Volume. 35, No. 2 july. 2011 - The Chest and Heart Association of ...

Subclavian Artery Pseudoaneurysm in a Nonagenarian ManMd. Saif Ullah Khan et al.middle third of the right clavicle. The patient wastreated conservatively with a figure-of-eightbandage.A few days after the fall, the patientnoticed a mass in the right supraclavicular fossawhich was progressively growing. Two monthsafter the fracture, a pulsatile tumour-like masswas palpated. The distal pulses and the neurologicalexamination were normal. Color Duplex scanshowed a pseudoaneurysm of the right subclavianartery. The patient was operated upon undergeneral anaesthesia. A right supraclavicularincision was used. After dissecting thepseudoaneurysmal sac subclavian artery wasclamped partially by a curved vascular clamp torepair the artery.Fig.-2: Color Duplex Scan image showingextravascular arterial sac having color flowDiscussion:The anatomical space between the clavicle and thefirst rib, where the neurovascular structures exitfrom the thorax towards the upper extremity, canbe narrowed by exuberant callus formation,pronounced fracture displacement orpseudarthrosis of the clavicle. A subclavian arterypseudoaneurysm can clinically present as apalpable, pulsatile and sometimes visible mass inthe supraclavicular fossa. This mass can compressthe subclavian vein, making the venous returndifficult. Distal pulses can be normal, as in othervascular lesions 3 . The brachial plexus, in closerelationship with the subclavian vessels, can alsobe affected; in fact, the neurological symptoms canbe noticed first 6,7,8 . In other cases there may bedistal ischaemic arterial symptoms in theextremity due to embolic episodes coming fromthe pseudoaneurysm 8,9 . Among the possiblecomplications the worst is rupture of thepseudoaneurysm, as it threatens the life of thepatient. In the series this happened in 10% of allcases 10 . Arterial ischemia and even cerebralischemia (due, probably, to retrogradeembolisation) are other possibilities. Subclavianartery pseudoaneurysm can jeopardise both theextremity and the life of the patient. Treatment isusually surgical. The pseudoaneurysm is eitherremoved, bridging the arterial defect along itslength with an end-to-end anastomosis or with agraft, or opened longitudinally and closed with anangioplasty or a simple suture 8,10 . The latter optionwas the one used in this case. Recently, opensurgical procedures have been partly replaced bypercutaneous transluminal placement ofendovascular devices. Uncovered endovascularflexible self-expanding stent placement withtransstent coil embolization of the pseudoaneurysmcavity is a promising new technique to treatposttraumatic pseudoaneurysm vascular diseaseby minimally invasive methods, while preservingthe patency of the vessel and side branches 11.References:1. B. Hansky, E. Murray, K. Minami, R. Kiirfer.Delayed brachial plexus paralysis due tosubclavian pseuoaneurysm after clavicularfracture. (Eur J Cardio-thorac Surg 1993;7:497-4981.2. Berga C, Prat S, Ninot S, et al. Complicacionesarteriales de los traumatismos cerrados de lacintura escapular. Angiologia 1992 ; 44 : 139-143.3. Chervu A, Quinones-Baldrich WJ. Vascularcomplications in orthopedic surgery. ClinOrthop 1988 ; 235 : 275-288.4. Craig EV. Fractures of the clavicle. RockwoodCA,Matsen FA III editors. The Shoulder. WBSaunders,Philadelphia, 1998, 428-482.133