REVIEW
Changing Profiles of Diagnostic and Treatment
Options in Subclavian Artery Aneurysms
B.P. Vierhout
a,*
, C.J. Zeebregts
b, J.J.A.M. van den Dungen
b,
M.M.P.J. Reijnen
ca
Department of Surgery, Wilhelmina Hospital Assen, Assen, The Netherlands
b
Department of Surgery, Division of Vascular Surgery, University Medical Center Groningen, Groningen, The Netherlands
cDepartment of Surgery, Alysis Zorggroep, Location Rijnstate, The Netherlands
Submitted 3 December 2009; accepted 9 March 2010 Available online 15 April 2010
KEYWORDS Aneurysm; Complications; Conventional; Endovascular; Subclavian artery; Treatment
Abstract Background: Subclavian artery aneurysms (SAAs) are rare and may cause life- and limb-threatening complications. Therapeutic options greatly differ as do access alternatives. The aim of the study was to assess its clinical presentation, diagnostics and therapeutic options as reported in the literature.
Method: A literature search was performed of the Medline, Cochrane and EMBASE databases. All articles, published until September 2009, describing treatment of an SAA were included. Results: A total of 191 reports, of which 126 met the inclusion criteria, were identified and were published from June 1915 until September 2009. Of these, 394 SAAs were described in 381 patients, with a mean age of 52 16 years. The median diameter was 40 mm (range: 10e180 mm). The aetiology appeared to change in time towards more exogenous causes. Fifty-one percent of the SAAs presented with a pulsating mass, shoulder pain and/or non-specific chest pain. Embolisation, rupture and thrombosis were present in 16%, 9% and 6% of patients, respec-tively, and their incidence was related to the anatomical localisation of the SAA. Open surgery and endovascular repair had a complication rate of 26% and 28%, respectively (p Z 0.49). Cardio-pulmonary complications were restricted to open repair. Mortality rates for open and endovascular techniques were similar (5%). The mortality rates for conventional elective and emergency proce-dures were 3% and 13%, respectively, and for endovascular repair 4% and 8%, respectively. Conclusion: The profiles of diagnostic and treatment options of SAAs are changing. Although guide-lines considering timing of intervention may not be conducted from available literature, interven-tion appears to be indicated, especially in distal SAAs, due to the risk of thrombo-embolic complications. Endovascular repair and hybrid procedures appear to be the preferred treatment modalities, due to a lower rate of cardiopulmonary complications.
ª 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.:þ31 592 325555; fax: þ31 592 325307. E-mail address:bas.vierhout@wza.nl(B.P. Vierhout).
1078-5884/$36ª 2010 European Society for Vascular Surgery. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.ejvs.2010.03.011
The incidence of subclavian artery aneurysms (SAAs) has been repeatedly reported to be rare.1e7Dent et al. identified only two SAAs in their series of 1488 aneurysms.8In that study, however, all false, postoperative, dissecting and mycotic aneurysms were excluded. According to Wickham and Martin, only 57 cases had been described until 1963.9Since then the
frequency of reports in literature has increased.
The SA consists of an intra- and an extra-thoracic part, while anatomically it may be divided into four parts.10From a surgical point of view, a more practical categorisation into three parts has been suggested: a proximal, a middle and a distal part.11 The proximal part extends from its origin, the innominate artery on the right and the aorta on the left side, to the medial border of the scalene muscles. The middle portion of the SA is located dorsal to the scalene muscles. The distal part of the SA extends from the lateral border of the anterior scalene muscle to the lateral border of the first rib.12
The aetiology of an SAA in early publications was frequently of mycotic, syphilitic or tuberculotic origin. In 1916, the thoracic outlet syndrome (TOS), also called costoclavicular compression syndrome, was recognised as an evoking mech-anism of SAA formation.13 Due to limb- or even life-threatening complications treatment is usually indicated.14
The current study was performed in order to summarise available data on all aspects related to SAA, including aetiology, clinical presentation, diagnostics, treatment modalities and complications.
Materials and methods
A search was conducted to identify reports in which treatment of a non-anomalous SAA was described, using the MEDLINE, EMBASE and Cochrane databases. Papers were included from the start of the databases until September 2009. Earlier publications were tracked using manual cross-referencing with the earliest article published in June 1915. The following MeSH search terms were used: aneurysm, subclavian artery and therapy. These terms were applied in various combinations in addition to the use of the ‘related articles’ function. Full-text articles were studied without restriction of language of publication and manual cross-referencing was performed. Demographic data, aneurysm characteristics, treatment modalities, complication and survival data were extracted using standardised criteria. Included reports had to contain above-mentioned data. When two or more studies from the same institution were identified, the study of larger size or better quality was included, unless the reported outcomes were mutually exclusive. Reports were excluded from further analysis if they did not clearly describe diagnostics and treatment, or if treatment of an aberrant right subclavian aneurysm (ARSA) was reported. Reports published before 1980 were compared to those published afterwards. This arbitrary cut-off point at 1980 was chosen since in that decade the first reports were published on endovascular repair.
Results
A total of 191 reports on SAAs were identified of which 126 met the inclusion criteria. A total of 49 reports presented
patients with an aberrant right SAA, 15 reports only described the existence or incidence of a SAA and one study was a duplicate publication. The 126 reports included could be categorised into 10 single-centre series and 116 case reports. Three-hundred and eighty-one patients were diagnosed with 394 SAAs. Two-hundred and eleven patients were described in single-centre series and 170 in case reports. The mean age of patients was 52 16 years, with a maleefemale ratio of 59:41. The median diameter of the SAA was 40 mm (range: 10e180 mm) and 57% were right-sided.
