Sedoanalgesia con ketodex para la intubación selectiva en la resección de un aneurisma gigante de la arteria subclavia. Reporte de caso / Sedoanalgesia with ketodex for selective intubation in the resection of a giant aneurysm of the subclavian artery associated. Case report

Resumen: El aneurisma gigante de la arteria subclavia asociado a un síndrome de vena cava superior se presenta de forma poco frecuente. La complejidad del abordaje dependerá del tamaño, forma y disposición del aneurisma, particularmente cuando el colapso de la vía aérea es potencial por un efecto compresivo de la masa mediastinal durante la aplicación del relajante neuromuscular. Presentamos el caso de un hombre de 57 años con disnea en decúbito dorsal que incrementa con el decúbito lateral izquierdo de cinco años de evolución. El estudio radiológico reporta masa mediastinal gigante compatible con aneurisma de la arteria subclavia derecha que causa compresión y desplazamiento de la vía aérea, particularmente en tráquea a nivel de la carina. El paciente es programado para resección del aneurisma y requiere de intubación selectiva para el aislamiento del pulmón derecho durante la cirugía, que fue realizada con la técnica de paciente despierto usando sedoanalgesia con ketodex. El objetivo del caso es compartir la experiencia con el uso de ketodex como una alternativa para la tolerancia de procedimientos que requieren de la cooperación del paciente, en donde el propofol y el relajante neuromuscular pueden ser un problema para la permeabilidad y el abordaje de la vía aérea.

Abstract: A giant subclavian artery aneurysm associated with superior vena cava syndrome occurs infrequently. Complexity of the approach will depend on the size, shape, and position of the aneurysm, particularly when a potential collapse of the airway is expected due to the compressive effect of the mediastinal mass after using neuromuscular relaxant for airway approach. We present a case in a 57-year-old male with shortness of breath in dorsal that increases with left lateral decubitus during five years of evolution. Radiological studies reported giant mediastinal mass compatible with an aneurysm of the right subclavian artery, which produces critical compression and airway displacement, particularly in trachea at level of the carina. The patient is scheduled for resection of the aneurysm and requires selective intubation for isolation of the right lung during surgery which was performed with the awake patient technique using sedoanalgesia with ketodex. The objective of the case is to share the experience using ketodex as an alternative for the tolerance of procedures that requires the cooperation of the patient where propofol and neuromuscular relaxant may be a problem for airway permeability and approach.

A Case of Infectious Pseudoaneurysms of the Left Subclavian Artery and Abdominal Aorta in a Patient with a Metal Allergy / 日本心臓血管外科学会雑誌

We report a case of surgery for an infectious left subclavian artery aneurysm in a patient with metal allergy. The patient was a 41-year-old man allergic to iron, silver, manganese, and chromium. He had received a Nitinol stent in the left subclavian artery at a previous hospital. One stent had fallen out during implantation, and was put away in the terminal aorta. Ten days after the left subclavian implantation, the patient developed left shoulder pain and fever, which continued for 2 weeks. Contrastenhanced CT scan revealed a pseudoaneurysm of the left subclavian artery and abdominal aortitis. The patient underwent left subclavian artery aneurysmectomy, aorto-left subclavian artery bypass using the great saphenous vein, and removal of the stents in the left subclavian artery and abdominal aorta. The surgery was performed through a median sternotomy with cardiopulmonary support. A contrast-enhanced CT scan taken on the 12th postoperative day revealed a pseudoaneurysm of the abdominal aorta, and the patient underwent abdominal aortic artery replacement surgery on the 14th postoperative day. The patient was discharged from the hospital on the 27th day after the first surgery. The treatment of an aneurysm should be selected according to the patient’s background as well as anatomical factors.

Sternal Cleft With Coarctation of Aorta and Vascular Anomalies - Learning Point in Young Stroke

@#Sternal cleft is a rare congenital anomaly that is known to be associated with other congenital abnormalities in particular coarctation of aorta and vascular anomalies. We present a case of a young teacher who presented with recurrent episodes of ischemic stroke. During the workup to look for the cause of stroke, it was discovered that this patient had complete midline sternal cleft with underlying coarctation of aorta and left subclavian artery aneurysm. We wish to highlight the relation between the presence of sternal cleft and coarctation of aorta as well as vascular anomalies as one of the rare cause of young stroke.

