Elective and emergent endovascular treatment of subclavian artery aneurysms and injuries

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.

Contralateral brachial arterial access for endovascular treatment of recurrent axillofemoral bypass graft stump syndrome: A case report

Axillofemoral bypass graft stump syndrome is an uncommon complication of axillofemoral bypass graft surgery. The traditional treatment is open surgical repair; however, endovascular recanalization can be achieved. Interventional treatment by approaching the brachial artery contralateral to the lesion site has rarely been reported in acute upper extremity ischemia. We report a case of recanalization through the left brachial artery due to embolic occlusion of the right brachial and axillary arteries and suspected axillofemoral bypass graft stump syndrome in a 71-year-old man. Access through the common femoral artery was impossible because the patient underwent reoperation of the left axillofemoral bypass and femorofemoral bypass due to occlusion of the right axillofemoral bypass and femorofemoral bypass surgery. Furthermore, bilateral radial arteries were occluded, allowing access to the left brachial artery. Two self-expandable stents were inserted into the occlusion of the right brachial and axillary arteries, and the stump area was covered. Aspiration thrombectomy was performed for embolism in the ulnar artery. Axillofemoral bypass graft stump syndrome can also be treated with interventional management. If access to the bilateral common femoral and radial arteries is not possible, an upper extremity arterial procedure through the contralateral brachial artery may be considered in cases of steno-occlusion of the upper extremities.

Operative repair of right intrathoracic subclavian artery aneurysms in patients with genetic arteriopathy

True intrathoracic subclavian artery aneurysms (SCAAs) are rare and have various etiologies. Right intrathoracic SCAAs pose specific anatomic challenges to repair. We present three different operative approaches, open, endovascular, and hybrid repair, for the repair of a right intrathoracic SCAA in three patients with genetic arteriopathy: Marfan syndrome, vascular Ehlers-Danlos syndrome, and unspecified Ehlers-Danlos syndrome, respectively. These cases demonstrate an individualized operative approach based on the genetic diagnosis for each patient presenting with a right intrathoracic SCAA.

Endovascular Stent Graft Repair for True and Post-Traumatic False Aneurysms of the Subclavian Artery

OBJECTIVE

Subclavian artery aneurysms (SAAs) are uncommon but life-threatening, and a standard treatment approach has yet to be established. The current study aimed to assess the safety and efficacy of endovascular treatment for SAAs.

METHODS

The clinical data of 18 SAA patients who underwent endovascular repair at 3 hospitals from January 2009 to December 2019 were retrospectively collected and analyzed.

RESULTS

Eighteen patients (12 men and 6 women) with a mean age of 61 years were included. Six patients (33.3%) had a history of hypertension, and 5 (27.8%) had a history of chest trauma. Five patients (27.8%) were asymptomatic. Thirteen (72.2%) SAAs were true aneurysms, and the others (27.8%) were posttraumatic false aneurysms. Endovascular stent graft repair was performed in all patients without conversion to open surgery. The immediate technique success rate was 94.4%, with no postoperative death and only one case (5.6%) of endoleak that was observed on intraoperative angiography and later resolved spontaneously. All patients survived over a median follow-up time of 57 months. Follow-up imaging showed that all stent grafts remained patent, with no endoleak.

CONCLUSIONS

Endovascular stent graft repair is feasible, safe, and effective for true and posttraumatic false SAAs and represents a promising treatment option for these SAAs.

Long-term outcomes of endovascular treatment of isolated subclavian artery aneurysms

OBJECTIVES

The aim of the present study was to review our institutional experience of endovascular treatment for isolated subclavian artery aneurysms and evaluate the long-term outcomes.

METHODS

A retrospective review of all patients with isolated subclavian artery aneurysms who underwent endovascular treatment between March 2008 and March 2020 was performed. The demographics, aneurysmal characteristics, treatment strategies, and in-hospital and follow-up outcomes were recorded and then analyzed.

RESULTS

From March 2008 to March 2020, 35 isolated subclavian artery aneurysms were endovascularly treated at our institution. Atherosclerosis was the most common cause of aneurysms in this series. Most aneurysms were intrathoracic (91.4%) and located at the right side (77.1%). There were 26 true aneurysms, seven pseudoaneurysms, and two ruptured isolated subclavian artery aneurysms. Five types of endovascular strategies were performed. Covered stent placement across the aneurysm was the most (54.3%) commonly used method. Technical success was achieved in all patients. The median postoperative in-hospital stay was 4.0 days (range, 1-15 days). One patient died after discharge but within 30 days of surgery due to myocardial infarction. The median follow-up time was 62.0 months (range, 3-132 months). No death, stroke, stent fractures, or severe upper limb ischemia developed during the follow-up period. The cumulative survival rate at five years was 97.1%. The overall complication rate was 25.7% and one-third of complications (8.6%) required reinterventions.

