successful percutaneous intervention for subclavian ... · successful percutaneous intervention for...
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CASE REPORT
Vascular Disease Management® December 2016 275
Successful Percutaneous Intervention for Subclavian Arterial AneurysmMuhammad Naeem Mengal, MBBS, FCPS1; Tariq Ashraf, MBBS, FCPS2; Abida Munir Badini, MBBS, MRCGP, FCPS3
From the 1National Institute of Cardiovascular Diseases Karachi, the 2National Institute of Cardiovascular Diseases, and the 3Aga Khan University Hospital, Karachi, Pakistan.
ABSTRACT: Aneurysms of the subclavian artery are rare, but when diagnosed they must be treated. We describe a case of a 25-year-old female with a pulsating supraclavicular bulge on the left side above the clavicle and painful left arm movements, neck pain, and headache. Doppler ultrasound scanning and computed tomographic angiography confirmed the diagnosis of aneurysm of the left subclavian artery. The patient underwent successful percutaneous stenting of the aneurysm.
VASCULAR DISEASE MANAGEMENT 2016;13(12):E275-E280 Key words: aneurysm repair, stent graft, endovascular grafts, endovascular therapy,
percutaneous coronary intervention
Arterial aneurysms can affect any of the ar-
teries of the human body, but aneurysm of
the subclavian-axillary segment is uncom-
mon.1 A literature review conducted by Hobson et al
identified 195 cases of aneurysms in this topography,
accounting for 1% of all peripheral aneurysms, 88% of
which were in the subclavian artery.2
True aneurysms of the subclavian artery are athero-
sclerotic in etiology.3 When these aneurysms involve
the more distal segments of the subclavian artery or
the axillary artery, they cause thoracic outlet syn-
drome.1,4,5 Aneurysms in this arterial segment can also
be posttraumatic, infectious, associated with coarc-
tation of the aorta, congenital, or related to Marfan
syndrome and cystic necrosis of the tunica media.1,6,7
When diagnosed, it is recommended in the litera-
ture that aneurysms of the subclavian artery should
be treated surgically, because of the risk of ischemic
complications secondary to thromboembolic phe-
nomena in upper extremities and in the carotid-
vertebral territory, due to the possibility of retrograde
embolization.1,5,8 Furthermore, peripheral neurologic
symptoms such as chest pain caused by compression
of the brachial plexus, dysphagia, and rupture are also
possible elements in the clinical presentation, depend-
ing on the location and diameter of the aneurysm.1,5
In this article, we describe a case of aneurysm of the
subclavian artery treated percutaneously in our hos-
pital. This is the first reported case treated percutane-
ously not only in our hospital but also in our country.
CASE PRESENTATIONThe patient was a 25-year-old female with no co-
morbidities. There was no history of trauma. She pre-
sented with complaints of a pulsating mass in the left
supraclavicular region with onset more than 1 year
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previously; painful left arm movements, neck pain,
and headache for 6 months. Physical examination of
the patient confirmed the presence of a pulsating mass
in the left supraclavicular region and revealed normal
pulses and perfusion in the ipsilateral extremity and no
neurologic deficits.
Doppler ultrasound scan showed a fusiform aneu-
rysm of the right subclavian artery. Computed tomo-
graphic (CT) angiography was done to confirm the
aneurysm and plan surgery. The aneurysm was seen
in the distal third of the artery as it crossed the first rib
(Figure 1). A diagnostic angiographic image can be
seen in Figure 2A.
The patient was referred for surgery to the vascular
surgeon, but the surgeon refused surgery because of a
high risk of mortality. The patient was given the option
for percutaneous stenting, which she accepted. With a
right femoral arterial approach, we stented the subcla-
vian artery aneurysm with a Wallgraft Endoprosthesis
self-expanding stent (Boston Scientific). We deployed
a 30 mm stent, but the stent slipped distally, which
required deployment of a second stent. A 40 mm Wall-
graft stent was deployed due to the unavailability of
smaller sizes. The stent was successfully deployed to
seal the aneurysm (Figure 2B). Doppler ultrasound
performed after 1 week confirmed no flow in the an-
Figure 1. Computed tomographic angiography showing aneurysm of the left subclavian artery (red arrow). White arrow shows venous system of the right upper limb.
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eurysmal sac (Figure 3). At 6-month follow-up, the
patient was free from symptoms and pulses were present
and normal. Doppler ultrasound at 6 months showed
a patent stent in subclavian artery with no flow sig-
nals beyond the arterial lumen. Diagnostic angiogram
performed at 9 months after stenting confirmed a pat-
ent stent in the subclavian artery with no flow in the
aneurysmal sac (Figure 4).
DISCUSSIONSubclavian artery aneurysms are rare compared to
peripheral arterial aneurysms, but their exact incidence
is unknown.1,9 Subclavian artery aneurysms are gener-
ally classified as intrathoracic or extrathoracic, because
their presentation and the treatment approach chosen
can differ between the two types.1,5
The patient may be asymptomatic but may also pres-
Figure 2. Diagnostic angiogram of left subclavian artery aneurysm (arrow) before stenting (A) and immediately after stenting (B) with the Wallgraft Endoprosthesis self-expanding stent (Boston Scientific).
A B
Figure 3. Doppler ultrasound of the left subclavian artery 1 week after stenting showing no flow in the aneurysmal sac.
