Delayed treatment of a traumatic left subclavian artery pseudoaneurysm

A 22-year-old man sustained 4 gunshot wounds to the upper torso resulting in left pneumothorax, an expanding right neck hematoma, left humerus fracture, a traumatic arteriovenous fistula from the right subclavian artery to the right brachiocephalic vein, and pseudoaneurysm formation from partial transection of the right subclavian artery. The patient underwent emergent repair of the confluence of the right internal jugular, subclavian and brachiocephalic veins, and laparotomy secondary to compartment syndrome. Seven weeks later, with the pseudoaneurysm enlarged to 6 cm, it was repaired with combined access via the right common femoral artery and right brachial artery. The pseudoaneurysm was covered with a 7 mm x 8 cm fluency-covered stent graft and postdilated with a 7 mm x 4 cm balloon. Postoperatively, the patient had palpable pulses, occlusion of the pseudoaneurysm, and excellent blood flow into the arm.     

Traumatic pseudoaneurysm of the brachiocephalic artery following medianoscopy: initial endovascular repair followed by open surgery--a case report

Endovascular stent graft repair of traumatic vessel injuries is gaining worldwide acceptance as a minimally invasive alternative to open surgical repair. However, effective endovascular repair fails if the aneurysm is not completely excluded. Conversion to open surgery may be unavoidable in such cases. Herein we describe the case of a 45-year-old man who was referred to our hospital with a pseudoaneurysm of the proximal brachiocephalic artery caused by biopsy during diagnostic medianoscopy. The pseudoaneurysm was primarily treated by stent-graft implantation into the proximal brachiocephalic artery. As a result of the unfavorable location of the lesion exclusion of the aneurysm failed and the initial therapy had to be extended to open reconstruction of the brachiocephalic artery. A bypass procedure from the aortic arch to the right common carotid artery was performed with reinsertion of the right subclavian artery to exclude the pseudoaneurysm.     

Faux anévrysme du tronc artériel brachio-céphalique consécutif à la mise en place d'un cathéter sous-clavier

The difficult insertion of a right subclavian catheter in a 63-year-old patient resulted in a pseudoaneurysm of the brachiocephalic artery requiring a resection-suture. The preventive measures of that complication are reminded.     

Spontaneous thrombosis of an iatrogenic pseudoaneurysm of the arterial brachiocephalic trunk following central venous catheterization

Following the unsuccessful puncture of the right subclavian vein during central catheterism, a 80-year-old women developed a pseudoaneurysm on the external face of the brachiocephalic artery. Her symptomatology and haemodynamic status having remained steady, the patient was closely observed. The pseudoaneurysm itself thrombosed spontaneously and the foreseen endovascular procedure doesn't have been achieved. A review of the literature has been done concerning the venous catheterism complications and the pseudoaneurysm treatment.     

Pseudoaneurysm of the aortic arch after aortosubclavian bypass treated with endoluminal stent grafting--a case report

This paper describes a case of aortic arch pseudoaneurysm treated with stent graft 2 years after aortosubclavian bypass repair of a subclavian artery aneurysm. An 84-year-old man presented with back pain. Two years before, he had had a left subclavian artery aneurysm repaired with aortosubclavian bypass. Upon examination by computed tomography (CT) scan and angiography he was found to have a bovine arch configuration, a 7-centimeter pseudoaneurysm arising from the stump f the native subclavian artery, a patent aortosubclavian bypass, and a left hemothorax. A 37 mm by 10 mm Gore Excluder thoracic graft was introduced into the right femoral artery cutdown and deployed across the arch, excluding the pseudoaneurysm and preserving the brachiocephalic vessels. Follow up CT scan at 1 year shows exclusion of the pseudoaneurysm. The patient continues to do well 1 year after implantation without evidence of endoleak. In the presence of unusual anatomical characteristics, endoluminal stent graft repair can be successfully performed across the aortic arch.     

