Aneurysm of the superior mediastinal veins

A case of true venous aneurysm with saccular dilation of the proximal half of the superior vena cava, the right innominate vein, and the distal two thirds of the left innominate vein in an 18-year-old white woman is presented. At surgery part of the aneurysmal wall was resected, and subsequently the mediastinal venous system was reconstructed with use of the rest of the aneurysmal wall. The postoperative course was uneventful. Operative treatment of mediastinal venous aneurysms is indicated to prevent possible major complications. We strongly suggest performance of this surgery only by means of a heart-lung machine. (J VASC SURG 1995;21:505-9.)     

An unusual combination of cardiovascular surgical disorders

A 53-year-year-old man presented with aortic regurgitation, subvalvular and supravalvular aortic stenoses, and aneurysms involving the ascending aorta, the arch, and the innominate, right subclavian, and left common carotid arteries. Surgery consisted of resection of the obstructive lesions, replacement of the aortic valve, graft replacement of the ascending aorta, and the arch resection of innominate and subclavian artery aneurysms and reconstruction with a side limb to which the right carotid artery was anastomosed. The patient has remained asymptomatic with full employment.     

Endovascular treatment of an innominate artery iatrogenic pseudoaneurysm following subclavian vein catheterization

Central venous catheterization is routinely required in a wide range of clinical situations such as hemodynamic monitoring, delivery of blood products and drugs, hemodialysis, total parental nutrition, and management of perioperative fluids. Pseudoaneurysms account for 4% of all innominate artery aneurysms. Clinical presentation may include airway and neurological compression, chest pain, mediastinal syndrome, upper limb ischemia, and hemodynamic instability. We report what we believe is the first documented case of a successful endovascular stent-graft repair of an innominate artery iatrogenic pseudoaneurysm.     

Endovascular management of a ruptured mycotic aneurysm of the innominate artery

Mycotic aneurysms of the innominate artery are infrequent lesions and, as such, represent challenging surgical problems. We describe herein a case of a ruptured mycotic innominate artery aneurysm, which developed after radical neck dissection and radiation therapy for tonsillar carcinoma. The aneurysm was successfully excluded from the systemic circulation with endoluminal placement of a covered stent, with efficacy confirmed by vascular imaging at 6 months follow-up. The patient suffered no permanent neurologic sequelae. Long-term follow-up and chronic antibiotic therapy will be necessary to avoid infection of the covered stent in this high-risk surgical patient.     

Delayed post-traumatic aneurysms of aorta, carotid and innominate arteries

We report here, to our knowledge, the first successful case of combined treatment (surgical and by interventional neuroradiology) in a patient with delayed post-traumatic aneurysms of the aorta, carotid and innominate arteries.     

Vein compression by arterial aneurysms

This study was done to emphasize the importance of early, accurate diagnosis of arterial aneurysms that show the symptoms of venous obstruction. Fourteen patients were identified as having atherosclerotic aneurysms producing venous compression. Nine patients had popliteal aneurysms, causing popliteal vein thrombosis in three patients and vein compression without thrombosis in six patients. Five patients had iliac artery aneurysms, producing left iliac vein thrombosis in one patient and venous compression without thrombosis in four patients. In 10 patients the cause of the venous compression symptoms was correctly identified and appropriate revascularization was performed with successful results. In four patients, two with iliac artery aneurysms and two with popliteal artery aneurysms, the associated aneurysm was not identified. One patient died of a ruptured aneurysm and three patients had below-knee amputations because of untreatable distal ischemia. Inappropriate treatment of patients with venous obstruction from unrecognized arterial aneurysms is associated with unacceptable morbidity and mortality. Accurate diagnosis with timely aneurysm repair eliminates the risk of aneurysm rupture or thrombosis and simultaneously alleviates venous compression symptoms.     

Total anomalous pulmonary venous connection with bronchogenic cyst in neonatal period.

Here, we report a case of a two-day-old neonate with total anomalous pulmonary venous connection to the innominate vein and a bronchogenic cyst arising from the trachea. Antenatal echocardiography had delineated both cardiac and extracardiac lesions, and a repeated examination on the day of birth disclosed progressive enlargement in the cyst in a manner so as to obstruct the innominate vein. On the second day of life, the patient underwent complete correction of the cardiac lesion and total excision of the cyst. The patient recovered uneventfully and was discharged on the thirteenth postoperative day.     

Innominate artery aneurysm: axial reconstruction via a cervical approach

True aneurysms of the innominate artery are rare. Successful axial reconstruction in the past has required a combined cervical and transthoracic approach with placement of a prosthetic graft. We describe herein the occurrence of an innominate artery aneurysm that extended to and involved the proximal common carotid artery and subclavian artery in a 63-year-old woman. The patient presented with thomboembolic sequelae in her fingertips and had a pulseless upper extremity. Successful aneurysmectomy and axial reconstruction with a bifurcated graft was achieved by using cervical exposure alone. A subsequent staged revascularization of the upper extremity was successfully accomplished with a brachial to radial artery bypass and ulnar artery transposition.     

