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Simultaneous Kissing Stent Technique with Stent Grafts for Subclavian Artery Aneurysm: A Case Report
Case Report Simultaneous Kissing Stent Technique with Stent Grafts for Subclavian Artery Aneurysm: A Case Report Liqiang Li, Hengxi Yu, Yixia Qi, Lixing Qi, Jianxin Li, Yongquan Gu, and Jian Zhang, Beijing, China
Treatment of subclavian artery aneurysm is typically performed as an open procedure. In recent years, the use of an endovascular approach has been reported. We experienced a case of subclavian artery aneurysm treated by simultaneous kissing stent technique. With fewer complications, this is a promising technique.
As reported by Dent et al.,1 subclavian artery aneurysm (SAA) is rare, representing only 0.1% of atherosclerotic peripheral artery aneurysms. Other causes of SAA include trauma, thoracic outlet syndrome, infection such as syphilis, and less frequently, genetic syndromes such as Turner’s syndrome and Marfan syndrome.2,3 Because SAA poses a significant risk of rupture, embolization, or thrombosis, surgical treatment is recommended. We present a case of aneurysm of the right subclavian artery initially detected by chest X-ray. Stent grafts were used to complete the endovascular repair.
CASE REPORT Chest X-ray examination in a 66-year-old woman revealed an unclear mass in the right supraclavicular fossa, and computed tomography (CT) was performed for further evaluation of the unidentified mass. The CT
Conflicts of Interest: None. Department of Vascular Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China. Correspondence to: Jian Zhang, MD, Department of Vascular Surgery, Xuan Wu Hospital, Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing 100053, China; E-mail: [email protected] Ann Vasc Surg 2015; -: 1–3 http://dx.doi.org/10.1016/j.avsg.2015.02.018 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: October 6, 2014; manuscript accepted: February 8, 2015; published online: ---.
scan revealed a false SAA close to the origin of the innominate artery. The aneurysm sac measured 2.6 3.5 cm and was without thrombus. The patient had no clinical symptoms of aneurysm and no history of hereditary disease or trauma. Physical examination revealed no substantial difference in blood pressure between the right (137/84 mm Hg) and left (132/79 mm Hg) arms. A vascular murmur was heard at the right supraclavicular fossa. On the basis of these findings, endovascular therapy was performed. We inserted 10-French introducer sheaths percutaneously via bilateral femoral arteries and administered 4000 IU of heparin intraluminally to prevent coagulation. A pigtail catheter with a 0.035-inch guidewire was advanced to the ascending aorta. Arteriography of the aortic arch was performed and showed 3 normal branches. A false aneurysm was found at the proximal right subclavian artery (Fig. 1), and an elbow catheter was used to implant 0.035-inch and 0.018-inch guidewires in the right carotid and right subclavian arteries, respectively. We then placed 8 mm 60 mm and 10 mm 60 mm Fluency Plus Endovascular Stent Grafts (Angiomed GmbH/C. R. Bard, Inc., Karlsruhe, Germany) at the right carotid and right subclavian arteries. Immediately after deployment of the stent grafts, angiography was performed and showed a perfect fit of the 2 stent grafts at the proximal ends and no expansion of the aneurysm (Fig. 2). Postoperatively, the patient was begun on a 14-day course of low-molecular-weight heparin 0.4 mL 2 times per day, to be followed by long-term anticoagulation with aspirin 100 mg daily. At 1-month follow-up, the patient felt well and had no symptoms or complaints. Color duplex ultrasound demonstrated no endoleak, and the 2 stent grafts were completely expanded with no evidence of stenosis.
1
2 Case Report
Fig. 1. Arch arteriography showing a pigtail catheter with 0.035-inch guidewire in the ascending aorta, 3 normal branches of the aortic arch, and a false aneurysm at the proximal end of the right subclavian artery.
