CASE REPORT

A Large Posttraumatic Subclavian Artery Aneurysm Complicatedby Artery Occlusion and Arteriobronchial Fistula SuccessfullyTreated Using a Covered Stent

Ludomir Stefanczyk • Jarosław Czeczotka •

Marcin Elgalal • Michał Sapieha • Olgierd Rowinski

Received: 7 May 2010 / Accepted: 13 July 2010 / Published online: 10 August 2010

� Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2010

Abstract The treatment of posttraumatic aneurysms of

peripheral arteries using covered stents is increasingly

commonplace. We present the case of a 10-year-old girl

with a pseudoaneurysm of the subclavian artery compli-

cated by an arteriobronchial fistula with hemorrhaging into

the bronchial tree and distal subclavian artery occlusion.

Despite the lack of artery patency, endovascular stent graft

implantation was successful. Pseudoaneurysm exclusion

and involution was achieved, together with a patent

implant and maintained collateral circulation patency.

Keywords Pseudoaneurysm � Stent graft � Subclavian

artery � Arteriobronchial fistula

Introduction

The treatment of posttraumatic aneurysms of peripheral

arteries using covered stents is increasingly commonplace

[1–5]. This procedure is an attractive alternative to surgery,

especially in cases where the localization makes surgical

access difficult or when the clinical situation requires

immediate intervention [6–9]. In order to achieve exclusion

of an aneurysm, it is necessary to completely cover the area

of the vessel that has been damaged, while the ends of the

stent graft must be placed in unaffected parts of the artery

proximal and distal to the lesion.

We present the case of a 10-year-old patient with an

pseudoaneurysm of the subclavian artery complicated by

an arteriobronchial fistula with hemorrhaging into the

bronchial tree and distal subclavian artery occlusion. We

also outline radiological findings and discuss the impor-

tance of endovascular treatment.

Case Report

The patient was a 10-year-old girl who had undergone

surgical treatment for a fracture of the distal end of the left

clavicle. Two weeks later, the patient was admitted to the

hospital as a result of bleeding from the postoperative site.

The site of bleeding was sutured and the wound was

dressed. After a further 2 weeks, the patient was readmitted

to the surgery department with massive hemoptysis,

increasing pain in the left supraclavicular fossa, and

increasing symptoms of ischemia of the upper left limb as

well as symptoms of brachial plexus paralysis. Computed

tomographic (CT) examination revealed a focal change in

the apex of the left lung, which increased in intensity after

administration of contrast agent. A CT angiography was

immediately performed (GE Lightspeed VCT, Waukesha,

WI), which revealed the presence of a pseudoaneurysm that

seemed to be penetrating into the supraclavicular fossa, an

arteriobronchial fistula with bleeding into the bronchial tree

and alveoli, and distal subclavian artery occlusion; the

axillary artery was filling from the collateral circulation

(Fig. 1A, B). The presence of the pseudoaneurysm and

ischemia of the upper limb were confirmed by color

L. Stefanczyk (&) � M. Elgalal � M. Sapieha

Department of Radiology and Diagnostic Imaging,

Medical University of Lodz, Kopcinskiego 22, 90-153 Lodz,

Poland

e-mail: stefanczyk_l@wp.pl

J. Czeczotka

Department of Surgery, Medical University of Lodz, Lodz,

Poland

O. Rowinski

Department of Radiology and Diagnostic Imaging, Medical

University of Warsaw, Warsaw, Poland

123

Cardiovasc Intervent Radiol (2011) 34:S146–S149

DOI 10.1007/s00270-010-9959-y

Doppler ultrasound. Both examinations confirmed the

patency of the carotid and vertebral arteries.

