Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 73-75

Giant subclavian artery aneurysm: Case report and review of literature


1 Narayana Institute of Vascular Sciences, Narayana Hrudayalaya, Bengaluru, Karnataka, India
2 Division of Vascular Surgery, Mayo Clinic, Rochester, USA

Date of Web Publication5-May-2017

Correspondence Address:
Ramesh Tripathi
Narayana Institute of Vascular Sciences, Narayana Hrudayalaya, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_44_16

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  Abstract 

Upper extremity aneurysms are quite uncommon when compared to other peripheral arterial aneurysms. Among them, giant (>5 cm) subclavian artery aneurysms (SCAAs) are extremely rare. We report a case of giant SCAA measuring 8.8 cm in its maximal diameter with an updated review of literature. Our case is unique in view of surgical exposure method used (modified trapdoor thoracotomy with claviculectomy).

Keywords: Aneurysm, subclavian artery, trapdoor thoracotomy


How to cite this article:
Singh Y, Verma H, Tripathi R. Giant subclavian artery aneurysm: Case report and review of literature. Indian J Vasc Endovasc Surg 2017;4:73-5

How to cite this URL:
Singh Y, Verma H, Tripathi R. Giant subclavian artery aneurysm: Case report and review of literature. Indian J Vasc Endovasc Surg [serial online] 2017 [cited 2020 Dec 2];4:73-5. Available from: https://www.indjvascsurg.org/text.asp?2017/4/2/73/205702


  Introduction Top


True subclavian artery aneurysms (SCAAs) are usually due to degenerative conditions, connective tissue disorders, or related to thoracic outlet syndrome (TOS). Pseudoaneurysms are more often due to blunt or penetrating trauma. Giant true SCAA (>5 cm) is rare. Very few case reports of large intrathoracic SCAA have been reported in the literature.[1]


  Case Report Top


A 77-year-old farmer presented with diffuse swelling in the right supraclavicular area, worsening hoarseness of voice, and dyspnea over 5 months duration. Computed tomography (CT) angiogram revealed a giant aneurysm of the right subclavian artery (SCA) just distal to its origin from innominate artery measuring 8.8 cm in its maximal diameter with massive displacement of mediastinum to the left side compressing trachea and upper lobe of the right lung. The right vocal cord had minimal movement on indirect laryngoscopy [Figure 1]a and [Figure 1]b. The right vertebral artery was occluded, and infraclavicular part of SCA was normal.
Figure 1: Computed tomography angiogram showing giant right subclavian artery aneurysm (a) axial view, (b) three-dimensional reconstruction

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Under general anesthesia, median sternotomy was performed for the patient. Mediastinal fat and thymus were dissected and pericardium exposed. A giant right subclavian aneurysm was noted arising from proximal one-third of the artery with a short proximal and long distal segment lying just behind the right clavicle with displacement of apex and middle lobes of the right lung. The right phrenic and recurrent laryngeal nerves were identified in front of the SCA and carefully looped and protected.

Due to the enormous size of aneurysm in a tightly packed thoracic outlet space and most of the right mediastinum, clavicle was divided in the middle to gain better exposure and access to the aneurysm (open-book approach). Proximal and distal clamps were applied, and aneurysmectomy and interposition graft with 6 mm InterGard Silver (Maquet Cardiovascular, Wayne, NJ, USA) was performed [Figure 2]a and [Figure 2]b. Although the postoperative recovery was delayed due to slow ventilator wean off, partially because of his vocal cord palsy, he made a full recovery and was discharged on day 9. Postoperative indirect laryngoscopy revealed no improvement in his vocal cord function, and he was subsequently treated by Teflon injection laryngoplasty. The right upper limb pulses were well felt with no blood pressure differential with opposite arm. There was also no residual motor and sensory deficit in the right upper limb.
Figure 2: Exposure of subclavian artery aneurysm by trapdoor thoracotomy (a) and aneurysm repair (b)

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  Discussion Top


Aneurysms of the SCA are extremely rare.[2] Only 1% of all peripheral aneurysms involve the subclavian and innominate arteries.[3] Dent et al. have reported that only 2 out of 1488 cases of atherosclerotic aneurysm had SCAA, with an incidence of about 0.13%.[2] The largest aneurysm thus far reported measured 12 cm.[3]

Vierhout et al. in a 2010 review found <400 cases of SCAA published reports in the world literature.[4]

SCAA s can be classified into two groups: (a) intrathoracic and (b) extrathoracic.[4],[5] Vierhout et al. found 39% of SCAAs in the proximal segment, 25% in the middle segment, and 24% in the distal segment. Each group differs with the other in etiology, presentation, and treatment. The etiology was trauma (37%), atherosclerosis (18%), TOS (18%), and iatrogenic (10%).

