Abstracts
Aneurysms of the subclavian-axillary segment are rare, but when diagnosed they must be treated. This article describes two cases of aneurysms of the upper extremities, one in a subclavian artery and the other in an axillary artery. The first case was a 71-year-old male with a pulsating supraclavicular bulge on the right and muscle weakness in the ipsilateral extremity. Duplex scanning and arteriography confirmed the diagnosis of aneurysm of the right subclavian artery and the patient underwent aneurysmectomy and end-to-end anastomosis. The second case was a 24-year-old female patient, with no history of comorbidities, who presented with a pulsating mass in the right axillary region and paresthesia of the ipsilateral extremity. Duplex scanning and arteriography confirmed an aneurysm in the right axillary artery, which was successfully treated with aneurysmectomy and end-to-end anastomosis. Pathology findings showed that the first case was an atherosclerotic aneurysm and the second was a congenital aneurysm.
aneurysm; subclavian artery; axillary artery; surgery
Os aneurismas do segmento subclávio-axilar são de ocorrência rara e, uma vez diagnosticados, devem ser tratados. Neste trabalho, relatamos dois casos de aneurismas de membros superiores, sendo um da artéria subclávia e outro da artéria axilar. No primeiro caso, o paciente de 71 anos, sexo masculino, apresentava abaulamento pulsátil supraclavicular direito associado à fraqueza muscular no membro ipsilateral. Foram realizados duplex scan e arteriografia, que confirmaram o diagnóstico de aneurisma da artéria subclávia direita, sendo o paciente submetido à aneurismectomia com anastomose término-terminal. No segundo caso, uma paciente de 24 anos, do sexo feminino, sem antecedentes mórbidos ou comorbidades, apresentava queixa de massa pulsátil na região axilar direita associada à parestesia no membro ipsilateral. O duplex scan e a arteriografia confirmaram o aneurisma da artéria axilar direita, que foi tratado com aneurismectomia e anastomose término-terminal com sucesso. O diagnóstico anátomo-clínico foi de aneurisma aterosclerótico no primeiro caso e, no segundo caso, de aneurisma congênito.
aneurisma; artéria subclávia; artéria axilar; cirurgia
INTRODUCTION
Aneurysms can affect any of the arteries of the human body, but the subclavian-axillary
segment is an uncommon site for this type of condition11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
. Hobson et al. conducted a literature review in 1982 and identified 195 cases of
aneurysms in this topography, accounting for 1% of all peripheral aneurysms, 88% of
which were in the subclavian artery22. Hobson II RW, Israel MR, Lynch TG. Axilosubclavian arterial
aneurysms. In: Bergan JJ, Yao JST. Aneurisms - Diagnosis and Treatment. New York:
Grune and Stratton; 1982. p. 435..
In general, true aneurysms that involve the subclavian artery have atherosclerotic
etiology. When these aneurysms emerge in the more distal segments of this artery or in
the axillary artery, they may be associated with thoracic outlet syndrome11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
33. Thomazinho F, Sardinha WE, Silvestre JMS, Morais D Fº, Motta F.
Complicações arteriais da síndrome do desfiladeiro torácico. J Vasc Bras.
2008;7(2):150-4. http://dx.doi.org/10.1590/S1677-54492008000200009
http://dx.doi.org/10.1590/S1677-54492008...
,
44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
. Aneurysms in this territory can also be posttraumatic; infectious; associated
with coarctation of the aorta; congenital; or related to Marfan syndrome and cystic
necrosis of the tunica media11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
55. Akar H, Sarac A, Iriz E, Kolbakir F, Dermican S. Intrathoracic
Aneurysm of the Right Subclavian Artery. Acta Chir Belg. 2004;104:730-2.
PMid:15663285.
,
66. Sullivan TM, Bacharach JM, Perl J, Gray B. Endovascular Management of
unusual aneurysms of the axillary and subclavian arteries. J Endovasc Surg.
1996;3:389-95. http://dx.doi.org/10.1583/1074-6218(1996)003%3C0389:EMOUAO%3E2.0.CO;2
http://dx.doi.org/10.1583/1074-6218(1996...
.
