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

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.

A case report of a ruptured subclavian artery aneurysm presenting to the emergency department

Subclavian artery aneurysms are uncommon and present a diagnostic dilemma. Our patient attended with life-threatening rupture, requiring prompt management. However, lack of on-site facilities and specialist input posed a logistical challenge. The patient was stable enough to allow an urgent transfer to a specialist unit for successful endovascular repair.

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.

Oropharyngeal Dysphagia: neurogenic etiology and manifestation

To determine the type, severity and manifestation of dysphagia in patients with neurogenic etiology. Clinical documentation was done on the different etiologies, its manifestation, assessment findings and management strategies taken for patients with neurogenic oropharyngeal dysphagia who were referred for assessment and management of dysphagia over a period of three months in a tertiary care teaching hospital. Flexible endoscopic examination was done in all the patients. The severity of dysphagia in these patients were graded based on Gugging Swallowing Screen (GUSS). A total of 53 patients with neurogenic oropharyngeal dysphagia were evaluated by an otolaryngologist and a speech language pathologist over a period of three months. The grading of severity based on GUSS for these patients were done. There were 30 patients with recurrent laryngeal nerve injury due to various etiologies, one patient with Neurofibroma-vestibular schwanoma who underwent surgical excision, 16 patients with stroke, two patients with traumatic brain injury, two patients with Parkinsonism and two patients with myasthenia gravis. The manifestation of dysphagia was mainly in the form of prolonged masticatory time, oral transit time, and increased number of swallows required for each bolus, cricopharyngeal spasms and aspiration. Among the dysphagia patients with neurogenic etiology, dysphagia is manifested with a gradual onset and is found to have a progressive course in degenerative disorders. Morbidity and mortality may be reduced with early identification and management of neurogenic dysphagia.

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.

Uncommon and rare causes of vocal fold paralysis detected via imaging

BACKGROUND

Cross-sectional imaging can be used to trace the course of the vagus nerve and its laryngeal branches to detect many of the causes of vocal fold paralysis. The most frequent aetiologies are surgical injury and tumoural involvement of the recurrent laryngeal nerve anywhere along its course.

METHOD

This review article focuses on the uncommon and rare causes of vocal fold paralysis that have been detected or diagnosed on cross-sectional imaging.

RESULTS AND CONCLUSION

Uncommon causes included a tortuous oesophagus, tracheal diverticulum, cervical osteophytes and cardiovocal syndrome. These examples are presented with clinical case histories and radiological appearances, and are discussed in the context of the current literature.

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.

A novel two-stage surgical approach for the treatment of symptomatic supra-aortic artery aneurysms

We describe the case of a 45-year-old man with a unique constellation of supra-aortic artery aneurysms detected by chest X-ray during work-up for chronic cough. During his diagnostic work-up, the patient suffered an embolic stroke likely secondary to disrupted plaque originating in an aneurysmal right vertebral artery. Endovascular repair was not a viable option due to the diffuse and bilateral nature of aneurysmal disease, including involvement of the innominate and right carotid and vertebral arteries. The patient was successfully treated with a two-stage open surgical approach involving an initial right carotid artery to vertebral artery bypass and subsequent in situ reconstruction utilizing a bifurcated Dacron graft sewn to the proximal aortic arch with distal extension to the right common carotid and axillary arteries.

CT evaluation of vocal cord paralysis due to thoracic diseases: a 10-year retrospective study

PURPOSE

To discuss computed tomography (CT) evaluation of the etiology of vocal cord paralysis (VCP) due to thoracic diseases.

MATERIALS AND METHODS

From records from the past 10 years at our hospital, we retrospectively reviewed 115 cases of VCP that were evaluated with CT. Of these 115 cases, 36 patients (23 M, 13 F) had VCP due to a condition within the thoracic cavity. From these cases, we collected the following information: sex, age distribution, side of paralysis, symptom onset date, date of diagnosis, imaging, and primary disease. The etiology of VCP was determined using both historical information and diagnostic imaging. Imaging procedures included chest radiograph, CT of neck or chest, and esophagography or esophagoscopy.

RESULTS

Thirty-three of the 36 patients with thoracic disease had unilateral VCP (21 left, 12 right). Of the primary thoracic diseases, malignancy was the most common (19, 52.8%), with 18 of the 19 malignancies presenting with unilateral VCP. The detected malignant tumors in the chest consisted of thirteen lung cancers, three esophageal cancers, two metastatic tumors, and one mediastinal tumor. We also found other underlying etiologies of VCP, including one aortic arch aneurysm, five iatrogenic, six tuberculosis, one neurofibromatosis, three benign nodes, and one lung collapse. A chest radiograph failed to detect eight of the 19 primary malignancies detected on the CT. Nine patients with lung cancer developed VCP between follow-ups and four of them were diagnosed with a progression of malignancy upon CT evaluation of VCP.

CONCLUSION

CT is helpful for the early detection of primary malignancy or progression of malignancy between follow-ups. Moreover, it can reveal various non-malignant causes of VCP.

Giant pseudoaneurysm of right subclavian artery presenting with severe respiratory distress

Subclavian artery pseudoaneurysms are rare; and cases involving subclavian artery pseudoaneurysms presenting with compression on trachea leading to breathing difficulty are exceptional. We present a case report of huge subclavian artery pseudoaneurysm presenting with hoarseness of voice, respiratory distress, and aphonia. Patient was operated through median sternotomy, with the incision extended over the swelling. Aortic looping was done before opening the aneurysm. Rent in the right subclavian artery was identified and repaired. Because of the absence of a distal pulsation beyond the repaired site, we placed a reversed saphenous vein graft from the ascending aorta (end-to-side) to the right subclavian artery distal to repaired site (end-to-side). Good pulsation was achieved in the right brachial, right radial, and right ulnar arteries. Patient was extubated after 6 hours in stable condition.

Operation for huge subclavian artery aneurysm: a case report

Subclavian artery aneurysm is extremely rare, and further aneurysm compressing trachea and leading to breathing difficulty is more exceptional. The most common causes of subclavian artery aneurysm are atherosclerosis, trauma and post-stenotic dilated aneurysm secondary to thoracic outlet syndrome, besides, the rare causes include infective, syphilitic media necrosis and so on. We present a case report in which the patient presented with sever dyspnea due to compression of trachea by a 7 cm large subclavian artery aneurysm. After operation, the patient improved symptomatically. The blood pressure remained stable, blood circulation of right upper extremity was fine, and pulse was improved comparing with that before operation. Chest film confirmed tumor shrank and depressed trachea improved significantly. The patient was discharged 14 days later and continued anticoagulant therapy after discharge. Follow up one month later after the operation revealed breathing difficulty disappeared, and patient was with normal right upper extremity movement and good blood circulation.

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.