Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 99-101

Posttraumatic subclavian artery pseudoaneurysm: An endovascular approach


Department of Vascular Surgery, Institute of Vascular Surgery, Madras Medical College, Chennai, Tamil Nadu, India

Date of Submission23-Aug-2019
Date of Decision25-Oct-2019
Date of Acceptance03-Nov-2019
Date of Web Publication16-Mar-2020

Correspondence Address:
Dr. Shabnam Fathima
Department of Vascular Surgery, Institute of Vascular Surgery, Madras Medical College, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_54_19

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  Abstract 


The use of minimally invasive vascular techniques for vascular injuries is on the rise. We report a case of stab injury with pseudoaneurysm of the subclavian artery treated with “covered” stent of the subclavian artery. The patient presented a month after the injury and was hemodynamically stable. Hence, a computed tomography angiogram of the arch of the aorta and left upper limb was performed and taken up for elective stenting of the left subclavian artery. The completion angiogram showed complete exclusion of the pseudoaneurysm, with normal runoff to the upper extremity. In conclusion, penetrating arterial trauma in inaccessible sites can be successfully managed with minimal morbidity by endovascular means.

Keywords: Covered stenting, endoleak, subclavian artery


How to cite this article:
Paramasivam I, Fathima S, Sritharan N, Muralidharan K, Vijaykumar J. Posttraumatic subclavian artery pseudoaneurysm: An endovascular approach. Indian J Vasc Endovasc Surg 2020;7:99-101

How to cite this URL:
Paramasivam I, Fathima S, Sritharan N, Muralidharan K, Vijaykumar J. Posttraumatic subclavian artery pseudoaneurysm: An endovascular approach. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2020 Jul 14];7:99-101. Available from: http://www.indjvascsurg.org/text.asp?2020/7/1/99/280676




  Introduction Top


Traumatic injury of the subclavian artery [1] is associated with significant morbidity and mortality. Due to the adjacent location of the brachial plexus, pleura, and the thoracic duct on the left, the surgical procedure is challenging and morbid as it may require a sternotomy for proximal control. Recently, endovascular techniques have emerged as a valuable alternative [2] to open surgical management. Although it can be associated with complications, they are amenable to multiple noninvasive management modalities.[3] We report a case of subclavian artery pseudoaneurysm presenting 1 month after injury treated by the endovascular procedure.


  Case Report Top


A 20-year-old male was referred to us with pulsatile swelling in his left supraclavicular fossa for 1 month, following a stab injury over his left supraclavicular fossa [Figure 1]. He had no distal neurovascular deficit and any syncope following injury. He had no comorbidities. On examination, he had a 4 cm × 4 cm × 3 cm pulsatile swelling left supraclavicular fossa, with an overlying sutured wound. He was hemodynamically stable.
Figure 1: Preoperative clinical picture

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Hence, he underwent a computed tomography (CT) angiogram which showed a 4.3 cm × 4.5 cm × 4.2 cm pseudoaneurysm of the left subclavian artery arising distal to its origin from arch, with the vertebral artery arising from the sac [Figure 2]. The right vertebral artery was normal, and the circle of Willis was complete. An open procedure would require a thoracotomy for proximal control in this young patient, hence endovascular repair was planned.
Figure 2: Preoperative computed tomography angiogram showing left subclavian pseudoaneurysm

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Procedure

A left brachial artery open access was planned. A 9 cm × 45 cm long sheath was used. Digital subtraction angiography showed a trilobed pseudoaneurysm from the subclavian artery [Figure 3]. The CT angiogram finding was confirmed. A 150 cm Amplatz stiff wire was used for support and wire placed in the aortic arch. A 8 mm × 60 mm fluency * stent was deployed with the proximal end of the stent jutting a little into the aortic arch [Figure 4]. The left vertebral artery was covered in this process. No retrograde filling is seen from the left vertebral artery. No cerebrovascular symptoms observed in the patient.
Figure 3: Digital subtraction angiography image showing trilobed pseudoaneurysm sac

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Figure 4: Subclavian stent placement

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In the immediate postoperative period, the patient showed persistent pulsatile swelling in the left supraclavicular fossa. Duplex assessment showed a Type 1b endoleak in the stented subclavian artery. He underwent serial compression of the region. On the postoperative day 10, CT angiogram was repeated, and it showed resolved endoleak and complete thrombosis of the pseudoaneurysm [Figure 5].
Figure 5: Postoperative computed tomography angiogram

