Subclavian Aneurysm Presenting with Massive Hemoptysis: A Case Report and Review of the Literature

Abstract

Aneurysms of the proximal subclavian artery are rare. Reported etiologies of this unusual clinical problem include arteriosclerosis, trauma, fibrodysplastic disease, degenerative connective tissue disorders, cervical ribs in association with thoracic outlet syndrome, congenital lesions, and infection. We present a case of a 70-year-old male with an extensive medical history who presented to an outside hospital with massive hemoptysis. His past medical history was significant for coronary artery disease and he had undergone coronary revascularization several years prior with a left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery bypass graft as well as a saphenous vein graft to the obtuse marginal branch (OMB) of the left circumflex coronary artery. His medical history was also notable for end stage renal disease, diabetes, hypertension, paroxysmal atrial fibrillation, and cardiomyopathy with left ventricular ejection fraction of 40%. Notably, he had complete heart block with pacemaker implantation two years before, then requiring explantation due to methicillin-resistant Staphylococcus aureus (MRSA) infection and subsequent replacement with epicardial nonintravascular leads.Chest CT scan revealed a pseudoaneurysm originating from the proximal left subclavian artery measuring 2.2 Â 2.9 cm with adjacent ground-glass opacity and consolidation of the lung (►Figs. 1 and 2). He had persistent hemoptysis but remained hemodynamically stable and was transferred to our facility for further management. An angiogram confirmed the subclavian artery aneurysm (►Fig. 3). Coronary angiography was pursued to delineate coronary artery anatomy. There was no significant left main coronary disease. There was an occluded vein graft with the OMB filling by right to left collaterals and a widely patent LIMA to LAD Keywords ► subclavian ► aneurysm ► hemoptysis ► hybrid ► endovascular repair AbstractWe present a case of a 70-year-old male with a past medical history of coronary artery bypass grafting and end stage renal disease who presented with massive hemoptysis. He had a history of methicillin-resistant Staphylococcus aureus endocarditis, with infection and removal of endocardial pacing leads. His work-up revealed a 2.9-cm proximal left subclavian artery aneurysm. Bronchoscopy confirmed bright red blood in the left upper lobe bronchus and coronary angiography confirmed a patent left internal mammary artery (LIMA) to left anterior descending bypass. Because of the consideration of maintaining coronary perfusion via the LIMA while excluding the subclavian aneurysm, he underwent a left carotid to left axillary artery bypass graft followed by deployment of an Amplatzer II vascular plug just distal to the aneurysm. A thoracic endograft was then deployed to exclude the origin of the subclavian. A review of the literature reveals hemoptysis as a rare presentation of a subclavian aneurysm. We discuss approaches to this challenging clinical problem, ranging from open repair to hybrid approaches.

Endovascular treatment of ruptured subclavian artery aneurysm presented with hemoptysis

“…Other cases were managed with open repair, endovascular repair, hybrid repair, and embolization. These cases were mainly associated with documented infection, lung abscess, or immunosuppression due to chemotherapy and/or malignancy [6].…”

Delayed Presentation of Catheter-related Subclavian Artery Pseudoaneurysm

“…3 Patients with subclavian pseudoaneurysm may be asymptomatic or they may present with chest pain, Horner syndrome, paresthesia, hoarseness, upper limb ischemia, a pulsatile mass,or hemoptysis. 4 Early recognition and optimal diagnostic tools are very important in those cases. The following methods may be used to aid in diagnosis.…”

Hybrid Repair of Proximal Subclavian Artery Aneurysm

“…Median clamping time of the CCA was 9.5 [6][7][8][9][10][11][12][13][14][15][16][17] min. A Matsui-Kitamura (MK) stent-graft (Kitamura Inc., Kanazawa, Japan) was used in cases 1 and 2, a Gore TAG (WL Gore) in cases 3 and 4 and the iliac extender of the Gore Excluder (WL Gore) in cases 5 and 6.…”

“…Reacscularization of the subclavian artery during TEVAR for proximal SCAAs tends to be the treatment of choice. 1,[10][11][12] Five patients in our study underwent hybrid repair, that is, TEVAR and supra-aortic bypass for three patients, stent-graft placement and supra-aortic bypass with reconstruction of the vertebral artery for one patient, and stent-graft placement and reconstruction of the vertebral artery for the remaining patient. Byrne et al analyzed 143 extra-anatomic procedures for carotid and subclavian reconstruction.…”

“…13) Most bypass grafts were made of ePTFE and the 5-year patency rate was 92%, indicating that artificial bypass grafts can result in excellent patency rates. We also used ePTFE grafts for all patients, and no graft occlusion was encountered during the follow-up period, nor was any cerebral complication associated with clamping of the CCA for 9.5 [6][7][8][9][10][11][12][13][14][15][16][17] min for construction of the supra-aortic bypass. However, one aortic dissection and two neurologic complications were encountered in the early and late term.…”