Case Report A Case of Superior Vena Cava Syndrome Caused by a Ruptured Brachiocephalic Artery Aneurysm Kun Tae Ahn,1 Takashi Murakami,2 Mitsuhisa Kotani,1 Yuji Kato,1 and Masaaki Toyama,1 Chiba, Japan
An 84-year-old man was transferred to the emergency department for the treatment of shock. His upper body was swollen. Hematoma from the ruptured brachiocephalic artery aneurysm was compressing and obstructing the superior vena cava (SVC). A stent graft was deployed from the brachiocephalic artery to the right common carotid artery, and the proximal right subclavian artery was coil embolized. On postoperative day 5, when his neck swelling subsided and tracheal stenosis seemed resolved, the patient was extubated and the subsequent recovery was uneventful. He was discharged from the hospital on postoperative day 24. Although the stent grafting does not directly decompress the SVC by removing aneurysm and hematoma, it seems to be the treatment option for the morbid patients.
Superior vena cava (SVC) syndrome results from direct obstruction of the SVC. The main causes of SVC syndrome include malignant tumors such as bronchogenic carcinoma, lymphoma, and mediastinal metastases. A ruptured aneurysm of the brachiocephalic artery is an unusual cause of SVC syndrome. We report the case of a patient who experienced dramatic onset of SVC syndrome caused by acute expansion and contained rupture of a brachiocephalic artery aneurysm.
1 Department of Cardiovascular Surgery, Kameda Medical Center, Chiba, Japan. 2 Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Chiba, Japan.
Correspondence to: Kun Tae Ahn, MD, Department of Cardiovascular Surgery, Kameda Medical Center, 929 Higashi-cho Kamogawa City, Chiba 296-8602, Japan; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–4 http://dx.doi.org/10.1016/j.avsg.2014.03.004 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: November 13, 2013; manuscript accepted: March 3, 2014; published online: ---.
CASE REPORT The patient was an 84-year-old man who was transferred to our hospital for the treatment of shock. Three years before admission, a brachiocephalic artery aneurysm of 3 cm in diameter was detected but had not been followed up. Previous medical history included pacemaker implantation, slight dementia, and poor exercise tolerance. On arrival, he was conscious and did not have any neurologic deficit. Systolic blood pressure was 90 mm Hg with inotropes. On physical examination, upper body edema was obvious, along with distended jugular vein and prominent superficial veins on arms and thorax. The trachea was deviated to the left. On physical examination, the patient’s upper body was edematous. Jugular stasis was present along with evidence of venous collateral circulation in the upper limbs and upper part of the thorax. No other abnormalities were revealed by the physical examination. Serum tests for syphilis were negative. Electrocardiography was normal. Chest roentgenograms in the frontal projection showed widening of the mediastinum. A computed tomography (CT) scan revealed a ruptured brachiocephalic artery aneurysm measuring 9 cm in diameter. This aneurysmal rupture had resulted in a massive mediastinal hematoma that compressed and obstructed the SVC (Fig. 1).
1
2 Case Report
Fig. 1. A CT scan revealed a ruptured 9-cm diameter brachiocephalic artery aneurysm that was compressing and obstructing the SVC.
Emergent operation was performed. An incision of 5 cm was made along the anterior border of the right sternocleidomastoid muscle to expose the right common carotid artery. Twelve-French sheath was introduced toward the ascending aorta and 10 mm 70 mm stent graft (Leg of the Exlcuder; Gore Co., Flagstaff, AZ) was deployed from the origin of the brachiocephalic artery to the right common carotid artery. In addition, we coil embolized the right subclavian artery via the right brachial artery, and the aneurysm was completely excluded. On intubation, it was noted by the anesthesiologist that his upper airway was stenosed because of edema. Even after the operation, the upper body edema did not resolve promptly. His carotid pulses were palpable, normal, and symmetrical. No arm claudication was reported, and the brachial arterial pressures were unchanged from the preoperative levels. After 5 days, the neck and vocal cord edema resolved, and the patient was extubated. After the edema gradually subsided, the recovery was uneventful, with an 11-day intensive care unit stay and 24-day hospital stay. At our hospital, we administer, in principle, 2 types of antiplatelet agents for stent placement in the cervical arterial branches. However, because the patient was aged and high-risk surgical candidate, we administered aspirin alone as the antiplatelet agent postoperatively. In a CT performed 11 months after the operation, no aneurysm expansion in the brachiocephalic artery was found and the graft patency was maintained (Fig. 2).
