Endovascular Repair of an Axillary Artery Aneurysm: A Novel Approach

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1 Endovascular Repair of an Axillary Artery Aneurysm: A Novel Approach Bao- Thuy D. Hoang, MD 1, Jonathan- Hien Vu, MD 2, Jerry Matteo, MD 3 1 Department of Surgery, University of Florida College of Medicine, Jacksonville, FL USA 2 Department of Vascular Therapy, Colorado Permanente Medical Group, Denver, CO USA 3 Division of Interventional Radiology, Department of Radiology, University of Florida College of Medicine, Jacksonville, FL USA Introduction Axillary aneurysm has been reported to occur from trauma, infection, atherosclerosis, iatrogenic, and genetic diseases such as Marfan s syndrome. Axillary artery aneurysms can thrombose, rupture, or cause mass effect- like symptoms on the adjacent neurovascular structures [1,2,3]. Therefore, an axillary artery aneurysm can potentially cause limb ischemia via compromised blood flow or threaten life secondary to rupture and hemorrhage. Case Report The patient is an 88 year- old female with a past medical history of hypertension and atrial fibrillation who presented to our Emergency Department with several days of worsening left arm pain and dyspnea. Physical examination showed symmetric non- palpable distal pulses in all four extremities and cyanosis of the distal left third finger. Initial thoracic CT angiogram showed bilateral axillary artery aneurysms, measuring 3.6 cm on the left and 3 cm on the right [Fig 1] in addition to bilateral pulmonary embolism [Fig 2]. The left side demonstrated flow within the axillary artery aneurysm. Angiography confirmed complete occlusion of the right axillary aneurysm with collateral reconstitution to the proximal right brachial artery [Fig 3]. Due to her overall medical co- morbidities and embolic complication related to the left axillary artery aneurysm, a decision was made to repair the left axillary artery aneurysm with endovascular stent grafts. Procedure Initially, a cutdown of the mid left brachial artery was performed in the usual manner. Hand contrast injection demonstrated a focal segment of severe stenosis at the proximal left brachial artery, just distal to a large left axillary artery aneurysm [Fig 4]. The brachial artery stenosis and axillary artery aneurysm were successfully crossed with a 4 French directional catheter and an angled glide wire combination. An 11- French Terumo Pinnacle Destination vascular sheath was placed into the brachial artery. First, a Viabahn s endoprosthetic stent (W. L. Gore and Assoc, Flagstaff, AZ) was placed across the proximal brachial artery stenosis and angioplastied. In a sequential and retrograde manner, a Viabahn s stent was deployed in the axillary aneurysm with 4 cm of overlap with the first stent. Finally, a Gore Excluder contralateral limb endograft (W. L. Gore and Assoc, Flagstaff, AZ) was deployed, with the proximal end of this stent graft positioned just distal to the origin of the internal mammary artery, and also with 10 mm Viabahn s stent distally. All the stents and overlapping regions were again angioplastied. A final angiogram showed that all the stents were widely patent and the left axillary aneurysm was completely excluded with no endoleak [Fig 5]. Postoperatively, the patient had a palpable left distal radial pulse and her immediate postoperative course was uneventful. At two months follow up, she has complete resolution of her left third finger cyanosis. Follow- up three month CT angiogram of the chest showed patent left axillary stents without endoleak [Fig 6]. Discussion True aneurysm of the axillary artery is rare. The first reported repair of axillary aneurysms was in 1836 with the ligation of the third portion of the subclavian artery [4]. Since then, the predominant treatment of axillary aneurysms has been open repair with bypass graft and ligation or resection of the aneurysm. However, open surgical repair is not without

2 significant complications including greater blood loss, higher risk of wound infection and graft infection, and injury to nearby brachial plexuses [5]. The advent of more sophisticated stent grafts has made endovascular repair of peripheral vascular aneurysms a reliable treatment option [5]. Endovascular repair of an axillary aneurysm can be performed through either a transbrachial or femoral route. We believe a complete transbrachial approach is better and has many advantages. It allows a more precise placement of the most critical proximal position of the endograft and thus prevents inadvertent covering of the vertebral or internal mammary arteries. It allows the larger diameter end of the Gore endograft limb to be placed proximally in the subclavian artery and the distal end, if needed, to be tapered into the smaller brachial artery as in our case. It allows direct access to the aneurysm in the event that the procedure needs to be converted to an open repair. Unfortunately, long- term outcomes of endovascular repair of axillary aneurysm remain unknown. Endovascular repair of axillary artery aneurysm is, however, a viable option and should be reserved for patients who are poor surgical candidates with complications related to the aneurysm. Conclusion Endovascular repair of axillary aneurysm, from a brachial artery cutdown approach, is feasible and a safe alternative treatment with minimal postoperative morbidities. References 1. Troutman DA, Mohan CR, Samhouri FA, Sohn RL. Open repair and endovascular covered stent placement in the management of bilateral axillary artery aneurysms. Vascular and Endovascular Surgery 2010; 44: Vijayvergiya R, Kumar RM, Ranjit A, Grover A. Endovascular management of isolated axillary artery aneurysm: A case report. Vascular and Endovascular Surgery 2005; 39: Rose JF, Lucas LC, Bui TD, Mills JL. Endovascular treatment of ruptured axillary and large internal mammary artery aneurysms in a patient with Marfan syndrome. Journal of Vascular Surgery 2011; 53: Godlee RJ. A case of ligature of the second part of the left subclavian artery for the cure of an axillary aneurysm. Medico- Chirugical Transactions 1892; 75: Onal B, Ilgit ET, Kosar S, Akkan K, Gumus T, Akpek S. Endovascular treatment of peripheral vascular lesions with stent- grafts. Diagnostic Interventional Radiology 2005; 11:

3 Fig 1. CTA of the chest in axial views shows left (A) and right (B) axillary aneurysms (arrow). The right axillary aneurysm is thrombosed and contrast enhancement is seen within the left sided aneurysm. Fig 2. CTA of the chest in axial view shows filling defects (arrows) within the right main pulmonary artery and within a left segmental pulmonary artery branch consistent with pulmonary embolism.

4 Fig 3. Initial diagnostic angiogram confirms a thrombosed right axillary aneurysm (A) (arrow) with collaterals (B) (arrow) reconstituting the proximal brachial artery (C) (arrow).

5 Fig 4. Intraoperative angiography (A & B) shows a very tortuous subclavian artery, a large left axillary aneurysm with a short segment of severe stenosis in the proximal brachial artery (arrow).

6 Fig 5. Final angiogram showing widely patent stents with complete exclusion of the left axillary artery aneurysm and no endoleak. Fig 6. Three- month follow- up angiogram showing patent left axillary artery stents (arrow) with no progression of aneurysm or endoleak.

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