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Left Brachiocephalic Venous Aneurysm: A Rare Clinical Finding
Case Report Left Brachiocephalic Venous Aneurysm: A Rare Clinical Finding Geraud Galvaing,1,2 Marie Gaudin,3 Marie Tardy Medous,1 and Marc Filaire,1,2 Clermont-Ferrand and Vichy, France
Brachiocephalic venous aneurysm is an extremely rare condition, with <20 cases reported in the literature. We present a case of a 72-year-old man who was referred to our department owing to a large aneurysm of the left brachiocephalic vein that was incidentally discovered on computed tomography. Further workup confirmed an isolated saccular aneurysm of the left brachiocephalic vein. The patient underwent aneurysmectomy via sternotomy with no requirement for a vascular graft or cardiopulmonary bypass. The postoperative course and follow-up were uneventful.
Aneurysmal dilatation of the thoracic veins is a rare cause of mediastinal widening, and when present, fusiform aneurysms of the superior vena cava are the most commonly observed. Only few case reports have discussed the surgical treatment of isolated aneurysms of the left brachiocephalic vein.
CASE REPORT A 72-year-old asymptomatic man was referred to our department owing to a large mediastinal mass that was incidentally discovered on abdominal and pelvic computed tomography (CT) that was performed because of hematuria. The patient had a medical history of prostate adenocarcinoma that was treated 9 years earlier by Conflict of interest: The authors have no conflicts of interest to declare. 1 Department of Thoracic and Endocrine Surgery, Jean Perrin Comprehensive Cancer Center, Clermont-Ferrand, France. 2
Department of Anatomy, Clermont-Ferrand School of Medicine, Universite Clermont Auvergne, Clermont-Ferrand, France. 3 Department of Vascular Surgery, Jacques Lacarin Hospital, Vichy, France.
Correspondence to: Geraud Galvaing, MD, MSc, Department of Thoracic and Endocrine Surgery, Jean Perrin Comprehensive Cancer Center, 58 rue Montalembert 63000, Clermont-Ferrand, France; E-mail: [email protected] Ann Vasc Surg 2018; -: 1–2 https://doi.org/10.1016/j.avsg.2017.10.027 Ó 2018 Elsevier Inc. All rights reserved. Manuscript received: September 23, 2017; manuscript accepted: October 24, 2017; published online: - - -
radiotherapy and stable ischemic cardiopathy. He did not report any trauma or endovascular procedure. The patient stated that he never had a chest X-ray over his medical history. A dedicated contrast-enhanced thoracic CT revealed a large saccular dilatation of the left brachiocephalic vein (Fig. 1). The aneurysm measured 65.9 42.1 55.8 mm. Stagnation of the contrast material was noted on delayed CT sequence. The right brachiocephalic vein and the superior vena cava were normal. No extravasation of the contrast material or arteriovenous fistulae was noted. Because of the risk for an embolic event, surgery was proposed. A median sternotomy was performed. We first controlled the superior vena cava to prevent excessive blood loss in case of hemorrhage. Thymectomy was then performed, and the aneurysm was carefully dissected. Its neck was identified (Fig. 2) and subsequently resected using an endostapler with a vascular load, taking great care to not narrow the left brachiocephalic vein. Pathologic examination of the aneurysm revealed no abnormality: the sampled tissue was made of a normal venous structure without any fibrosis around, making it a true aneurysm. The patient had an uneventful postoperative course and was discharged home on the postoperative day 3. Three months after the surgery, the patient had recovered completely from the procedure. An enhanced-CT of his chest was obtained that showed no abnormality. Discussion Brachiocephalic venous aneurysm is a rare condition, and <20 cases have been reported in the literature.1 Little is 1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Contrast-enhanced computed tomography shows a large saccular aneurysm (arrow) in the left brachiocephalic vein (dotted arrow). known regarding the etiology of brachiocephalic venous aneurysm. Potential causes