Surgical treatment of traumatic pseudoaneurysm of the brachiocephalic artery; report of a case

Traumatic injury to the great vessels may be one of the highly lethal states. In many of these cases, the lesion was confirmed at the aortic isthmus. We report a case of successful surgical treatment of the traumatic pseudoaneurysm of the brachiocephalic artery. Pre-operative 3-dimension computed tomography (CT) showed an aneurysm at the left dorsal of the artery. At surgery, the proximal portion of the brachiocephalic artery, the right common cartid artery and the right subclavian artery were clamped with the simple extracorporeal shunting between the aortic arch and the distal of the right common cartid artery for maintaining the blood flow to the brain. A longitudinal dissection was found at the left dorsal position when the aneurysm was opened. The aneurysm was removed and interposed using an artificial vessel. After surgery, no neurologic complication or aftereffects were revealed, and the cerebral infarction due to the procedure was not detected by the brain CT.     

Distal septic emboli and fatal brachiocephalic artery mycotic pseudoaneurysm as a complication of stenting

The use of percutaneous angioplasty with subsequent intravascular metallic stent placement has gained increasing acceptance over the past decade. Infections of these stents appear to be uncommon; however, the rarity of this complication may in part be the result of a lack of availability of long-term follow-up data. A number of examples of infected cardiac and peripheral vascular stents have been reported, often with fatal consequences. Herein, we report a 74-year-old woman who underwent subclavian and brachiocephalic artery angioplasty and stent placement for symptomatic stenoses. Six months after the initial intervention, the patient returned with restenosis of the stents and underwent repeat angioplasty to restore full patency. Two weeks later, the patient was readmitted with generalized malaise and multiple erythematous, macular lesions on the right forearm and hand. Blood cultures grew Staphylococcus aureus, and a computed tomographic scan of the chest showed a large brachiocephalic artery pseudoaneurysm with surrounding hematoma. Despite prompt surgical intervention, this complication proved ultimately fatal. Infections of metallic endovascular stents are potentially life-threatening complications and must be addressed urgently, including possible surgical intervention.     

A case of traumatic aneurysm of the brachiocephalic artery

Traumatic aneurysm of the brachiocephalic artery is rate. We presented a case of traumatic aneurysm of the brachiocephalic artery caused by traffic accident. A 28-year-old woman suffered a blunt chest trauma. A chest X-ray revealed a widening of the superior mediastinum and multiple rib fractures. CT scanning demonstrated left hemothorax with lung contusion and upper mediastinal hematoma. An aortography was performed which showed aneurysmal dilatation at the origin of the brachiocephalic artery. The patient underwent an operation 24 hours after chest injury. An aorto-right common carotid artery and right subclavian artery bypass with bifurcated Dacron graft was performed while monitoring temporary artery pressure. After resection of aneurysm, We found that about 3 cm longitudinal laceration of intima on the posterior wall of brachiocephalic artery. Her post operative condition was good and no neurological defect was noted.     

A simple and safe operation method for brachiocephalic artery aneurysms

A 64-year-old man was referred to our hospital due to dyspnea and fever. The chest computed tomogram revealed a 60-mm aneurysm of the brachiocephalic artery with mural thrombus. The aneurysm of the brachiocephalic artery and the right subclavian artery were exposed through only median sternotomy. Cardiopulmonary bypass with synchronized pulsatile perfusion was established with the ascending aorta and bi-caval cannulation. A mean arterial pressure was kept at between 60 and 70 mmHg with the unloaded beating heart. Mild hypothermia was induced (blood temperature 27 degrees C, nasopharyngeal temperature 32 degrees C). The brachiocephalic artery, right carotid artery, and right subclavian artery were clamped when nasopharyngeal temperature was 32 degrees C after decreasing blood temperature to 27 degrees C. After opening the aneurysm, the mural thrombus and calcified aneurysmal wall were removed. First, an ascending aorta to the right common carotid artery bypass was performed using a 16-8 mm Y- prosthetic graft with side-clamp forceps. After the anastomosis, the right side cerebral perfusion was restarted and the patient was rewarmed. Then the right subclavian artery was anastomosed in an end-to-end fashion. The duration of the right side cerebral circulatory arrest was 30 minutes. The patient left hospital seven days after the operation.     

