Aneurysms of the subclavian artery accounts for
about %1 of all peripheral arterial aneurysms.[
1,
2] In a
literature review, Hobson et al.[
13] identified 195 cases
of aneurysms and found only 1% of all peripheral
aneurysms originated from the subclavian artery. The
aneurysms can be classified in terms of location on the
subclavian artery, as extrathoracic and intrathoracic.[
2]
While the aneurysms of extrathoracic subclavian artery
are mostly related to thoracic outlet syndrome or to
previous injuries (iatrogenic), intrathoracic aneurysms
are mainly due to atherosclerosis or less often seen
with cystic medial degeneration, Ehler Danlos
syndrome, Marfan's syndrome, giant cell arteritis,
Takayasu's arteritis, infection, or injuries.[
5,
7] Herein,
we discuss the surgical management of a young and
non-atherosclerotic, vasculopathy in a case with a
giant intrathoracic right subclavian artery aneurysm,
as a rare pathological cause of intrathoracic subclavian
aneurysms.
Although intrathoracic aneurysms of the
subclavian artery are often asymptomatic, they may
present with symptoms caused by compression or
acute aneurysm expansion, such as upper chest or
shoulder pain, tumor body can erode the apex of
the lung may cause hemoptysis, compression to the
recurrent laryngeal nerve resulting in hoarse voice;
however, dyspnea caused by trachea compression
is seldom reported.[5] Distal embolization to the
upper limb and ischemia is an unusual complication. Aneurysms of extrathoracic subclavian artery
most commonly presents with a pulsatile mass in
the superior fossa and is often tender.[6] Brachial
plexopathy and distal embolization are complications
of the extrathoracic aneurysms.[3,4,6]
Elective surgical repair is the treatment of choice for
most subclavian aneurysms, as they have an increased
risk of rupture, embolization, thrombosis, and other
complications.[1,7,9] Surgical approach for aneurysms of
the left subclavian artery, a left-side lateral thoracotomy
is used, for aneurysms on the right subclavian, are best
approached by median sternotomy, improved control
of the ascending aorta and the aneurysm's neck
can be achieved with sternotomy with or without a
supraclavicular incision and the sternoclavicular joint
may or may not be disarticulated.[4,10] The resection
of the aneurysm is preferred to simple ligation, as
continued growth and rupture of ligated aneurysms
have been reported.[8,9] Soylu et al.[10] reported a case
presented with an intrathoracic giant subclavian artery
aneurysm and the performed sternotomy and bypass
with aortoasubclavian graft procedures successfuly.
We preferred combined mini-sternotomy and
supraclavicular incision, as a safe and acceptable
method for such young and non-atherosclerotic
vasculopathy suspected patients. Fragile vasculature
due to the connective tissue abnormality may cause some technical challenges during the operation, as
in our case. Recently, as a less invasive alternative
to surgical repair, endovascular stent grafting has
become possible. However, it necessitates an acceptable
proximal and distal neck, which serves as a proximal
and distal landing zone for the stent graft. On the
other hand, the upper extremity has an extensive
collateral circulation which may lead to a potential
risk for leakage during endoluminal treatment.[11,12]
Therefore, surgery still the standard treatment of
choice in the literature in such cases. In our case,
pathological report of the aneurysmal sac was reported
as cystic medial degeneration and supported our
suspicion for vasculopathy and open surgery decision.
In conclusion, surgical treatment should be preferred
for young and non-atherosclerotic vasculopathy
suspected patients. Aneurysmectomy in conjunction
with graft interposition via mini-sternotomy and right
supraclavicular incision is a safe and precautionary
approach in such cases.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.
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