Bilateral Bidirectional Glenn Anastomosis in an Adult Patient with Aneurysmal Degeneration after an Original Blalock-Taussig Shunt / 日本心臓血管外科学会雑誌

A male patient with single ventricle pulmonary stenosis, and persistent left superior vena cava underwent original Blalock-Taussig shunt (BTS) at 2 years of age and suffered from infective endocarditis at 38 years of age. A systemic work-up detected dural arteriovenous fistula and aneurysmal dilatation of the original BTS. Cardiac catheterization and cardiac magnetic resonance imaging revealed an appropriate pulmonary vasculature for bidirectional Glenn anastomosis and sufficient antegrade pulmonary blood flow through the pulmonary valve. Bilateral bidirectional Glenn anastomosis and resection of the aneurysm of the BTS-associated aneurysm were successfully performed.

Determination of Clamp Site with Reference to a Cerebral Blood Flow Monitoring System in a Patient with a Right Subclavian Artery Aneurysm Complicated by Right Internal Carotid Artery Occlusion / 日本心臓血管外科学会雑誌

A 66-year-old man was referred to our hospital for the treatment of a right subclavian artery aneurysm. Computed tomography showed a 35-mm aneurysm in the right subclavian artery, and occlusion of the right internal carotid artery. A surgical approach with maintenance of intracranial blood flow was required. During anastomosis of the graft to the native vessel, we clamped the distal and proximal portions of the right subclavian artery, to maintain the blood flow of the right common carotid artery. The INVOS® cerebral oximeter (Somanetics Corp., Troy, MI, USA) was useful in determining the clamping site and surgical strategy. The procedure was completed without complications, and the patient was discharged from the hospital on postoperative day 8 following a good clinical course.

Endovascular Treatment with Stent Graft for Left Subclavian Artery Aneurysm / 日本心臓血管外科学会雑誌

A 71-year-old man underwent a medical checkup at another hospital with principal complaint of chest discomfort, and was diagnosed by computed tomography (CT) to have a left subclavian artery aneurysm. The CT revealed a 33-mm saccular aneurysm that was located at the proximal portion of the left subclavian artery. Because of the high risk of surgery, we planned to insert a stent graft into the left subclavian artery. We could not avoid occluding the ostium of the left vertebral artery with commercially-available stent grafts, and so decided to insert a surgeon-modified stent graft, in which the fabric of the distal portion of the stent graft was stripped away. The surgeon-modified stent graft was inserted from the conduit of the left axillary artery. Postoperative course was uneventful and the postoperative examination confirmed complete exclusion of the aneurysm and patency of the left vertebral artery.

Right Subclavian Artery Bypass Grafting and Replacement of Two-Thirds of the Aortic Arch for a Rare Case Involving Aneurysm of the Right Subclavian Artery with Dissection / 日本心臓血管外科学会雑誌

A 69-year-old man was referred to our hospital because of a right upper mediastinal mass observed on chest roentgenogram. Computed tomography showed a dissecting aneurysm of the right subclavian artery and dissection of the ascending aorta. Furthermore, the ascending aorta was dilated. We subsequently reconstructed the right subclavian artery with a bypass graft and replaced the ascending aorta. Two-thirds of the aortic arch was placed in deep hypothermic circulatory arrest with retrograde cerebral perfusion. His postoperative course was uneventful with no neurological complications. While subclavian artery aneurysms are relatively rare in comparison to other peripheral artery aneurysms, subclavian artery aneurysms with aortic dissections are even rarer. The most important concerns during subclavian artery aneurysm repair are the method of surgical approach and the maintenance of sufficient cerebral flow. We suggested that deep hypothermic circulatory arrest with retrograde cerebral perfusion might prove useful in cases involving an intramural thrombus adherent to cerebral vessels. Therefore, patients with subclavian artery aneurysms must undergo extensive preoperative evaluation.

Hybrid treatment of a true thyreocervical trunk aneurysm in a patient with Type B aortic dissection.

We would like to describe a case with a complex aortic disease treated in hybrid fashion. We present an interesting case of a 65‑year‑old man with a medical history of hypertension, hyperlipidemia, and coronary artery disease percutaneously treated. An acute Type B aortic dissection occurred and treated with the implantation of a stent‑graft which occluded the left subclavian artery due to its extension to the aortic arch. This event required a carotid‑subclavian artery bypass due to ischemia of the left arm. An aneurysm in the innominate artery also detected, was treated with another stent‑graft implantation 3 months later. At 5‑year follow‑up, an aneurysm of the thyreocervical trunk was found while the stent‑graft of the aorta was well‑tolerated without endoleak and the carotid‑subclavian graft was patent. The aneurysm was asymptomatic but considering the risk of spontaneous rupture of an aneurysm of this size, elective surgery was indicated. Because the aneurysm was very close to the brachiocephalic bifurcation, open surgical repair would require a sternotomy. The right common carotid artery and right subclavian artery were exposed. The thyrocervical trunk, right internal mammary artery and right vertebral artery were occluded by ligations to isolate the aneurysm. An 8‑mm Dacron graft was anastomosed end‑to‑end to the distal part of subclavian artery. We would like through this case, discuss the role of the hybrid cardiovascular surgery to minimize the postoperative complications in complex cardiovascular pathology. We also discuss the international bibliography about the thyreocervical trunk aneurysm and the treatment options.