Aetiology and localisation
The aetiology of SAAs has been summarised inTable 1. Until 1980, most SAAs were related to TOS, infection or athero-sclerosis. Afterwards, traumatic and iatrogenic causes were more frequently described, while atherosclerosis and collagen disorders remained important.
The majority (39%) of SAAs were located in the proximal segment of the SA. The middle segment accounted for 25%, and 24% was located in the distal segment. In the remaining 11% of cases, localisation of the SAA was not described. The evoking mechanisms of SAA formation seemed to differ between each region of the SA. Proximal aneurysms were mostly caused by atherosclerosis (19%), collagen disorders (18%), trauma (15%), infection (13%) and in-hospital procedures (12%). The middle segment SAAs were mainly caused by collagen disorders (23%), trauma (15%), in-hospital procedures (10%), infection (10%) and TOS (15%). A distal SAA was mostly described in relation to TOS (46%) or as a consequence of blunt or penetrating trauma (23%).
Clinical presentation
Fifty-one percent of patients presented with a pulsating mass, shoulder pain and/or non-specific chest pain. Other symptoms included local compression, embolisation, thrombosis and rupture (Table 2). Brachial plexopathy was the most frequently described sign of local compression.15e 32
Symptoms of local compression were atypical in many cases. In this context, compression of the stellate ganglion induced Horner syndrome18,20,22,30,32e35 or facial
anhyd-rosis,18,22,36 while recurrent laryngeal nerve compression caused hoarseness.7,18,32,34,37e40 Dysphagia and dyspnoea,
due to compression of the oesophagus and trachea, respectively, have also been reported.10,33,34,38,41e46
Subclavian vein compression, causing venous congestion, was described once47 and another report described compression of the mammarian artery after coronary artery bypass surgery.48
Embolisation, often related to TOS, was described in 16% (n Z 56) of cases both to the upper extremity (n Z 44) and the cerebrum (n Z 12). Cerebrovascular accidents were also reported in a patient with fibromuscular dysplasia,4in a patient 18 months after a motor vehicle accident49and in
a patient with an atherosclerotic aneurysm.37Limb-loss due to embolisation has never been reported, but embolisation was fatal in one patient.44
Thrombosis occurred in 21, mostly female, patients with TOS, in the age range of 17e57 years. These were all true
aneurysms with a relatively small diameter of 12e 25 mm.9,17,50,51Thrombosis never appeared to have a fatal outcome, but two patients50,51lost their hand because of
gangrenous complications.
Rupture was reported in 32 patients (9%) and was fatal in six of them. In another patient, rupture resulted in ampu-tation.52 Most survivors presented with an episode of hae-moptysis, which may be considered as an early sign of rupture (n Z 9).18,37,38,53e57 A rupture towards superficial tissues might also facilitate early recognition.35,52,53,58e62
One SAA, in a patient suffering from syphilis, ruptured into a lung.63Two others, related to aortic coarctation and
an aspergilloma, respectively, ruptured into the pleural cavity and had a fatal outcome.64,65 Two other patients survived a pleural rupture.66,67 Ten ruptures towards
superficial tissues were described in seven cases after trauma59,68 and three others after medical
interven-tions.35,53,60Two SAAs presented with a pulsatile bleeding following cervical sympathectomy58 and radiotherapy,53
respectively.
Sixteen percent of patients with a SAA presented without symptoms. Most of them were described in the past decade. They were mainly found unexpectedly during preoperative screening or in a routine chest X-ray following introduction of a central venous catheter.
Diagnostic tools
Diagnosis of an SAA is strongly related to its symptoms and localisation. SAAs, located in the middle and distal segment, are regularly diagnosed at physical examination (48% and 59%, respectively). Aneurysms of the proximal part of the SA are mostly diagnosed on a routine chest X-ray (41%) and less frequently at physical examination (13%).
A suspicion of an SAA was often confirmed by angio-graphy, which used to be the gold standard. Nowadays, the investigation of choice for initial diagnosis is duplex ultra-sound scanning.69Angiography was performed in 50% of the reports before surgical exclusion. Computed tomography angiography (CTA; 14%) and magnetic resonance angiog-raphy (MRA; 3%) are increasingly being used (Fig. 1).
Treatment modalities
The indication for exclusion of an SAA is usually based on prevention of upper limb thrombosis, embolisation and rupture. The risk of development of these complications may depend on various aneurysm-related characteristics, including its aetiology and localisation. Treatment modali-ties include conservative management, open surgical repair, endovascular exclusion and various hybrid techniques.
Conservative management
Conservative management, consisting of best medical treatment and observation, was described in seven patients. Four patients, having an underlying disease that withheld them from surgery, eventually died of rupture.39,41,57,63Three of these patients had a mycotic SAA and one suffered from severe pulmonary insufficiency. The remaining three patients refused surgery and showed no aneurysm growth within a follow-up duration of 1 year.2,6,70 The aetiology of the SAA in these patients was associated with coarctation of the aorta, atherosclerosis and idiopathic.
Table 1 Aetiology of SAA.