Use of axillary artery to maintain cerebral perfusion in a patient requiring reconstruction of the brachiocephalic trunk and coronary arteries: technical note

Our patient had 80% stenosis of the brachiocephalic artery and total occlusion of the left carotid and left subclavian arteries. Ascending aorta to brachiocephalic artery bypass grafting was performed, with a 10 mm Dacron graft. The right axillary artery was cannulated, and during construction of the distal anastomosis cerebral blood flow was from the right axillary artery. We believe this technique may be beneficial in surgery on an artery in which cerebral blood flow depends exclusively.     

A hybrid approach to appendicitis with right external iliac artery pseudo aneurysm: A case report

IntroductionWhile acute appendicitis is a common surgical problem, the simultaneous occurrence of appendicitis and an infected iliac artery pseudoaneurysm is exceedingly rare. We report the successful treatment of an infected right external iliac artery pseudo aneurysm in the 1setting of acute appendicitis.Presentation of caseThe patient is an 83-year-old male who presents with severe sepsis, right lower quadrant and right leg pain. Additional past medical history is significant for rectal cancer status post resection and radiation therapy in 1997. Computed tomography (CT) on admission revealed a right iliopsoas muscle abscess, an inflamed Appendix and a pseudo aneurysm arising from the right external iliac artery. After consultations by multiple specialties, the plan was to proceed with percutaneous drainage of the abscess, antibiotic therapy and subsequent repair of the pseudoaneurysm. CT guided drainage of the iliopsoas abscess was performed with return of hemorrhagic fluid. Due to the concern of contained pseudoaneurysm rupture, the patient was taken for expedited repair. Due to the patient’s frailty and hostile abdomen, we performed embolization of the right external iliac artery pseudoaneurysm with Amplatzer I plugs (St. Jude Medical, St. Paul MN) and left common femoral to right superficial femoral bypass with cryopreserved cadaveric femoral vein. Following pseudoaneurysm exclusion, continued percutaneous drainage and antibiotic therapy, the patient has done well with no further evidence of infection.ConclusionRepair of infected pseudo aneurysms can prove challenging. Ongoing infection, a hostile surgical abdomen and patient frailty further complicates the treatment of these patients. This case displays a minimally invasive approach to this rare but morbid condition.     

经升主动脉和头臂干右侧间隙切除T3和T4椎体肿瘤

目的 探讨经升主动脉右侧间隙与头臂干右侧间隙行椎体切除治疗上胸椎T3、T4肿瘤的术式及疗效。方法 2000年6月至2006年1月共治疗上胸椎肿瘤患者12例，男7例，女5例；年龄29-60岁，平均42岁。原发性肿瘤8例，转移瘤4例。T3肿瘤4例，T4肿瘤6例，T3，4肿瘤2例。采用改良的经胸骨柄入路，经升主动脉右侧间隙和头臂干右侧间隙显露椎体肿瘤病灶。采用刮除方式切除肿瘤3例（巨细胞瘤1例，嗜酸性肉芽肿1例，动脉瘤样骨囊肿1例），余采用整块切除方式切除。椎体间采用自体髂骨或骨水泥进行重建，颈椎前路带锁钛钢板内固定。脊髓损伤程度按Frankel分级标准评定。结果术中发生血压下降和（或）气道阻力增加6例。术后随访4-66个月，平均28．6个月。12例患者术后神经功能均有改善。3例植骨患者植骨均融合。1例L骨肉瘤患者和3例转移瘤患者术后10-18个月因全身多处转移，衰竭死亡。1例巨细胞瘤患者采用刮除方式切除后10个月局部复发。结论经升主动脉右侧间隙和头臂干右侧间隙行L、T4椎体切除重建内固定术可获得良好的暴露，近期疗效满意，适用于脊髓前方存在压迫的上胸椎L、T4椎体肿瘤。     