DISCUSSION Aneurysms of the brachiocephalic artery occur rarely but can be potentially severe because of the possibility of rupture and compression of adjacent structures. These types of aneurysms represent 3% of arterial aneurysms.1
Annals of Vascular Surgery
Kieffer et al.2 proposed an anatomic classification of aneurysms of the brachiocephalic artery. The classification includes 3 groups based on the extent of the aneurysmal disease: group A, no involvement of the origin of brachiocephalic artery; group B, involvement of the origin of brachiocephalic artery but not of the aorta; and group C, involvement of the brachiocephalic artery and aorta. Group A aneurysms are rare. Our patient had a group A aneurysm. Endovascular aneurysm repair by stent graft is indicated in patients in group A, because a landing zone can be secured. However, for group C, treatment by endovascular aneurysm repair is difficult, as these patients also have ascending aortic aneurysm. When patients in group B are treated by endovascular aneurysm repair, use of the applicable therapeutic method for aortic arch aneurysm (chimney technique, branched stent graft, and so forth) is necessary. In 1983, Stolf et al.1 reported 3 cases of ruptured brachiocephalic artery aneurysms. In this report, Stolf said, ‘‘The only form of treatment for aneurysms of the innominate artery is operative intervention.’’ However, the strategy for the treatment of brachiocephalic artery aneurysms has since changed dramatically. Stent-graft implantation for the brachiocephalic artery has evolved as an effective and safe treatment techniques since the 1990s.3,4 The use of an endovascular stent constitutes a treatment option for a less invasive treatment option for aortic disease and may be considered an alternative to conventional surgical treatment. The advantages of endovascular treatment over surgical correction of aortic diseases include avoiding thoracotomy and cardiopulmonary bypass and minimizing the complications associated with an open procedure.5 However, to our knowledge, endovascular treatment has been mainly described in individual case reports, with limited follow-up periods (Table I). In our case, open repair with removal of hematoma was considered the treatment of choice to directly relieve the symptoms related to the SVC obstruction; however, the patient’s multiple comorbidities prompted us to adopt a more palliative endovascular approach. Although cerebral and right arm ischemia is a major concern, coverage of the right subclavian artery after stent-graft repair of aneurysms involving the distal portion of the brachiocephalic artery is usually well tolerated. In the present case, because communication between the right and left vertebral arteries was confirmed by the intraoperative angiogram, reconstruction of the right subclavian artery was considered unnecessary.
Vol.
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No.
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2014
Case Report 3
Fig. 2. Postoperative CT.
Table I. Follow-up study of endovascular repair for brachiocephalic artery aneurysm Author
Year
Type
Follow-up
Patency
Axisa et al.10 Puech-Leao and Orra11 Bush et al.12 Huang and Kao13 Angiletta et al.14
2000 2001 2002 2008 2012
Traumatic pseudoaneurysm True aneurysm Mycotic pseudoaneurysm Traumatic pseudoaneurysm True aneurysm due to Takayasu arteritis
18 months 21 months 6 months 1 year 8 years
O.K. O.K. O.K. O.K. O.K.