When diagnosed, the literature recommends that aneurysms of the subclavian-axillary
segment should be treated surgically, because of the risk of ischemic complications
secondary to thromboembolic phenomena in upper extremities and in the carotid-vertebral
territory, due to the possibility of retrograde embolization11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
,
77. Malik MK, Kraev AI, Hsu EK, Clement MHC, Landis GS. Spontaneous
axillary artery aneurysm: a case report and review of the literature. Vascular.
2012;20:46-8. PMid:22328621. http://dx.doi.org/10.1258/vasc.2011.cr0293
http://dx.doi.org/10.1258/vasc.2011.cr02...
. Furthermore, peripheral neurological symptoms such as chest pain, caused by
compression of the brachial plexus, dysphagia and rupture are also possible elements in
the clinical presentation, depending on the location and diameter of the aneurysm11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
.
In this article we describe two cases of aneurysms of the subclavian-axillary segment that were treated at our Vascular Service.
CASE DESCRIPTIONS
Case 1
The patient was a 71-year-old male with a history of difficult to control systemic arterial hypertension, myocardial revascularization (two saphenous vein grafts four years earlier) and a mitral valve replacement two years previously because of infectious endocarditis. He complained of a pulsating bulge in the right supraclavicular region with onset more than 1 year previously and episodes of muscle weakness in the upper homolateral extremity. There were no other complaints. Physical examination of the patient confirmed the presence of a pulsating mass in the right supraclavicular region and revealed normal pulses and perfusion in the ipsilateral extremity and no neurological deficits.
A duplex scan showed a fusiform aneurysm of the right subclavian artery. Arteriography was then conducted in order to plan surgery and once more the aneurysm was seen in the proximal third of the right subclavian artery, soon after the emergence of the right vertebral artery (Figure 1).
Arteriography of patient from case 1, showing extrathoracic aneurysm of the right subclavian artery.
Conventional surgery was prescribed, approaching through a right-side supraclavicular incision, with ipsilateral sternoclavicular disarticulation and displacement of the clavicle downwards to expose the entire aneurysmal segment of the right subclavian artery. An aneurysm with diameter of 6 cm was observed (Figure 2). The artery was clamped proximally and distally and the aneurysm opened and it was possible to displace the artery sufficiently to conduct an end-to-end anastomosis (Figure 3) without the need for a graft. The patient complained of chest pains during the postoperative period, provoking an unconfirmed suspicion of acute myocardial infarction. Since the patient had a history of myocardial revascularization, his discharge was delayed after the procedure, despite good surgical results. The etiology of the aneurysm was diagnosed as atherosclerotic on the basis of pathology and clinical findings. The patient has been free from postoperative complaints for 2 years of outpatients follow-up.
Intraoperative image of the right subclavian artery aneurysm, via right supraclavicular access.
Final appearance of right subclavian artery with end-to-end anastomosis after resection of the aneurysmal dilatation.
Case 2
A 24-year-old female patient with no history of traumatism or any comorbidities presented at our service with a pulsating mass in the right axillary region with onset two years previously. She complained of paresthesia in the right upper extremity, particularly if she held objects for more than 30 seconds and at night. Physical examination of the patient revealed a pulsating mass in the right axillary region, normal pulses and perfusion in the right upper limb and no neurological deficits.
A duplex scan showed a fusiform aneurysm of the right axillary artery. Digital subtraction angiography was conducted to plan surgery and it also confirmed the diagnosis (Figure 4). Conventional surgery was prescribed, with access via a right-side infraclavicular incision, and an aneurysmal dilatation with diameter of 4 cm was seen (Figure 5). The artery was clamped proximally and distally and the aneurysm sac was opened and found not to contain thrombi. Arterial reconstruction was achieved by dislocation of the proximal and distal portions of the artery and end-to-end anastomosis, with no need to use a graft (Figure 6). The patient was discharged from hospital on the third day after the operation, free from complaints. The final diagnosis, on the basis of pathology, was a congenital aneurysm. The patient was followed for one year and was free from complaints and all pulses were present and normal.
Final appearance of right axillary artery with end-to-end anastomosis after resection of the aneurysmal dilatation.
