Delayed Presentations of False Aneurysms of the Subclavian Artery
Article Outline
Abstract
Delayed presentation of a false aneurysm following blunt trauma is rare with only five cases discussed in literature. We describe two cases of late false aneurysms of the Subclavian artery following blunt injury.
Keywords: False aneurysms, Subclavian artery, Aneurysm
Introduction
False aneurysms occur following leakage of blood through a full thickness injury of the arterial wall. The surrounding tissues contain the resultant haematoma. Over a course of time the false aneurysm acquires an elastin wall. Most false aneurysms occur following penetrating trauma or are associated with fractures or dislocations. False aneurysms caused by blunt trauma are very rare. When secondary to trauma, they are often associated with other medical and genetic conditions like osteochondromas,1 Ehlers Danlos syndrome2 or acute pancreatitis.3
Delayed presentation of a false aneurysm following blunt trauma is rare with only five cases discussed in literature. These include two involving the dorsalis pedis artery and three involving the superficial femoral artery.4, 5, 6 We describe two cases of late false aneurysms of the Subclavian artery following blunt injury.
Cases
Case 1
A 47-year-old man presented with a three-week history of a tender swelling above the right clavicle. He was otherwise asymptomatic. He did not have any significant past medical history. The patient had suffered a blunt injury caused by a scaffold pole thirty years previously on the same side. There were no associated fractures at the time of the injury.
On examination there was a smooth and pulsatile supraclavicular mass measuring 3
×5cm. An ultrasound scan suggested that the mass was vascular. Magnetic resonance imaging confirmed the presence of a false aneurysm containing thrombus which was arising from a branch of the adjacent subclavian artery (Fig. 1) and the aneurysm was successfully treated by embolisation using coils placed through a microcatheter via a trans-femoral approach (Fig. 2).
Figure 1
MRI showing false aneurysm of subclavian artery (pre embolisation).
Figure 2
Digital subtraction angiography showing post embolisation phase.
Case 2
A 57-year-old woman presented with a one-month history of a lump in her left supraclavicular fossa. The patient was otherwise asymptomatic. The patient had fallen off a horse several years ago injuring her shoulder. There was no associated bony injury. She did not have any other significant past medical history.
Clinical examination revealed a 2×3cm smooth pulsatile mass in the left supraclavicular fossa. An ultrasound scan confirmed a false aneurysm of the costocervical branch of the subclavian artery. Using the trans-femoral approach, the costocervical trunk of the left subclavian artery was selectively catheterised and embolised using coils (Figure 3, Figure 4).
Figure 3
Digital subtraction angiography showing pre embolisation phase of subclavian artery aneurysm.
Figure 4
Digital subtraction angiography showing post embolisation phase of subclavian artery aneurysm.
Discussion
Subclavian artery injuries account for only 2% of acute vascular injuries.7, 8 Major trauma centres report only about two to four injuries per year.8, 9, 10 Hence most vascular surgeons have limited expertise in their management. The overwhelming majority of these injuries are from penetrating trauma. A minority of these, 1–5% of all subclavian artery injuries result from blunt trauma8, 9, 10 and are usually associated with fractures or dislocations. A past history of trauma with or without bony injury should raise the index of suspicion. In our cases, there was a positive history of trauma around the aneurysm site in both of these patients leading to the diagnosis of traumatic pseudoaneurysm. A careful history and clinical examination followed by an ultrasound scan will confirm the diagnosis. Percutaneous endovascular treatment with stents and coils is a good alternative to conventional surgery. In fact, physical examination is the best initial diagnostic method in the evaluation of subclavian artery trauma. Angiography to delineate the aneurysm will help plan treatment. The anatomical position of these aneurysms poses a technical challenge in dealing with them by conventional surgery. Various therapy options are conservative observations, open surgical repair and endovascular treatment. In our cases, conservative strategy had high risk due to size of the aneurysm and increase in size. Open operation may be performed using the supraclavicular approach combined with a thoracotomy, with risks of severe bleeding and reoperation for graft thrombosis. Embolisation of the aneurysm using coils under radiological guidance is the treatment of choice.
Conflict of Interest
None.
References
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PII: S1533-3167(09)00003-X
doi:10.1016/j.ejvsextra.2009.01.002
© 2009 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Delayed Presentations of False Aneurysms of the Sub-clavian Artery , 27 March 2009