Proximal and middle segment SCAAs were most often caused by atherosclerosis, collagen disorders, and trauma or iatrogenic insults.[6] TOS accounted for almost 15% of cases in the mid segment and almost half in the distal SCAs (46%).[6]

Extrathoracic aneurysms are often related to a TOS or old trauma, intrathoracic aneurysms are often caused by atherosclerotic (as in our reported case) or rarely due to fibrodysplastic, infectious, or traumatic etiologies.[7]

Extrathoracic aneurysm usually presents with pulsatile mass over supraclavicular fossa with or without vascular bruit whereas intrathoracic aneurysm or poststenotic aneurysm compress brachial plexus or upper extremity vessels leading to the edema.[1],[4],[5] These aneurysms may erode into the apex of the lung and cause hemoptysis and compress recurrent laryngeal nerve resulting in hoarse voice, vocal cord paralysis, or dysphagia due to esophageal compression.[1],[8],[9] Severe respiratory distress caused by tracheal compression has been rarely reported.[10]

Embolization, rupture, and thrombosis causing ischemic limb were present in 16%, 9%, and 6% of patients, respectively.[6] Finally, some aneurysms can be diagnosed after a rupture causing fatal hemorrhage presenting as massive hemothorax and shock.[8]

Aneurysms of the distal part of the SCA are frequently associated with TOSs which present as poststenotic dilatation.[7] Unlike visceral and aortoiliac aneurysms which may lead to rupture, the upper extremity aneurysms usually present as acute thromboembolic episodes, neuromuscular, or sensory dysfunctions resulting from pressure on the brachial plexus, thromboembolic episodes causing neurologic deficits, etc.[11]

The chest CT can detect this condition noninvasively; however, CT or digital subtraction angiography is necessary to plan surgical or endovascular repair.[12] Multiplanar reconstruction of CT angiogram is very helpful in planning the approach for the surgery.

The surgical or endovascular principle is to restore inflow and outflow tracts, which would benefit by exposing bilateral ends of aneurysm.[1]

Common surgical approaches include (1) posterolateral thoracotomy, (2) third anterior intercostal space thoracotomy (thoracic), (3) T-shaped median sternotomy with transverse extension over the second or third intercostals space, (4) trapdoor thoracotomy (combination of 3 plus supraclavicular incision), and (5) paraclavicular incision.[1] In our case, as the aneurysm was huge with severe inflammatory adhesions to the lung and retrosternal tissues, a modified trapdoor thoracotomy with division of clavicle was used for extensive exposure. Claviculectomy permitted excellent exposure for distal SCA, especially in trauma and complex SCA surgery.[13],[14]

During the operation, it is generally recommended to expose proximal and distal ends of SCA first and then handle the aneurysmal body. In our case, there was a 1 cm stump of the right SCA available to clamp proximally followed by opening of the aneurysm removal of mural thrombus and Fogarty balloon control of the distal SCA. The aneurysm was excised in toto after dissection of distal end for application of a vascular clamp. There is usually a large cavity left after resection of a giant subclavian aneurysm and this requires pleural and mediastinal drainage till full lung expansion is achieved. The overall complication rate was reported to be 26% in the 2010 review by Vierhout et al., of 329 patients who underwent open surgery. There was an overall mortality of 5%, and a variety of complications, including laryngeal nerve palsy, upper limb ischemia, pulmonary problems, (including chylothorax and esophagopleural fistula), cardiac complications, graft occlusion, and brachial plexus injuries.[6] Treatments that were performed in an elective setting had a mortality rate of 3%, and for the one-fifth of patients who had surgery in an emergency setting, the mortality rate was 13%.[4],[6]

The clavicle is repaired by K-wires or plate and screw, ensuring the graft is not injured in the process of thoracotomy closure.