DISCUSSION
Aneurysms of the subclavian-axillary segment are rarer than other peripheral aneurysms,
although their exact incidence is unknown11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
88. Argotte AF, Giron F, Bilfinger TV. Bilateral subclavian aneurysms
with pseudocoarctation of the aorta. Case report and review of the literature. J
Cardiovasc Surg. 1998;39:747-50.. They are generally subclassified as intrathoracic or extrathoracic, because
both symptomology and the treatment approach chosen can differ between the two
types11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
.
Patients may be asymptomatic, but they may also present a wide range of ischemic
symptoms, signs secondary to compression of the brachial plexus and mediastinal
symptoms11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
,
99. Troutman DA, Mohan CR, Samhouri FA, Sohn RL. Aneurysms Open Repair
and Endovascular Covered Stent Placement in the Management of Bilateral Axillary
Artery. Vasc Endovasc Surg. 2010;44:708-9. PMid:20675316.
http://dx.doi.org/10.1177/1538574410377239
http://dx.doi.org/10.1177/15385744103772...
. 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 artery1010. Sacchi AA, Medeiros AZ, Ribeiro R Fº. Tratamento endovascular
híbrido de aneurisma da artéria subclávia associado à síndrome de Marfan:relato de
caso. J Vasc Bras. 2008;7(2):144-9. http://dx.doi.org/10.1590/S1677-54492008000200008
http://dx.doi.org/10.1590/S1677-54492008...
,
1111. Clagett GP. Upper Extremity Aneurysms. In: Rutherford RB. Vascular
Surgery. 5th ed. W. B. Saunders Company; 2000. p. 1356-1369.. Both cases described here presented with a pulsating mass within the area of
the aneurysm that was observed on physical examination and led to the diagnosis by
ultrasonography.
In asymptomatic patients, a suspicion of aneurysm 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 lobe55. Akar H, Sarac A, Iriz E, Kolbakir F, Dermican S. Intrathoracic
Aneurysm of the Right Subclavian Artery. Acta Chir Belg. 2004;104:730-2.
PMid:15663285.
,
1212. Stahl RD, Lawrence PF, Bhirangi K. Left subclavian artery aneurysm:
Two cases of rare congenital etiology. J Vasc Surg. 1999;29:715-8.
http://dx.doi.org/10.1016/S0741-5214(99)70319-8
http://dx.doi.org/10.1016/S0741-5214(99)...
. Bin et al.1313. 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(4):674-6. PMid:16100464 PMCid:PMC2782168.
http://dx.doi.org/10.3346/jkms.2005.20.4.674
http://dx.doi.org/10.3346/jkms.2005.20.4...
and Takagi et al.1414. Takagi H, Mori Y, Umeda Y, et al. Proximal left subclavian artery
aneurysm presenting with hemoptysis, hoarseness, and diplopia: repair through partial
cardiopulmonary bypass and perfusion of the left common carotid artery. Ann Vasc
Surg. 2003;17(4):461-3. PMid:14670028. http://dx.doi.org/10.1007/s10016-003-0014-1
http://dx.doi.org/10.1007/s10016-003-001...
have described cases of subclavian aneurysms in which patients suffered
hoarseness, diplopia and hemoptysis. Other authors have described cases of respiratory
insufficiency and upper digestive obstructions secondary to aneurysms of the subclavian
artery1515. Bates MC, Aburahma AF, Crotty B. Successful urgent endovascular
surgery for symptomatic subclavian artery aneurysmal compression of the trachea.
Catheter Cardiovasc Interv. 2005;64(3):291-5. PMid:15736257.
http://dx.doi.org/10.1002/ccd.20289
http://dx.doi.org/10.1002/ccd.20289...
16. Windfuhr JP, Schubert D, Remmert S. Aneurysm of the subclavian
artery. An unusual cause of dysphagia. HNO. 2004;52(12):1097-102. PMid:15029424.
http://dx.doi.org/10.1007/s00106-004-1043-y
http://dx.doi.org/10.1007/s00106-004-104...
-
1717. Delap TG, Jones SE, Johnson DR. Aneurysm of an aberrant right
subclavian artery presenting as dysphagia lusoria. Ann Otol Rhinol Laryngol.
