Rare presenta*on and management of a complex subclavian artery aneurysm

Speaker:DrSandeepMohananInterven2onists:DrVinayakumarD,ProfMNKrishnan,DrCicyBas2an

DepartmentofCardiology,CalicutMedicalCollege

The pa'ent... •  32yearoldfemale,motheroftwo• Dysphagiatosolids-2m• No8cedswellingwithdiscomfortintheneck• Nosignificantpastmedicalhistory

• Clinicalexamina2on:-  Pulsa8leswellingintherootofrightsideoftheneck-  Bruit+-  Allperipheralpulsespalpable-  Allsystems–wnl-  Nofever

Chest Xray

MDCT angiogram

MDCT-angio reconstruc'on

Complexmul2loculatedsaccularaneurysminRightSCA

Ae'ological work up •  CBC-Normal•  ESR,CRP-Normal•  ANA,RF:-ve•  HIV,HBsAg,HCV:-ve•  VDRL:-ve•  C-ANCA,p-ANCA:-ve•  TFT:-ve

•  OGDscopy:Normal•  Echocardiography:Normalstudy•  Coronaryangiogram:Normal•  CECTchest(16sliceCT):Noaddi8onalvascularabnormali8es

Barium swallow

APview RAOview

Selec've right innominate DSA

Management

Diagnosis:Idiopathicrightsubclavianarterycomplexaneurysmwithcompressivesymptoms.

Op8ons:Surgicalcorrec8onvsEndovascularstent-graK-AVerfewweeksshepresentedwithpain,visibleenlargementinrootofneck.

!AdmiLedandurgentlyarrangedBardFluencyvascularstent-gra2s

Right radial and right femoral access

ADemp'ng to pass Terumo wire across the aneurysm

Terumo wire successfully crossed with JR support from above and snared from below

ADemp'ng to track catheter across the aneurysm

Exchanged with Amplatzer wire and 10F ASD sheath inserted

Deployment of 1st stent (10 *80mm 9F Fluency stent graQ)

Undeployed proximal stent - ? Tight stenosis

Stent displaced into the aneurysm

Deployment of 2nd stent (12 * 40mm 10F Fluency plus)

Dumbell shaped stent- stenosis at aneurysm mouth

Final injec'on

Post procedure imaging

1 year Follow up

• Noswallowingdifficulty• Asymptoma8c,

• Nobruit/swelling• Allpulsespalpable

Literature Review •  Epidemiology:0.13%ofallaneurysms.• Ae2ology: Atherosclerosis(60%), trauma, infec8ons(TB, syphilis,bacterial), vasculi8s, CTDs, thoracic outlet obstruc8on, Marfanssyndrome,collagenvasculardiseases,aberrantSCA,congenital.

•  Common Presenta2ons: Pulsa8le lump, brachial plexuscompression, upper limb ischema, incidentalmedias8nalwidening,hemoptysis(erosionoflungapex),hoarsenessofvoice

• Rarepresenta2ons:Dyspnoea,dysphagia,Hornerssyndrome

1.   Dentetal.Atheroscelro9carterialaneurysms:ArchSurg1972.2.   Doughertyetal.Atherosclero9caneurysmiftheintrathoracicsubclavianartery:acasereportand

reviewofliterature.JVascSurg1995

Inves'ga'ons

• Vasculi8s:PAN,Takayasuarteri8s• CTDs-SLA,RA,Ankylosingspondyli8s•  Infec8on:TB,HIV,HCV,HBsAg,Syphilis• ACVD• USG-Doppler• CTAisinves2ga2onofchoiceforanatomydelinea2on

Treatment

•  Surgical:Liga8on,Arteriorrhapphy,graVing

•  Endovascularstent-graVing(mul8plecasereports)

THANK YOU