J Thorac Cardiovasc Surg 2005;129:682-684
© 2005 The American Association for Thoracic Surgery
Endovascular treatment of right-sided subclavian artery aneurysm in a congenitally malformed aortic arch
Gabriele Iannelli, MDa,*,
Luigi Di Tommaso, MDa,
Mario Monaco, MDa,
Federico Piscione, MDb
a Cardiac Surgery
b Cardiology, University "Federico II" of Naples, Naples, Italy
Received for publication July 26, 2004; revisions received August 6, 2004; accepted for publication August 10, 2004.
* Address for reprints: Gabriele Iannelli, MD, Via Santo Strato, 8, 80121 Naples, Italy
(E-mail: gabrieleiannelli{at}libero.it).
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Dr Iannelli
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Encouraging results obtained with endovascular treatment of subclavian artery aneurysms (SAAs)1 led us to use this technique as an alternative to conventional operation in a young female patient with an intrathoracic SAA on the right side complicated by a left-sided cervical aortic arch and agenesis of the left common carotid and vertebral arteries.
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Clinical summary
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A pulsatile mass was detected in a 38-year-old woman during an echocardiographic assessment of the thyroid. Computed tomographic (CT) scanning showed a 14-mm left-sided cervical aortic arch at the T2 level, a 36-mm enlargement of the ascending aorta, and a normal-sized descending aorta (25 mm). An angiographic study confirmed the presence of a saccular aneurysm of the right subclavian artery with a broad neck, agenesis of the left carotid artery, and narrowing of the aortic arch (Figure 1). Because of the complexity of the patient's vascular abnormalities, we elected to use an endovascular procedure to treat the right SAA only.
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Figure 1. A, Angiogram showing subclavian artery aneurysm on the right side (rSAA) and cervical aortic arch on the left (LCCA). B, Digital subtraction angiogram of the right-sided subclavian artery aneurysm (rSAA).
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The size of the right subclavian artery was 7 mm, and the aneurysm neck was 20 mm at the CT scan: the ideal stent graft length was 40 mm, considering 10 mm from the aneurysm neck to be a good seal. Otherwise, a more than desirable length could occlude the common carotid artery proximally or the right vertebral artery distally. Fluoroscopic imaging was used throughout the procedure.
General anesthesia was achieved, the right brachial artery was exposed by means of a surgical procedure, and a 12F introducer was inserted into the vessel. A 6F angiographic pigtail catheter (Cordis Corp, Miami, Fla) was inserted through the femoral artery into the brachiocephalic artery. A 0.035-in Radifocus guidewire M (Terumo Corp, Tokyo, Japan) was inserted through the brachial artery to cross the SAA and to position the stent graft at the proximal end of the subclavian artery. Two stent grafts (Viabahn; W. L. Gore & Associates, Inc, Flagstaff, Ariz; 8 mm wide and 25 mm long) were implanted with the telescope technique, placing the second stent graft to overlap the first distally to obtain the foreseen length.
An angiogram obtained after insertion of the stent grafts showed complete exclusion of the SAA and patency of the right subclavian and vertebral arteries (Figure 2, A). The patient recovered uneventfully and was discharged from the hospital 3 days after the procedure. At 6 months' follow-up, the patient was doing well, and a CT scan showed aneurysm exclusion and no endoleaks (Figure 2, B).
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Figure 2. A, Perioperative angiogram of the right subclavian artery after implantation of a stent graft. B, A 6-month 3-dimensional CT follow-up scan.
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Discussion
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Of the 6 pairs of embryonic aortic arches that connect the ventral and dorsal portions of the aorta, only the third, fourth, and sixth arches remain recognizable after birth (Figure 3, A). The cervical aortic arch, first described by Reid in 1914, is a rare embryologic malformation caused by nondevelopment of the left-sided fourth embryonic arch and persistence of the third (Figure 3, B).2
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Figure 3. Normal and abnormal development of the aorta. A, Normal development of the 6 pairs of embryonic aortic arches. B, Abnormal development of the aorta and side branches in our patient. ICA, Internal carotid artery; ECA, external carotid artery; RSA, right subclavian artery; LSA, left subclavian artery; Ao, thoracic aorta; III, third embryonic aortic arch; IV, fourth embryonic aortic arch; VI, sixth embryonic aortic arch; PA, pulmonary artery; CAA, cervical aortic arch.
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An aortic arch formed from an embryologic remnant designed to regress might not have normal structural integrity. This characteristic, together with the hemodynamic changes in the tortuous cervical aortic arch, can create conditions favorable for formation of an aneurysm.3
Surgical treatment of SAAs is necessary because of the high risk of rupture of large aneurysms and of embolization or thrombosis in smaller aneurysms.4 Only a few cases of congenital aneurysm of the major supraortic branches and cervical aortic arch have been reported.5
The type of complex pathology found in our patient led to an in-depth analysis of the most appropriate surgical strategy, either conventional or endovascular, both of which required prosthetic material. The patient was unwilling to undergo open surgery for cosmetic reasons, and moreover, the traditional surgical approach, which would have involved a median sternotomy with a supraclavicolar extension, would entail a considerable risk of damage to the cerebral blood flow caused by the reduction of collateral arterial supply and the very close localization to the aneurysm of the carotid and vertebral right arteries.
Endovascular surgery, on the other hand, was considered feasible for the presence of a satisfactory landing zone, measuring proximally 1.5 cm from the right common carotid artery and distally 1.0 cm from the right vertebral artery. Use of the endovascular approach in our patient allowed us to comply with the patient's requests regarding cosmetic results. In addition, use of endovascular treatment does not preclude subsequent use of conventional surgery if required because of unsatisfactory results or deterioration of materials used.
Successful use of endovascular grafts in other locations and in our experience suggests that endovascular surgery might be a safe and reliable treatment for some very rare vascular disorders.
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Acknowledgments
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We thank Mr Lucio Riccardi for his contribution to this effort.
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References
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- Iannelli G, Piscione F, Di Tommaso L, Monaco M, Chiariello M, Spampinato N. Thoracic aortic emergencies: impact of endovascular surgery. Ann Thorac Surg 2004;77:591-596.[Abstract/Free Full Text]
- Pearson GD, Kan JS, Neill CA, Misgley FM, Gardner TJ, Hougen TJ. Cervical aortic arch with aneurysm formation. Am J Cardiol 1997;79:112-114.[Medline]
- Farsak B, Yilmaz M, Kaplan S, Boke E. Cervical aortic arch with aneurysm formation. Eur J Cardiothorac Surg 1998;14:437-439.[Abstract/Free Full Text]
- Davidovic LB, Markovic DM, Pejkic SD, Kovacevic NS, Colic MM, Doric PM. Subclavian artery aneurysms. Asian J Surg 2003;26:7-11.[Medline]
- Tsukamoto O, Seto S, Moriya M, Yano K. Left cervical aortic arch associated with aortic aneurysm and coartation, and branch artery aneurysm: a case report and review. Angiology 2003;54:257-260.
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Clinical summary
Discussion