2000;109(2):231-4. PMid:10685579.. These intrathoracic aneurysms may occur in subclavian arteries with aberrant
origins ("Arteria Lusoria"), leading to symptoms of dysphagia11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
.
In the literature, the choice of diagnostic imaging methods for these cases depends both
on the aneurysm site and on the evolution of image processing software over the years.
Duplex scans are one method of initial diagnosis for extrathoracic aneurysms44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
,
99. Troutman DA, Mohan CR, Samhouri FA, Sohn RL. Aneurysms Open Repair
and Endovascular Covered Stent Placement in the Management of Bilateral Axillary
Artery. Vasc Endovasc Surg. 2010;44:708-9. PMid:20675316.
http://dx.doi.org/10.1177/1538574410377239
http://dx.doi.org/10.1177/15385744103772...
. Since this is a rare disease, the majority of patient series and case reports
describe angiography as playing a fundamental role in diagnosis, particularly when
planning surgery for these patients, with emphasis when aneurysms are extrathoracic11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
33. Thomazinho F, Sardinha WE, Silvestre JMS, Morais D Fº, Motta F.
Complicações arteriais da síndrome do desfiladeiro torácico. J Vasc Bras.
2008;7(2):150-4. http://dx.doi.org/10.1590/S1677-54492008000200009
http://dx.doi.org/10.1590/S1677-54492008...
,
44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
,
77. Malik MK, Kraev AI, Hsu EK, Clement MHC, Landis GS. Spontaneous
axillary artery aneurysm: a case report and review of the literature. Vascular.
2012;20:46-8. PMid:22328621. http://dx.doi.org/10.1258/vasc.2011.cr0293
http://dx.doi.org/10.1258/vasc.2011.cr02...
,
1212. Stahl RD, Lawrence PF, Bhirangi K. Left subclavian artery aneurysm:
Two cases of rare congenital etiology. J Vasc Surg. 1999;29:715-8.
http://dx.doi.org/10.1016/S0741-5214(99)70319-8
http://dx.doi.org/10.1016/S0741-5214(99)...
. Computed tomography is also considered necessary for diagnostic examination,
particularly for intrathoracic aneurysms44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
,
1818. Nawa S, Ikeda E, Ichihara S, Sugiyama N, Takagaki K, Kunitomo T. A
True Aneurysm of Axillary-subclavian Artery with Cystic Medionecrosis: An Unusual
Manifestation of Marfan Syndrome. Ann Vasc Surg. 2003;17:562-64. PMid:14738086.
http://dx.doi.org/10.1007/s10016-003-0045-7
http://dx.doi.org/10.1007/s10016-003-004...
. Notwithstanding, a more recent case report used angiotomography for diagnosis
and for planning surgery in a patient who underwent this imaging examination to
investigate Marfan syndrome1919. Morisaki K, Kobayashi M, Miyachi H, et al. Subclavian Artery
Aneurysm in Marfan Syndrome. Ann Vasc Surg. 2012;26:731.e1-4.. Thus, while the greater part of the literature recommends angiography for
planning surgery, for investigating whether there are distal occlusive lesions, and for
assessing the extent of the aneurysm and the patency of the contralateral vertebral
artery, in cases in which the ipsilateral vertebral artery originates within the
aneurysm,11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
in practice it is being substituted by angiotomography. During the period in
which the cases described here were treated, our service did not have angiotomography
and so angiography was used to plan surgery after a duplex scan had diagnosed the
aneurysm.
Surgical treatment is recommended for subclavian-axillary aneurysms in the literature,
although the details of incidence rates of complications are unknown11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
. Surgical access to intrathoracic aneurysms of the subclavian artery depends on
which side the aneurysm is. For 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 disarticulated11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
,
55. Akar H, Sarac A, Iriz E, Kolbakir F, Dermican S. Intrathoracic
Aneurysm of the Right Subclavian Artery. Acta Chir Belg. 2004;104:730-2.
PMid:15663285.. 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 cervicotomy,
depending on the peculiarities of each patient11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
33. Thomazinho F, Sardinha WE, Silvestre JMS, Morais D Fº, Motta F.
Complicações arteriais da síndrome do desfiladeiro torácico. J Vasc Bras.
