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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Vascular Disease Management® December 2016 276

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: naeem.mengal@hotmail.com

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