CONCLUSIONS

Endovascular treatment for isolated subclavian artery aneurysms is safe, effective and technically achievable in most patients. Short- and long-term outcomes are promising. Reasonable and flexible use of covered stents can also get satisfactory outcomes in some complicated lesions such as isolated subclavian artery aneurysms located at the origin of the right subclavian artery, avoiding the huge surgical trauma caused by conventional open repair.

[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.

Emergency management of iatrogenic arterial injuries with a low-profile balloon-expandable stent-graft: Preliminary results

Endovascular treatment of arterial injuries with stent-graft is a reliable alternative approach in patients not suitable for embolization or at high risk for surgery. The aim of our study was to evaluate the efficacy and the safety of the BeGraft stent-graft, a low-profile balloon expandable covered stent, for emergency endovascular treatment of iatrogenic arterial injuries.Between August 2015 and September 2018, 34 consecutive patients (mean age 71 ± 12 years, 9 females) underwent implantation of BeGraft stent-grafts for iatrogenic arterial injuries (22 active bleedings, 11 pseudoaneurysms, and 1 enteric-iliac fistula). The primary endpoints were technical and clinical success and rates of major and minor complications. The secondary endpoint was the patency of the device during the follow-up. Imaging follow-up was performed by duplex ultrasound and/or computed tomography angiography (according to lesion site/target vessel), at 1-6-12-15 and 24 months.In all 34 patients (100%), the lesion or the defect was effectively excluded with a cumulative amount of 42 stent-grafts. The clinical success was documented in 30/34 patients (88.2%). Neither device- or procedure-related deaths, or major complications occurred. A minor complication was reported in 1 patient (2.9%), successfully treated during the same procedure. Thirty (88.2%) patients were available for a mean follow-up time of 390 ± 168 days (minimum 184, maximum 770), with no observed loss of patency, yielding a 100% Kaplan-Meier cumulative survival patency function. The percentage of patent patients was 30/30 at 6 months, 22/22 at 12 months, and 5/5 at 15 months.Endovascular treatment of iatrogenic arterial injuries with the BeGraft stent-graft is minimally invasive and effective, with good patency rate at midterm follow-up.

Non-aortic vascular findings on chest CT angiogram: including arch vessels and bronchial arteries

CT angiogram (CTA) has become the modality of choice for imaging of thoracic vascular pathologies, involving the aorta and the pulmonary arteries. Apart from showing exquisite details of these large arteries, pathologies and anatomic variants of their branches can also be studied to a great extent. The major branches of aortic arch can be affected by a wide variety of pathologies ranging from atherosclerosis to trauma and vasculitis. Bronchial arteries in spite of supplying only 1% of lung parenchyma can become hypertrophied in various congenital and acquired conditions, becoming an important source of collateral circulation as well as a source for life threatening hemoptysis. CT also plays an important role in diagnosis of vascular compression at the thoracic outlet. With advances in CT technology, the acquisition, interpretation and clinical applications of CT angiography will continue to grow in the years to come.

[Endovascular repair of subclavian artery injury secondary to internal jugular vein catheterization: case report]

BACKGROUND AND OBJECTIVES

Ultrasound-guided internal jugular vein catheterization is a common and generally safe procedure in the operating room. However, inadvertent puncture of a noncompressible artery such as the subclavian artery, though rare, may be associated with life-threatening sequelae, including hemomediastinum, hemothorax, and pseudoaneurysm.

CASE REPORT

We describe a case of the successful endovascular repair of right subclavian artery injury in a 75-year-old woman. Subclavian artery was injured secondary to ultrasound-guided right internal jugular vein catheterization under general anesthesia for orthopedic surgery.

CONCLUSION

Under general anesthesia several factors such as hypotension can mask the signs of subclavian artery injury. This case report indicates that clinicians should be aware of the complications of central venous catheterization and take prompt action.

Endovascular repair of subclavian artery injury secondary to internal jugular vein catheterization: case report

Background and objectives

Ultrasound-guided internal jugular vein catheterization is a common and generally safe procedure in the operating room. However, inadvertent puncture of a noncompressible artery such as the subclavian artery, though rare, may be associated with life-threatening sequelae, including hemomediastinum, hemothorax, and pseudoaneurysm.

Case report

We describe a case of the successful endovascular repair of right subclavian artery injury in a 75-year-old woman. Subclavian artery was injured secondary to ultrasound-guided right internal jugular vein catheterization under general anesthesia for orthopedic surgery.

