P-086 - GIANT SUBCLAVIAN ARTERY ANEURYSM: A CASE REPORT

TOPIC:
Case Reports
AUTHORS:
Herrero Gutiérrez M. (Department of Angiology and Vascular Surgery. Hospital Universitario La Princesa ~ Madrid ~ Spain) , Portero García J.L. (Department of Angiology and Vascular Surgery. Hospital Universitario La Princesa ~ Madrid ~ Spain) , Breteau Agote I. (Department of Angiology and Vascular Surgery. Hospital Universitario La Princesa ~ Madrid ~ Spain) , Lodeiro Sanz J.C. (Department of Angiology and Vascular Surgery. Hospital Universitario La Princesa ~ Madrid ~ Spain) , González Sánchez S. (Department of Angiology and Vascular Surgery. Hospital Universitario La Princesa ~ Madrid ~ Spain) , Abarrategui Soria C. (Department of Angiology and Vascular Surgery. Hospital Universitario La Princesa ~ Madrid ~ Spain) , Ruiz Grande F. (Department of Angiology and Vascular Surgery. Hospital Universitario La Princesa ~ Madrid ~ Spain)
Introduction:
Subclavian artery aneurysms (SAA) are a very uncommon form of aneurysmal disease, being estimated to be around 1% of all peripheral aneurysms. Most of them are due to atherosclerosis, but they can also be related to trauma, thoracic outlet syndrome (TOS), and in rarer cases infections, cystic medial necrosis, fibromuscular dysplasia or connective tissue disorders. About 70-75% of SAA are asymptomatic and discovered incidentally , but they can also be associated with symptoms such as painful mass, compression, hemorrhage or ischemic events. The indication for an intervention is made regarding the risk of rupture, thrombosis or embolization.
Methods:
A 41-year-old woman with no previous medical history was admitted to the hospital because of swelling of the right arm and hand. She also had a sensation of a painful right infraclavicular mass. In the physical examination the distal pulses were present and an increased venous collateral circulation in the right upper limb was evident. An angioCT scan was performed, revealing a 76 mm right subclavian aneurysm in the middle third that displaced the rest of the superior mediastinum and was compressing the superior cava and innominate veins. Additionally, a 43 mm ascendent aortic aneurysm was described. A conventional surgical approach was performed because of the severe angulation and the compression symptoms. Under general anesthesia, median sternotomy and right supraclavicular access was made. A giant aneurism was displacing the trachea and the proximal and distal portions of the subclavian artery. The structures were carefully dissected, including the right phrenic and recurrent laryngeal nerves, which were looped and protected. Some collateral veins had to be ligated and resected. Proximal and distal clamps were applied, and an aneurysmectomy was performed. Due to the elongation of the artery, a reconstruction by direct end-to-end anastomosis was feasible and considered the best option. The closure was performed according to the usual fashion, including drainages which could be removed a few days later. After the intervention, the patient presented positive pulses in the right upper limb and the decrease of swelling and vein engorgement. There was also no residual sensory or motor deficit. A deep vein thrombosis (DVT) was documented in the humeral and subclavian veins during the postoperative period without signs of pulmonar emboli. For this reason, she was discharged with anticoagulant therapy.
Results:
After three months of anticoagulant therapy, the DVT was partially recanalized. The anastomosis performed did not show any sign of degeneration or dilatation and the patient was completely recovered and asymptomatic. The histological examination did not reveal a significant finding and neither did the genetic study.
Conclusion:
Subclavian aneurysms are a rare entity and the treatment must be performed in order to prevent future complications. While large aneurysms are more likely to develop symptoms of compression or rupture, main complications of small aneurysms are thrombosis and embolism. In this patient, intervention was mandatory due to the size, painful mass and compressive symptoms. New techniques in endovascular surgery allow the performance of minimum invasive treatment of SAA, but in this case, the choice of an open repair instead of an endovascular therapy was made in regard to the anatomy and the symptoms in the patient.
References:
Dent TL, Lindenauer SM, Ernst CB, Fry WJ. Multiple arteriosclerotic arterial aneurysms. Arch Surg. 1972;105:338-44. Cury M, Greenberg RK, Morales JP, Mohabbat W, Hernandez AV. Supra-aortic vessels aneurysms: diagnosis and prompt intervention. J Vasc Surg [Internet]. 2009;49(1):4-10. Available from: DOI: 10.1016/j.jvs.2008.08.088 Davidovic LB, Markovic DM, Pejkic SD, Kovacevic NS, Colic MM, Doric PM. Subclavian Artery Aneurysms. Asian J Surg [Internet]. 2003;26(1):7-11. Available from: DOI: 10.1016/S1015-9584(09)60206-2 Singh Y, Verma H, Tripathi R. Giant Subclavian Artery Aneurysm: Case Report and Review of Literature. Indian J Vasc Endovasc Surg [Internet]. 2017;4:73-5. Available from: DOI: 10.4103/ijves.ijves_44_16 Sun J, Qi H, Shi Y, Guo H, Shen C, Ouyang C, Qian X. Isolated True Subclavian Aneurysm without Aberrant Subclavian Artery or Coarctation of Descending Aorta. Ann Vasc Surg [Internet]. 2021;75:294-300. Available from: DOI: 10.1016/j.avsg.2021.01.108 Vierhout BP, Zeebregts CJ, Van Den Dungen JJAM, Reijnen MMPJ. Changing Profiles of Diagnostic and Treatment Options in Subclavian Artery Aneurysms. Eur J Vasc Endovasc Surg [Internet]. 2010;40:27-34. Available from: DOI: 10.1016/j.ejvs.2010.03.011 Maskanakis A, Patelis N, Moris D, Tsilimigras DI, Schizas D, Diakomi M, Bakoyiannis C, Georgopoulos S, Klonaris C, Liakakos T. Stenting of Subclavian Artery True and False Aneurysms: A Systematic Review. Ann Vasc Surg [Internet]. 2018;47:291-304. Available from: DOI: 10.1016/j.avsg.2017.08.013.
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