoplastic left vertebral artery using temporary cerebral perfusion to prevent cerebral ischemia

A 71-year-old man had a right subclavian artery aneurysm (dimension, 30 × 38 mm) that was adjacent to the right common carotid artery and exceedingly close to the right vertebral artery. The patient had a marked hypoplastic left vertebral artery, dominant right vertebral artery, and an incompletely formed and underdeveloped circle of Willis in the skull. While performing a median sternotomy and supraclavicular incision during the operation, we used temporal shunting for the cerebral perfusion. The subclavian artery aneurysm was resected, and a 10-mm diameter woven Dacron graft was used for reconstructing the subclavian artery. The postoperative course was uneventful, and the patient was discharged from the hospital 18 days after surgery. Temporal shunting for maintaining cerebral perfusion was useful in preventing cerebral ischemia, and the median sternotomy plus supraclavicular incision approach afforded an unobstructed view of the surgical field.

Repair of left subclavian artery and aberrant right subclavian artery aneurysms

Left subclavian artery aneurysm with an aneurysm of the aberrant right subclavian artery is a rare condition with a reported incidence of 0.13% to 1%. We report the successful surgical correction of both conditions in a 34-year-old man.

Coil occlusion of a subclavian mycotic aneurysm

We report the first successful application of nonferromagnetic embolization coils for endovascular exclusion of a mycotic right subclavian artery aneurysm. A 58-year-old woman presented with acute cervical pain and a pulsatile mass in the right supraclavicular fossa under antibiotic medication for subacute infectious endocarditis. Diagnostic work-up including duplex sonography, digital subtraction angiography, and magnetic resonance imaging demonstrated a saccular aneurysm of the extrathoracic right subclavian artery. As an alternative to open surgery or stent-graft repair, this pathology was electively treated by transcatheter coil embolization. No neurological deficit or ischemic symptoms were noted during 9 months clinical follow-up. Multislice computed tomography scan revealed complete occlusion of the mycotic aneurysm 6 months after the interventional procedure. Transcatheter closure with Inconel embolization coils is a cost-effective and safe therapeutic option in patients with mycotic aneurysm originating from the subclavian artery.

Glue embolus complicating the endovascular treatment of a patient with Loeys-Dietz syndrome

A 34-year-old [corrected] woman was diagnosed with Loeys-Dietz syndrome. Five months later, the patient presented with a symptomatic 2.6-cm subclavian pseudoaneurysm. Staged endovascular treatment was initiated with left vertebral artery embolization, followed by sac ablation and stent graft exclusion. The pseudoaneurysm cavity was filled with n-butylcyanoacrylate ("glue") via a microcatheter. Despite balloon occlusion of the pseudoaneurysm orifice, a small amount of glue debris embolized to the brachial artery, necessitating a vein bypass. In this case, distal embolization of glue may have been avoided by leaving a microcatheter in the aneurysm sac for glue injection after first deploying the stent graft.

Aneurysms in the arteries of the upper extremity in a Kenyan population

BACKGROUND

Aneurysms in the arteries of the upper extremity are rare but important in predicting aortic aneurysms and their potential to thromboembolize and cause limb loss. Their localization, age, and gender distribution vary between countries depending on ethnic background and cause. These data are valuable in the management of aneurysms, but are largely lacking from the Kenyan population.

OBJECTIVE

This study aimed at examining the pattern of these aneurysms in a Kenyan population.

STUDY DESIGN

Retrospective.

SETTING

Kenyatta National Hospital, Kenya.

PATIENTS AND METHODS

Hospital records of aneurysms in upper limb arteries over 10 years from January 1998 to December 2007 were examined. Ethical approval was given by the Kenyatta National Hospital Ethics and Research Committee. Site, age, gender, and risk factors were recorded. Unconfirmed diagnoses were excluded. Results were analyzed using SPSS 11.50 and presented using tables.

RESULTS

Aneurysms of the upper extremity arteries comprise 34 (35.4%) out of 96 peripheral aneurysms. Of these, brachial artery was the most common site (35.3%), followed by brachiocephalic (11, 32.4%), subclavian (9, 26.5%), radial (1, 2.9%), and anterior interosseous (1, 2.9%). Trauma was the commonest predisposing factor (41.2%), followed by atherosclerosis and related comorbidities (32.4%), infection (11.8%), and autoimmune disease (8.8%). The mean age was 39.5 years (range: 13-79) with a variable gender distribution.

CONCLUSION

Aneurysms of the upper extremity arteries are not uncommon in the Kenyan population. They occur more commonly in individuals aged 50 years and less, and although most of them are traumatic, atherosclerosis constitutes a significant proportion. Prudent management of risk factors is recommended.

An unusual etiology of a subclavian artery aneurysm

Abstract

A 22-year-old woman presented with a 3-month history of a pulsatile swelling in the right supraclavicular region. A CT angiogram revealed an aneurysm arising from the distal right subclavian artery. At surgery, the subclavian artery was almost entirely replaced by a well-vascularized tumor mass. The vascular tumor along with the native vessel was excised and replaced with a vascular prosthesis. Biopsy was suggestive of an epithelioid hemangioma (EH). In conclusion, an EH is a rare vascular tumor. The presence of vascular hyperplasia with plump endothelial cells protruding into the lumen is the most important discriminator in establishing the diagnosis of EH. Vascular neoplasms presenting as aneurysms should be considered, especially if other etiologies can be excluded.