Etiology Before 1980 After 1981 Overall Number of cases (%) Number of cases (%) Number of cases (%) Trauma 5 (10%) 123 (37%) 128 (33%) Atherosclerosis 12 (24%) 60 (18%) 72 (19%) T.O.S. 12 (24%) 59 (18%) 71 (18%) Iatrogenic 0 (0%) 32 (10%) 32 (8%) Collagen disorders 5 (10%) 24 (7%) 29 (7%) Mycotic 8 (16%) 13 (4%) 21 (5%) Unknown 3 (6%) 4 (1%) 7 (2%) Coarctation aortae 2 (4%) 5 (1%) 7 (2%) Congenital 1 (2%) 4 (1%) 5 (1%) Post-radiotherapy 0 (0%) 5 (1%) 5 (1%) H.I.V. 0 (0%) 3 (1%) 3 (1%) Not defined 3 (6%) 4 (1%) 7 (2%) Total 51 336 387
Table 2 Incidence of reported symptoms of a SAA.
Type Symptoms Percentage
Local signs Pulsating mass, shoulder pain, non-specific chest pain
51% Rupture Hemoptysis, hematothorax,
open rupture, hemorrhage
9% Compression Dysphagia, dyspnoe, brachial
plexopathy, Horner’s syndrome, hoarseness
36%
Thrombosis Ischemic arm 6%
Embolization Numb or cyanotic fingers, cerebral infarction
16% Figure 1 CT-angiography of a 36-year old female patient with a middle segment SAA related to TOS. Arrow pointing at the SAA.
Conventional surgical repair
Three-hundred and twenty-nine patients underwent conventional surgery. Access options for the proximal SA greatly differed and included right and left thoracotomy, sternotomy with and without supraclavicular or trans-clavicular access, axillary access and anterior thoracoto-mies in combination with mini-sternotomy and supraclavicular access. The middle segment of the SA appeared usually easier to reach using a supraclavicular access. This approach may be combined with an infracla-vicular incision, clainfracla-vicular division and (partial) clainfracla-vicular resection. In cases of a SAA due to TOS, aneurysm repair was often combined with first-rib resection.71,72
Various surgical procedures have been described for the exclusion of a SAA. The first described treatment option was ligation only11,18,20e22,35,38,42,52,55,58,68,73e76 and later in combination with a carotidesubclavian (n Z 5)77e81 or
femoro-axillary bypass (n Z 1).66 Ligation of the SAA was fatal in two early reports; both patients died of exsangui-nation, on the day of surgery and the 76th postoperative day, respectively.11,42 Aneurysmorraphy was mainly used for smaller and false aneurysms.19,29,45,50,61,68,75,82,83
Aneurysm resection combined with vein- or polyester-graft reconstruction provided a useful alternative and was performed in 51% of cases prior to 1980. Only one proce-dure was reported with fatal outcome, due to a ruptured Stanford type-A aortic dissection during surgery in a patient with EhlerseDanlos syndrome.47In the single-centre series, the mortality rate of open repair was 8%, while the overall mortality in the surgically treated group was 5%. Seventy-eight percent of treatments were performed in an elec-tive setting with a mortality rate of 3%, while 18% was carried out in an emergency setting, with a mortality rate of 13%. In the remaining patients, it was unclear whether the procedure was performed in an elective or emergency setting.
A variety of postoperative complications have been described following surgical repair (Table 3). Postoperative recurrent laryngeal nerve injury was described in 3%.35,43,84 In 1%, an abscess had to be drained11,42and seven patients
(2%) developed an ischemic arm, of which four needed a (partial) amputation.16,50,51The overall complication rate
was 26%. Systemic complications, such as massive coagul-opathy, acute tubular necrosis and cerebrovascular acci-dents, were all reported once.18,36,59 Pulmonary complications, including a chylothorax85and an oesophago-pleural fistula38 occurred in 5% of patients and was often
related to trauma. Paraesthesia due to a brachial cord lesion (3%) may be temporary17,19,86or persistent.29,84,87In
2% of cases, the presence or absence of complications was not mentioned.
Endovascular and hybrid repair
To date, 63 cases of endovascular SAA repair have been published (Fig. 2a and b). In the mid-1990s, the first endovascular subclavian aneurysm repair (EVSAR) proce-dures were published. After a follow-up period of 6 months, no complications were observed.88e92 In 1996, a patient
died 6 days after an EVSAR, presumably due to pre-existent cardiac insufficiency.44Beregi et al. have published a series of 19 patients with peripheral aneurysms, including five SAAs. All SAAs were successfully excluded using various
stent-grafts, but, at the 1-year follow-up, two stent-grafts had occluded. It was concluded that treatment of peripheral aneurysms with stent-grafts not only had a high rate of immediate success, but also had a high incidence of thrombosis.93 Schoder et al. described 10 patients that were electively treated with a stent-graft to repair an SAA due to trauma or a misplaced central venous catheter. The primary patency at the 1-year follow-up was 100%. Strut dislocation without stenosis was observed in one patient and a 50% stenosis, due to compression between the clavicle and the first rib, occurred in another.94 Other published procedure-related complications include in-stent stenosis,62,96 stent-fracture,96,97 pseudo-aneurysm formation,93,98 early thrombosis95 and wound infection after surgical closure of the groin.98The overall
compli-cation rate for EVSAR was 28% with a mortality rate of 5%. Eighty percent of patients were operated upon in an elective setting, with a mortality rate of 4%. The remain-ing 20% were emergency procedures and had a mortality rate of 8%.
Case-series with endovascular treatment have not been published to date.
Fourteen percent of EVSAR procedures were performed in combination with open techniques,67,99e101including the
re-implantation of the SA or vertebral artery in the common carotid artery46,102,103 and first-rib resection in case of
TOS.104
Complications were allocated in the endovascular group. Table 3 Incidence of complications following SAA repair.