For selection of the stent-graft size, we select a stent graft that is w10e20% bigger in diameter than that of the landing zone in the artery. Because the brachiocephalic artery protruding the sacshaped aneurysm was 7 mm in diameter, a stent graft of 10 mm in diameter was selected. Nowadays, atherosclerosis is the most frequently cited etiology of the brachiocephalic artery aneurysm. Mycotic aneurysm, at one time more frequent because of the diffusion of syphilis, has decreased but not completely disappeared. Our patient was negative for syphilis tests and had no history of trauma. In addition, because he had no past history of diseases such as tuberculosis, Takayasu disease, Behcet disease, or connective tissue disorders, atherosclerosis was thought to be responsible for the aneurysm. SVC syndrome is characterized by a set of clinical signs and symptoms resulting from the obstruction of the SVC. The main causes include malignant tumors such as bronchogenic carcinoma, lymphoma, and mediastinal metastases. Lung cancer accounts for 80% of cases, mediastinal lymphomas for 15%
of cases, and other causes for 5% of cases.5 Acute compression and obstruction of the SVC is an unusual complication of isolated aneurysm with contained rupture of the brachiocephalic artery.6 Currently, endovascular stenting is frequently performed for SVC syndrome.7 However, the present patient did not undergo SVC stenting, because the patient had previously undergone pacemaker implantation. Although there have been some reports of percutaneous stent placement over permanent pacemaker wires in the treatment of SVC,8,9 the safety of the procedure is not established. Therefore, we chose a conservative approach. The patient’s symptoms resolved gradually, and he could be extubated within 5 days. We treated a case of SVC syndrome caused by a ruptured brachiocephalic artery aneurysm. Because the patient’s comorbidities precluded open repair, endovascular repair was chosen, leaving the hematoma compressing the SVC. Although the symptoms related to SVC syndrome persisted, they resolved in a week. Endovascular repair seemed to be a treatment option for the morbid patients.
4 Case Report
REFERENCES 1. Noedir AGS, Delmont B, Geraldo V, et al. Surgical treatment of ruptured aneurysms of the innominate artery. Ann Thorac Surg 1983;35:394e9. 2. Edouard K, Laurent C, Fabien K, et al. Aneurysms of the innominate artery: surgical treatment of 27 patients. J Vasc Surg 2001;34:222e8. 3. Queral LA, Criado FJ. The treatment of focal aortic arch branch lesions with Palmaz stents. J Vasc Surg 1996;23: 368e75. 4. Hadjipetrou P, Cox S, Piemonte T, et al. Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels. J Am Coll Cardiol 1999;33:1238e45. 5. Katsuro HJ, Rento GLB, Renata KBH. Aortic pseudoaneurysm as cause of superior vena cava syndrome: a case report. Rev Bras Cir Cardiovasc 2012;27:481e4. 6. James JM, Mark BK, Charles FB, et al. Superior vena cava syndrome caused by aneurysm of the innominate artery. Ann Thorac Surg 1995;59:227e9. 7. Jan MR, Jan AV, Wim JM, Wim JPB. Surgical management of superior vena cava syndrome after failed endovascular stenting. Interact CardioVasc Thorac Surg 2012;15:915e7.
Annals of Vascular Surgery
8. Suzanne MS, Charles PS, Daniel YS, et al. Placement of SVC stents over pacemaker wires for the treatment of SVC syndrome. J Vasc Interv Radiol 2000;215e9. 9. Garcia-San R K. Percutaneous treatment of superior vena cava syndrome after pacemakers electrodes implantation and/or surgical correction of congenital heart disease. Rev Esp Cardiol 2012;65:965e7. 10. Axisa BM, Loftus IM, Fishwick G, et al. Endovascular repair of an innominate artery false aneurysm following blunt trauma. J Endovasc Ther 2000;7:245e50. 11. Puech-Leao P, Orra HA. Endovascular repair of an innominate artery true aneurysm. J Endovasc Ther 2001;8:429e32. 12. Bush RL, Hurt JE, Bianco CC. Endovascular management of a ruptured mycotic aneurysm of the innominate artery. Ann Thorac Surg 2002;74:2184e6. 13. Huang CL, Kao HL. Endovascular management of posttraumatic innominate artery transection with pseudoaneurysm formation. Catheter Cardiovasc Interv 2008;72: 569e72. 14. Angiletta D, Marinazzo D, Guido G, et al. Eight-year followup of endovascular repair of a brachiocephalic trunk aneurysm due to Takayasu’s arteritis. J Vasc Surg 2012;56: 504e7.
An 84-year-old man was transferred to the emergency department for the treatment of shock. His upper body was swollen. Hematoma from the ruptured brachiocephalic artery aneurysm was compressing and obstructing the superior vena cava (SVC). A stent graft was deployed from the brachiocephalic artery to the right common carotid artery, and the proximal right subclavian artery was coil embolized. On postoperative day 5, when his neck swelling subsided and tracheal stenosis seemed resolved, the patient was extubated and the subsequent recovery was uneventful. He was discharged from the hospital on postoperative day 24. Although the stent grafting does not directly decompress the SVC by removing aneurysm and hematoma, it seems to be the treatment option for the morbid patients.