include congenital malformation, inflammation, trauma, degenerative changes in the vessel wall, and arteriovenous fistulae.2 The cause of the aneurysm in our patient remains unclear. Most patients with brachiocephalic venous aneurysms are asymptomatic, and the lesion is incidentally detected as a mediastinal mass on chest radiography or CT. However, aneurysms can cause chest pain, dyspnea, and recurrent nerve paralysis and may sometimes be associated with a rupture3 or pulmonary embolism.4 There are no guidelines for treatment, which is largely dictated by clinical presentation and radiologic characteristics. It is suggested that saccular aneurysms should be surgically repaired via cardiopulmonary bypass to avoid complications, whereas asymptomatic fusiform aneurysms can be safely observed. Endovascular interventions that involve coil embolization of the aneurysm and stent implantation have been proposed as treatment options, depending on the anatomic characteristics of the aneurysm and its parent vessel. Thrombin injection into the sac of the aneurysm has also been recently proposed.5 Cross-sectional imaging, either using magnetic resonance imaging or CT, is sufficient for accurately diagnosing venous and arterial aneurysms and enabling planning of the surgical strategy. Cardiopulmonary bypass is frequently reported to be necessary to allow safe
Fig. 2. Operative view. The neck of the aneurysm is identified (arrow). mobilization and resection; however, in our patient, we believed that we could obtain the same safety with gentle dissection of the aneurysm and rapid control of the superior vena cava without the adverse effects of systemic heparin administration. According to previous reports, the prognosis of brachiocephalic venous aneurysm after resection is excellent. There are no reported cases of recurrence or of development of similar lesions elsewhere. REFERENCES 1. Hosaka A, Kato M, Kato I, et al. Brachiocephalic venous aneurysm with unusual clinical observations. J Vasc Surg 2011;54:77Se9S. 2. Schatz IJ, Fine G. Venous aneurysms. N Engl J Med 1962;266:1310e2. 3. Taira A, Akita H. Ruptured venous aneurysm of the persistent left superior vena cava. Angiology 1981;32:656e9. 4. Hosein RB, Butler K, Miller P, et al. Innominate venous aneurysm presenting as a rapidly expanding mediastinal mass. Ann Thorac Surg 2007;84:640e2. 5. Jargiello T, Durakiewicz M, Sojka M, et al. Saccular aneurysm of superior vena cava treated with percutaneous, transcatheter thrombin injection. Cardiovasc Intervent Radiol 2014;37:529e32.
Brachiocephalic venous aneurysm is an extremely rare condition, with <20 cases reported in the literature. We present a case of a 72-year-old man who was referred to our department owing to a large aneurysm of the left brachiocephalic vein that was incidentally discovered on computed tomography. Further workup confirmed an isolated saccular aneurysm of the left brachiocephalic vein. The patient underwent aneurysmectomy via sternotomy with no requirement for a vascular graft or cardiopulmonary bypass. The postoperative course and follow-up were uneventful.
Aneurysmal dilatation of the thoracic veins is a rare cause of mediastinal widening, and when present, fusiform aneurysms of the superior vena cava are the most commonly observed. Only few case reports have discussed the surgical treatment of isolated aneurysms of the left brachiocephalic vein.
CASE REPORT A 72-year-old asymptomatic man was referred to our department owing to a large mediastinal mass that was incidentally discovered on abdominal and pelvic computed tomography (CT) that was performed because of hematuria. The patient had a medical history of prostate adenocarcinoma that was treated 9 years earlier by Conflict of interest: The authors have no conflicts of interest to declare. 1 Department of Thoracic and Endocrine Surgery, Jean Perrin Comprehensive Cancer Center, Clermont-Ferrand, France. 2
Department of Anatomy, Clermont-Ferrand School of Medicine, Universite Clermont Auvergne, Clermont-Ferrand, France. 3 Department of Vascular Surgery, Jacques Lacarin Hospital, Vichy, France.