Open repair Endovascular Hybrid Number of cases (%) Number of cases (%) Number of cases (%) No complications 239 (73%) 36 (75%) 8 (80%) Early thrombosis 4 (1%) 1 (2%) 1 (10%) Late thrombosis 4 (1%) 3 (6%) 0 (0%) Stenosis 0 (0%) 2 (4%) 0 (0%) False aneurysm 0 (0%) 4 (8%) 0 (0%) Disintegrating nitinol wire 0 (0%) 2 (4%) 0 (0%) Abscess 3 (1%) 1 (2%) 0 (0%) Graft infection 2 (1%) 0 (0%) 0 (0%) Ischemic arm 6 (2%) 1 (2%) 0 (0%) Recurrent laryngeal nerve injury 9 (3%) 0 (0%) 0 (0%) Injury of the brachial
cords 7 (2%) 1 (2%) 0 (0%) Rebleeding 4 (1%) 0 (0%) 0 (0%) Unsuccessful ligation 1 (1%) 0 (0%) 0 (0%) Disarticulation 1 (1%) 0 (0%) 0 (0%) Shoulder instability 8 (3%) 0 (0%) 0 (0%) Cardiac complications 4 (1%) 0 (0%) 0 (0%) Pulmonary complications 15 (5%) 0 (0%) 0 (0%) Massive coagulopathy 1 (1%) 0 (0%) 0 (0%) Cerebrovascular accident 2 (1%) 0 (0%) 1 (10%) Acute tubular necrosis 1 (1%) 0 (0%) 0 (0%)
Discussion
In the present study, we have shown that a SAA is a rare entity with <400 published reports in world literature. The true prevalence, however, may well be higher because common presentations and adverse outcomes are likely to be under-reported. This review of the historical literature was based entirely on case reports and small series and, therefore, the level of evidence presented is low, as is the nature of evidence related to other rare conditions. The profile of diagnostic and treatment options of SAAs is changing. While a mycotic cause is less common nowadays, traumatic and iatrogenic causes are reported more frequently.
The occurrence of life- and limb-threatening complica-tions, such as rupture, embolisation and thrombosis, seemed to depend on the anatomical localisation of the aneurysm. Proximal and mid-clavicular aneurysms had a higher incidence of rupture, when compared to distal aneurysms. We could not deduct a diameter at which an SAA should be excluded. Whether other parameters may be better predictors for rupture remain to be elucidated. Thrombo-embolic complications were mainly related to distally located aneurysms. Nevertheless, 9% of
thrombo-embolic complications occurred in proximal SAAs. The risk of thrombo-embolic complications was unrelated to the diameter of the SAA and did also occur in small aneurysms of only 12e25 mm, emphasising that early intervention may be indicated, especially in distal SAAs.
As a result of the complication risk, prompt diagnosis and treatment are indicated. In recent years, the number of reported asymptomatic SAAs has increased, due to routine chest X-rays. The non-invasive nature of duplex ultrasound scanning may facilitate early diagnosis. None-theless, nowadays, CTA and MRA are being used more frequently and are likely to become the new gold standard, because of their ability to image the relation of the SAA with its surrounding tissues.
Morbidity and mortality rates of open and endovascular repair were within the same range. Mortality rates may be underestimated since the publication of cases may have been partly restricted to successfully treated patients. In the single-centre series, the mortality of open repair was 3% higher, but these included trauma patients that may have increased mortality rates. Complications following EVSAR and hybrid procedures seem to be less severe when compared to those following open repair. Systemic complications were strictly reserved to open surgery as were plexopathy of the brachial cord and injury of the recurrent laryngeal nerve. Endovascular options mainly depend on anatomical characteristics of the aneurysm and access. Especially in trauma25,28,53,61,67,90,93,96,98,105 and iatrogenic SAAs,46,53,60,89,90,94,98,103EVSAR has proven to be of value. It seems reasonable to assume that emergency repair is associated with an increased mortality. In the present study, 18% of conventional and 20% of endovascular procedures were performed in an emergency setting, with a mortality rate of 13% and 8%, respectively. The great diversity of symptoms and treatment modalities of these patients made a reliable comparison between groups impossible.
The SA is extremely mobile and exposed to rotationary forces during abduction and ante-flexion of the arm. Therefore, a stent-graft, used for EVSAR, has to be flexible and resistant to kinking and fracture. To date, a variety of stent-grafts have been used. In-stent stenosis and throm-bosis were seen in early series; however, in recent studies, patency seems to have increased. Patency results of endovascular treatment may further increase with the development of better stent-grafts and improved post-procedural pharmacotherapy.
In conclusion, we have shown that the SAA is a rare vascular entity with life- and limb-threatening complica-tions. Diagnostic and treatment options are evolving. Although guidelines considering the timing of intervention may not be conducted from available literature, early intervention appears to be indicated, especially in distal SAAs, due to the risk of thrombo-embolic complications. Endovascular repair and hybrid procedures appear to be the preferred treatment modalities, due to a lower rate of cardiopulmonary complications.
Conflict of Interest
None declared. Figure 2 (a) Pre-procedural angiogram of a 36-year old
female patient with a middle segment SAA related to TOS. (b) Post-procedural angiogram after exclusion of the SAA with a stentgraft (Viabahn, W.L. Gore & Associates, Flagstaff, AZ, U.S.A.). The EVSAR was followed by a first rib resection.
Funding
None.