It was not certain at the time whether it would be pos-

sible to place a stent graft and exclude the pseudoaneu-

rysm. In the event that the use of a stent graft would not

have been possible, the alternative plan was to use a bal-

loon and perform a temporary occlusion of the artery. This

would have been followed by a surgical carotid branchial

bypass performed by the vascular surgeons. Retrograde

access was obtained through the right common femoral

artery via a 6F sheath. Contrast media was injected via a

vertebral 4F catheter, and a large pseudoaneurysm of the

left subclavian artery distal to the vertebral artery was

revealed (Fig. 2A). A 0.035-inch angled soft Radiofocus

Guidewire M, 260 cm (Terumo, Somerset NJ), was intro-

duced into the pseudoaneurysm sac. However, despite

several attempts, it was impossible to overcome the

occlusion and catheterize the axillary artery. Therefore,

under ultrasound guidance, retrograde access was obtained

through the left brachial artery via a 4F sheath, and a

second 0.035-inch angled soft Radiofocus Guidewire M,

260 cm (Terumo, Somerset NJ) and vertebral 4F catheter

were introduced into the pseudoaneurysm sac via the distal

end of the subclavian artery. The ends of the two catheters

were then placed close together within the pseudoaneurysm

sac, and the guide wire that had been introduced into the

left axillary artery was passed from the distal catheter to

the proximal one. This guide wire was then maneuvered

out of the artery via the sheath in the common femoral

artery (Fig. 2B). This is known as the rendezvous tech-

nique (sometimes also referred to as the Michelangelo

maneuver). As a result of this, it was possible to introduce a

6 mm 9 10 cm covered stent (Viabahn Endoprosthesis,

WL Gore, Flagstaff, AZ) over this guide wire, which tra-

versed the pseudoaneurysmal sac, and to successfully

exclude the wide-necked pseudoaneurysm. This stent graft

was the best that was available at the time and there were

no contraindications for its use. Because this was an

emergency, there was not enough time to obtain a different

graft that could potentially have been a better choice.

The stent graft was secured in place with a 6 9 20-mm

balloon. Initially, a 5-mm balloon was used after deploying

the stent graft. However, because a stenosis was still

present in the region of the first rib, a second 6-mm balloon

was used in an attempt to dilate the part of the stent graft

that was slightly narrowed. This second attempt was also

unsuccessful. A follow-up angiography did not reveal fill-

ing of the pseudoaneurysmal sac while flow to the axillary

artery was maintained (Fig. 2C). Manual pressure was

applied to the puncture site until hemostasis was achieved.

Next a compression dressing was applied to this area for

6 h. Because of the high of risk of respiratory tract and

pseudoaneurysmal sac infection, antibiotic therapy was

initiated with Augmentin (amoxicillin–clavulanic acid,

100 mg/kg body weight/24 h) for 14 days.

In a control CT angiography that was performed

1 month after the procedure, patency of the implant and the

axillary artery was confirmed. The pseudoaneurysm sac

had decreased in size and did not increase in intensity after

contrast agent administration (Fig. 3). Vessel patency was

also confirmed by color Doppler ultrasound examination.

Six months after the procedure, examination revealed that

the implant remained patent.

Fig. 1 Computed tomographic angiography revealing pseudoaneu-

rysm in the left subclavian artery with large mural thrombus

compressing and displacing the distal subclavian artery resulting in

an occlusion. The axillary artery is filling with contrast agent (A).

Slitlike leakage of contrast-enhanced blood in the vicinity of the

thrombus indicates the position of the arteriobronchial fistula.

Increased density of the lung tissue shows features of a massive

hemorrhage into the bronchial tree and alveoli (B)

L. Stefanczyk et al.: Posttraumatic Subclavian Artery Aneurysm S147

123

Discussion

Pseudoaneurysms may be caused by a variety of factors

such as blunt or penetrating trauma, clavicle fracture, dis-

location of the shoulder joint, iatrogenic injuries (e.g.,

central venous access, catheterization), inflammatory or

neoplastic processes, and, rarely, arteriovenous malforma-

tions [3–8, 10]. The perforation of a pseudoaneurysm into

the bronchial tree is a rare but dangerous complication of

trauma to branches of the aortic arch. In such cases,

diagnosis must be established rapidly because an acute

hemorrhage in this area is difficult to control and often

results in sudden death [11–13]. It is important to note that

in this article, as well as in other reported cases in the

literature [7], serious trauma to the vessels was suspected at

a late stage, and only as a consequence of the complica-

tions present. Such a situation is common in the case of

lesions occurring within the thorax [11, 12]. The diagnostic

method of choice in such a condition is multislice CT,

which shows vessels, surrounding soft tissue, and bones.