2008;7(2):150-4. http://dx.doi.org/10.1590/S1677-54492008000200009
http://dx.doi.org/10.1590/S1677-54492008...
,
44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
. For aneurysms of the axillary artery, surgical access can vary from
infraclavicular incisions to incisions along the vessel path, above the pulsating mass,
and the extent of access depends on the case in question.77. Malik MK, Kraev AI, Hsu EK, Clement MHC, Landis GS. Spontaneous
axillary artery aneurysm: a case report and review of the literature. Vascular.
2012;20:46-8. PMid:22328621. http://dx.doi.org/10.1258/vasc.2011.cr0293
http://dx.doi.org/10.1258/vasc.2011.cr02...
In the first case described here, disarticulation of the sternoclavicular joint
and displacement of the clavicle downwards in the surgical field allowed sufficient
access for surgery via a single supraclavicular incision, in a patient who had already
undergone a sternotomy for myocardial revascularization. In the second case, a surgical
approach within the topography of the aneurysmal dilatation provided adequate access,
with no complications involving the brachial plexus, which was adjacent to the
aneurysm.
Interposition of dacron, polytetrafluoroethylene (PTFE) or saphenous vein grafts are
also described in the literature on treatment of these patients11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
. However, since there is always a fear of infectious complications with
synthetic prostheses and since 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.
There are reports in the literature reports of endovascular treatment of aneurysms in
the subclavian-axillary segment,66. Sullivan TM, Bacharach JM, Perl J, Gray B. Endovascular Management of
unusual aneurysms of the axillary and subclavian arteries. J Endovasc Surg.
1996;3:389-95. http://dx.doi.org/10.1583/1074-6218(1996)003%3C0389:EMOUAO%3E2.0.CO;2
http://dx.doi.org/10.1583/1074-6218(1996...
,
99. Troutman DA, Mohan CR, Samhouri FA, Sohn RL. Aneurysms Open Repair
and Endovascular Covered Stent Placement in the Management of Bilateral Axillary
Artery. Vasc Endovasc Surg. 2010;44:708-9. PMid:20675316.
http://dx.doi.org/10.1177/1538574410377239
http://dx.doi.org/10.1177/15385744103772...
,
1515. Bates MC, Aburahma AF, Crotty B. Successful urgent endovascular
surgery for symptomatic subclavian artery aneurysmal compression of the trachea.
Catheter Cardiovasc Interv. 2005;64(3):291-5. PMid:15736257.
http://dx.doi.org/10.1002/ccd.20289
http://dx.doi.org/10.1002/ccd.20289...
,
2020. Danzi GB, Sesana M, Bellosta R, Capuano C, Baglini R, Sarcina A.
Endovascular treatment of a symptomatic aneurysm of the left subclavian artery. Ital
Heart J. 2005;6(1):77-9. PMid:15773278.
,
2121. Corral JS, Zúñiga CG, Sánchez JB, Guaita JO, Basail AM, Gimeno CC.
Treatment of aberrant right subclavian artery aneurysm with endovascular exclusion
and adjunctive surgical bypass. J Vasc Interv Radiol. 2003;14(6):789-92.
PMid:12817048. http://dx.doi.org/10.1097/01.RVI.0000079990.80153.FE
http://dx.doi.org/10.1097/01.RVI.0000079...
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,66. Sullivan TM, Bacharach JM, Perl J, Gray B. Endovascular Management of
unusual aneurysms of the axillary and subclavian arteries. J Endovasc Surg.
1996;3:389-95. http://dx.doi.org/10.1583/1074-6218(1996)003%3C0389:EMOUAO%3E2.0.CO;2
http://dx.doi.org/10.1583/1074-6218(1996...