Acknowledgements
The authors thank Romel Zamudio, M.D., of the Almenara Hospital in Lima, Peru, for his help in the retrieval of Hispanic reports.
References
1 Stahl RD, Lawrence PF, Bhirangi K. Left subclavian artery aneurysm: two cases of rare congenital etiology. J Vasc Surg 1999;29:715e8.
2 Trujillo Santos AJ, Jurado Ga´mez B. Aneurisma de la arteria subclavia izquierda: causa infrecuente de masa pulmonar superior. An Med Interna 2001;18:84e5.
3 Tanaka K, Makuuchi H, Naruse Y, Kobayashi T, Goto M, Arimura Y, et al. Multiple atherosclerotic aneurysms of the bilateral subclavian artery, aortic arch and abdominal aorta. Ann Thorac Cardiovasc Surg 2004;10:126e9.
4 McCready RA, Pairolero PC, Hollier LH, Brown OW, Lie JT. Fibromuscular dysplasia of the right subclavian artery. Arch Surg 1982;117:1243e5.
5 Coselli JS, Crawford ES. Surgical treatment of aneurysms of the intrathoracic segment of the subclavian artery. Chest 1987;91(5):704e8.
6 Clemente C, Vidal MT, Tornos MP, Soler-Soler J. Right subcla-vian artery aneurysm and coarctation of the aorta. Int J Car-diol 1993;43:199e201.
7 Schindler N, Calligaro KD, Dougherty MJ, Diehl J, Modi KH, Braffman MN. Melioidosis presenting as an infected intratho-racic subclavian artery pseudoaneurysm treated with femoral vein interposition graft. J Vasc Surg 2002;35:569e72. 8 Dent TL, Lindenauer SM, Ernst CB, Fry WJ, Arbor A. Multiple
arteriosclerotic arterial aneurysms. Arch Surg 1972;105(2): 334e8.
9 Wickham JEA, Martin P. Aneurysm of the subclavian artery in association with cervical abnormality. Br J Surg 1963;50:205e 9.
10 Windfuhr JP, Schubert D, Remmert S. Dysphagie durch aneur-ysma der a. subclavia. HNO 2004;52:1097e102.
11 Thompson JE. Ligature of the innominate artery for cure of subclavian aneurisms. Ann Surg 1915;61(6):641e57.
12 Caparrelli DJ, Tabulov DM, Freischlag JA. Subclavian artery aneurysm secondary to cervical rib. Arch Surg 2006;141:513e 4.
13 Halsted WS. An experimental study of circumscribed dilation of an artery immediately distal to a partially occluding band, and its bearing on the dilation of the subclavian artery observed in certain cases of cervical rib. J Exp Med 1916;24: 271e90.
14 Gupta AK, Gupta PC, Abrol R, Mann SBS. Pseudoaneurysm of subclavian artery e atypical presentation. J Laryngol Otol 1998;112:1095e7.
15 Yoo WH, Kim HK, Park JH, Park TS, Baek HS. Mediastinal mass and brachial plexopathy caused by subclavian arterial aneu-rysm in Behc¸et’s disease. Rheumatol Int 2000;19:227e30. 16 Cakir O¨, Eren N, U¨lku¨ R, Nazarog˘lu H. Bilateral subclavian
arterial aneurysm and ruptured abdominal aorta pseudoa-neurysm in Behc¸et’s disease. Ann Vasc Surg 2002;16:516e20. 17 Shucksmith HS. Cerebral and peripheral emboli caused by
cervical ribs. Br Med J 1963;2:835e7.
18 Miller CM, Sangiuolo P, Schanzer H, Haimov M, McElhinney AJ, Jacobson JH. Infected false aneurysms of the subclavian artery: a complication in drug addicts. J Vasc Surg 1984;1: 684e8.
19 Davis JM, Gollinger D. Cervical rib, subclavian artery aneu-rysm, axillary and cerebral emboli. Proc R Soc Med 1966;59: 1002e4.
20 Muller GP. Subclavian aneurism: with report of a case. Ann Surg 1935;101:568e71.
21 Rodgers RE. A case of unilateral clubbing of the fingers; with a summary of the literature. Br Med J 1941;2:439e40. 22 Daniel Jr RA. Syphilitic aneurysm of the subclavian artery. Ann
Surg 1951;134:251e8.
23 Hobson RW, Sarkaria J, O’Donnell JA, Neville WE. Atherosclerotic aneurysms of the subclavian artery. Surgery 1979;4:368e71. 24 MacSweeney STR, Holden A, Hartley D, Lawrence-Brown M.
Endovascular repair of subclavian artery aneurysm. J Vasc Surg 1996;24:304e5.
25 Pagni S, DeNatale RW, Ferneini AM. Atherosclerotic aneurysm of the proximal subclavian artery: a case report. Am Surg 1998;64:323e7.
26 Pfammatter T, Kunzli A, Hilfiker PR, Schubiger C, Turina M. Relief of subclavian venous and brachial plexus compression syndrome caused by traumatic subclavian artery aneurysm by means of transluminal stent-grafting. J Trauma 1998;45:972e4. 27 Nawa S, Ikeda E, Ichihara S, Sugiyama N, Takagaki K, Kunitomo T. A true aneurysm of axillary-subclavian artery with cystic medionecrosis: an unusual manifestation of Marfan syndrome. Ann Vasc Surg 2003;17:562e4.
28 Renger RJ, Bruijn AJ, Aarts HC, Hem LG. Endovascular treat-ment of a pseudoaneurysm of the subclavian artery. J Trauma 2003;55:969e71.