This allows for rapid diagnosis, evaluation of any com-

plications present, and assessment of regional anatomy and

the planning of any interventions. Planning entails both the

selection of an implant as well as the logistics of the pro-

cedure [3, 12–16]. CT angiography evaluation of the car-

otid and in particular the vertebral arteries is important

because their origins may be covered by a stent graft. The

potential for collateral circulation is an important aspect in

planning any intervention because it reduces the risk of

cerebral ischemia [6]. In this case, despite the risk of

radiation exposure to the young patient, CT was necessary

for follow-up to assess the bronchial tree after fistula clo-

sure and to provide information on vessel patency,

Fig. 2 Angiography

confirming the presence of a

pseudoaneurysm of the

subclavian artery distal to the

left vertebral artery. Axillary

artery not visible (A).

Rendezvous technique includes

catheterization of both the left

subclavian artery and left

axillary artery with a guide wire

passing from the distal to the

proximal catheter. After the

guide wire is inserted into the

lumen of the proximal catheter,

it is maneuvered out of the

introducer placed in the

common femoral artery (B).

After stent graft implantation,

lack of flow into the

pseudoaneurysm sac is evident;

the patency of the vessel is

preserved. Narrowing of the

implant is visible in the region

where it crosses the first rib (C)

Fig. 3 Computed tomographic angiography 4 weeks after implan-

tation showing preserved patency of the stent graft and artery. Lack of

filling of the left vertebral artery is evident. Pseudoaneurysm sac

dimensions are 42 9 43 9 51 mm without signs of contrast enhance-

ment, filled with mural thrombus

S148 L. Stefanczyk et al.: Posttraumatic Subclavian Artery Aneurysm

123

pseudoaneurysm exclusion, structural integrity of the graft,

and its patency in the region of the first rib.

In the presented case, endovascular treatment was the

optimal therapeutic option because it could be imple-

mented rapidly and also because surgical access in this case

would have been difficult. Furthermore, there was a high

risk of an acute hemorrhage during the initial phase of a

surgical procedure. Embolization using coils would not

have been appropriate because of the extreme size of the

pseudoaneurysm, a high risk of coil migration, and the

need to maintain patency of the axillary artery [3, 6]. The

wide-necked nature of the psuedoaneurysm made it

impossible to carry out different interventions such as

percutaneous thrombin injection [3, 6, 7, 10]. By cathe-

terizing the pseudoaneurysm from two ends (the rendez-

vous technique), it was possible to implant the stent graft

despite an occlusion of the distal part of the vessel. How-

ever, skill and dexterity are required to maneuver the guide

wire between two catheters. Because the stent graft had a

diameter of 6 mm, this quells any reservations regarding

the use of implants in children before they have stopped

growing [14, 15]. We used a Viabahn stent graft in a

similar manner to a previously reported case of a

psuedoaneurysm after a clavicular fracture [7]. However, it

is probable that other peripheral stent grafts have also been

used successfully. Continued observation is necessary to

assess the implant function.

In general after excluding a pseudoaneurysm, decom-

pression of any present hematoma is indicated [6, 9, 15].

However, in this case, the condition of the patient greatly

improved, and a decision was made not to perform the

decompression because of the risk of pneumothorax and

infection. Despite prophylactic antibiotic therapy, there

was a concern regarding infection of the pseudoaneurysm

sac because it had been in direct contact with the bronchial

tree. Prevention of any infections is an important aspect

because such a complication would necessitate the removal

of the implant [17]. Follow-up CT and clinical observation

6 months after the procedure were favorable.

Conflict of interest The authors declare that they have no conflict

of interest.

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