aneurysm of the subclavian artery A case report of the literature - PDF document

aneurysm of the subclavian artery: A case report of the literature intrathoracic and review J. Dougherty, MD, Keith Calligaro, MD, Ronald P. Savarese, MD, and A. DeLaurentis, Pa. aneurysm of the subclavian artery is extremely rare. Excluding the more common aneurysms of an aberrant right subclavian artery, those associated with thoracic outlet syndrome, and posttraumatic "aneurysms," atherosclerosis is the most common cause. Syphilis, tuberculosis, and cystic aneurysm of the subclavian artery From the Section of Vascular Surgery, Pennsylvania Hospital, Thomas Jefferson University, Philadelphia. Supported by a grant from the John F. Connelly Foundation. Reprint requests: Matthew J. Dougherty, MD, 700 Spruce St., Suite 101, Philadelphia, PA 19106. Copyright © 1995 by The Society for Vascular Surgery and International Society for Cardiovascular Surgery, North Ameri- can Chapter. 0741-5214/95/$3.00 + 0 24/4/60893 normal arterial anatomy with a saccular aneurysm begin- ning 1 Mott is acknowledged to have first attempted surgical 521 OF VASCULAR SURGERY 522 et al. 1995 Table I. English literature summary of Age Author Yr. patients (yr.) Sex Location Cause 26 1926 4 35 ~ M 2 Sup, 2 thor syphilis Eliot 16 1932 1 30 M Sup - Muller a7 1935 1 37 r Sup syphilis Daniel 19 1951 1 38 F Thor syphilis Erman 28 1952 1 52 M Sup syphilis Perry 29 1952 1 14 M Sup - Moloney a 1955 1 62 M Thor TB Green a° 1958 1 64 M Thor ASO Dobbins 7 1961 1 18 M Sup TB Hara al 1963 2 42 M Sup TB 51 F Thor TB Bjork 8 1965 2 57 M Thor ASO 65 M Thor Syphilis Howell 2°

1966 1 - - Thor ASO Persaud 32 1968 1 22 F Sup CMN Thomas 2 1972 1 61 M Thor ASO Fee 24 1978 1 42 M Sup CMN McCollumSt 1979 6 - - Mainly thor# ASO; also CMN, arteritis Hobson a3 1979 3 62 M Thor ASO 63 M Sup ASO 60 M Sup ASO Lombardo 34 1983 1 62 F Sup ASO Elefteriades a~ 1983 1 50 M Thor ASO Boundy 1987 1 40 F Thor Syphilis Coselli 6. 1987 3 42 F Thor Marfans - - Thor ASO - - Thor ASO Akasaka 1 38 F Thor Turner's Kulpati 22 1990 1 60 M Thor ASO Salo is 1990 10 60%? 2/3 M, 1/3 F$ Mainly thor# ASO 9, mycotic 1 Bower n 1991 14 - - - ASO Mii 23 1991 I 62 M Thor ASO Lakhar ~7 1992 1 11 mos. M Thor Congenital Present report 1993 1 62 F Thor ASO R, right; L, left; CMN, cystic median necrosis; ~Average. tSeries may include same patients. :~Data extrapolated from larger series, including diseases that do not fit our definition of SAA. treatment of choice. Halsted wrote of the procedure in 1924: "The moment of tying the ligature is a dramatic one. The monstrous, booming tumor is stilled by a thread, the tempest silenced by the magic wand."a, 4 Further experience showed that the wand's magic was not always durable, with many surviving patients requiring further operations and ligations. In 1920 Braithewaite accidentally ruptured a subclavian an- eurysm while attempting proximal ligation, and the first successful resection was then performed. 3 This technique, as well as proximal, distal, and branch ligation, gave satisfactory resuks over the ensuing decades. Upper extremity ischemia and gangrene were mainly observed in traumatic cases. Thou