29 Tsutsumi K, Saito H, Ohkura M. Traumatic pseudoaneurysm of the subclavian artery following anterior dislocation of the shoulder: a report of a surgical case. Ann Thorac Cardiovasc Surg 2006;12:74e6.
30 Koseoglu K, Cildag B, Sen S, Boga M, Parildar M. Endovascular treatment of a mycotic subclavian artery aneurysm using stent-graft. Eur J Vasc Endovasc Surg 2006;11:97e101. 31 Sarkar BK, Sarkar UN. Anomalous course of the left subclavian
artery leading to aneurysm formation and thoracic outlet syndrome e a case report. Eur J Vasc Endovasc Surg 2008;15: 27e9.
32 Riga C, Bicknell C, Jindal R, Cheshire N, Hamady M. Endovas-cular stenting of peripheral infected aneurysms: a temporary measure or a definitive solution in high-risk patients. Car-diovasc Intervent Radiol 2008;31:1228e35.
33 Okita Y, Ando M, Minatoya K, Kitamura S, Matsuo H. Multiple pseudoaneurysms of the aortic arch, right subclavian artery, and abdominal aorta in a patient with Behc¸et’s disease. J Vasc Surg 1998;28:723e6.
34 Ozeren M, Sucu N, Aytacoglu BN, Do¨ven O, Dikmengil M. Esophageal and tracheal compression of huge right subclavian artery aneurysm secondary to aortic coarctation. Eur J Vasc Endovasc Surg 2007;13:33e5.
35 Moloney GE. Excision of an aneurysm of the right subclavian artery: case history and discussion. Br J Surg 1955;43:94e9. 36 Kasashima F, Urayama H, Ohtake H, Watanabe Y. Intrathoracic
aneurysm of the innominate and right subclavian arteries: report of a case. Surg Today 2001;31:51e4.
37 Takagi H, Mori Y, Umeda Y, Fukumoto, Yoshida K, Shimokawa K, et al. Proximal left subclavian artery aneurysm presenting hemoptysis, hoarseness, and diplopia: repair through partial cardiopulmonary bypass and perfusion of the left common carotid artery. Ann Vasc Surg 2003;17:461e3. 38 Baldwin RT, Kieta DR, Gallagher MW. Complicated right
subclavian artery pseudoaneurysm after central venipuncture. Ann Thorac Surg 1996;62:581e2.
39 Cuxart M, Matas M, Sans R, Valle´s M. Pseudoaneurisma de arteria subclavia tras colocacio´n de cate´ter de hemodia´lisis. Nefrologı´a 1998;18:343e4.
40 Lin PH, Bush RL, Weiss VJ, Dodson TF, Chaikof EL, Lumsden AB. Subclavian artery disruption resulting from endovascular intervention: treatment options. J Vasc Surg 2000;32:607e11. 41 Nair R, Abdool-Carrim ATO, Chetty R, Robbs JV. Arterial aneurysms in patients infected with HIV: a distinct clin-icopathology entity? J Vasc Surg 1999;29:600e7.
42 Ho KL, Rassekh ZS. Mycotic aneurysm of the right subclavian artery. Chest 1978;74:116e7.
43 Olinde AJ. Traumatic subclavian-axillary artery aneurysm. J Vasc Surg 1990;11:848e9.
44 Rousseau H, Gieskes L, Joffre F, Dube M, Roux D, Soula P, et al. Percutaneous treatment of peripheral aneurysms with the Cragg Endopro system. J Vasc Interv Radiol 1996;7:35e9. 45 Hohls M, Ghanem N, Wilhelm M, Stoelben E. Tracheal stenosis
caused by false aneurysm of the right subclavian artery. Eur J Cardiothorac Surg 2002;21:946e7.
46 Aalami OO, Lisagor P, Victorino GP, McDaniel H, Nikolic B. Repair of iatrogenic subclavian artery pseudoaneurysm with covered stent placement after vertebral artery transposition. J Vasc Interv Radiol 2005;16:1759e60.
47 Teebken OE, Krack M, Schulz R, Haverich A. Rupture of the ascending aorta in EhlerseDanlos syndrome after surgical repair of multiple AV malformations with the use of cardio-pulmonary bypass. J Thorac Cardiovasc Surg 1998;116:660e1. 48 Douglas DA, Adelman MA, Esposito R, Rockman C. Surgical repair of a left subclavian artery aneurysm causing stenosis of a left internal mammary graft. Vasc Endovascular Surg 2005;39:281e5. 49 Zelenock GB, Kazmers A, Graham LM, Erlandson EE, Cronenwett JL, Whitehouse WM, et al. Nonpenetrating subclavian artery injuries. Arch Surg 1985;120:685e92. 50 Eastcott HHG. Reconstruction of the subclavian artery for
complications of the cervical-rib and thoracic-outlet-syndrome. Lancet 1962;7268:1243e6.
51 Mathes SJ, Salam AA. Subclavian artery aneurysm; sequela of thoracic outlet syndrome. Surgery 1974;76:506e10.
52 Har-shai Y, Schein M, Molek AD, Peled IJ, Best LA. Ruptured mycotic aneurysm of the subclavian artery after irradiation. Eur J Surg 1993;159:59e60.
