Unusual Axillo-Subclavian Artery Aneurysm
Alan B Lumsden
Houston Methodist DeBakey Heart & Vascular Center, Houston, TX
INTRODUCTION: Subclavian artery aneurysms are uncommon, typically atherosclerotic and difficult to treat. Clinical manifestations include pain, arm ischemia secondary to thrombosis or embolization. This patient had all of these symptoms, from a TOS related aneurysm, then subsequently developed a secondary aneurysm of a femoral vein graft used for reconstruction.
METHODS: We demonstrate, using intraoperative video, the steps taken in treatment of this complex aneurysm. This procedure was performed in a hybrid room complete with audiovisual recording capability.
This history is unusual in many respects and illustrates some of the potential complications from therapy. Initially the subclavian aneurysm was treated by another subspecialty with embolization which resulted in acute arm ischemia. A reconstruction was performed using superficial femoral vein which underwent aneurysmal degeneration and development of neurologic compressive symptoms.
We opted to perform a more traditional reconstruction, but were concerned about neurologic injury in a re-operative aneurysmal field. Consequently we chose to prepare for endoluminal control, minimal dissection around the aneurysm and intra aneurysmal graft tunneling.
Initially a selective left subclavian angiogram was performed and a wire placed into the aneurysm. This was performed in case endoluminal control was necessary and using the road map function we planned the optimal position for our skin incision. The aneurysm was approached via supraclavicular and an infraclavicular incisions, centered over the proximal and distal anastamoses. Once the proximal and distal anastomoses were controlled by minimizing dissection away from the aneurysm, the aneurysm was opened and red rubber catheter placed through the aneurysm and used to deliver reversed saphenous vein to the distal anastamosis. The anastamoses were performed in standard fashion. Post operative the patient did well, there was relief of his arm pain and no neurologic injury. CONCLUSIONS: This patient sustained a series of complications from what we believe were inappropriate therapies for subclavian artery aneurysms complicating TOS. Salvage operations are made much more complex and a minimal dissection strategy as employed here can minimize risk go neurological injury.
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