Figure 4. Diagnostic angiogram done at 9 months after stenting confirmed patent stent in subclavian artery with almost no flow in the aneurysmal sac.
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ent with a wide range of ischemic symptoms, signs
secondary to compression of the brachial plexus, and
mediastinal symptoms.1,5,10 The presence of a pulsating
mass, with or without a palpable thrill, is one of the
most often reported signs of extrathoracic aneurysms
of the subclavian artery.11,12 The patient in the case
described here presented with a pulsating mass above
the clavicle over the aneurysm that was observed on
physical examination, which led to the diagnosis by
ultrasonography.
In cases of asymptomatic patients, a suspicion of an-
eurysm of the intrathoracic subclavian artery may be
aroused by a chest x-ray, on which it will appear as a
mediastinal mass, but they may be confused with tumors
of the lung upper lobe.6,13 Cases of subclavian aneu-
rysms have been described in which patients suffered
hoarseness, diplopia and hemoptysis.14,15 Besides this,
cases of respiratory insufficiency and upper GI obstruc-
tions secondary to aneurysms of the subclavian artery
have also been described.16,17 Intrathoracic aneurysms
may occur in subclavian arteries with aberrant origins
leading to symptoms of dysphagia.1
Diagnostic imaging methods for these cases depend
both upon the aneurysm site and on the imaging mo-
dality. Doppler ultrasound scans are one method of
initial diagnosis for extrathoracic aneurysms5,10 Patient
series and case reports describe angiography playing a
fundamental role in diagnosis, particularly when plan-
ning surgery for these patients, especially when aneu-
rysms are extrathoracic.1,3,5,8 Computed tomography is
also considered necessary for diagnostic examination,
particularly for intrathoracic aneurysms.5,18 While the
greater part of the literature recommends angiography
for planning surgery, we used CT angiography to plan
management after a Doppler ultrasound scan had di-
agnosed the aneurysm.
In the literature, surgical treatment is recommended
for subclavian arterial aneurysms, although the details
of incidence rates of complications are unknown.1,5
Surgical access to intrathoracic aneurysms of the sub-
clavian artery depends on which side the aneurysm is
on. In aneurysms of the left subclavian artery, a left-
side thoracotomy is used, whereas for aneurysms of
the right subclavian, the need for better control of the
ascending aorta and of the aneurysm’s necks means
that sternotomy is recommended, with or without a
supraclavicular incision, and the sternoclavicular joint
may or may not be disarticulated.1,5,6 The incision most
often described in relation to cases of extrathoracic
aneurysms of the subclavian artery is a supraclavicular
access, although there are also reports of combination
supraclavicular and infraclavicular incisions or cervi-
cotomy, depending on the patient.1,4,5
Interposition of Dacron, polytetrafluoroethylene
(PTFE), or saphenous vein grafts are also described in
the literature on treatment of these patients.1,5 How-
ever, because there is always a fear of infectious com-
plications with synthetic prostheses, and because it was
possible to draw the arterial stumps together without
creating tension, we employed end-to-end anastomosis
in both cases, with good long-term results.
In the literature, there are reports of endovascular
treatment of aneurysms in the subclavian-axillary seg-
ment,7,10,16,20,21 whether as a first option or for patients
in which the clinical conditions for major conventional
surgical procedures are poor. Despite the existence of
reports of endovascular treatment in this area,7,10 the
low incidence rate of true aneurysms in this topogra-
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phy makes it difficult to compare the long-term re-
sults of this option in relation to conventional surgery,
which remains the standard treatment recommended
in the literature. Additionally, the fact that the upper
extremity has extensive collateral circulation has been
considered a potential source of leakage when endolu-
minal treatment is chosen.9 Hybrid treatment has also
been described for a complex case involving a patient
with Marfan syndrome and an aneurysm of the right
subclavian artery, with previous surgery for type A
dissection of the aorta.10
The patient described above underwent percutaneous
stenting because the vascular surgery team thought it
would be a complicated case with high risk of mortal-
ity. This was our first experience and we await long-
term results. In terms of etiologies, the majority of
aneurysms of the subclavian artery are atherosclerotic
(around 60%), and other causes are related to Mar-
fan syndrome or another connective tissue disease in
around 10% of cases.1,5,13 In young patients, aneurysms
of the subclavian artery may be traumatic, infectious,
congenital, or linked with thoracic outlet syndrome
or with repetitive rotational movements of the shoul-
der in athletes.1,4,5,8,19 Two case reports of congenital
aneurysms of the subclavian artery in young patients,
one 21 years old and the other 22 years old, have been
described.13
CONCLUSIONAneurysms of the subclavian artery are rare, and when
they are diagnosed, treatment is indicated to prevent
complications. The approach should be chosen on a
case-by-case basis, depending on the topography of the
aneurysm and the patient’s characteristics.
Editor’s note: The authors have completed and returned the
ICMJE Form for Disclosure of Potential Conflicts of Interest.
The authors report no disclosures related to the content herein.
Manuscript received June 8, 2016; provisional acceptance
given July 19, 2016; manuscript accepted August 5, 2016.
Address for correspondence: Muhammad Naeem Mengal,
MBBS, FCPS, National Institute of Cardiovascular Dis-
eases Karachi, Interventional Cardiology, Cath Lab, Raf-
fique Shaheed Rd., Bizerta Lines, Cantt, Karachi, Sindh
Pakistan. Email: [email protected]
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