DISCUSSION SAA is a rare peripheral vascular disease with a prevalence of about 1%4 and a number of etiologies. However, it is not possible to identify the exact cause of aneurysm formation in every case. This disease is often symptomatic because of the effect of extrinsic pressure. Typical symptoms include a pulsatile mass, shoulder pain, hoarseness or cough, dysphagia, dyspnea, coldness or numbness of the ipsilateral upper extremity caused by thromboembolism, and acute pain because of rupture of the aneurysm. Symptomatic SAA is dangerous and poses limbor life-threatening risk. If the patient is in good general health, surgical intervention should be performed to relieve symptoms and prevent thromboembolism and rupture of the aneurysm.5 Surgical intervention can be performed through a median sternotomy or left thoracotomy, or via a supraclavicular approach, depending on its location, size, and etiology.6e8 Endovascular treatment with stent grafting has recently been performed and is considered to be less invasive and to confer lower risk than surgical treatment.9 The use of coil embolization and the Amplatzer Septal Occluder (St. Jude Medical, Inc., St. Paul, MN) for endovascular repair has also been reported.10,11 This SAA is diagnosed from chest X-ray and CT scan images. Digital subtraction angiography, which is able to show only the nonthrombosed area of an aneurysm, can be complemented with CT
Annals of Vascular Surgery
Fig. 2. An elbow catheter is used to implant 0.035-inch and 0.018-inch guidewires in the right carotid and right subclavian arteries, respectively. Following this, 8 mm 60 mm and 10 mm 60 mm stent grafts are placed at the right carotid and right subclavian arteries, respectively. A perfect fit of the 2 stent grafts at the proximal end and a nonexpanding aneurysm are seen.
scanning.12,13 Before proceeding with surgery, tests for inflammatory aneurysms should be performed. If an inflammatory aneurysm is identified, hormone therapy or anti-inflammatory therapy should be given before surgery to prevent recurrence or development of vascular inflammation. In situations in which the neck of the aneurysm is very close to the start of subclavian artery, it can be difficult to apply stent grafts to the sites of aneurysm without affecting vertebral or carotid artery blood flow. To prevent a type I endoleak, the proximal part of the stent graft has to be released at least 1 cm proximal to the aneurysm neck. The proximal end of the stent graft will inevitably be located in the innominate artery, reducing blood flow in the right carotid artery. We used kissing stent technique with 2 stent grafts to maintain the blood flow of the right subclavian and carotid arteries.
CONCLUSION We successfully treated a right SAA using 2 stent grafts without incurring endoleak or reducing cerebral blood flow. This minimally invasive operation can avoid the technical issues and complications associated with surgical or hybrid procedures. Percutaneous approaches are advised in cases with
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No.
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2015
suitable anatomy. This case demonstrates the feasibility of using a subclavian artery stent graft for aneurysm exclusion while preserving the take off of the carotid artery with another stent graft. However, long-term outcomes should be determined before this new technique can safely be put into wider use.
Case Report 3
6.
7.
8.
REFERENCES 9. 1. Dent TL, Lindenauer SM, Ernst CB, et al. Multiple arteriosclerotic arterial aneurysms. Arch Surg 1972;105:338e44. 2. Columbo J, Simons JP, Baril DT, et al. Management of a patient with Turner syndrome presenting with an isolated left subclavian artery aneurysm. Vasc Endovasc Surg 2013;47: 397e9. 3. Morisaki K, Kobayashi M, Miyachi H, et al. Subclavian artery aneurysm in Marfan syndrome. Ann Vasc Surg 2012;26:731.e1e4. 4. Dougherty MJ, Calligaro KD, Savarese RP, et al. Atherosclerotic aneurysm of the intrathoracic subclavian artery: a case report and review of the literature. J Vasc Surg 1995;21: 521e9. 5. Kasirajan K, Matteson B, Marek JM, et al. Covered stents for true subclavian aneurysms in patients with degenerative
10.
11.
12.
13.
connective tissue disorders. J Endovasc Ther 2003;10: 647e52. Balar N, Ganatra V, Sampson LN, et al. Left subclavian artery aneurysm: surgical repair via a sternal incisionda case report. Vasc Endovasc Surg 2004;38:557e61. Luciani N, Gaudino M, Mattens M, et al. Surgical treatment of recurrence of an aneurysm of aberrant right subclavian artery. J Card Surg 1997;12:51e4. Sefranek V, Tomka J, Janotik P, et al. A modified supraclavicular approach for resection of a subclavian aneurysm. Rozhl Chir 1998;77:214e7. Gafoor S, Stelter W, Bertog S, et al. Fully percutaneous treatment of an aberrant right subclavian artery and thoracic aortic aneurysm. Vasc Med 2013;18:139e44. Kische S, Ince H, Peuster M. Coil occlusion of a subclavian mycotic aneurysm. Catheter Cardiovasc Interv 2010;75: 1116e20. Suthananthan A, Sieunarine K. Innovative use of an Amplatzer septal occluder for occlusion of a large right subclavian artery aneurysm and reconstruction of the posterior aortic arch wall. Vasc Endovasc Surg 2012;46:401e4. Visrutaratna P, Charoenkwan P, Saeteng S. Mycotic aneurysm of the left subclavian artery: CT findings. Singapore Med J 2006;47:77e9. Kutlu R, Baysal T, Sigirci A, et al. Right subclavian artery aneurysm: yin-yang sign on CT. Cardiovasc Intervent Radiol 2003;26:184e5.