Melioidosis presenting as an infected intrathoracic subclavian artery pseudoaneurysm treated with femoral vein interposition graft

We present the first case of in situ replacement of an infected subclavian artery using superficial femoral vein and the fourth reported case of an infected arterial pseudoaneurysm caused by pseudomonas pseudomallei. Sepsis and hoarseness developed in a 58-year-old man after recent travel to Borneo, Indonesia. Indirect laryngoscopy revealed a paralyzed right vocal cord. Computed tomography and arteriography revealed a 6.5-cm pseudoaneurysm of the proximal right subclavian artery. Blood cultures grew pseudomonas pseudomallei. An abnormal cardiac stress test prompted a coronary angiography, which revealed severe coronary artery disease.The patient underwent coronary artery bypass and in situ replacement of the infected subclavian artery pseudoaneurysm with a superficial femoral vein, along with placement of a pectoralis major muscle flap to cover the vein graft. Operative cultures of the pseudoaneurysm grew pseudomonas pseudomallei. The patient was treated with a 6-week course of intravenous ceftazidime and oral doxycycline and then continued on oral amoxicillin-clavulanate. One week after discontinuing intravenous antibiotics, the patient presented to the emergency department with a rapidly expanding, pulsatile mass in the right supraclavicular space. He was taken emergently to the operating room. After hypothermic circulatory arrest was accomplished, the disrupted vein graft and aneurysm cavity were resected and the subclavian artery was oversewn proximally and distally. Parenteral ceftazidime was continued for 3 months and oral amoxicillin-clavulanate (augmentin) was continued indefinitely. There was no evidence of infection clinically or by computed tomographic scan 2 years later. Although autogenous vein replacement of infected arteries and grafts may be successful in the majority of cases, this strategy should probably be avoided when particularly virulent bacteria such as the organism in this case are present.     

Giant iatrogenic pseudoaneurysm of the brachial artery: A case report

IntroductionPseudoaneurysms are a pulsatile hematoma caused by hemorrhage on soft tissues. It is an uncommon condition with many different etiologies. We report a case of a giant pseudoaneurysm caused by iatrogenic injury on the brachial artery.Presentation of caseA 42 year-old male was submitted to our Vascular Surgery service with an enlargement of the right upper limb and a history of myocardial infarction. 60 days before the patient reached our service, he was submitted to a cardiac catheterization performed by another medical team, since the catheter was placed on the right brachial artery near the cubital fossa, we suspected an iatrogenic pseudoaneurysm, which was confirmed by his clinical history and physical exam. It was opted to treat the pseudoaneurysm with an implant of polytetrafluoroethylene prosthesis. There were no complications whatsoever and the patient was discharged.DiscussionPseudoaneurysms are more common after interventional procedures than diagnostic procedures, although brachial artery pseudoaneurysms are rare. Complications of pseudoaneurysms can cause serious threat to the afflicted limb and the patient’s life. The management of any pseudoaneurysm is dependent on its size, location and pathogenesis.ConclusionPseudoaneurysms develop slowly and should be diagnosed as early as possible in order to avoid complications and a better outcome. Due to an increase in recent endovascular procedures and the fact that brachial artery puncture is being performed more routinely, incidence of brachial artery pseudoaneurysms among overall population may rise.     

Malignant fibrous histiocytoma masquerading as a pseudoaneurysm of the profunda femoris.

We describe a patient with an aggressive soft tissue sarcoma masquerading as a profunda femoris pseudoaneurysm. A 73-year-old patient presented with a pulsatile swelling in her right groin. Femoral angiography demonstrated what appeared to be a pseudoaneurysm of the right profunda femoris artery and she underwent an open surgical repair. The patient represented 2 months later with an enlarging non-pulsatile, non-tender mass at the site of the wound. Open biopsy determined the diagnosis as malignant fibrous histiocytoma (MFH). An en bloc resection of the mass with reconstruction of the femoral artery and vein using PTFE grafts was performed.     