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  Discussion Top


Penetrating injuries of the neck are associated with arterial injuries in 25%–56%, with mortality of 10%.[4] The neck is divided into three zones. Zone 1 is between the clavicle and the cricoid cartilage with potential for major vessel injury. Zone 2 is between the cricoid cartilage and the angle of the mandible. Zone 3 is above the angle of the mandible till base of the skull. The vessel injury in Zone 1 can occur following a posttraumatic penetrating injury or iatrogenic injury. Multiple reports of iatrogenic injury following central venous catheterization has been reported in literature.[5] Such case of subclavian artery pseudoaneurysm can be managed through multiple endovascular techniques such as thrombin injection,[6] coil embolization,[7] and covered stenting,[8] or through open surgical approach which will require a thoracotomy and is morbid. Thrombin injection has been associated with allergy in some patients. Subclavian artery stenting is immediately successful in most patients. A 8 mm × 60 mm stent graft was used based on the distal normal subclavian artery diameter measured during angiogram and the availability in our inventory. The proximal extent of stent was extended into aorta and flared up to prevent an endoleak. There are reports of post stenting endoleak in literature, as we encountered in our case. Thus, the endoleak in our case is possibly not due to undersizing of the stent graft. It can also be tackled through thrombin injection through interstices of the graft. Coil embolization and percutaneous injection of thrombin have also been reported with success. However, we opted to manage our patient conservatively with compression and serial monitoring, though there is a risk of stent deformation with this approach. The bare-metal stent has a notable risk of deformation or fracture due to biomechanical interaction as a result of repeated stent flexion and significant dynamic compression of the subclavian artery, in particular, at the lateral portion within the costoclavicular space (between the clavicle and the first rib) during arm abduction, but a stent graft has been used in ours patient. A major limitation of covered-stent exclusion is the risk of occlusion of the vertebral artery, leading to risk of cerebellar or posterior fossa infarction.


  Conclusion Top


In this era of minimally invasive therapy being used in all spheres of surgery, such posttraumatic pseudoaneurysm of major vessels in a patient can be approached through endovascular techniques with reduced morbidity. Complications are minimal and they can be treated with endovascular techniques.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understood that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Rich NM, Hobson RW, Jarstfer BS, Geer TM. Subclavian artery trauma. J Trauma 1973;13:485-96.  Back to cited text no. 1
    
2.
May J, White G, Waugh R, Yu W, Harris J. Transluminal placement of a prosthetic graft-stent device for treatment of subclavian artery aneurysm. J Vasc Surg 1993;18:1056-9.  Back to cited text no. 2
    
3.
Lee GS, Brawley J, Hung R. Complex subclavian artery pseudoaneurysm causing failure of endovascular stent repair with salvage by percutaneous thrombin injection. J Vasc Surg 2010;52:1058-60.  Back to cited text no. 3
    
4.
Asensio JA, Valenziano CP, Falcone RE, Grosh JD. Management of penetrating neck injuries. The controversy surrounding zone II injuries. Surg Clin North Am 1991;71:267-96.  Back to cited text no. 4
    
5.
Guilbert MC, Elkouri S, Bracco D, Corriveau MM, Beaudoin N, Dubois MJ, et al. Arterial trauma during central venous catheter insertion: Case series, review and proposed algorithm. J Vasc Surg 2008;48:918-25.  Back to cited text no. 5
    
6.
Yamashita Y, Kimura S, Kurisu K, Ueno Y. Successful treatment of iatrogenic subclavian artery pseudoaneurysm by ultrasound-guided thrombin injection. Ann Vasc Dis 2016;9:108-10.  Back to cited text no. 6
    
7.
Li L, Zhang J, Wang R, Li J, Gu Y, Yu H. Endovascular repair of a right subclavian artery aneurysm with coil embolization and stent graft: Case report and literature review. Ann Vasc Surg 2016;36:290.e1-5.  Back to cited text no. 7
    
8.
Maskanakis A, Patelis N, Moris D, Tsilimigras DI, Schizas D, Diakomi M, et al. Stenting of subclavian artery true and false aneurysms: A systematic review. Ann Vasc Surg 2018;47:291-304.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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