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Serdar Akgün, Ali Civelek, Feyyaz Baltacioglu, Gazanfer Ekici, Successful endovascular repair of a subclavian artery pseudoaneurysm, Nephrology Dialysis Transplantation, Volume 14, Issue 9, September 1999, Pages 2219–2221, https://doi.org/10.1093/ndt/14.9.2219
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Introduction
Serious complications of central venous access occur in 0.4–9.9% of patients undergoing attempted central venepuncture [1]. Potential complications include failure to locate or cannulate the vein, puncture of the subclavian artery, misplacement of the catheter, pneumothorax, mediastinal haematoma, haemothorax and injury to adjacent nerves [2]. Pseudoaneurysm formation of the great vessels and the right subclavian artery is rare in patients undergoing central venepuncture [3]. The evolution of pseudoaneurysm is continued expansion and eventually rupture; therefore, pseudoaneurysms should be repaired to prevent inevitable rupture. Endovascular stent grafts offer an alternative approach to standard treatments for a variety of vascular pathologies including aneurysm.
We observed a case of a large subclavian artery pseudoaneurysm that caused pressure necrosis of the skin. The pseudoaneurysm occurred after subclavian vein catheterization for haemodialysis access and was successfully repaired using the endovascular approach.
Case
A 21-year-old male with a history of dialysis for 2 months via a right subclavian vein catheter was referred to our hospital because of a bleeding bullous lesion eroding the skin underneath the right clavicle (Figure 1). The patient was unable to walk because of sequela of polio at the age of 1 year. The catheter was removed 2 weeks after implantation because of thrombosis of the subclavian vein diagnosed by Doppler ultrasonography. The skin lesion appeared 1 week before admission, it enlarged rapidly causing erosion of the skin and blood leakage. The auscultation of the lesion revealed a pansystolic murmur around the lesion radiating to the sternum. After initial thoracic aortography via the right common femoral artery, selective angiography of the right subclavian artery was performed which showed an aneurysm, approximately 4 × 5 cm in size, originating from the upper contour of the right subclavian artery and extending anteriorly and superiorly (Figure 2). The clavicle provoked a depression of the aneurysm resulting in a bilobulated shape. The aneurysm had a neck of ∼1.5–2 cm. Total occlusion of the right subclavian vein was observed by venography. As the aneurysm was false, repair was obviously necessary and the surgical approach risky, since the aneurysm had eroded the skin and there was a high risk of aneurysm rupture during dissection, therefore an endovascular repair was chosen. At first a 0.035 in. hydrophylic exchange guidewire (Terumo Europe N.V., Belgium) was passed through the lesion. A 28 mm balloon expandable PTFE-covered Jostent Peripheral Stent Graft (Jomed Implantate GmbH, Rangendingen, Germany) was then loaded onto a 6 × 30 mm balloon and introduced over the guidewire to the right subclavian artery against the neck of the aneurysm. We inflated the balloon and deployed the stent graft. Arteriography revealed complete exclusion of the lesion and normal flow through the subclavian artery and its branches (Figure 3).
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