Hybrid Treatment of the Intrathoracic Right Subclavian Artery Aneurysm / 日本心臓血管外科学会雑誌

Subclavian artery aneurysm (SCAA), a peripheral arterial aneurysm, is a rare entity. The surgical procedure and approach depend on the location of the aneurysm. We present a case of the endovascular therapy combined with cross axillary bypass. The patient was a 75-year-old man with a small abdominal aortic aneurysm. Multi-detector computed tomography (MDCT) revealed an intrathoracic right SCAA 38 mm in diameter. The operation was performed successfully under general anesthesia. After cross bypass of bilateral axillary artery, the orifice of the right subclavian artery was covered with a stent-graft inserted into the right common carotid artery-brachiocephalic artery and the right subclavian artery was occluded with coils distal to the aneurysm. Post operation angiogram showed complete exclusion of the SCAA and patency of the right common carotid and right vertebral artery. We thought this hybrid treatment for the intrathoracic SCAA could be a useful surgical strategy.

Giant Subclavian Artery Aneurysm Associated with Airway Stenosis / 日本心臓血管外科学会雑誌

A 65-year-old man presented to our hospital with a chief complaint of hoarseness. Chest radiography and computed tomography detected a right subclavian artery aneurysm. The aneurysm had a maximum diameter of 85 mm, and was associated with a mural thrombus and displacement of the trachea to the left, which led to airway stenosis. In case ventilatory insufficiency developed during anesthesia induction, an extracorporeal membrane oxygenator was prepared, followed by administration of anesthesia. Careful administration of anesthesia allowed for anesthesia management without the extracorporeal membrane oxygenator. We approached the periphery and the proximal portion of the aneurysm through a right subclavicular incision and partial median sternotomy, respectively. After excision of the aneurysm, we performed EPTFE prosthesis implantation. The patient's postoperative course was uneventful, which led to postoperative improvement of the airway stenosis. The combination of a right subclavicular incision and partial median sternotomy is useful for the surgical treatment of large subclavian artery aneurysms such as the one in this case. Moreover, careful anesthesia management after close consultation with anesthesiologists is important for patients who exhibit preoperative airway stenosis.

Successful Endovascular Treatment of an Intrathoracic Left Subclavian Artery Aneurysm with TEVAR and Coil Embolism / 日本心臓血管外科学会雑誌

A 77-year-old man with an abdominal aortic aneurysm, detected by abdominal ultrasonography, was referred to our hospital. Multi-detector computed tomography (MDCT) revealed an intrathoracic left subclavian artery aneurysm 30 mm in diameter and a small distal arch aortic aneurysm as well as an abdominal aortic aneurysm 40 mm in diameter. Surgery was indicated for the subclavian artery aneurysm considering the risks of rupture and distal embolism. Our choice for treatment was endovascular repair ; thoracic endovascular aortic repair (TEVAR) and coil embolism. The operation was performed successfully. Orifices of the left subclavian artery and the distal arch aneurysm were covered with a stent graft and the left subclavian artery was occluded with coils distal to the aneurysm. The operation time was 1 h and 44 min. He was extubated in the operation theater. A follow-up CT scan performed at 1 week showed the correct position of the TEVAR device, patency of the common trunk of the brachiocephalic and right common carotid arteries, and complete exclusion of the aneurysms. He was discharged on the 12th postoperative day without complication. Subclavian artery aneurysms, in particular in the intrathoracic location, are rare. Conventional surgery for this entity tends to require arch replacement to be unreasonably invasive as a therapy for peripheral artery disease. We believe this endovascular therapy can be a useful, less-invasive alternative to conventional open surgery.

