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Saudi Journal of Kidney Diseases and Transplantation
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LETTER TO THE EDITOR  
Year : 2015  |  Volume : 26  |  Issue : 5  |  Page : 1023-1025
Endovascular repair of iatrogenic subclavian artery pseudo-aneurysm


Department of Radiology, Christian Medical College, Tamil Nadu, Vellore, India

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Date of Web Publication7-Sep-2015
 

How to cite this article:
Mammen S, Koshy GC, Khurana A, David V. Endovascular repair of iatrogenic subclavian artery pseudo-aneurysm. Saudi J Kidney Dis Transpl 2015;26:1023-5

How to cite this URL:
Mammen S, Koshy GC, Khurana A, David V. Endovascular repair of iatrogenic subclavian artery pseudo-aneurysm. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2022 Sep 26];26:1023-5. Available from: https://www.sjkdt.org/text.asp?2015/26/5/1023/164598
To the Editor,

Central venous catheterization is a commonly performed procedure for delivery of large volumes of blood products, prolonged courses of antibiotic therapy and central venous pressure monitoring and to place dialysis ports. Serious mechanical complications amounting to arterial puncture, mediastinal hematoma, injury to adjacent nerves, hemothorax, pneumothorax and misplacement of the catheter can occur in 0.4-9.9% of patients following central venous catheterization. [1],[2] Pseudo-aneurysms are rare complications following central venous catheterization. [3] We present a case of iatrogenic pseudo-aneurysm of the subclavian artery in an attempted catheterization elsewhere, of the innominate vein for a dialysis port, who had come to our institution for further management.

A 28-year-old man with chronic kidney disease stage-5 presented to a hospital in his home town. Because of severe renal failures, a plan to start hemodialysis was made. After a failed attempt to cannulate the right subclavian vein, a right internal jugular catheter was placed to start hemodialysis. After one week, a small infra-clavicular swelling was noticed, which gradually increased in size. Color Doppler evaluation of the swelling revealed an aneurysm of the subclavian artery. This was later confirmed by a conventional angiogram. The patient was referred to our institution for further management. Examination of the right supraclavicular swelling revealed a shiny overlying skin with ecchymotic patch; palpation and auscultation revealed thrill and a continuous murmur [Figure 1].
Figure 1: Clinical photograph of the patient demonstrating a swelling on the right aspect of the lower neck. The right upper limb is diffusely swollen due to reduced venous return secondary to compression of the right subclavian vein by the enlarging pseudo-aneurysm.

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A vascular surgery opinion raised concerns over the risk involved in the procedure and advised endovascular stenting of the aneurysm. A computed tomography (CT) angiogram performed to plan possible intervention revealed an aneurysm measuring 9.6 cm × 8 cm with mural thrombus arising from the right sub-clavian artery proximal to the origin of the right vertebral artery [Figure 2] and [Figure 3].
Figure 2: CT images (A) axial and (B) coronal demonstrating contrast agent flowing out of the subclavian artery into the pseudo-aneurysm (arrow).

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Figure 3: Angiogram of the right subclavian artery (a) before and (b) after deploying the covered stent. On the pre-stenting angiogram, contrast agent is seen flowing out of the subclavian artery into the pseudoaneurysm (arrow).

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Trans-femoral selective angiography of the right subclavian artery showed a narrow necked pseudo-aneurysm arising 2 cm distal to the origin of the right common carotid artery and 1 cm proximal to the origin of the right vertebral artery. A 10 mm × 38 mm (Atrium Medical corporation, Hudson, NH, USA) balloon-mounted covered stent was deployed across the rent of the pseudo-aneurysm. Post-procedure check angiogram showed nonopacification of the pseudo-aneurysm, right vertebral artery, internal mammary artery and thyrocervical trunk and with flow across the stent distally. The residual hematoma at the site of repair was treated by surgical evacuation and drain. After three days, the drain was removed and he was discharged in a stable condition. He was advised to continue hemodialysis.