Correspondence to: Geraud Galvaing, MD, MSc, Department of Thoracic and Endocrine Surgery, Jean Perrin Comprehensive Cancer Center, 58 rue Montalembert 63000, Clermont-Ferrand, France; E-mail: [email protected] Ann Vasc Surg 2018; -: 1–2 https://doi.org/10.1016/j.avsg.2017.10.027 Ó 2018 Elsevier Inc. All rights reserved. Manuscript received: September 23, 2017; manuscript accepted: October 24, 2017; published online: - - -
radiotherapy and stable ischemic cardiopathy. He did not report any trauma or endovascular procedure. The patient stated that he never had a chest X-ray over his medical history. A dedicated contrast-enhanced thoracic CT revealed a large saccular dilatation of the left brachiocephalic vein (Fig. 1). The aneurysm measured 65.9 42.1 55.8 mm. Stagnation of the contrast material was noted on delayed CT sequence. The right brachiocephalic vein and the superior vena cava were normal. No extravasation of the contrast material or arteriovenous fistulae was noted. Because of the risk for an embolic event, surgery was proposed. A median sternotomy was performed. We first controlled the superior vena cava to prevent excessive blood loss in case of hemorrhage. Thymectomy was then performed, and the aneurysm was carefully dissected. Its neck was identified (Fig. 2) and subsequently resected using an endostapler with a vascular load, taking great care to not narrow the left brachiocephalic vein. Pathologic examination of the aneurysm revealed no abnormality: the sampled tissue was made of a normal venous structure without any fibrosis around, making it a true aneurysm. The patient had an uneventful postoperative course and was discharged home on the postoperative day 3. Three months after the surgery, the patient had recovered completely from the procedure. An enhanced-CT of his chest was obtained that showed no abnormality. Discussion Brachiocephalic venous aneurysm is a rare condition, and <20 cases have been reported in the literature.1 Little is 1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Contrast-enhanced computed tomography shows a large saccular aneurysm (arrow) in the left brachiocephalic vein (dotted arrow). known regarding the etiology of brachiocephalic venous aneurysm. Potential causes include congenital malformation, inflammation, trauma, degenerative changes in the vessel wall, and arteriovenous fistulae.2 The cause of the aneurysm in our patient remains unclear. Most patients with brachiocephalic venous aneurysms are asymptomatic, and the lesion is incidentally detected as a mediastinal mass on chest radiography or CT. However, aneurysms can cause chest pain, dyspnea, and recurrent nerve paralysis and may sometimes be associated with a rupture3 or pulmonary embolism.4 There are no guidelines for treatment, which is largely dictated by clinical presentation and radiologic characteristics. It is suggested that saccular aneurysms should be surgically repaired via cardiopulmonary bypass to avoid complications, whereas asymptomatic fusiform aneurysms can be safely observed. Endovascular interventions that involve coil embolization of the aneurysm and stent implantation have been proposed as treatment options, depending on the anatomic characteristics of the aneurysm and its parent vessel. Thrombin injection into the sac of the aneurysm has also been recently proposed.5 Cross-sectional imaging, either using magnetic resonance imaging or CT, is sufficient for accurately diagnosing venous and arterial aneurysms and enabling planning of the surgical strategy. Cardiopulmonary bypass is frequently reported to be necessary to allow safe
Fig. 2. Operative view. The neck of the aneurysm is identified (arrow). mobilization and resection; however, in our patient, we believed that we could obtain the same safety with gentle dissection of the aneurysm and rapid control of the superior vena cava without the adverse effects of systemic heparin administration. According to previous reports, the prognosis of brachiocephalic venous aneurysm after resection is excellent. There are no reported cases of recurrence or of development of similar lesions elsewhere. REFERENCES 1. Hosaka A, Kato M, Kato I, et al. Brachiocephalic venous aneurysm with unusual clinical observations. J Vasc Surg 2011;54:77Se9S. 2. Schatz IJ, Fine G. Venous aneurysms. N Engl J Med 1962;266:1310e2. 3. Taira A, Akita H. Ruptured venous aneurysm of the persistent left superior vena cava. Angiology 1981;32:656e9. 4. Hosein RB, Butler K, Miller P, et al. Innominate venous aneurysm presenting as a rapidly expanding mediastinal mass. Ann Thorac Surg 2007;84:640e2. 5. Jargiello T, Durakiewicz M, Sojka M, et al. Saccular aneurysm of superior vena cava treated with percutaneous, transcatheter thrombin injection. Cardiovasc Intervent Radiol 2014;37:529e32.