Total Arch Replacement with Frozen Elephant Trunk Technique for Aortic Arch Aneurysm Complicated with Left Subclavian Artery Aneurysm / 日本心臓血管外科学会雑誌

A 61-year-old man who had hypertension and renal dysfunction (serum creatinine : 1.5-2.0 mg/dl) was referred to our hospital for an abnormal shadow on chest roentgenogram. Chest CT scan with contrast revealed a distal aortic arch aneurysm (maximum diameter 52 mm) and left subclavian artery aneurysm (maximum diameter 30 mm). For the surgical treatment of the aneurysms, left hemi-collar incision and left subclavian incision followed by median sternotomy were performed. After the left subclavian artery was secured distal to the aneurysm, a ringed dacron graft was anastomosed with the distal left subclavian artery. Cardiopulmonary bypass was commenced, and selective cerebral perfusion was instituted at 25°C. The aorta was transected at the origin of the left common carotid artery. A 30 mm stent graft (length 13 cm) was inserted and was fixed on the transected aorta using 4-0 Prolene continuous suture. Then a branched dacron graft was sewn onto the transected aorta and the stent graft. The left common carotid artery and the brachiocephalic artery were anastomosed onto side branches of the graft. The left subclavian artery was reconstructed by anastomosing the ringed bypass graft onto one of the side branches. The left subclavian artery was ligated between the aneurysm and the origin of the vertebral artery, thereby interposing the subclavian artery aneurysm. After proximal anastomosis was done and the heart was reperfused, the patient was weaned from cardiopulmonary bypass. The patient was discharged without any major complication. Two years after the operation, the patient is doing well and there is no evidence of aneurysmal dilatation or endoleak. In conclusion, frozen elephant trunk technique provides an alternative to conventional graft replacement, resulting in complete exclusion of these aneurysms in a single stage. However, long-term follow up is warranted in order to ensure the durability of the stent graft.

It's Aneurysmal, it's Stenotic, it's Tuberculosis

Tuberculous vasculitis is a very rare presentation of tuberculosis. So far this is the second reported case in the literature. The diagnosis of this disorder is based on the clinical presentation as well as blood investigation results. With the ever improvement in modern medicine and improvement in endovascular treatment of such diseases, the morbidity and mortality of these patients have been dramatically reduced with better clinical and survival results. We present a case of endovascular stenting of a stenotic subclavian artery with good results.

Subclavian Artery Aneurysm due to Takayasu's Arteritis

Takayasu's arteritis is a non-specific inflammatory process that involves the aorta and its main branches, the etiology of which remains unknown. This arteritis occurs predominantly in young Asian women, although there have been many documented cases in males and non-Asians. Criteria for the diagnosis of Takayasu's arteritis were developed by The Subcommittee on Classification of Vasculitis of the American College of Rheumatology in 1990, of which a modified version is shown in Table 1. The presence of three or more of the six criteria shown demonstrated a diagnostic sensitivity of 90.5% and a specificity of 97.8%. Takayasu's arteritis is known as 'pulseless disease,' and this non-specific inflammatory arteriopathy typically produces segmental arterial narrowing and occlusion with resultant end-organ ischemic consequences, including upper extremity digital necrosis, stroke, visceral ischemia and renal failure. Previously reported sites of aneurysm formation include the thoracic and abdominal aorta, as well as the innominate, the carotid and the superior mesenteric arteries, but rarely the subclavian artery. A 26-year-old man presented with a progressively enlarging and tender pulsatile mass at the base of the left neck, intermittent Claudication of the upper limbs in association with a decreased brachial artery pulse and a bruit over the subclavian artery. Computed tomography and aortography demonstrated a 4 cmX5 cm aneurysm of the left subclavian artery. There was no evidence of occlusive disease. An aneurysmectomy with 8 mm hemashield graft interposis was performed . Pathology revealed a chronic, active inflammatory process. Aneurysm formation is an unusual complication of Takayasu's arteritis. Emergency department physicians must carefully observed patiens with symptomatic upper extremity pain and paresthesia and must consider whether those symptoms might be due to the formation of a subclavian artery aneurysm due to Takayasu's arteritis

Recurrent hemoptysis caused by left subclavian artery aneurysm: A case report.

A 41 year old man with a left subclavian artery aneurysm was presented to the hospital with clinical symptom of recurrent hemoptysis. CT scan and angiography confirmed the diagnosis. Surgical treatment consisted of femoro-femoral cardiopulmonary bypass and left thoracotomy, aneurysm resection and descending aortico-subclavian vein bypass grafting. The incidental two small saccular aneurysms of the lower descending thoracic aorta were excised and directly repaired. The pathologic study revealed typical atherosclerotic changes. The patient had postoperative persistent chyle leakage and required rethoracotomy and supradiaphragmatic ligation of the thoracic duct. The patient was able to resume his usaul activity after two months of surgery.