,
99. Troutman DA, Mohan CR, Samhouri FA, Sohn RL. Aneurysms Open Repair
and Endovascular Covered Stent Placement in the Management of Bilateral Axillary
Artery. Vasc Endovasc Surg. 2010;44:708-9. PMid:20675316.
http://dx.doi.org/10.1177/1538574410377239
http://dx.doi.org/10.1177/15385744103772...
the low incidence rate of true aneurysms in this topography makes it difficult
to compare the long-term results 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 endoluminal treatment is chosen99. Troutman DA, Mohan CR, Samhouri FA, Sohn RL. Aneurysms Open Repair
and Endovascular Covered Stent Placement in the Management of Bilateral Axillary
Artery. Vasc Endovasc Surg. 2010;44:708-9. PMid:20675316.
http://dx.doi.org/10.1177/1538574410377239
http://dx.doi.org/10.1177/15385744103772...
. A 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 aorta1010. Sacchi AA, Medeiros AZ, Ribeiro R Fº. Tratamento endovascular
híbrido de aneurisma da artéria subclávia associado à síndrome de Marfan:relato de
caso. J Vasc Bras. 2008;7(2):144-9. http://dx.doi.org/10.1590/S1677-54492008000200008
http://dx.doi.org/10.1590/S1677-54492008...
.
Both of the patients described here underwent conventional surgery via approaches that
provided the access needed to conduct safe procedures with good long term outcomes. In
terms of etiologies, in the subclavian aneurysm case the first hypothesis was an
infectious aneurysm, in view of the history of infectious endocarditis, but this was not
confirmed by pathology findings, which indicated an atherosclerotic aneurysm. The
axillary artery aneurysm in a young women was diagnosed as congenital. The majority of
aneurysms of the subclavian artery are atherosclerotic (around 60%), other causes are
related to Marfan syndrome or another connective tissue disease in around 10% of
cases11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
,
1212. Stahl RD, Lawrence PF, Bhirangi K. Left subclavian artery aneurysm:
Two cases of rare congenital etiology. J Vasc Surg. 1999;29:715-8.
http://dx.doi.org/10.1016/S0741-5214(99)70319-8
http://dx.doi.org/10.1016/S0741-5214(99)...
. The histology of aneurysms linked with Marfan syndrome may or may not reveal
cystic necrosis of the arterial tunica media1818. Nawa S, Ikeda E, Ichihara S, Sugiyama N, Takagaki K, Kunitomo T. A
True Aneurysm of Axillary-subclavian Artery with Cystic Medionecrosis: An Unusual
Manifestation of Marfan Syndrome. Ann Vasc Surg. 2003;17:562-64. PMid:14738086.
http://dx.doi.org/10.1007/s10016-003-0045-7
http://dx.doi.org/10.1007/s10016-003-004...
,
1919. Morisaki K, Kobayashi M, Miyachi H, et al. Subclavian Artery
Aneurysm in Marfan Syndrome. Ann Vasc Surg. 2012;26:731.e1-4.. In young patients, aneurysms in this topography may be traumatic, infectious,
congenital or linked with the thoracic outlet syndrome or with repetitive rotational
movements of the shoulder in athletes11. Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R.
Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4.
http://dx.doi.org/10.1016/S0950-821X(05)80206-3
http://dx.doi.org/10.1016/S0950-821X(05)...
,
33. Thomazinho F, Sardinha WE, Silvestre JMS, Morais D Fº, Motta F.
Complicações arteriais da síndrome do desfiladeiro torácico. J Vasc Bras.
2008;7(2):150-4. http://dx.doi.org/10.1590/S1677-54492008000200009
http://dx.doi.org/10.1590/S1677-54492008...
,
44. Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić
PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11.
http://dx.doi.org/10.1016/S1015-9584(09)60206-2
http://dx.doi.org/10.1016/S1015-9584(09)...
,
77. Malik MK, Kraev AI, Hsu EK, Clement MHC, Landis GS. Spontaneous
axillary artery aneurysm: a case report and review of the literature. Vascular.
2012;20:46-8. PMid:22328621. http://dx.doi.org/10.1258/vasc.2011.cr0293
http://dx.doi.org/10.1258/vasc.2011.cr02...
,
1919. Morisaki K, Kobayashi M, Miyachi H, et al. Subclavian Artery
Aneurysm in Marfan Syndrome. Ann Vasc Surg. 2012;26:731.e1-4.. Aneurysms of the axillary artery are extremely rare in the literature. There is
a report of conventional surgical treatment of an axillary aneurysm secondary to
thoracic outlet syndrome33. Thomazinho F, Sardinha WE, Silvestre JMS, Morais D Fº, Motta F.