53 Criado E, Marston WA, Ligush J, Mauro MA, Keagy BA, Hill C. Endovascular repair of peripheral aneurysms, pseudoaneurysms, and arteriovenous fistulas. Ann Vasc Surg 1997;11:256e63. 54 Mii S, Ienaga S, Motohiro A, Okadome K. An unusual symptom
of subclavian artery aneurysm: hemoptysis. J Vasc Surg 1991; 14:243e5.
55 Saliou C, Badia P, Duteille F, D’Attellis N, Ricco JP, Barbier J. Mycotic aneurysm of the left subclavian artery presented with hemoptysis in an immunosuppressed man: case report and review of the literature. J Vasc Surg 1995;21:697e702. 56 Sanada J, Matsui O, Terayama N, Kobayashi S, Minami T,
Chujo T, et al. Stent-graft repair of a mycotic left subclavian artery pseudoaneurysm. J Endovasc Ther 2003;10:66e70. 57 Cosmo LY, Risi G, Nelson S, Subramanian P, Martin D,
Haponik EF. Fatal hemoptysis in acute bacterial endocarditis. Am Rev Respir Dis 1988;137:1223e6.
58 Flye MW, Wolkoff JS. Mycotic aneurysm of the left subclavian and vertebral arteries. Am J Surg 1971;122:427e9.
59 Posner MP, Deitrick J, McGrath P, Mendez G, Sobel M, Lower RR, et al. Nonpenetrating vascular injury to the subclavian artery. J Vasc Surg 1988;8:611e7.
60 Akgun S, Civelek A, Baltagioglu F, Ekici G. Successful endo-vascular repair of a subclavian artery pseudoaneurysm. Nephrol Dial Transplant 1999;14:2219e21.
61 Xenos ES, Freeman M, Stevens S, Cassada D, Pacanowski J, Goldman M. Covered stents for injuries of subclavian and axillary arteries. J Vasc Surg 2003;38:451e4.
62 Ewings EL, Wittgen CM, Paletta CE. Prolonged success with a covered endovascular stent after emergent use in radiation-induced subclavian artery blowout: a case report. Vasc Endo-vascular Surg 2008;42:187e91.
63 Boundy K, Bignold LP. Syphilitic aneurysm of the right subclavian artery presenting with hemoptysis. Aust NZ J Med 1987;17:533e5.
64 Bahcivan M, Nural MS, Baydin A, Genc S, Gokce E, Kolbakir F. Left subclavian artery aneurysm rupture in association with aortic coarctation. Cardiovasc Intervent Radiol 2006;29:717e9. 65 Attinga N, Herpel E, Kotelis D, Hyhlik-Du¨rr A, Bo¨ckler D.
Endo-vaskula¨re therapie einer aspergilloseinduzierten septische arrosionsblutung der a. subclavia. Chirurg 2008;79:984e7. 66 Elefteriades JA, Kay HA, Stansel HC, Geha AS. Extraanatomical
reconstruction for bilateral intrathoracic subclavian artery aneurysms. Ann Thorac Surg 1983;35:188e91.
67 Babatasi G, Massetti M, LePage O, Theron J, Khayat A. Endo-vascular treatment of a traumatic subclavian artery aneurysm. J Trauma 1998;44:545e7.
68 Matloff DB, Morton JH. Acute trauma to the subclavian arteries. Am J Surg 1968;115:675e80.
69 Beissert M, Jenett M, Trusen A, Wittenberg G, Krause U, Gassel HJ, et al. Asymptomatic aneurysm of the proximal right subclavian artery: a rare ultrasound diagnosis. Eur Radiol 2000;10:459e61.
70 Fedullo LM, Meranze SG, McLean GK, Burke DR. Embolization of a subclavian artery aneurysm with steel coils and thrombin. Cardiovasc Intervent Radiol 1987;10:134e7.
71 Balar N, Ganatra V, Sampson LN, Reitknecht F, Gupta S. Left subclavian artery aneurysm: surgical repair via a sternal inci-sion. Vasc Endovascular Surg 2004;38:557e61.
72 Machleder HI. Arterial compression at the thoracic outlet. Vascular disorders of the upper extremity. Armonk NY: Futura Publishing Co Inc; 1998. pp. 197e225.
73 Anderson CB, Butcher HR, Ballinger WF. Mycotic aneurysms. Arch Surg 1974;109:712e7.
74 Jime´nez JA, Martinez A, Alamo O, Hernandez A, Saez L, Sanchez S, et al. Aneurisma de arteria subclavia consecutivo a sı´ndrome de escaleno y costilla cervical. Angiologı´a 1981;33:86e92. 75 Buckenham TM, Watkins G. The recalcitrant subclavian
pseu-doaneurysm: a case report. Australas Radiol 1991;35:281e3. 76 Tabata S, Saito J, Takizawa M, Imagawa T. Atherosclerotic
aneurysm of the right subclavian artery: report of a case. Ann Thorac Cardiovasc Surg 2007;13:139e42.
77 McCollum CH, Da Gama AD, Noon GP, DeBakey ME. Aneurysm of the subclavian artery. J Cardiovasc Surg (Torino) 1979;20: 159e64.
78 Salo JA, Ala-Kulju K, Heikkinen L, Bondestam S, Ketonen P, Luosto R. Diagnosis and treatment of subclavian artery aneu-rysms. Eur J Vasc Surg 1990;4:271e4.
79 Bower TC, Pairolero PC, Hallett JW, Toomey BJ, Gloviczki P, Cherry KJ. Brachiocephalic aneurysm: the case for early recognition and repair. Ann Vasc Surg 1991;5:125e32. 80 Dougherty MJ, Calligaro KD, Savarese RP, DeLaurentis DA.
