Diagnosis and treatment of subclavian artery aneurysms

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.

Endovascular Repair of an Intrathoracic Subclavian Artery Aneurysm in a Patient With Dextrocardia

This manuscript describes an endovascular repair of a symptomatic, large proximal left subclavian artery aneurysm in a patient with dextrocardia and right-sided aortic arch and absent bilateral internal carotid arteries. The patient had surgical reconstruction as an infant for congenital heart disease with Ventricular Septal Defect, bifid sternum . Given her previous surgical history, we declined an open operation and performed an endovascular repair with stent grafts to successfully repair the subclavian artery aneurysm. The patient had an uneventful postoperative course and follow-up ultrasonography demonstrated successful repair with preservation of flow through the left subclavian and vertebral arteries with resolution of her symptoms.

Extra-thoracic rupture of giant subclavian artery aneurysm

Subclavian artery aneurysms are rare, but they are frequently responsible for limb or life-threatening complications. The clinical presentation, as supraclavicular mass to rupture, has been reported in literature, with management strategies being endovascular intervention to open conventional surgery. We report a case of giant subclavian artery aneurysm measuring 10 cm × 12 cm, which presented with a large anterior chest wall lump and massive bleed to our emergency department. We successfully treated this patient by ligating the aneurysm and evacuating the chest wall haematoma.

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.

Interventional repair of a vascular aneurysm in a patient with Marfan syndrome

Marfan syndrome is a heritable connective tissue disorder affecting skeletal, ocular and cardiovascular systems. Cardiovascular manifestations comprise aneurysmal dilatation of aortic root, aortic dissection and rupture; peripheral arterial aneurysms have been reported in femoral, iliac and subclavian arteries with surgical reconstruction as the first-line therapeutic option. We report a Marfan patient with a symptomatic aneurysm of left subclavian artery in the intrathoracic retro-clavicular space; instead of open surgical resection, an endovascular solution was successfully applied by use of a flexible self-expanding stent-graft (W.L Gore^® Viabahn^® Endoprosthesis 9 × 100 mm) to exclude the aneurysm. This case exemplifies a modern option to manage vascular pathology even in patients with Marfan syndrome. Follow-up over 1 year proved very reassuring with complete remodelling and resolution of the aneurysm; long-term follow-up is certainly warranted, considering the potential of recurrence or initial reactive hyperplasia.

Bidirectional Transradial and Transfemoral Approach for Stent-Assisted Coil Embolization of Right Subclavian Artery Saccular Aneurysm

Subclavian artery aneurysms are rare lesions that usually require treatment for complications. Bidirectional stent-assisted coil embolization is the most effective treatment of complex wide-necked aneurysms. The stents provide a rigid scaffold that allows coil deposition with reduced risk of coil herniation into the parent vessel lumen. Bidirectional transradial and transfemoral approaches contribute to stable procedure. We report a successful bidirectional stent-assisted coil embolization of a saccular aneurysm of the subclavian artery as an alternative to stent graft implantation to diminish the risk of right vertebral artery occlusion.

Delayed Subclavian Artery Aneurysm Following Fixation of a Clavicular Fracture

Aneurysms of the subclavian artery are rare phenomena that have the potential for limb and life-threatening complications. Delayed diagnosis increases the risk of life-threatening complications or at the very least may result in a detrimental effect to both functional capacity and quality of life; primary care offers a vital opportunity to screen for such rare vascular complications and should be a consideration in all patients with evolving peripheral nerve or vascular symptoms with a history of localized clavicular trauma. We present the case of a left subclavian artery aneurysm with radial artery thrombotic sequelae following an injury and screw-plate fixation of his left clavicle. This required a 2-stage surgical approach to treatment and provides useful learning considerations for identifying rare vascular anomalies early in a primary care setting.

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.