Treatment of subclavian artery aneurysm is typically performed as an open procedure. In recent years, the use of an endovascular approach has been reported. We experienced a case of subclavian artery aneurysm treated by simultaneous kissing stent technique. With fewer complications, this is a promising technique.
As reported by Dent et al.,1 subclavian artery aneurysm (SAA) is rare, representing only 0.1% of atherosclerotic peripheral artery aneurysms. Other causes of SAA include trauma, thoracic outlet syndrome, infection such as syphilis, and less frequently, genetic syndromes such as Turner’s syndrome and Marfan syndrome.2,3 Because SAA poses a significant risk of rupture, embolization, or thrombosis, surgical treatment is recommended. We present a case of aneurysm of the right subclavian artery initially detected by chest X-ray. Stent grafts were used to complete the endovascular repair.
CASE REPORT Chest X-ray examination in a 66-year-old woman revealed an unclear mass in the right supraclavicular fossa, and computed tomography (CT) was performed for further evaluation of the unidentified mass. The CT
Conflicts of Interest: None. Department of Vascular Surgery, Xuan Wu Hospital, Capital Medical University, Beijing, China. Correspondence to: Jian Zhang, MD, Department of Vascular Surgery, Xuan Wu Hospital, Capital Medical University, No. 45, Changchun Street, Xicheng District, Beijing 100053, China; E-mail: [email protected] Ann Vasc Surg 2015; -: 1–3 http://dx.doi.org/10.1016/j.avsg.2015.02.018 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: October 6, 2014; manuscript accepted: February 8, 2015; published online: ---.
scan revealed a false SAA close to the origin of the innominate artery. The aneurysm sac measured 2.6 3.5 cm and was without thrombus. The patient had no clinical symptoms of aneurysm and no history of hereditary disease or trauma. Physical examination revealed no substantial difference in blood pressure between the right (137/84 mm Hg) and left (132/79 mm Hg) arms. A vascular murmur was heard at the right supraclavicular fossa. On the basis of these findings, endovascular therapy was performed. We inserted 10-French introducer sheaths percutaneously via bilateral femoral arteries and administered 4000 IU of heparin intraluminally to prevent coagulation. A pigtail catheter with a 0.035-inch guidewire was advanced to the ascending aorta. Arteriography of the aortic arch was performed and showed 3 normal branches. A false aneurysm was found at the proximal right subclavian artery (Fig. 1), and an elbow catheter was used to implant 0.035-inch and 0.018-inch guidewires in the right carotid and right subclavian arteries, respectively. We then placed 8 mm 60 mm and 10 mm 60 mm Fluency Plus Endovascular Stent Grafts (Angiomed GmbH/C. R. Bard, Inc., Karlsruhe, Germany) at the right carotid and right subclavian arteries. Immediately after deployment of the stent grafts, angiography was performed and showed a perfect fit of the 2 stent grafts at the proximal ends and no expansion of the aneurysm (Fig. 2). Postoperatively, the patient was begun on a 14-day course of low-molecular-weight heparin 0.4 mL 2 times per day, to be followed by long-term anticoagulation with aspirin 100 mg daily. At 1-month follow-up, the patient felt well and had no symptoms or complaints. Color duplex ultrasound demonstrated no endoleak, and the 2 stent grafts were completely expanded with no evidence of stenosis.
1
2 Case Report
Fig. 1. Arch arteriography showing a pigtail catheter with 0.035-inch guidewire in the ascending aorta, 3 normal branches of the aortic arch, and a false aneurysm at the proximal end of the right subclavian artery.
DISCUSSION SAA is a rare peripheral vascular disease with a prevalence of about 1%4 and a number of etiologies. However, it is not possible to identify the exact cause of aneurysm formation in every case. This disease is often symptomatic because of the effect of extrinsic pressure. Typical symptoms include a pulsatile mass, shoulder pain, hoarseness or cough, dysphagia, dyspnea, coldness or numbness of the ipsilateral upper extremity caused by thromboembolism, and acute pain because of rupture of the aneurysm. Symptomatic SAA is dangerous and poses limbor life-threatening risk. If the patient is in good general health, surgical intervention should be performed to relieve symptoms and prevent thromboembolism and rupture of the aneurysm.5 Surgical intervention can be performed through a median sternotomy or left thoracotomy, or via a supraclavicular approach, depending on its location, size, and etiology.6e8 Endovascular treatment with stent grafting has recently been performed and is considered to be less invasive and to confer lower risk than surgical treatment.9 The use of coil embolization and the Amplatzer Septal Occluder (St. Jude Medical, Inc., St. Paul, MN) for endovascular repair has also been reported.10,11 This SAA is diagnosed from chest X-ray and CT scan images. Digital subtraction angiography, which is able to show only the nonthrombosed area of an aneurysm, can be complemented with CT
Annals of Vascular Surgery
Fig. 2. An elbow catheter is used to implant 0.035-inch and 0.018-inch guidewires in the right carotid and right subclavian arteries, respectively. Following this, 8 mm 60 mm and 10 mm 60 mm stent grafts are placed at the right carotid and right subclavian arteries, respectively. A perfect fit of the 2 stent grafts at the proximal end and a nonexpanding aneurysm are seen.