gh Bahnson has been widely credited with the first report of successful resection and grafting for sub- clavian aneurysm, 2'3's'6 his two patients actually had innominate artery aneurysms treated by partial resec- tion and lateral suture repair (tangential aneurysm- orrhaphy). Dobbins 7 described resection of a tuber- culous left subclavian aneurysm with primary anas- OF VASCULAR SURGERY Volume 21, Number 3 Dougherty et al. 523 Cm Side Presentation Treatment - - -- Proximal ligation -- Proximal ligation "large" L arm pain, plexopathy Ligation (2 stages) 12 x 13 x 18 R Horner's syndrome, brachial plexopathy Excision 4 L Painless neck mass Ligation Thrombosis, ischemia No treaunent large R Painful neck mass Ligation (staged) 4 x 5 R Asymptomatic No treatment (autopsy only) 2 Bilat Thrombosis, no SX L excised, primary reanastomosis 7 x 8 x 10 R Neck mass/arm pain Ligated 7 x 6 R Asymptomatic Ligated "Orange sized" R Chest pain, rupture Tangential aneurysmorrhaphy R Arm pain Excision and graft "Small" R - Excision and graft 8 L Painless neck mass Excision and graft Painless neck mass Excision and graft 5 Bilat Brachial plexopathy Ligation, carotid-SC bypass (bilateral); later ex- cision of enlarging R SC aneurysm. - 1/3 L, 2/3 R$ Thrombosis/ischemia in one patient; Mainly excision and grafts neck pain, mass, or no SX equally prevalent in remainders 3 x 4 R Painful neck mass Excision and graft 3 x 4 R Asymptomatic Excision and graft 4 Bilat Painful neck mass R excision and graft; L excision and primary anastomosis. 12 R Excision and graft L

igation on L (ruptured); later ligation with Fem-SC-carotid bypass on R - R No treatment (autopsy only) Ligation, carotid-SC bypass (bilat) Excision and graft - - Excision and graft 6 L Excision and graft 6 L Excision 2.5-15 58% L$ Excision and graft in two-thirds; ligation & carotid-SC bypass in remainders 4.3 cm ave$ 1/3L, 2/3R$ Excision and graft(5); ligation only(4); tangen- tial aneurysmorrhaphy(3); excision with SC- carotid implant(i); exploration only(l) Excision and graft Excision Excision, SC-carotid implant "fist-sized" R 7.5 L 5 L Painless neck mass Ctiest pain/rupture Exsanguinating hemoptysis Chest pain, Horner's, tracheal compression Rupture Chest pain Hemoptysis Half asymptomatic; 2-brachial embolism; I-dysphagia; 1-neck mass; 1-chest pains Pain in half; mass in half; neurologic Sx in half; one rupture; 3-thrombosis; 2-emboli/gangrene$ Hemoptysis Cough; asymptomatic thrombosis Asymptomatic in 1961. In his 1965 report of two subclavian aneurysms, Bjork 8 described resection and Dacron interposition grafting for a syphilitic right subclavian aneurysm, which appears to be the first in the English-language literature. The latter has become the procedure of choice. Aneurysmal degeneration of aberrant subclavian arteries has been amply documented in the medi- cal literature, 2,9,1° and innominate artery aneurysms have likewise received attention. 11,12 However, there have been only a few small institutional series and scattered case reports of aneurysms of a nonaberrant subclavian artery. In a review of 1488 patients with ath

