Open Journal of Thoracic Surgery
Vol.4 No.2(2014), Article
ID:46174,6
pages
DOI:10.4236/ojts.2014.42006
Dartevelle Approach for Intra-Thoracic Subclavian Artery Aneurysm Repair
Chris Bond1*, Jameel Muzaffar1, Donald Adam2, Ehab Bishay1
1Department of Cardiothoracic Surgery, Heart of England NHS Foundation Trust, Birmingham, UK
2Department of Vascular Surgery, Heart of England NHS Foundation Trust, Birmingham, UK
Email: *Chrisbond1@nhs.net
Copyright © 2014 by authors and Scientific Research Publishing Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY).
http://creativecommons.org/licenses/by/4.0/
Received 26 February 2014; revised 26 March 2014; accepted 2 April 2014
ABSTRACT
Subclavian artery aneurysm is a rare phenomenon in the West, but its prevalence is increasingly proportionate to incidence of atherosclerotic disease in the population. It is generally accepted that gold standard care is surgical resection but with limited experience opportunity remains to optimise this. We report on a 66-year-old female arteriopath with an 8 cm intra-thoracic aneurysm of the right subclavian artery, just distal to the brachiocephalic trunk. Lack of a proximal landing zone prohibited endovascular repair thus we utilised the anterior transcervical approach described by Dartevelle. This approach provided excellent visualisation of the aneurysm, along with right vagus and phrenic nerves, facilitating proximal and distal control and subsequent decompression. Post operative recovery was swift and not marred by substantial pain or inhibition of chest wall mechanics, associated with median sternotomy and thoracotomy incisions usually advocated for such aneurysms. As such we purport this approach to offer excellent operative exposure for this increasing disease burden, with less morbidity associated than the currently accepted approach, representing an advance in the management of this condition.
Keywords:Aneurysm, Subclavian Artery, Dartevelle Approach
1. Introduction
Subclavian Artery Aneurysm (ScAAn) is a rare phenomenon with incidence in Western populations ~1/100,000 per annum, comprising only 0.5% of diagnosed aneurysmal disease. Mean age of incidence is 49 years, twice as common in males. ScAAn is classified based upon anatomical location which generally reflects aetiology. Extra-thoracic ScAAn commonly results from trauma or thoracic outlet syndrome, occurring in females typically <45 years. Intra-thoracic ScAAn is most often due to atherosclerosis, and consequently it is most frequent in males > 60 years. Remaining aetiologies include inflammatory processes, Marfan’s disease, cystic medial necrosis and of course congenital abnormality, and these have no preponderance for either anatomical location [1] .
Presentation of ScAAn is via three modalities: direct symptoms such as upper limb pain, distal emboli or rupture resulting in profound hypotension, and in some cases, death. Secondly by mass effect, within the thorax this may produce dysphagia or haemoptysis, in the axilla and it may present as a palpable pulsatile mass or brachial plexopathy. Finally, ScAAn is often an incidental finding.
The paucity of experience with ScAAn leaves its natural history uncertain. Growth rates of 5 - 15 mm/year have been observed but rupture risk at a given diameter is undetermined [2] . Consequently the consensus that operative management is gold standard therapy is based upon extrapolation from other aneurysmal disease. Furthermore, the optimal approach to operative management is not established.
2. The Case Figures 1-7
We report a 66-year-old known arteriopath who presented with a 2 month history of right upper limb pain following a minor fall. After conservative measures failed to alleviate symptoms the General Practitioner ordered a shoulder radiograph which identified part of a large opacification in the apex of the right hemithorax. Chest radiograph ensued confirming the mass and highlighting a calcified rim suggestive of aneurysmal disease. Referral to Thoracic Surgery was made.
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