Surgical Treatment Options of Subclavian Artery Pseudoaneurysms: A Case Report and Litterature Review.

ABSTRACT

INTRODUCTION: Subclavian artery pseudoaneurysms are rare and occur mostly as a consequence of an inadvertent arterial puncture during central venous catheterization, endovascular therapeutic procedures or after penetrating or blunt trauma. They usually have a late clinical presentation, with pain, swelling or other compressive symptoms. The optimal treatment in this situation is still a matter of debate. The authors describe a case of late presentation of subclavian artery pseudoaneurysm after transjugular hepatic biopsy and discuss the several options for treatment. METHODS: A 41-year-old woman was admitted in our hospital due to symptomatic subclavian artery pseudoaneurysm. She underwent a biopsy 20 years earlier for an undetermined febrile syndrome. The pseudoaneurysm was diagnosed during investigation of a right non-pulsatile cervical mass that was associated to cervical edema and Horner's syndrome. CTA revealed a pseudoaneurysm of right subclavian artery with 35 mm of diameter and an arteriovenous fistula to jugular vein which presented with significant enlargement. Additionally, the vertebral venous plexus was also ingurgitated. The pseudoaneurysm caused a left shift of the thyroid, common carotid artery and trachea. The vertebral artery arised 4 mm distal to pseudoaneurysm. RESULTS: After a multidisciplinary evaluation including vascular surgery, neuroradiology and cardiac surgery, she underwent surgical exclusion of false aneurysm and arteriovenous fistula via partial upper sternotomy with cervicotomy. Care was taken to preserve the vertebral artery. There was a complete resolution of compressive symptoms and there were no complications during the first year of follow up. CONCLUSION: Subclavian artery pseudoaneurysms impose a major surgical challenge, especially when originating from the proximal third. Large pseudoaneurysms may rupture or produce signs and symptoms of compression. If intervention is considered necessary, several options are available open surgical resection and vascular reconstruction, endovascular exclusion, stentgraft implantation or ultrasound-guided thrombin injection have all been described. The choice of procedure should be tailored to the patient, based on comorbidities, clinical presentation and anatomic characteristics. When compressive symptoms exist, an open approach is advised. However, because of their location, surgical exposure of the pseudoaneurysm may be technically difficult, requiring a sternotomy or a clavicular resection for adequate exposure. An endovascular approach demands an adequate landing zone and absence of severe tortuosity. When arteriovenous fistulae and enlargement of vertebral veins are verified, with subsequent increase in venous pressure, there is a risk of cervical radiculopathy (2-4%). This case report describes an uncommon presentation of subclavian pseudoaneurysm and exemplifies the complexity of their treatment.