Thrombotic complications of venous aneurysms

Background: Venous aneurysms are rare vascular anomalies that have been reported to occur throughout the body. We report a unique variation, namely a thrombosed subclavian vein aneurysm. Methods: A review of the records of patients with documented venous aneurysms presenting to the St George Hospital and their associated imaging was made. A literature search for articles pertaining to venous aneurysms was performed. Results: Four cases of venous aneurysms were identified; one subclavian vein, one inferior vena cava and two popliteal. The clinical course of these cases is detailed, along with a review of the literature. Conclusions: Venous aneurysms are infrequent findings and indicate that the patient is at significant risk of thrombosis. Popliteal vein aneurysms should be treated surgically.     

Novel repair of venous aneurysms secondary to arteriovenous dialysis fistulae

This report describes the surgical management of 12 hemodialysis patients with arteriovenous fistulae in whom non-infected, fusiform venous aneurysms developed that compromised access for dialysis. The venous aneurysmal changes were too extensive to permit excision and primary veno-venous anastomosis. To avoid the use of synthetic interpositional grafts, the venous aneurysms were left in situ and reduced in size to match the diameters of the veins entering and exiting the aneurysms. After decompression, the lumens of the venous aneurysms were reduced by firing staple lines along the longitudinal axes of the venous aneurysms and excision of the aneurysmal tissue anterior to the staple lines. Twenty-eight aneurysms were repaired by this method of reduction aneurysmoplasty, in 15 operations on 12 patients over the past 10 years. There were no wound infections or dehiscences and no bleeding or hematomas. After the operations, the arteriovenous fistulae were used continuously for hemodialysis until the patients died (7 patients for 36 months -/+ 28 SD), were lost to follow-up (1 patient at 30 days postoperatively), until the arteriovenous fistulae thrombosed following revision of the arteriovenous anastomosis (1 patient at 41 months postoperatively), or until the arteriovenous fistulae was ligated to relieve pain in the upper arm (1 patient at 6 months postoperatively). Two patients continue to use their arteriovenous fistulae until and including the time of this report at 10 and 11 months, respectively. Reduction aneurysmoplasty as described in this report offers an effective and low-risk option for the management of venous aneurysms secondary to arteriovenous fistulae in hemodialysis patients.     

Das venöse Popliteaaneurysma

Popliteal venous aneurysms are very rare. Due to the risk of a venous thrombosis or pulmonary embolism, aneurysms of the popliteal vein are treated primarily surgically. Indications for surgery are a previous venous aneurysm, in case of large aneurysms, flow irregularities on duplex sonography and sac-like aneurysms. Popliteal venous aneurysms are most often resected tangentially and the popliteal vein closed with a continuous suture, however, more complex reconstructions may also be necessary. Monitoring of the patient is only possible in cases of small, fusiform and asymptomatic aneurysms. Continuous anticoagulation may be required in individual cases when a reconstruction is not possible due to previous thrombosis and repeated pulmonary embolisms.     

Complete repair of concomitant interrupted aortic arch and partial anomalous pulmonary venous connection

We report a rare case of concomitant presentation of partial anomalous pulmonary venous connection and type A interrupted aortic arch in a 4-week-old, 2.1 kg newborn. She presented in extremis and was found to have a closed ductus arteriosus with the entire left pulmonary venous return obstructed at its connection with the innominate vein. Emergent operative repair was performed in one-stage, consisting of aortic arch reconstruction and anomalous vein translocation. Postoperative recovery was unremarkable and the patient was discharged from hospital 12 days after operation.     

Repair of lesions of the descending thoracic aorta with the TDMAC-heparin shunt

Utilizing a heparinized tridodecylmethylammonium chloride (TDMAC) shunt makes it possible to treat various surgical diseases of the descending thoracic aorta without cardiopulmonary bypass. Since the initial report by Gott and associates on the use of the heparinized shunt, few subsequent clinical trials have appeared in the literature. Six patients with Type III dissecting thoracic aneurysm, acquired and congenital coarctation of the aorta, saccular arteriosclerotic aneurysm, and transection of the descending thoracic aorta were operated upon by means of this technique. Only one patient had more than 500 ml. of chest tube drainage in the first 8 hours postoperatively. There were no instances of paraplegia, renal failure, or death. This technique is also recommended for repair of innominate artery aneurysms, endarterectomy of the innominate or subclavian artery, arch aneurysm, penetrating injuries of the thoracic aorta, and proximal abdominal aneurysms. Surgical indications, operative management, and postoperative follow-up are discussed.     

Benign intracranial hypertension: a complication of subclavian vein catheterization and arteriovenous fistula

Thrombosis of the right innominate vein occurred in a patient on maintenance hemodialysis following repeated subclavian vein catheterization. The patient had a functional right brachial arteriovenous fistula for blood access that resulted in a massive retrograde blood flow into the cerebral venous system with the development of the benign intracranial hypertension. The symptoms and signs of intracranial hypertension abated following ligation of the arteriovenous fistula. This unusual association of benign intracranial hypertension with an arteriovenous fistula and innominate vein thrombosis has not been reported previously. Pertinent literature dealing with benign intracranial hypertension and complications of subclavian vein catheterization is reviewed.     