Complicações arteriais da síndrome do desfiladeiro torácico. J Vasc Bras.
2008;7(2):150-4. http://dx.doi.org/10.1590/S1677-54492008000200009
http://dx.doi.org/10.1590/S1677-54492008...
. There are also reports of two cases of young patients, one 21 and the other 22,
with congenital aneurysms of the subclavian artery1212. Stahl RD, Lawrence PF, Bhirangi K. Left subclavian artery aneurysm:
Two cases of rare congenital etiology. J Vasc Surg. 1999;29:715-8.
http://dx.doi.org/10.1016/S0741-5214(99)70319-8
http://dx.doi.org/10.1016/S0741-5214(99)...
.
In summary, aneurysms of the subclavian and axillary arteries are rare and when found surgery is indicated in order 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.
REFERENCES
-
1Salo JA, Ala Kulju L, Heikkinen S, Bondestan S, Ketonen P, Luosto R. Diagnosis and Treatment of Subclavian Artery Aneurysms. Eur Vasc Surg. 1990;4:271-4. http://dx.doi.org/10.1016/S0950-821X(05)80206-3
» http://dx.doi.org/10.1016/S0950-821X(05)80206-3 -
2Hobson II RW, Israel MR, Lynch TG. Axilosubclavian arterial aneurysms. In: Bergan JJ, Yao JST. Aneurisms - Diagnosis and Treatment. New York: Grune and Stratton; 1982. p. 435.
-
3Thomazinho F, Sardinha WE, Silvestre JMS, Morais D Fº, Motta F. Complicações arteriais da síndrome do desfiladeiro torácico. J Vasc Bras. 2008;7(2):150-4. http://dx.doi.org/10.1590/S1677-54492008000200009
» http://dx.doi.org/10.1590/S1677-54492008000200009 -
4Davidović LB, Marković DM, Pejkić SD, Kovacević NS, Colić MM, Dorić PM. Subclavian Artery Aneurysms. Asian J Surg. 2003;26(1):7-11. http://dx.doi.org/10.1016/S1015-9584(09)60206-2
» http://dx.doi.org/10.1016/S1015-9584(09)60206-2 -
5Akar H, Sarac A, Iriz E, Kolbakir F, Dermican S. Intrathoracic Aneurysm of the Right Subclavian Artery. Acta Chir Belg. 2004;104:730-2. PMid:15663285.
-
6Sullivan TM, Bacharach JM, Perl J, Gray B. Endovascular Management of unusual aneurysms of the axillary and subclavian arteries. J Endovasc Surg. 1996;3:389-95. http://dx.doi.org/10.1583/1074-6218(1996)003%3C0389:EMOUAO%3E2.0.CO;2
» http://dx.doi.org/10.1583/1074-6218(1996)003%3C0389:EMOUAO%3E2.0.CO;2 -
7Malik MK, Kraev AI, Hsu EK, Clement MHC, Landis GS. Spontaneous axillary artery aneurysm: a case report and review of the literature. Vascular. 2012;20:46-8. PMid:22328621. http://dx.doi.org/10.1258/vasc.2011.cr0293
» http://dx.doi.org/10.1258/vasc.2011.cr0293 -
8Argotte AF, Giron F, Bilfinger TV. Bilateral subclavian aneurysms with pseudocoarctation of the aorta. Case report and review of the literature. J Cardiovasc Surg. 1998;39:747-50.
-
9Troutman DA, Mohan CR, Samhouri FA, Sohn RL. Aneurysms Open Repair and Endovascular Covered Stent Placement in the Management of Bilateral Axillary Artery. Vasc Endovasc Surg. 2010;44:708-9. PMid:20675316. http://dx.doi.org/10.1177/1538574410377239
» http://dx.doi.org/10.1177/1538574410377239 -
10Sacchi AA, Medeiros AZ, Ribeiro R Fº. Tratamento endovascular híbrido de aneurisma da artéria subclávia associado à síndrome de Marfan:relato de caso. J Vasc Bras. 2008;7(2):144-9. http://dx.doi.org/10.1590/S1677-54492008000200008
» http://dx.doi.org/10.1590/S1677-54492008000200008 -
11Clagett GP. Upper Extremity Aneurysms. In: Rutherford RB. Vascular Surgery. 5th ed. W. B. Saunders Company; 2000. p. 1356-1369.