erosclerotic aneurysms by Dent et al. ~3 in two subclavian artery aneurysms were noted. Reports that have been published have included a diversity of causes and associated features. False aneurysms caused by blunt and penetrating trauma dominated the early literature, and these have been included in most series, as have postsurgical false ancurysms. 2,4,s't4'ls Likewise, cases of poststenotic dilation of the subclavian artery associated with thoracic outlet syndrome have been included, s,t* Some reports include patients with thoracic aortic aneurysms and dissections contiguously involving the great vessels, s,6,16 This review excludes the aforementioned entities, confining attention to true JOURNAL OF VASCULAR SURGERY Dougherty et 1. Lateral chest demonstrates mass. the current SAA have have been century and account for been reported. SAA has a 2 : 1 2. A, or shoulder March 1995 3. Flush aortogram and select arteriogram demonstrate aneurysm anatomy. should be been the VASCULAR SURGERY Volume 21, Aneurysm adherent aortic arch. Aneurysm opened. Pledgetted repair Subclavian implanted carotid artery surgical. A best approached OF VASCULAR SURGERY 528 et al. 1995 left-sided aneurysms. Resection or endaneurysm- orrhaphy is preferred to simple ligation, because continued growth and rupture of ligated aneurysms has been reported. 3,18,24 Reestablishment of arterial continuity has been accomplished by interposition or aortic arch graft, primary reanastomosis, and ex- traanatomic procedures (usually in cervical cases) such as carotid-subclav

ian transposition or bypass. Intrathoracic subclavian-to-common carotid artery implantation, as in our case, has been reported only once, in that case for an aneurysm of an aberrant right subclavian artery. 15 This approach seemed to work well in our case and avoided the need for a prosthetic graft. Though disastrous upper extremity ischemia has been reported with subclavian artery liga- 3'17'2s modern series only arm "claudication" has been documented for SAA ligation without revascularization.~4,15 In most cases revascularization should be considered a secondary goal. When approaching a patient with intrathoracic SAA, it is important to be prepared for aortic clamping and repair. Despite an angiographic ap- pearance that suggested a good proximal stump of nonaneurysmal subclavian artery in the case pre- sented (Fig. 2), we found the vessel to be dilated with laminar thrombus and unsuitable for anastomosis or even clamping. A larger experience confirms the potential for technical misadventure in intrathoracic SAAs, is with five of 10 patients having inadvertent entry of the aneurysm at surgery. Significant opera- five blood loss, morbidity, and death were the result. In our case, a good quality side-biting aortic clamp and careful blood pressure control were essential to attain satisfactory closure. Given the rarity of this entity, it is unlikely that reliable data on the natural history of small, asymp- tomatic SAA will be forthcoming. Modern surgical results with SAA and other procedures for disease of the supraaortic trunks are genera

lly quite good, and an operative mortality rate of less than 5% should be anticipated for uncomplicated cases. Thus most rea- sonably healthy patients with SAA should be offered surgical repair. Because patients with atherosclerotic SAA commonly have or have development of aneu- rysmal disease elsewhere, careful and complete evalu- ation and follow-up are of critical importance. Greenough J. of the artery: of successful ligation. Arch Surg 1929;19:1484-9. 2. Thomas TV. Intrathoracic aneurysms the and subclavian arteries. J Thorac Cardiovasc Surg 1972;63:461- 71. 3. Moloney GE. Excision of an aneurysm the subclavian artery: case history and discussion. Br J Surg 1955;43:94-9. 4. Temple LJ. Aneurysm the first part of the left artery: review the and case history. J Thorac Surg 1950;19:412-21. 5. McCollum CH, DaGama AD, Noon GP, DeBakey ME. Aneurysm of the subclavian artery. J Cardiovasc Surg (Torino) 1979;20:159-64. 6. Coselli JS, Crawford ES. Surgical of aneurysms of the intrathoracic segment of the artery. Dobbins WO. Bilateral calcified subclavian arterial aneurysms in a young male: report unique case. N Engl J 8. Bjork VO. Aneurysm and occlusion the subclavian artery. Acta Chir Scand 1965;356(suppl):103-9. 9. Austin EH, Wolfe WG. Aneurysm of aberrant subclavian artery with a review the J VAsc SURG 1985;2: 571-7. 10. McCallen AM, Schaff B. Aneurysm of an anomalous right subclavian artery. Radiology 1956;66:561-3. 11. Bower TC, Pairolero PC, Hallert JW Jr, Toomey BJ, Gloviczki P, Cherry KJ Jr. Brachiocephalic aneurysm: the case recogniti

