THORACIC OUTLET SYNDROME COMPLICATED BY DOUBLE SUBCLAVIAN ARTERY ANEURYSMS — AN HYBRID APPROACH
Keywords:Thoracic Outlet Syndrome, Subclavian Artery Aneurysm, Hybrid Approach
Introduction: Subclavian artery aneurysm (SAA) can be an extremely rare complication of thoracic outlet syndrome (TOS). The arterial dilation usually occurs distal to the stenosis site causing TOS. We describe a rare case of a patient with neurological TOS with two voluminous SAA proximal and distal to interscalene triangle.
Case report: A 55 years-old female patient, with no prior medical conditions, was referred to vascular surgery clinic with symptoms of neurological TOS. The radial pulses were absent in the affected limb but the patient had no arterial complains. In the work-up angio-CT two consecutive SAA (31 and 42mm) divided by anterior scalenus muscle were diagnosed.
The aneurysms were excluded by covered stent angioplasty after circle of Willis flow assessment by transcranial Doppler. Subsequently the patient was submitted to anterior scalenectomy in operating theatre. The symptoms completely reversed and the patient was discharged two days after surgery. Follow-up angio-CT confirmed SAA exclusion. Patient remains asymptomatic 6 months after the treatment.
Discussion: The term thoracic outlet syndrome was originally used in 1956 by RM Peet to designate compression of the neurovascular bundle at the thoracic outlet3. Since its original description, a multitude of clinical entities was associated with TOS. SAA is a rare but potential dangerous complication of TOS. Whereas historically SAA have been managed by open surgery, the novel endovascular methods offer an elegant and safer approach to this condition. Although first rib resection is emerging as the regular method of thoracic outlet decompression, this particular case imaging was highly suggestive of scalenus muscle compression. This case exemplifies how endovascular and open approaches can elegantly work together with remarkable results. To the best of our knowledge, this is the first description of a double subclavian artery aneurysm in the context of TOS.
Vascular medicine 2015;20:493–5.
2. Gruss JD, Geissler C. [Aneurysms of the subclavian artery in thoracic
outlet syndrome]. Zentralblatt fur Chirurgie 1997;122:730-4.
3. Peet RM, Henriksen JD, Anderson TP, et al. Thoracic-outlet syndrome:
evaluation of a therapeutic exercise program. Proceedings of
the staff meetings Mayo Clinic 1956;31:281–7.
4. Rochlin DH, Orlando MS, Likes KC, et al. Bilateral first rib resection
and scalenectomy is effective for treatment of thoracic outlet
syndrome. J Vasc Surg 2014;60:185–90.
5. Sanders RJ, Hammond SL, Rao NM. Diagnosis of thoracic outlet
syndrome. J Vasc Surg 2007;46:601–4.
6. Durham JR, Yao JS, Pearce WH, et al. Arterial injuries in the thoracic
outlet syndrome. J Vasc Surg 1995;21:57–69; discussion 70.
7. Salo JA, Ala-Kulju K, Heikkinen L, et al. Diagnosis and treatment
of subclavian artery aneurysms. European journal of vascular
8. Davidovic LB, Markovic DM, Pejkic SD, et al. Subclavian artery
aneurysms. Asian journal of surgery / Asian Surgical Association
2003;26:7–11; discussion 2.
9. Patton GM. Arterial thoracic outlet syndrome. Hand clinics
10. Malliet C, Fourneau I, Daenens K, et al. Endovascular stent-graft
and first rib resection for thoracic outlet syndrome complicated
by an aneurysm of the subclavian artery. Acta chirurgica Belgica
11. Sheth RN, Campbell JN. Surgical treatment of thoracic outlet
syndrome: a randomized trial comparing two operations. Journal
of neurosurgery Spine 2005;3:355–63.