Subclavian and axillary arterial aneurysms: two case reports

Aneurysms of the subclavian-axillary segment are rare, but when diagnosed they must be treated. This article describes two cases of aneurysms of the upper extremities, one in a subclavian artery and the other in an axillary artery. The first case was a 71-year-old male with a pulsating supraclavicular bulge on the right and muscle weakness in the ipsilateral extremity. Duplex scanning and arteriography confirmed the diagnosis of aneurysm of the right subclavian artery and the patient underwent aneurysmectomy and end-to-end anastomosis. The second case was a 24-year-old female patient, with no history of comorbidities, who presented with a pulsating mass in the right axillary region and paresthesia of the ipsilateral extremity. Duplex scanning and arteriography confirmed an aneurysm in the right axillary artery, which was successfully treated with aneurysmectomy and end-to-end anastomosis. Pathology findings showed that the first case was an atherosclerotic aneurysm and the second was a congenital aneurysm.

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.

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.

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.

Tratamento endovascular híbrido de aneurisma da artéria subclávia associado à síndrome de Marfan: relato de caso

Descreve-se o caso de uma paciente feminina de 46 anos com síndrome de Marfan que foi diagnosticada com aneurisma da artéria subclávia direita após cirurgia aberta para reparo de dissecção aórtica tipo A. A paciente foi tratada por abordagem híbrida, que combinou o implante de uma endoprótese recoberta da artéria inominada para a carótida comum direita com uma ponte carótida para a artéria axilar direita. O pós-operatório transcorreu sem complicações, com a confirmação, por ultra-som, do sucesso da exclusão do aneurisma.

Subclavian artery pseudoaneurysm: a rare and serious complication of central venous catheterization in an infant

Serious complications of central venous access occur in 0.4-9.9% of patients undergoing attempted central venepuncture. We report an unusual case of an 18-month-old infant in whom a right subclavian artery pseudoaneurysm developed rapidly after attempted subclavian vein catheterization without US guidance failed.

Endovascular repair of a symptomatic subclavian artery aneurysm in a patient with Marfan syndrome: a case report

Endovascular techniques are being employed with increasing frequency in the management of peripheral arterial aneurysms. A 57-year-old patient with Marfan syndrome presented with a symptomatic 5 cm left subclavian artery aneurysm. He underwent successful endovascular exclusion of the aneurysm with immediate improvement of his symptoms. Duplex ultrasound 3 months after the procedure confirmed a patent graft and complete exclusion of the aneurysm.

Intrathoracic aneurysm of the right subclavian artery presenting with hoarseness: a case report

Intrathoracic segment of the subclavian artery is an unusual location for peripheral arterial aneurysms. They are normally caused by atherosclerosis, medial degeneration, trauma, and infection. We report a case of a patient with right subclavian artery aneurysm presenting with hoarseness. Chest radiograph demonstrated a superior mediastinal mass. Laryngoscopy showed a fixed right vocal cord. By chest computed tomography, magnetic resonance imaging, and angiography, preoperative diagnosis was established as a saccular aneurysm with afferent loop and efferent loop. Patient underwent complete resection of the aneurysm followed by endto-end anastomosis via median sternotomy. Postoperative pathology was consistent with an atherosclerotic aneurysm filled with thrombus. After surgical operation, hoarseness is still continued.

Dysphagie durch Aneurysma der A. subclavia

BACKGROUND

Dysphagia may be due to oral, pharyngeal or esophageal dysfunction and poses a frequent problem for the otolaryngologist. Motor disturbances, structural disorders, functional problems, congenital lesions and malignancies have to be excluded in an interdisciplinary diagnostic approach. Currently, vascular diseases play a minor role in the diagnosis of dysphagia.

CASE REPORT

A 70-year-old female presented with constant dysphagia and a foreign body feeling in the throat of about 2 months duration. Palpation and ultrasound revealed a tumor situated in the right supraclavicular region. The lesion was identified as a true aneurysm of the subclavian artery by digital subtraction angiography. Successful resection and reconstruction was accomplished using a PTFE graft.