Endovascular repair of a pseudo-aneurysm of the subclavian or any other major artery is well described, [4] and was first reported by May et al. [5] Subclavian artery pseudo-aneurysm is a complication in patients undergoing central venous catheterization. Other complications in our patient were thrombosis and signs of limb ischemia, which required immediate intervention. The aneurysm expands by erosion of the overlying skin area as observed in our patient and is prone for rupture and attendant fatal complications.

The treatment modalities available include open operation or endovascular repair. The open approach includes opening of the lumen that can lead to torrential hemorrhage and a potential risk of embolization to the distal part due to manipulation as these patients have peripheral thrombus in the aneurysm. [5] Control of hemorrhage is easy in endovascular repair. [6] Considering the pros and cons of open surgery versus endovascular repair, endovascular repair was decided.

The success of trans-luminal endovascular grafting for the treatment of aneurysms of the abdominal aorta and subclavian artery as well as arteriovenous fistulae is well documented. [5],[7] Stent grafting has been exclusively studied in the setting of pseudo-aneurysm of the subclavian artery. [5] Some case reports have shown the advantage of blocking the vertebral artery when the pseudo-aneurysm was close to the vertebral artery ostium to avoid type-2 endoleak. [8] In our case, the pseudo-aneurysm was 9 mm distal to the origin of the vertebral artery, and we had a sufficient landing zone distal to the pseudo-aneurysm and proximal to the vertebral artery. We placed the covered stent right across to prevent type-1 endoleak.

Treatment of subclavian artery pseudo-aneurysm is an emergency and endovascular stenting and is a feasible and alternative approach to surgical repair because it is less invasive and cost-effective with a shorter duration of hospital stay.

Conflict of interest: None declared.

 
   References Top

1.
Borja AR, Masri Z, Shruck L, Pejo S. Unusual and lethal complications of infraclavicular subclavian vein catheterization. Int Surg 1972;57:42-5.  Back to cited text no. 1
    
2.
Mansfield PF, Hohn DC, Fornage BD, Gregurich MA, Ota DM. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994;331:1735-8.  Back to cited text no. 2
    
3.
Shield CF 3 rd , Richardson JD, Buckley CJ, Hagood CO Jr. Pseudoaneurysm of the brachiocephalic arteries: A complication of percutaneous internal jugular vein catheterization. Surgery 1975;78:190-4.  Back to cited text no. 3
    
4.
de Troia A, Tecchio T, Azzarone M, Biasi L, Piazza P, Franco Salcuni P. Endovascular treatment of an innominate artery iatrogenic pseudoaneurysm following subclavian vein catheterization. Vasc Endovascular Surg 2011;45:78-82.  Back to cited text no. 4
    
5.
May J, White G, Waugh R, Yu W, Harris J. Transluminal placement of a prosthetic graftstent device for treatment of subclavian artery aneurysm. J Vasc Surg 1993;18:1056-9.  Back to cited text no. 5
    
6.
Akgün S, Civelek A, Baltacioglu F, Ekici G. Successful endovascular repair of a subclavian artery pseudoaneurysm. Nephrol Dial Transplant 1999;14:2219-21.  Back to cited text no. 6
    
7.
Marin ML, Veith FJ, Panetta TF, et al. Percutaneous transfemoral insertion of a stented graft to repair a traumatic femoral arteriovenous fistula. J Vasc Surg 1993;18:299-302.  Back to cited text no. 7
    
8.
Demirel S, Winter C, Weigand H, Gamstatter G. Stent-graft repair of iatrogenic subclavian artery pseudoaneurysm with planned exclusion of the vertebral artery. EJVES 2008;16:16-8.  Back to cited text no. 8
    

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Correspondence Address:
Dr. Suraj Mammen
Department of Radiology, Christian Medical College, Tamil Nadu, Vellore
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-2442.164598

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