Conclusion

Under general anesthesia several factors such as hypotension can mask the signs of subclavian artery injury. This case report indicates that clinicians should be aware of the complications of central venous catheterization and take prompt action.

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 Therapy of Vascular Trauma—Current Options and Review of the Literature

Objective:

To review the current use of endovascular techniques in trauma.

Summary Background Data:

Multiple studies have demonstrated that, despite current guidelines, endovascular therapies are used in instances of arterial trauma.

Methods:

The existing literature concerning arterial trauma was reviewed. Studies reviewed included case reports, single-center case series, large database studies, official industry publications and instructions for use, and society guidelines.

Results:

Endovascular therapies are used in arterial trauma in all systems. The use of thoracic endografts in blunt thoracic aortic trauma is accepted and endorsed by society guidelines. The use of endovascular therapies in other anatomic locations is largely limited to single-center studies. Advantages potentially include less morbidity due to smaller incisions as well as shorter operating room times. Many report using endovascular therapies even with hard signs of injury. Long-term results are limited by a lack of long-term follow-up but, in general, suggest that these techniques produce acceptable outcomes. The adoption of these techniques may be limited by resource and surgeon availability.

Conclusions:

The use of endovascular therapies in trauma has gained acceptance despite not yet having a place in official guidelines.

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.

Endovascular treatment of penetrating arterial trauma with stent grafts

Abstract. Background: The endovascular management of arterial injuries has resulted in reduced operating time, blood loss, hospital mortality, lower incidence of sepsis, and decrease in mortality rates. For penetrating trauma, however, the benefits of endovascular therapy are questionable. Patients and methods: Data were obtained by retrospective analysis of electronic medical records. All patients with vascular trauma seeking care at our institution from January 2010 to December 2015 were reviewed. A total of 223 vascular trauma patients were enrolled. Of these, 18 patients (8 %) were treated with endovascular techniques. The data related to clinical presentation, patient characteristics, technical aspects of the treatment, and follow-up were analysed. Results: The mean patient age was 35.4 ± 17.8 years, 94 % were male. The mean injury severity score was 10.4 ± 2.5. The most commonly observed trauma mechanism was a gunshot in 10 cases (55 %), followed by lesions provoked by arterial catheter misplacement in five cases (27 %), and stab wounds in three cases (16.6 %). The main injury site was the subclavian artery, accounting for eight cases (44 %), followed by the superficial femoral artery and the tibiofibular trunk in two cases, respectively (18 %). The anterior tibial, fibular artery, axillary, common carotid, superior mesenteric, and profunda femoris were each affected once. Arteriovenous fistula was detected in nine cases (50 %), pseudoaneurysms in nine cases (50 %), and short occlusion in two cases (11 %). The mean follow-up duration was 753 days. The primary patency rate was 92.3 and 61.5 % after one and two years, respectively. The survival rate was 94.4 % after one and two years. Infection of the stents or limb amputations were not identified at follow-up. Conclusions: The endovascular treatment of penetrating arterial injuries with covered stents is feasible. However, the criteria used to choose the best method must be individualized.

Keywords: Trauma, endovascular, stent graft, gunshot, stab wound

History and Current Status of Endovascular Management for the Extracranial Carotid and Supra-Aortic Vessels

Few procedures in the history of medicine have been more controversial than carotid artery stenting (CAS) for the management of carotid artery occlusive disease. Introduced just as the randomized trials were establishing carotid endarterectomy as the gold standard for carotid interventions, CAS has finally reached the point in its development when dedicated stenting systems are being tested in randomized clinical trials. Assisted by the concomitant use of distal protection devices, CAS has shown equipoise with endarterectomy in terms of safety at 30 days. This review summarizes the completed and ongoing CAS trials and the applications of endovascular techniques in the supra-aortic vessels.

Endovascular Repair Using Suture-Mediated Closure Devices and Balloon Tamponade following Inadvertent Subclavian Artery Catheterization with Large-Caliber Hemodialysis Catheter

Accidental subclavian artery cannulation is an uncommon but potentially serious complication of central venous catheterization. Removal of a catheter inadvertently placed in the subclavian artery can lead to substantial bleeding, as achieving hemostasis in this area through manual compression presents considerable difficulty. Additionally, surgical treatment might be unsuitable for high-risk patients due to comorbidities. Here, we report a case of an inadvertently-inserted 11.5-French hemodialysis catheter in the subclavian artery during internal jugular venous catheterization. We performed percutaneous closure of the subclavian artery using three 6-French Perclose Proglide® devices with a balloon tamponade in the proximal part of the subclavian artery. Closure was completed without embolic neurological 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.