SCAAs should be treated when encountered; there are no criteria for size, and SCAAs can be well treated with both open and endovascular techniques.[6] There are still currently <100 reports of endovascular SCAA repair in the literature, with the overall complication rate for endovascular SCAA repair was 28% with a mortality rate of 5%.[6] The durability of endovascular techniques is not yet proven.[6] Beregi et al. found that 40% of SCAA stent grafts were occluded within 1 year.[15]


  Conclusion Top


Although subclavian aneurysms are rare, their management remains primarily surgical due to proximity of major branches. Anterior trapdoor thoracotomy with claviculectomy provides excellent exposure for unhindered excision and reconstruction of large SCAAs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Zhan B, Zhang S, Shao Y. Operation for huge subclavian artery aneurysm: A case report. J Thorac Dis 2010;2:117-20.  Back to cited text no. 1
    
2.
Dent TL, Lindenauer SM, Ernst CB, Fry WJ. Multiple arteriosclerotic arterial aneurysms. Arch Surg 1972;105:338-44.  Back to cited text no. 2
    
3.
Dougherty MJ, Calligaro KD, Savarese RP, DeLaurentis DA. Atherosclerotic aneurysm of the intrathoracic subclavian artery: A case report and review of the literature. J Vasc Surg 1995;21:521-9.  Back to cited text no. 3
    
4.
Vierhout BP, Zeebregts CJ, van den Dungen JJ, Reijnen MM. Changing profiles of diagnostic and treatment options in subclavian artery aneurysms. Eur J Vasc Endovasc Surg 2010;40:27-34.  Back to cited text no. 4
    
5.
Salo JA, Ala-Kulju K, Heikkinen L, Bondestam S, Ketonen P, Luosto R. Diagnosis and treatment of subclavian artery aneurysms. Eur J Vasc Surg 1990;4:271-4.  Back to cited text no. 5
    
6.
Mohan IV, Stephen MS. Peripheral arterial aneurysms: Open or endovascular surgery? Prog Cardiovasc Dis 2013;56:36-56.  Back to cited text no. 6
    
7.
Davidovic LB, Markovic DM, Pejkic SD, Kovacevic NS, Colic MM, Doric PM. Subclavian artery aneurysms. Asian J Surg 2003;26:7-11.  Back to cited text no. 7
    
8.
Windfuhr JP, Schubert D, Remmert S. Aneurysm of the subclavian artery. An unusual cause of dysphagia. HNO 2004;52:1097-102.  Back to cited text no. 8
    
9.
Pairolero PC, Walls JT, Payne WS, Hollier LH, Fairbairn JF 2nd. Subclavian-axillary artery aneurysms. Surgery 1981;90:757-63.  Back to cited text no. 9
    
10.
Sahu KK, Thirtha A, Devgarha S, Mathur RM. Giant pseudoaneurysm of right subclavian artery presenting with severe respiratory distress. Ann Vasc Surg 2011;25:1139.e13-5.  Back to cited text no. 10
    
11.
Bin HG, Kim MS, Kim SC, Keun JB, Lee JH, Kim SS. Intrathoracic aneurysm of the right subclavian artery presenting with hoarseness: A case report. J Korean Med Sci 2005;20:674-6.  Back to cited text no. 11
    
12.
Schoder M, Cejna M, Hölzenbein T, Bischof G, Lomoschitz F, Funovics M, et al. Elective and emergent endovascular treatment of subclavian artery aneurysms and injuries. J Endovasc Ther 2003;10:58-65.  Back to cited text no. 12
    
13.
Buscaglia LC, Walsh JC, Wilson JD, Matolo NM. Surgical management of subclavian artery injury. Am J Surg 1987;154:88-92.  Back to cited text no. 13
    
14.
Lin PC, Jacobowitz GR, Rockman CB. Subclavian artery aneurysm in association with congenital absence of ipsilateral internal carotid artery. J Vasc Surg 2004;39:682-5.  Back to cited text no. 14
    
15.
Beregi JP, Prat A, Willoteaux S, Vasseur MA, Boularand V, Desmoucelle F. Covered stents in the treatment of peripheral arterial aneurysms: Procedural results and midterm follow-up. Cardiovasc Intervent Radiol 1999;22:13-9.  Back to cited text no. 15
    


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