on and repair. Ann Vasc Surg 1991;5:125- 32. 12. Schumacher PD, Wright CB. Management of arteriosclerotic aneurysm of the innominate artery. Surgery 1979;85:489-95. 13. Dent TL, Lindenauer SM, Ernst CB, Fry WJ. arterial aneurysms. Arch Surg 1972; 105:338- 44. 14. Pairolero PC, Walls IT, Payne WS, Hollier LH, Fairbaim JF. Subclavian axillary artery aneurysms. Surgery 1981;90:757- 63. 15. Salo JA, Ala Kulju K, Heikkinen L, Bondestam S, Ketonen P, Diagnosis and of artery aneurysm. Eur J Vasc Surg 1990;4:271-4. 16. Elliort E. Subclavian aneurysm. Ann Surg 1932;96: 670-82. 17. Lakhkar BN, Lakhkar BB, Ghosh MK, Shenoy PD, Patil UD. Congenital subclavian artery aneurysm. Indian Pediatr 1992; 29(9):1165-8. 18. Akasaka T, Mitsuishi T, Nakajima H, Suzuki R, Shimizu S. Aneurysm the left artery associated with Tumer's syndrome. Successful surgical treatment. J Cardio- vasc Surg (Torino) 1989;30:945-7. 19. Daniel RA. Syphilitic aneurysm of subclavian artery. Ann Surg 1951;134:251-8. 20. Howell JF, Crawford ES, Morris GC, Garrett HE, DeBakey ME. Surgical of peripheral aneu- rysm. Surg Clin N Am 1966;46:979-88. 21. Boundy K, Bignold LP. Syphilitic aneurysm the subclavian artery presenting hemoptysis. N Z J 22. Kulpati DD, Gupta K, Kapoor R, Roopa N. Subclavian artery aneurysm presenting with recurrent haemoptysis: a case Radiol 1990;34:175-6. 23. Mii S, Ienaga S, Motohiro A, Okadome K. An unusual subclavian artery aneurysm: hemoptysis Letter. J VASC SURG 1991;14:243-5. 24. Fee HJ, Gewirtz HS, O'Connell TX, Grotlman JH. Bilateral subclavian artery aneury

sm associated with idiopathic cystic medial necrosis. Ann Thorac Surg Geiss D, Williams Wg, Lindsay WK, Rowe RD. OF VASCULAR SURGERY Volume 21, Number 3 et al. extremity gangrene: a complication of subclavian artery division. Ann Thorac Surg 1980;30:487-9. 26. Matas R. A summary of personal experience in the surgery of the subclavian arteries. Tr Sout SA 1926;39:213-27. 27. Muller GP. Subclavian aneurysm with report of a case. Ann Surg 1935;101:568-71. 28. Erman ED. Syphilitic aneurysm of the third portion of the subclavian artery. US Armed Forces Medical Journal 1952; 11:1673-8. 29. Perry SP, Massey CW. Bilateral aneurysms of the subclavian and a~xillary arteries. Radiology 1953;61:53-5. 30. Green R. Enlargement of the innominate and subclavian arteries simulating neoplasm. Am Rev Tuberc 1959;79: 790-8. 31. Hara M, Bransford RM. Aneurysm of the subclavian artery associated with contiguous pulmonary tuberculosis. J Thorac Cardiovasc Surg 1963;46:256-64. 32. Persaud V. Subclavian artery aneurysm and idiopathic cystic medionecrosis. Br Heart J 1968;30:436-9. 33. Hobson RW, Sarkaria J, O'Donnell JA, Neville WE. Athero- sclerotic aneurysms of the subclavian artery. Surgery 1979; 85:368-71. 34. Lombardo R, Benetti FJ, Meletti E. Atherosclerotic aneurysm of the subclavian artery. J Cardiovasc Surg (Torino) 1983; 24:675-6. 35. Elefteriades JA, Kay HA, Stansel .HC, Geha AS. Extra- anatomical reconstruction for bilateral intrathoracic subcla- vian artery aneurysms. Ann Thorac Surg 1983;35: 188-91. Submitted July 13, 1994; accepted Sept. 27, 19