Risk of continuing planned surgery after endovascular repair of subclavian artery injury: a case report

Endovascular repair with covered stents has been widely used to treat subclavian and axillary artery injuries and has produced promising early results. The possibility of a thromboembolism occurring in cerebral arteries during an endovascular procedure should be a cause for concern. In the case of endovascular management of arterial traumas, a prompt and sufficient period for check-up of the patient's neurological signs is needed, even if it requires postponing elective intervention for the patient's safety. We report a rare case of liver transplantation immediately after endovascular repair of an iatrogenic subclavian arterial injury to describe the risk of continuing planned surgery without neurologic assessment.

Hemoptysis caused by a left subclavian pseudoaneurysm: endovascular solution for a challenging case

This is one of the first reports of a left subclavian pseudoaneurysm in a patient presenting with massive hemoptysis. We present a challenging case of a patient who consulted for hemoptysis. Imaging revealed a left subclavian artery pseudoaneurysm that caused a pulmonary parenchymal lesion. Treatment with a self-expanding thoracic stent-graft and a subclavian occluder was successful.

Vertebral artery occlusion with Amplatzer vascular plug 4 to prevent subsequent endoleak in stent-graft treatment of subclavian artery gunshot injury

Endovascular treatment options have evolved in many ways and become an important alternative for open surgical repairs in various vascular territories. Herein, we present a case of an 18-year-old man with complex injury to the left subclavian artery and vein caused by a gunshot 4 months ago. After the gunshot, a high-flow fistula between the left subclavian artery and the vein occurred with pseudoaneurysm formation. This fistula led to a significant left subclavian steal phenomenon. A stent-graft was deployed along the injured left subclavian artery after embolization of the left vertebral artery by Amplatzer vascular plug 4 (AVP-4) in order to prevent subsequent endoleak due to the subclavian steal syndrome.

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.

[Cave canulam et dilatationem. Cardiopulmonary resuscitation and surgical repair of a vessel perforation following central venous catheterization]

A 58-year-old female patient was scheduled for minimally invasive cardiac surgery. For drainage of venous blood to the heart-lung machine insertion of a central venous large diameter catheter was a prerequisite. During insertion into the right internal jugular vein by the anesthesiologist a life-threatening perforation of the subclavian artery occurred. The patient suffered hemorrhagic shock and advanced cardiac life support was carried out for approximately 18 min. Immediate surgical repair was successful and the originally planned operation was then performed. Concurrently, mild therapeutic hypothermia was established for 24 h to protect the cerebrum. Within 4 days the patient recovered without any neurological deficits.

Endovascular grafts for treatment of traumatic injury to the aortic arch and great vessels

BACKGROUND

Treatment of traumatic vascular injury using endovascular techniques has evolved as endovascular capabilities have advanced over the past several decades. Several endovascular techniques have been employed to address the challenges of traumatic arterial injury, including coil embolization and the use of stents, which may be either bare metal or covered with graft material. Compared with traditional surgical repair, endovascular stent grafting for the repair of traumatic arterial injury offers the advantage of decreased morbidity because a remote access site may be used, avoiding surgical dissection and lengthy operating times.

METHODS

A Medline (1995-2007) search was performed to find all studies discussing the use of endovascular means to treat supradiaphragmatic arterial trauma.

RESULTS

In this review of 195 studies published between January 1995 and December 2007, the overall technical success rate of endovascular treatment of supradiaphragmatic arterial injury was 96.7%, and the complication rate was 6.4%.

CONCLUSION

The results of this review suggest a potential morbidity and mortality benefit over traditional open repair; however, long-term data are lacking. Long-term follow-up for stent durability is of particular concern in the trauma population, which tends to comprise younger patients with minimal atherosclerotic disease. The success of endovascular techniques is also limited by the availability of skilled interventionalists, properly outfitted angiography suites, and suitable stent graft devices. Despite these challenges, the potential advantages of endovascular stenting make it a welcome addition to the armamentarium of the vascular interventionalist who treats arterial traumatic injuries.

Combined supra-aortic extra-anatomic revascularization and endovascular hybrid procedure for recurrent hemoptysis caused by a symptomatic aneurysm of the right subclavian artery

Acute hemoptysis might be caused by aneurysms of the subclavian artery. We report a 75-year-old female patient presenting with recurrent hemoptysis, dyspnea, fever, and episodes of unclear pneumonia. Further examination revealed a large intrathoracic aneurysm of the right subclavian artery. After an initial transfemoral interventional attempt to occlude the entry of the aneurysm, the patient developed persistent thoracic pain. The patient was then treated by a combined extrathoracic hybrid procedure with a left to right carotid-carotid-axillary artery bypass and an endovascular aneurysm exclusion by insertion of two iliac artery occluder stent grafts in the proximal brachiocephalic trunk and the distal right subclavian artery. After this combined intervention, hemoptysis disappeared, and the patient recovered remarkably during a follow-up of 24 months.