scanning.12,13 Before proceeding with surgery, tests for inflammatory aneurysms should be performed. If an inflammatory aneurysm is identified, hormone therapy or anti-inflammatory therapy should be given before surgery to prevent recurrence or development of vascular inflammation. In situations in which the neck of the aneurysm is very close to the start of subclavian artery, it can be difficult to apply stent grafts to the sites of aneurysm without affecting vertebral or carotid artery blood flow. To prevent a type I endoleak, the proximal part of the stent graft has to be released at least 1 cm proximal to the aneurysm neck. The proximal end of the stent graft will inevitably be located in the innominate artery, reducing blood flow in the right carotid artery. We used kissing stent technique with 2 stent grafts to maintain the blood flow of the right subclavian and carotid arteries.
CONCLUSION We successfully treated a right SAA using 2 stent grafts without incurring endoleak or reducing cerebral blood flow. This minimally invasive operation can avoid the technical issues and complications associated with surgical or hybrid procedures. Percutaneous approaches are advised in cases with
Vol.
-,
No.
-, -
2015
suitable anatomy. This case demonstrates the feasibility of using a subclavian artery stent graft for aneurysm exclusion while preserving the take off of the carotid artery with another stent graft. However, long-term outcomes should be determined before this new technique can safely be put into wider use.
Case Report 3
6.
7.
8.
REFERENCES 9. 1. Dent TL, Lindenauer SM, Ernst CB, et al. Multiple arteriosclerotic arterial aneurysms. Arch Surg 1972;105:338e44. 2. Columbo J, Simons JP, Baril DT, et al. Management of a patient with Turner syndrome presenting with an isolated left subclavian artery aneurysm. Vasc Endovasc Surg 2013;47: 397e9. 3. Morisaki K, Kobayashi M, Miyachi H, et al. Subclavian artery aneurysm in Marfan syndrome. Ann Vasc Surg 2012;26:731.e1e4. 4. Dougherty MJ, Calligaro KD, Savarese RP, et al. Atherosclerotic aneurysm of the intrathoracic subclavian artery: a case report and review of the literature. J Vasc Surg 1995;21: 521e9. 5. Kasirajan K, Matteson B, Marek JM, et al. Covered stents for true subclavian aneurysms in patients with degenerative
10.
11.
12.
13.
connective tissue disorders. J Endovasc Ther 2003;10: 647e52. Balar N, Ganatra V, Sampson LN, et al. Left subclavian artery aneurysm: surgical repair via a sternal incisionda case report. Vasc Endovasc Surg 2004;38:557e61. Luciani N, Gaudino M, Mattens M, et al. Surgical treatment of recurrence of an aneurysm of aberrant right subclavian artery. J Card Surg 1997;12:51e4. Sefranek V, Tomka J, Janotik P, et al. A modified supraclavicular approach for resection of a subclavian aneurysm. Rozhl Chir 1998;77:214e7. Gafoor S, Stelter W, Bertog S, et al. Fully percutaneous treatment of an aberrant right subclavian artery and thoracic aortic aneurysm. Vasc Med 2013;18:139e44. Kische S, Ince H, Peuster M. Coil occlusion of a subclavian mycotic aneurysm. Catheter Cardiovasc Interv 2010;75: 1116e20. Suthananthan A, Sieunarine K. Innovative use of an Amplatzer septal occluder for occlusion of a large right subclavian artery aneurysm and reconstruction of the posterior aortic arch wall. Vasc Endovasc Surg 2012;46:401e4. Visrutaratna P, Charoenkwan P, Saeteng S. Mycotic aneurysm of the left subclavian artery: CT findings. Singapore Med J 2006;47:77e9. Kutlu R, Baysal T, Sigirci A, et al. Right subclavian artery aneurysm: yin-yang sign on CT. Cardiovasc Intervent Radiol 2003;26:184e5.