Surgical repair of superior vena cava syndrome

We present the case of a 53-year-old woman with a history of breast cancer, chemotherapy, and a long-term central venous access catheter, who presented with acute, severe superior vena cava syndrome. Angiography showed fibrous obstruction of the superior vena cava with thrombosis of the innominate, both axillary subclavian and internal jugular veins. Surgical repair consisted of thrombectomy of all the involved vessels and patch repair of superior vena cava and innominate vein. The patient had an uneventful recovery and remains asymptomatic 12 months after the procedure.     

Superior sagittal sinus thrombosis complicated with multiple aneurysms presenting as subarachnoid hemorrhage. Case report]

A 48-year-old female suffered from severe headache, vomiting, and disturbance of consciousness. On admission, she was somnolent with mild paresis of the left leg. Precontrast computed tomography (CT) scans showed a high-density area in the left sylvian fissure and the posterior horn of the left lateral ventricle. Angiographically, a right middle cerebral artery aneurysm and a basilar artery aneurysm were recognized. Furthermore, on the venous phase of bilateral carotid angiograms, superior sagittal sinus (SSS) thrombosis was recognized. Subarachnoid hemorrhage (SAH) was probably induced by rupture of a dilated vein associated with SSS thrombosis, because high-density area on CT scan and location of the aneurysms were different. The patient was initially treated conservatively. Two months later, craniotomy was performed which did not disclose any trace of hemorrhage around the aneurysms and aneurysms themselves. Postoperatively, acute brain swelling and generalized convulsion were induced. The patient became ambulatory 5 months after surgery. In SAH cases, the venous phase should be examined at least in one side of the carotid arteries. In such a SAH case induced by venous thrombosis complicated by aneurysms it is very difficult to decide the timing of surgery for aneurysms.     

Extrapleural pneumonectomy with venous confluence resection for stage IVA thymic tumors

We report 4 patients with stage IVA thymic tumors who underwent extrapleural pneumonectomy and thymectomy with venous confluence resection using a temporary percutaneous venous jugular-femoral bypass technique. The superior vena cava was replaced in 2 patients, and the innominate vein was resected in 2 patients. Complete tumor resection was obtained in all patients. There was no 90-day postoperative mortality. One patient died at 6 months postoperatively of an unrelated cause, without recurrent disease, and 3 are alive and disease-free with a follow-up ranging from 19 to 80 months. Extrapleural pneumonectomy can be combined with thymectomy and venous confluence resection for stage IVA thymic tumors.     

Incidental discovery of a partial anomalous pulmonary venous connection in the surgical critical care unit

Routine chest roentgenogram to confirm catheter placement in a postsurgical patient showed a left-sided internal jugular central venous catheter that did not appear to cross the midline. Arterial blood gas samples showed greater oxygenation from the central catheter as compared with the peripheral arterial sample. However, a transduced waveform showed a venous tracing and pressure. Computed tomographic scan of the thorax without intravenous contrast showed a partial anomalous pulmonary venous connection with drainage of the left upper lobe pulmonary vein into the innominate vein.     

Axillary to saphenous vein bypass for treatment of central venous obstruction in patients receiving dialysis

OBJECTIVE: Venous hypertension due to subclavian or innominate vein stenosis coexisting with a functioning arteriovenous access in the ipsilateral arm is a complex problem in patients undergoing hemodialysis. Therapeutic solutions must optimally relieve symptoms, permit use of the angioaccess, and carry minimal surgical risk. The purpose of this study was to evaluate a simple surgical option, bypassing central venous obstruction to the great saphenous vein. METHODS: Eight patients undergoing hemodialysis with severe symptoms and signs of venous hypertension due to subclavian or innominate vein obstruction and ipsilateral arteriovenous fistula or graft underwent axillosaphenous bypass via a subcutaneous 8-mm polytetrafluoroethylene bridge graft. RESULTS: No intraoperative or immediate postoperative morbidity was observed. Early and 6-month patency rates were 100% and 87.5%, respectively. All patients reported improvement of symptoms, and the angioaccess was usable in all cases. Average follow-up was 21.5 months. One patient had a relapse at 5 months, which necessitated revision of the graft-saphenous vein anastomosis. CONCLUSION: Bypassing a central vein occlusion to the saphenous vein relieves symptoms of venous hypertension and prolongs use of the hemodialysis angioaccess.     

Management of arteriosclerotic aneurysms of the innominate and subclavian arteries

Two patients with innominate artery aneurysm and four with subclavian artery aneurysm are presented. Resection of the aneurysm and reconstruction of the vascular continuity were performed in all cases. No patient died in association with surgery. The complications included paralysis of the recurrent laryngeal nerve in one patient and postoperative infection of the vascular prosthesis, necessitating removal of the graft, in another. Because of the absence of surgical mortality and the acceptable complication rate, surgical resection of these aneurysms is recommended.