DISCUSSION

Aneurysms of the subclavian artery are rare and in most cases related to thoracic outlet syndrome (TOS) or arteriosclerosis. It can be assumed that an increasingly aged population will present with an increasing incidence of diseases related to atherosclerosis. Moreover, the increasing incidence of specific infections may contribute to this phenomenon. This neglected disease should be included in the differential diagnosis when dealing with supraclavicular lesions, foreign body feeling or dysphagia.

Covered stents for true subclavian aneurysms in patients with degenerative connective tissue disorders

PURPOSE

To report the endovascular repair of rare true aneurysms of the subclavian artery in patients with degenerative connective tissue disorders.

CASE REPORTS

Two patients, one with Marfan syndrome and the other with idiopathic cystic medial necrosis, presented with 3 subclavian artery aneurysms. A Wallgraft and 2 Viabahn covered stents were used to successfully exclude these aneurysms. After 3 months, the Wallgraft thrombosed, but the contralateral Viabahn remained patent at the most recent examination 13 months after treatment. The other patient with the unilateral aneurysm had a patent Viabahn stent-graft at 10 months.

CONCLUSIONS

Patients with degenerative connective tissue disorders may benefit from less invasive treatment with stent-grafts. The more flexible Viabahn stent-graft may be better able to adapt to arterial tortuosity. However, the long-term results of this new technique have not yet been established.

Subclavian artery aneurysms

We report the management of 14 subclavian artery aneurysms (13 true, one false) occurring in seven male and seven female patients (average age, 48 years). The aetiology of the aneurysms included thoracic outlet syndrome in eight, atherosclerosis in five and infection in one patient. Twelve aneurysms were of extrathoracic location, while two aneurysms were intrathoracic. Symptoms related to subclavian artery aneurysms were present in 11 patients (compression in four, haemorrhage in one, and ischaemia in six patients), whereas three aneurysms were asymptomatic. All aneurysms were treated surgically. The supraclavicular approach was used in 11 cases, and the combined transsternal and supraclavicular approach was used in two cases. After aneurysm resection, the reconstruction was performed with end-to-end anastomosis in five cases and with saphenous vein or synthetic grafts in eight cases. One infected subclavian artery aneurysm was treated with carotid to axillary saphenous vein bypass after exclusion of the aneurysm. Five associated brachial embolectomies and one bypass from the axillary to the distal brachial artery were performed. In all thoracic outlet syndrome cases, decompression at the thoracic outlet was also performed. There was no operative mortality, and the early patency rate was 100%. The follow-up period was from 6 months to 10 years (mean, 3.92 years). During this period, one patient died of malignancy and one patient required reoperation due to aneurysmal degeneration of the saphenous vein graft. Surgical treatment is recommended for all patients with subclavian artery aneurysms to prevent potential complications.

Presentation, diagnosis, and management of arterial mycotic pseudoaneurysms in injection drug users

Injection drug users frequently present with abscess, cellulitis, and endocarditis. The development of arterial mycotic pseudoaneurysm (AMP) as a sequela of injection drug use, however, is much less frequently reported. We undertook a study to determine the prevalence and presenting clinical characteristics of AMP, utilizing a retrospective review of all emergency department cases seen at one city public hospital for the 5-year period 1994-1999. Initial evaluation included physical examination, CT scan, ultrasound, and/or angiography. There were 7,795 patient visits for complications of injection drug use; 11 patients had AMP (0.14%). AMP involved the brachial (n = 5), subclavian (n = 2), radial (n = 2), femoral (n = 1) and popliteal arteries (n = 1). Fever was absent in the majority of patients (7/11). Either pulsatility or a mass was noted in three cases, and both were seen in 6/11 (54%). AMP was not initially suspected in three cases, which were treated as abscesses and surgically incised, resulting in arterial rupture. The annual prevalence of AMP in the presenting population was estimated to be 0.03%. However, a high index of suspicion for AMP should be maintained with injection drug users presenting with a mass or pulsatility over an artery, as there is risk of rupture, rapid exsanguination, and distal embolization.

