On September 12, 2024, during the 9th China Vascular Conference (CVC 2024), the annual Top 10 Case Showcase of the Vascular Surgery Group of the Chinese Clinical Case Database was successfully held. Numerous surgical experts provided in-depth interpretations and experience sharing on the selected top 10 cases of the year. During the event, Professor Chang Yi from Fuwai Hospital, Chinese Academy of Medical Sciences, shared a case of open surgery treatment for a giant subclavian artery aneurysm post-stent. 

Case Sharing

Case Information (Male, 32 years old)

Medical History: Three years ago, the patient sought treatment for shoulder and back pain and was diagnosed with a left subclavian artery aneurysm. Endovascular treatment was performed, but the symptoms did not fully resolve and intermittently recurred. Six months ago, the symptoms worsened.

Past History: Twenty years ago, the patient underwent artificial vessel replacement for an abdominal aortic aneurysm.

Physical Examination: No significant abnormalities.

CT Pre-Stent Placement: Giant left subclavian artery aneurysm, with a maximum diameter exceeding 80 mm.

CT Pre-Surgery: The left subclavian artery aneurysm showed widening with minimal heterogeneous enhancement, with endoleakage from the paravertebral vascular branches.

Surgical Plan: Open surgery to remove the aneurysm and replace it with an artificial vessel.

Surgical Procedure

The procedure involved opening the left fourth intercostal space; cannulating the femoral vein, connecting to a cardiopulmonary bypass machine to prepare for blood transfusion; freeing the adhered lung tissue; directly cutting open the aneurysm wall, removing the thrombus, and tying off the side branches under direct vision. A 10 mm artificial vessel was then anastomosed to both the distal and proximal ends of the subclavian artery.

Postoperative Condition

The patient recovered smoothly post-surgery.

Postoperative CT: The artificial vessel showed unobstructed blood flow.

Aneurysm Wall Pathology: Partial loss of elastic fibers in the arterial tunica media, tearing near the tunica adventitia, with collagen fiber proliferation in the tunica adventitia.

Clinical Presentation and Intervention Indications for Subclavian Artery Aneurysms

Subclavian artery aneurysms are rare, accounting for less than 1% of all aneurysms. The location and involvement of the aneurysm influence its etiology, with proximal aneurysms often due to atherosclerosis, midsection aneurysms due to collagen diseases, and distal aneurysms often related to thoracic outlet syndrome. Trauma (including iatrogenic causes) is the most common cause and can occur in any location.

The symptoms of subclavian artery aneurysms vary based on size and location. Many aneurysms are incidentally found, often asymptomatic or presenting as a palpable mass in the neck. Local compression can cause symptoms such as difficulty swallowing, hoarseness, or Horner’s syndrome. Thrombus formation can lead to arm ischemia or cerebral infarction.

Intervention is indicated for symptomatic aneurysms or those at high risk of rupture or embolism. Preoperative angiography is essential to assess vertebral artery patency and perform revascularization of the dominant vertebral artery, ensuring adequate vertebral artery blood flow.

Clinical Treatment of Subclavian Artery Aneurysms

Surgical treatment of subclavian artery aneurysms can be divided into endovascular and open surgical procedures. Endovascular treatment is less invasive, with a higher success rate and avoids the challenges of exposure and damage to surrounding tissues, but it carries a high risk of endoleaks due to the numerous branches.

A retrospective study by Fudan University spanning 12 years with 35 patients (26 true aneurysms, 7 pseudoaneurysms, and 2 ruptured aneurysms) showed that all patients underwent endovascular treatment with no perioperative mortality or complications. Long-term complications occurred in 25.7% of patients during a follow-up period of 62 months (ranging from 3 to 132 months). About one-third of these patients required re-intervention (8.6%).

Exposure and mobilization are the main challenges in open surgery. Approaches vary, including left or right thoracotomy, median sternotomy with or without supraclavicular or transclavicular incisions. The supraclavicular approach is generally easier for accessing the midsection of the subclavian artery. This approach can be combined with a subclavian incision, clavicular dissection, and (partial) clavicle resection. Although large-scale case reports are lacking, individual case reports have shown favorable outcomes. Bleeding remains the most challenging intraoperative complication, requiring various measures to ensure blood return, and even cardiopulmonary bypass protection may be needed.