-
12Stahl RD, Lawrence PF, Bhirangi K. Left subclavian artery aneurysm: Two cases of rare congenital etiology. J Vasc Surg. 1999;29:715-8. http://dx.doi.org/10.1016/S0741-5214(99)70319-8
» http://dx.doi.org/10.1016/S0741-5214(99)70319-8 -
13Bin 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(4):674-6. PMid:16100464 PMCid:PMC2782168. http://dx.doi.org/10.3346/jkms.2005.20.4.674
» http://dx.doi.org/10.3346/jkms.2005.20.4.674 -
14Takagi H, Mori Y, Umeda Y, et al. Proximal left subclavian artery aneurysm presenting with hemoptysis, hoarseness, and diplopia: repair through partial cardiopulmonary bypass and perfusion of the left common carotid artery. Ann Vasc Surg. 2003;17(4):461-3. PMid:14670028. http://dx.doi.org/10.1007/s10016-003-0014-1
» http://dx.doi.org/10.1007/s10016-003-0014-1 -
15Bates MC, Aburahma AF, Crotty B. Successful urgent endovascular surgery for symptomatic subclavian artery aneurysmal compression of the trachea. Catheter Cardiovasc Interv. 2005;64(3):291-5. PMid:15736257. http://dx.doi.org/10.1002/ccd.20289
» http://dx.doi.org/10.1002/ccd.20289 -
16Windfuhr JP, Schubert D, Remmert S. Aneurysm of the subclavian artery. An unusual cause of dysphagia. HNO. 2004;52(12):1097-102. PMid:15029424. http://dx.doi.org/10.1007/s00106-004-1043-y
» http://dx.doi.org/10.1007/s00106-004-1043-y -
17Delap TG, Jones SE, Johnson DR. Aneurysm of an aberrant right subclavian artery presenting as dysphagia lusoria. Ann Otol Rhinol Laryngol. 2000;109(2):231-4. PMid:10685579.
-
18Nawa S, Ikeda E, Ichihara S, Sugiyama N, Takagaki K, Kunitomo T. A True Aneurysm of Axillary-subclavian Artery with Cystic Medionecrosis: An Unusual Manifestation of Marfan Syndrome. Ann Vasc Surg. 2003;17:562-64. PMid:14738086. http://dx.doi.org/10.1007/s10016-003-0045-7
» http://dx.doi.org/10.1007/s10016-003-0045-7 -
19Morisaki K, Kobayashi M, Miyachi H, et al. Subclavian Artery Aneurysm in Marfan Syndrome. Ann Vasc Surg. 2012;26:731.e1-4.
-
20Danzi GB, Sesana M, Bellosta R, Capuano C, Baglini R, Sarcina A. Endovascular treatment of a symptomatic aneurysm of the left subclavian artery. Ital Heart J. 2005;6(1):77-9. PMid:15773278.
-
21Corral JS, Zúñiga CG, Sánchez JB, Guaita JO, Basail AM, Gimeno CC. Treatment of aberrant right subclavian artery aneurysm with endovascular exclusion and adjunctive surgical bypass. J Vasc Interv Radiol. 2003;14(6):789-92. PMid:12817048. http://dx.doi.org/10.1097/01.RVI.0000079990.80153.FE
» http://dx.doi.org/10.1097/01.RVI.0000079990.80153.FE
-
*All authors should have read and approved of the final version of the article submitted to J Vasc Bras.
-
Study carried out at the School of Medical Sciences, Santa Casa de Misericórdia de São Paulo (FCMSCSP).
Publication Dates
-
Publication in this collection
15 Dec 2013 -
Date of issue
Oct-Dec 2013
History
-
Received
29 Apr 2012 -
Accepted
05 Aug 2013