Hybrid Open and Endovascular Therapy for a Proximal Subclavian Artery Aneurysm

A 57-year-old male presented with a large proximal right subclavian artery aneurysm that had been the source of upper extremity emboli on two occasions. A combined open and endovascular approach was undertaken involving a common carotid to vertebral artery autogenous bypass via a supraclavicular incision and endovascular repair of the aneurysm from a transbrachial approach. The patient did well postoperatively and recovered fully following a short hospitalization.

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.

Combined surgery for the treatment of bilateral subclavian artery aneurysm in Marfan syndrome

Large bilateral aneurysm of the subclavian artery is an infrequent entity that can progress to thrombosis, embolization, or rupture if left untreated. Treatment consists of exclusion of the aneurysm by an endovascular procedure or open surgery. We present a case of large bilateral subclavian artery aneurysm in a patient with Marfan syndrome that was treated by a combination of endovascular and conventional surgery. This therapeutic approach provided good results for patency with lower morbidity and mortality.

Haemothorax: A potentially fatal complication of subclavian cannulation--A case report

Central venous cannulation forms one of the mainstays of management of trauma and haemodynamically unstable patients. Frequently this procedure has to be done as an emergency in the emergency department. Ultrasound guidance has been recommended, especially for use by trainee members of the emergency department. We report a case of 44% full thickness burns with subclavian artery puncture due to a misplaced central venous catheter. This led to massive haemothorax, which eventually caused the patient to succumb. We re-emphasise the need for ultrasound guidance for insertion of central venous lines, especially in the emergency setting.

Combined open and endovascular treatment of a right subclavian artery aneurysm: A case report

A 69-year-old man with previous ascending aortic repair combined with valve replacement for an ascending aortic aneurysm presented with a type 2 thoracoabdominal aneurysm and a 4.4-cm aneurysm of the right subclavian artery. Because of the anatomic location of the aneurysm and his previous operation, an innominate to carotid artery stent graft and a carotid-subclavian bypass and vertebral artery bypass were performed. Postoperative computed tomographic angiography confirmed good flow in the right carotid and vertebral artery, and the patient recovered without complication.

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.

History and current status of endovascular management for the extracranial carotid and supra-aortic vessels

Few procedures in the history of medicine have been more controversial than carotid artery stenting (CAS) for the management of carotid artery occlusive disease. Introduced just as the randomized trials were establishing carotid endarterectomy as the gold standard for carotid interventions, CAS has finally reached the point in its development when dedicated stenting systems are being tested in randomized clinical trials. Assisted by the concomitant use of distal protection devices, CAS has shown equipoise with endarterectomy in terms of safety at 30 days. This review summarizes the completed and ongoing CAS trials and the applications of endovascular techniques in the supra-aortic vessels.

Endovascular management of axillofemoral bypass graft stump syndrome

OBJECTIVE

Upper extremity embolic complications of occluded axillofemoral bypass grafts are infrequent. However, traditional management of dissection of axillary anastomosis for removal of the stump can be challenging. We report two patients with critical upper extremity ischemia secondary to stump syndrome and its successful management with endovascular techniques.

METHODS

One hundred fifty-two patients underwent axillofemoral bypass grafting over 10 years from 1991-2001. Two patients from this series had acute ischemia involving the ipsilateral upper extremity of occluded axillofemoral bypass graft. Duplex ultrasound scans revealed occlusion of the axillofemoral bypass graft and acute occlusion of ipsilateral upper extremity arteries. Both patients underwent brachial artery exploration and embolectomy. Completion angiograms revealed persistent axillofemoral bypass graft stump as the source of embolus. The stump was obliterated with a 10-mm/40-mm Wallgraft introduced through the same arteriotomy made for brachial embolectomy. Transesophageal echocardiography and magnetic resonance angiography of the arch and great vessels were performed to exclude other sources of origin for the embolus.

RESULTS

Both patients remained symptom-free and with patent stent grafts, as seen on duplex scans at 3, 6, and 9 months of follow-up.

CONCLUSIONS

Upper extremity embolism is a rare complication after occlusion of axillofemoral bypass grafts. The endovascular approach to obliterate the stump of occluded axillofemoral bypass grafts is minimally invasive and an effective alternative treatment of this rare condition.