Sudden death due to spontaneous acute dissection of the left subclavian artery with rupture during postpartum period: a case report

Abstract

Subclavian artery dissection is usually associated with coexisting aortic disease. Isolated and spontaneous acute subclavian artery dissection is uncommon and rarely reported. In addition, no case of left subclavian artery dissection during pregnancy and early puerperium has been described. We report the autopsy case of a 24-year-old female who died suddenly 3 days after delivery due to a spontaneous left subclavian artery dissection with rupture.

Spontaneous rupture of the branches of left subclavian artery

“…However, the biological mechanism of the vessel damage remained unclear. According to clinical practice and reported cases, [ 2 – 4 ] HBP is thought to be the main precipitating factor linked to the rupture of vessel. With this specific patient, there was no history of HBP, arteries abnormalities, hereditary diseases as neurofibromatosis or discernible trauma.…”

“…An 17 examples of spontaneous rupture of the branches of LSA in patients including ours (Table 1 ), have been reported in the literature. [ 4 – 18 ] The most common clinical feature of rupture was pain (70.6%, 12/17) with the position of chest, back, and neck, others included sensory deficit (23.5%, 4/17), expanding mass (17.6%, 3/17), dyspnea (17.6%, 3/17), stridor (11.8%, 2/17), hae- mothorax (11.8%, 2/17), and dysphagia (5.9%, 1/17). Among these 17 patients, we found that spontaneous rupture was happened with congenital or acquired vascular anomalies of the aortic arch, comprised of aberrant LSA itself, such as aneurysms (58.8%, 10/17), right aortic arch (RAA) (17.6%, 3/17), aortic dissection (11.8%, 2/17), and aortic coarctation (5.9%, 1/17).10 of 17 patients with von Recklinghausen's disease (VRD) (neurofibromatosis) had rupture of LSA, which was considered as mainly hereditary disease that was at risk of rupturing of LSA.…”

“…LSA rupture was also reported in postpartum period of pregnancy patient. [ 4 ] In pregnancy, and postpartum period, hormonal changes could result in histological changes in the large artery, including fracture of elastic fiber and degradation of acid mucopolysaccharides. However, hemodynamic changes like substantial cardiovascular stress would deteriorate these pathologic changes, and increase the risk of dilation, dissection, or rupture in the large artery.…”

Pregnancy-associated Death – Clarifying the Cause of Death and Medico-legal Assessments in Accusations of Malpractice

“…Such deaths from natural causes were the most commonly identified deaths. Information on these causes of death is found in the literature, particularly cases of arterial rupture or dissecting arterial aneurysm with fatal hemorrhage during pregnancy or very shortly after delivery 5 , 35 , 44 , 46 , 50 and cases of fulminant pulmonary embolism 33 . Causes of death reported in the literature include amniotic fluid embolism 7 , 13 , 21 , 25 , 26 , 30 , 31 , 32 and – although this is rare – pregnancy-associated air embolism 4 .…”

“…arteriellen Dissektionen mit letaler Blutung während bzw. zeitnah nach Beendigung der Schwangerschaft 5 , 35 , 44 , 46 , 50 , auch fulminante Lungenthrombembolien 33 . Zusätzlich sind kasuistisch Fruchtwasserembolien 7 , 13 , 21 , 25 , 26 , 30 , 31 , 32 oder – als Rarität – eine schwangerschaftsassoziierte Luftembolie beschrieben 4 .…”