A subclavian artery aneurysm associated with aortitis syndrome

We performed surgery on a 61-year-old woman who had increasingly severe right shoulder pain and paresthesia in her right upper extremity as a result of a large right subclavian artery aneurysm. She had suffered from aortitis syndrome for 10 years for which she was treated with steroids and had multiple arterial lesions, including bilateral subclavian artery aneurysms, abdominal aortic aneurysm and obstruction of bilateral superficial femoral arteries. The right subclavian artery aneurysm measured 4 cm in diameter and rupture appeared imminent, prompting surgical therapy. Via the supraclavicular incision approach and additional partial sternotomy, the aneurysm was excluded and the brachiocephalic to right axillar arterial bypass was set up using an extended polytetrafluoroethylene graft. The patient recovered without complications and a subclavian artery aneurysm demonstrated by computed tomography was thrombosed 1 month after surgery. In conclusion, we recommend the exclusion technique to treat subclavian artery aneurysms in cases in which aneurysmectomy is likely to injure adjacent veins and nerves.

Mycotic aneurysm presenting as Pancoast's syndrome in an injection drug user

Injection drug users frequently present to emergency departments with fever. A careful history and physical examination with attention to anatomic localization of symptoms and signs are often necessary to unmask unusual underlying medical conditions. We report a case of a woman with recent injection drug use who presented with fever, a palpable neck mass, and Pancoast's syndrome. She had been seen recently at the ED of another hospital and discharged with oral antibiotics for presumed cellulitis. A mycotic aneurysm of the subclavian artery causing Pancoast's syndrome was later diagnosed by using computed tomography and angiography. A high index of suspicion for anatomically localized infective processes should always be maintained with febrile injection drug users.

Mycotic aneurysm of the left subclavian artery presented with hemoptysis in an immunosuppressed man: case report and review of literature

We report the case of a 32-year-old man with a mycotic aneurysm of the left subclavian artery. This patient had immunosuppression caused by chemotherapy administered for treatment of leukemia. This aneurysm was revealed by two episodes of hemoptysis caused by a lung parenchyma fistulization. The patient was treated successfully by simple ligation and exclusion via a thoracotomy with partial lung resection. Histologic examination confirmed the presence of aspergilloma filaments in the false aneurysm. We suspect that aspergilloma could have been the cause of the mycotic aneurysm in this particular case. The literature on subclavian artery mycotic aneurysms is reviewed.

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

True aneurysm of the subclavian artery is extremely rare. Excluding the more common aneurysms of an aberrant right subclavian artery, those associated with thoracic outlet syndrome, and posttraumatic "aneurysms," atherosclerosis is the most common cause. Syphilis, tuberculosis, and cystic medial necrosis are less often the cause. These aneurysms can rupture, thrombose, embolize, or cause symptoms by local compression. Surgical treatment is generally indicated, and has evolved from ligation procedures to extirpation or endoaneurysmorrhaphy to the present practice of resection with revascularization. A case of a surgically treated, asymptomatic, atherosclerotic aneurysm of the intrathoracic left subclavian artery is presented, with a review of the English-language literature on the subject.

Right subclavian artery aneurysm and coarctation of the aorta

A patient, diagnosed with coarctation of the aorta at the age of 59, was found to have a pulmonary mass in his right upper lobe. A chest scan and digital intravenous arteriography revealed a right artery subclavian aneurysm. Such an unusual association is described.

Dissecting left subclavian artery aneurysm: an unusual presentation of coarctation of the aorta

We report a patient with coarctation of the aorta who presented with acute dissection of a large left subclavian artery aneurysm. The patient underwent successful reconstructive surgery.