Endovascular repair of isolated post-traumatic subclavian artery false-aneurysm (FA) using gore viabahn vbx-balloon-expandable (BE) stent-graft: case report and literature review

Abstract

True and false aneurysms (FA) of the subclavian artery are at high risk of rupture due to their localization and proximity/closeness to the articular bone structures of the upper thoracic outlet and shoulders. Surgical and endovascular treatments are good options to avoid complications such as aneurysms rupture, thrombosis and distal embolism alone or in combination. Self-expandable (SE) covered stents are the most used devices for the treatment of subclavian artery aneurysms. We report on a case of post traumatic left intra-thoracic subclavian artery FA treated using endovascular technique, highlighting the usefulness of the new covered Gore Viabahn VBX-BE stent-graft that combines the advantages of a high radial strength of a BE stent with the deliverability and conformability of a SE stent.

Figure 1.

(a) Frontal left hemitorax x-ray projection that shows middle third clavicle, scapula body, coracoid process, IV,V and VI rib fractures combined with moderate soft tissue density in the left supraclavicular region. (b,c,d) ultrasound(US) and doppler images of the pulsatile hematoma with inside arterial-type Doppler flow signal; a regular flow was found in the ipsilateral subclavian artery(d). Frontal plane image (e) of an Angio CT multi-planar-reconstruction (MPR) that shows enhanced FA of 8x5x6 cm with no evidence of clear signs of rupture, originating from the medial tract/middle third of the left subclavian artery after the origin of the ipsilateral vertebral artery.

Figure 2.

Different digital subtraction angiograms (DSA) performed via the right femoral artery access and catheterization of left subclavian artery. The images (a,b) shows the VBX-BE positioned with the proximal end distally to the level of the left vertebral artery before(a) and after dilation (b) with its pre-assembled balloon. The image (c) shows no complete FA exclusion after the first dilation of the device. The fluoroscopic images (d,e) show proximal portion stent-graft remodeling respectively with 10 and 12 mm balloon catheters. DSA image (f) obtained at the end of the procedure demonstrating no FA endoleak with adequate flow through the graft; at the same time this image shows patency of the subclavian artery distal to the stent graft and vertebral artery with exclusion of the ipsilateral internal mammary artery and thyrocervical trunk. (g) Frontal x-ray projection that shows fracture stabilization by positioning midshaft clavicle plate after the endovascular procedure.

Figure 3.

Digital angiography (DA) image (a) obtained by MDC injection from the left brachial arterial access that shows thrombotic occlusion of the device treated previous fibrinolytic catheter positiong (b). DSA image (c) reveals incomplete recanalization with thrombus adjacent to the wall of the stent after fibrinolytic therapy. Fluoroscopic image (d) that shows balloon angioplasty at the end of the fibrinolytic therapy and post control DA image (e) with evidence of almost complete patency of the stent without signs of FA endoleak. Frontal plane image (f) of Angio CT multi-planar-reconstruction (MPR) that shows circumscribed small caliber reduction at the stent outflow; (g) left antero-lateral 3D-image CT reconstruction and (h) frontal x-ray projection that prove the impingment by the clavicular bone synthesis plates on the stent. (i) Frontal x-ray projection obtained after orthopedic surgical revision of the plate with screws repositioning that reveals no apparent contiguity with the stent. (l,n,o) Different subtracted angiograms performed via the right femoral artery access and catheterization of left subclavian artery. The DSA image (l) shows the small VBX-BE outflow caliber reduction. After dilation with 8X40mm balloon (m) control DSA images (n,o) show respectively complete FA exclusion with adequate flow through the graft, and late onset of retrograde flow in the thyrocervical trunk.