Chapter 84 - Upper extremity aneurysm Flashcards
Usual age at which aneurysm degeneration occur in aberrant right subclavian
> 50 years
Define Kommerell’s diverticulum
Degenerative aneurysmal change in proximal portion of aberrant subclavian artery
Rate of Kommerell’s diverticulum in aberrant right subclavian
60%
Astley Cooper 1805, 1808 on arch vessel aneurysm
CCA aneurysm ligation
Mott 1818 on arch vessel aneurysm
Innominate artery ligation for subclavian artery aneurysm
dead in 1 month from necrotic aneurysm
1864 Smyth in New Orleans on subclavian artery aneurysm
first successful treatment by ligating CCA and innominate artery
recurred and ruptured 10 years later
Halsted 1892 John Hopkins on arch vessel aneurysm
Successful resection of subclavian artery aneurysm
Matas 1913 on arch vessel aneurysms
7 cases of subclavian aneurysm endoaneurysmorrhaphy
% of arch aneurysms that were degenerative
63%
Demographic of arch vessel aneurysms
men > 60 years
Causes of arch vessel aneurysms
1) degenerative
2) trauma
3) FMD
4) syphilis
5) cystic medial necrosis
6) vasculitis
7) contiguous tuberculous lymphadenitis
8) idiopathic congenital cause
Arch aneurysms as a percentage of all peripheral aneurysms
1%
Percentage of patients with arch aneurysms to have other peripheral aneurysms
30-50%
Subclavian aneurysm as percentage of all arch aneurysms
50%
Innominate aneurysm as percentage of arch aneurysms
2-5%
Causes of true aneurysms in the CCA
1) degenerative
2) FMD
3) marfan
4) Behcet
5) takayasu
Chance of bilateral CCA aneurysm
very rare
1) takayasu
2) cogan syndrome
Cogan syndrome
Multisystemic disease with vestibuloauditory dysfunction, inflammatory eye disease and vasculitis
Can cause recurrent aortic and carotid aneurysms
Mimic Marfans
Symptoms of arch vessel aneurysm
1) chest/neck/shoulder pain
2) UE ischemic symptoms
3) UE pain/neurologic dysfunction
4) hoarseness
5) respiratory insufficiency
6) TIA/stroke
7) dysphagia
8) hemoptysis
9) supraclavicular bruit
10) Horner syndrome
Risk of ligation in causing ischemia in arch aneurysms
25%
Kieffer et al innominate artery types
Type A: confined to innominate artery distal to origin
Type B (most common): innominate and origin
Type C: innominate artery and ascending aorta
Subclavian artery aneurysm classification
Proximal (degenerative): stenotomy
Distal (TOS): supra and infraclavicular incision
Relative contraindication to open repair of arch aneurysms
1) severely compromised pulmonary function
2) prior sternotomy
3) prior left thoracotomy
4) hemodynamic instability due to poly trauma
Mortality of open arch aneurysm repair
11%
What to do if needing to cover vertebral artery
1) contralateral needs to be adequate
2) carotid vertebral bypass first if needed
3) coil embolize vert if not ligated to limit endoleak
Hybrid approach to subclavian and innominate aneurysms
Carotid-subclavian bypass or transposition
Proximal plug or endograft in innominate into CCA
Subclavian stent graft patency
83-100% over 7-29 months
Aberrant subclavian artery prevalence
0.5-1% of population
Aberrant subclavian artery first described by
Hunauld 1735
Dysphagia lusoria first described by
Impingement of aberrant vessel on esophagus
Bayford 1794
Track of the anomalous right subclavian
Distal to left subclavian origin
Posterior and inferior on arch
80% cross midline between esophagus and spine
less likely cross between esophagus and trachea or anterior to trachea
Embryology, left fourth arch becomes
Part of aortic arch
Embryology, right fourth arch becomes
root of right subclavian artery
Embryologic cause of aberrant subclavian
Right fourth aortic arch and rigth dorsal aorta involute cranial to 7th intersegmental artery
What is aberrant subclavian artery associated with
Non-recurrent right laryngeal nerve
Epidemiology of aberrant subclavian aneurysm
1) Age > 50
2) either sex
Indication to repair aberrant artery aneurysm
Repair > 3cm in good risk patients
Kommerell Diverticulum define
Proximal aberrant subclavian artery aneurysm
Described by Kommerell 1936
Rate of Kommerell in aberrant subclavian
60%
Who first called attention to the significance of aneurysm change in aberrant subclavian
McCallen and Schaff 1956
Aberrant subclavian Classification by Kiefer
Group 1: nonaneurysmal aberrant right subclavian artery
Group 2: occlusive disease of nonaneurysmal ARCA
Group 3: aneurysmal dilation of ARSA without aortic involvement
Group 4: aneurysmal ARSA with aortic involvement
Aberrant subclavian artery aneurysm presented as rupture or dissection in this % of patients
14-53%
% of patients with aberrant subclavian aneurysm also have AAA
20%
Mortality of open repair of Kommerell diverticulum
Up to 30%
Hybrid approach to bilateral subclavian revasc and endo TEVAR - mortality
10% in 36 months
Causes of axillary artery aneurysm
1) trauma: repetitious forceful extension of UE - abduction, external rotation and downward displacement of humeral head
2) congenital (Rare)
baseball pitchers
Rob and Standeven 1956 on axillary artery aneurysms
Crutch-induced blunt trauma first described
Thickened walls and wrinkled roughed intima
loss of brachial pulse or emboli after prolonged crutch use
Histological signs of chronic trauma
1) Fragmentation of medial elastic fibers
2) periadventitial fibrosis
Symptoms of axillary artery aneurysm
1) emboli
2) brachial plexus compression
Patency of open interpositional grafting of axillary artery
100% 3.2 years
Patency of Endovascular treatment of axillary artery aneurysm
84.4% up to 70 months
Causes of brachial artery aneurysm
1) traumatic (including IVDU injection and infecdtion)
2) Congenital aneurysm
3) idiopathic
4) Type IV Ehlers-Danlos
5) Kawasaki
6) Buerger
7) Kaposi sarcoma
8) cystic adventitial disease
9) dissection
Symptoms of brachial artery aneurysm
1) median nerve compression
2) digital ischemia (thrombosis or emboli)
Patency of brachial artery aneurysm open repair
100% 16 months
Rate of brachial artery pseudoaneurysm and thrombosis after percutaneous access
Pseudoaneurysm 0.3%
Thrombosis 1-7%
Thrombin injection for brachial artery pseudoaneurysm
1) too superficial
2) usually short neck
Can be done but usually not suitable