Atherosclerotic aneurysm of the intrathoracic subclavian artery: a case report and review of the literature. J Vasc Surg 1995;21:512e29.
81 Davidovic LB, Markovic´ Dm, Pejkic´ SD, Kovacevic´ NS, Colic´ MM, äoric´ PM. Subclavian artery aneurysms. Asian J Surg 2003;26: 7e11.
82 Wong JM, Shermak MA, Tihan T, Jones CE. A subclavian artery aneurysm in a patient with HIV infection: a case report. J Vasc Surg 2002;35:1006e9.
83 Bernik TR, Friedman SG, Scher LA, Safa T. Pseudoaneurysm of the subclavian-vertebral artery junction: case report and review of the literature. Vasc Endovascular Surg 2002;6:461e4. 84 Brzowski BK, Mills JL, Beckett WC. Iatrogenic subclavian artery
85 Hiller N, Verstanding A, Simanovsky N. Coarctation of the aorta associated with aneurysm of the left subclavian artery. Br J Radiol 2004;77:335e7.
86 Hara M, Bransford RM. Aneurysm of the subclavian artery associated with contiguous pulmonary tuberculosis. J Thorac Cardiovasc Surg 1963;46:256e64.
87 Modi MP, Shah VR. Brachial plexus palsy due to subclavian artery pseudo aneurysm from internal jugular cannulation. Indian J Crit Care Med 2007;11:93e5.
88 de Virgilio C, Cherry KJ, Schaff HV. Multiple aneurysms and aortic dissection: an unusual manifestation of Marfan’s syndrome. Ann Vasc Surg 1994;8:383e6.
89 May J, White G, Waugh R, Yu W, Harris J. Transluminal placement of a prosthetic graft-stent device for treatment of subclavian artery aneurysm. J Vasc Surg 1993;18:1056e9. 90 Marin ML, Veith FJ, Panetta TF, Cynamon J, Sanchez LA,
Schwartz ML, et al. Transluminally placed endovascular stented graft repair for arterial trauma. J Vasc Surg 1994;20:466e72. 91 Schmitter SP, Marx M, Bernstein R, Wack J, Semba CP, Dake MD.
Angioplasty-induced subclavian artery dissection in a patient with internal mammary artery graft: treatment with endovas-cular stent and stent-graft. Am J Roentgenol 1995;165:449e51. 92 Ackroyd R, Singh S, Beard JD, Gaines PA. Simultaneous brachial embolectomy and endoluminal stenting of a subclavian artery aneurysm. Eur J Vasc Endovasc Surg 1995;10:248e9.
93 Beregi JP, Prat A, Willoteaux S, Vasseur MA, Boularand V, Desmoucelle F. Covered stents in the treatment of peripheral arterial aneurysms: procedural results and midterm follow-up. J Vasc Interv Radiol 1999;22:13e9.
94 Schoder M, Cejna M, Ho¨lzenbein T, Bischof G, Lomoschitz F, Funovics M, et al. Elective and emergent endovascular treat-ment of subclavian artery aneurysms and injuries. J Endovasc Ther 2003;10:58e65.
95 Kasirajan K, Matteson B, Marek JM, Langsfeld M. Covered stents for true subclavian aneurysms in patients with
degenerative connective tissue disorders. J Endovasc Ther 2003;10:647e52.
96 Szeimies U, Kueffer G, Stoeckelhuber B, Steckmeier B. Successful exclusion of subclavian aneurysm with covered nitinol stents. Cardiovasc Intervent Radiol 1998;21:246e9. 97 Phipp LH, Scott JA, Kessel D, Robertson I. Subclavian stents and
stent-grafts: cause for concern? J Endovasc Surg 1999;6:223e6. 98 Hilfiker PR, Razavi MK, Kee ST, Sze DY, Semba CP, Dake MD. Stent-graft therapy for subclavian artery aneurysms and fistulas: single-center mid-term results. J Vasc Interv Radiol 2000;11:578e84.
99 Domı´nguez JS, A´lvares B, Maeso J, Matas M. Combined surgery for the treatment of bilateral subclavian artery aneurysm in Marfan syndrome. J Vasc Surg 2007;45:180e2.
100 Leemput A, Maleux G, Heye S, Nevelsteen A. Combined open and endovascular repair of a true right subclavian artery aneurysm without proximal neck. Interact Cardiovasc Thorac Surg 2007;6:406e8.
101 Harding GE, Kribs SW, Forbes TL. Hybrid open and endovas-cular therapy for a subclavian artery aneurysm. Vasendovas-cular 2008; 16:236e8.
102 Resch TA, Lyden SP, Gavin TJ, Clair DG. Combined open and endovascular treatment of a right subclavian artery aneurysm: a case report. J Vasc Surg 2005;42:1206e9.
103 Karkos CD, Mair R, Morkoze G, Fishwick G, London NJM, Naylor AR. Hybrid procedures combining open and endovas-cular surgical techniques for the management of subclavian artery injuries. J Trauma 2007;63:E107eE110.
104 Malliet C, Fourneau I, Daenens K, Maleux G, Nevelsteen A. Endovascular stent-graft and first rib resection for thoracic outlet syndrome complicated by an aneurysm of the subcla-vian artery. Acta Chir Belg 2005;105:194e7.
105 Bukhari HA, Saadia R, Hardy BW. Urgent endovascular stenting of subclavian artery pseudoaneurysm caused by seatbelt injury. Can J Surg 2007;50(4):303e4.