Brain protection with mild hypothermia during carotid artery clamping

A 71-year-old man was scheduled for removal of a Kirchner wire malpositioned in the mediastinum, which had been placed for fixing the fractured right clavicle five months before. Anesthesia was induced and maintained with propofol, fentanyl and vecuronium. The wire was found to be penetrating the brachiocephalic artery after sternotomy. An emergency angiography performed in the operating room showed that Willis arterial circle was sufficiently developed for clamping the brachiocephalic artery. The wire was removed under clamping the brachiocephalic artery for 9 minutes, but massive bleeding from the left common carotid artery continued, then the left common carotid artery was clamped and injured region was resected and reconstructed for 68 minutes. The body temperature was reduced to 32.5-33 degree with a cooling water mattress for brain protection and prostaglandin E1 was infused for vasodilation during hypothermia. Monitoring with somatosensory evoked potential was added during anesthesia. The surgery was performed uneventfully and the patient showed no neurological sequelae postoperatively.     

Giant pseudoaneurysm of posterior division of renal artery: A rare complication of pyelolithotomy

Giant renal artery pseudoaneurysm after pyelolithotomy is an uncommon but important disorder. A case of giant pseudoaneurysm arising from the posterior division of right renal artery following pyelolithotomy is presented. The patient presented with a flank mass six months after pyelolithotomy. CT-scan as well as selective renal angiography revealed a giant pseudoaneurysm arising from the posterior division of renal artery. Nephrectomy was necessitated as selective embolization was not possible due to its extraordinarily large size. This revised version was published online in September 2006 with corrections to the Cover Date.     

Direct repair of an extracranial vertebral artery pseudoaneurysm: case report and review of the literature

A case of a 47-year-old man with weakness secondary to ossification of the posterior longitudinal ligament is presented. During removal of the ossified ligament, the patient's dominant right vertebral artery was injured. Although the bleeding from this artery was controlled intraoperatively, the patient developed an expanding cervical hematoma on the 3rd postoperative day. An angiogram demonstrated a large pseudoaneurysm of the right vertebral artery. The patient was taken back to the operating room where the cervical hematoma was removed, and direct repair of the pseudoaneurysm of the vertebral artery was performed. The previously reported cases of pseudoaneurysms of the extracranial vertebral artery are reviewed. We advocate the use of direct vascular repair as the treatment of choice in these lesions.     

Stanford type A aortic dissection with occlusion of the brachiocephalic artery; report of a case

A 73-year-old female was referred to our hospital because of pain in the right upper extremity, left hemiparesis and syncope. Computed tomography (CT) of the head showed no active lesion, but chest CT showed Stanford type A aortic dissection with occlusion of the brachiocephalic artery. Carotid ultrasonography showed occlusion of the right common carotid artery. Emergent graft replacement of the ascending aorta and aortic arch was performed. The right common carotid artery was opened but no thrombus was found. In order to restore and maintain the cerebral circulation, the right carotid artery was cannulated. Postoperative head CT showed a small cerebral infarction of the right parietal lobe. Syncope did not recur and her hemiparesis was treated by rehabilitation. Cannulation of the carotid artery is useful for cases with occlusion of the brachiocephalic artery.     

Reconstruction of nonconfluent pulmonary artery using the retroaortic innominate vein for a single ventricle

The innominate vein usually courses anterior to the aortic arch, where it joins the right brachiocephalic vein to form the superior caval vein. A retroaortic innominate vein is an uncommon finding in patients with congenital heart disease. We report a patient with a single ventricle, single atrium, pulmonary atresia, nonconfluent pulmonary artery, persistent left superior caval vein, absent inferior caval vein (azygos connection), right aortic arch, and retroaortic innominate vein. His innominate vein took an anomalous course. The right brachiocephalic vein crossed from right to left underneath the aortic arch and formed a left superior caval vein with the left brachiocephalic vein and the azygos vein. We reconstructed the nonconfluent pulmonary artery using the retroaortic innominate vein and then performed a total cavopulmonary shunt when he was 32 months of age. Thereafter, a total cavopulmonary connection was carried out at age 42 months.