Superior vena cava (SVC) syndrome results from direct obstruction of the SVC. The main causes of SVC syndrome include malignant tumors such as bronchogenic carcinoma, lymphoma, and mediastinal metastases. A ruptured aneurysm of the brachiocephalic artery is an unusual cause of SVC syndrome. We report the case of a patient who experienced dramatic onset of SVC syndrome caused by acute expansion and contained rupture of a brachiocephalic artery aneurysm.
1 Department of Cardiovascular Surgery, Kameda Medical Center, Chiba, Japan. 2 Department of Cardiovascular Surgery, Chiba-Nishi General Hospital, Chiba, Japan.
Correspondence to: Kun Tae Ahn, MD, Department of Cardiovascular Surgery, Kameda Medical Center, 929 Higashi-cho Kamogawa City, Chiba 296-8602, Japan; E-mail: [email protected] Ann Vasc Surg 2014; -: 1–4 http://dx.doi.org/10.1016/j.avsg.2014.03.004 Ó 2014 Elsevier Inc. All rights reserved. Manuscript received: November 13, 2013; manuscript accepted: March 3, 2014; published online: ---.
CASE REPORT The patient was an 84-year-old man who was transferred to our hospital for the treatment of shock. Three years before admission, a brachiocephalic artery aneurysm of 3 cm in diameter was detected but had not been followed up. Previous medical history included pacemaker implantation, slight dementia, and poor exercise tolerance. On arrival, he was conscious and did not have any neurologic deficit. Systolic blood pressure was 90 mm Hg with inotropes. On physical examination, upper body edema was obvious, along with distended jugular vein and prominent superficial veins on arms and thorax. The trachea was deviated to the left. On physical examination, the patient’s upper body was edematous. Jugular stasis was present along with evidence of venous collateral circulation in the upper limbs and upper part of the thorax. No other abnormalities were revealed by the physical examination. Serum tests for syphilis were negative. Electrocardiography was normal. Chest roentgenograms in the frontal projection showed widening of the mediastinum. A computed tomography (CT) scan revealed a ruptured brachiocephalic artery aneurysm measuring 9 cm in diameter. This aneurysmal rupture had resulted in a massive mediastinal hematoma that compressed and obstructed the SVC (Fig. 1).
1
2 Case Report
Fig. 1. A CT scan revealed a ruptured 9-cm diameter brachiocephalic artery aneurysm that was compressing and obstructing the SVC.
Emergent operation was performed. An incision of 5 cm was made along the anterior border of the right sternocleidomastoid muscle to expose the right common carotid artery. Twelve-French sheath was introduced toward the ascending aorta and 10 mm 70 mm stent graft (Leg of the Exlcuder; Gore Co., Flagstaff, AZ) was deployed from the origin of the brachiocephalic artery to the right common carotid artery. In addition, we coil embolized the right subclavian artery via the right brachial artery, and the aneurysm was completely excluded. On intubation, it was noted by the anesthesiologist that his upper airway was stenosed because of edema. Even after the operation, the upper body edema did not resolve promptly. His carotid pulses were palpable, normal, and symmetrical. No arm claudication was reported, and the brachial arterial pressures were unchanged from the preoperative levels. After 5 days, the neck and vocal cord edema resolved, and the patient was extubated. After the edema gradually subsided, the recovery was uneventful, with an 11-day intensive care unit stay and 24-day hospital stay. At our hospital, we administer, in principle, 2 types of antiplatelet agents for stent placement in the cervical arterial branches. However, because the patient was aged and high-risk surgical candidate, we administered aspirin alone as the antiplatelet agent postoperatively. In a CT performed 11 months after the operation, no aneurysm expansion in the brachiocephalic artery was found and the graft patency was maintained (Fig. 2).
DISCUSSION Aneurysms of the brachiocephalic artery occur rarely but can be potentially severe because of the possibility of rupture and compression of adjacent structures. These types of aneurysms represent 3% of arterial aneurysms.1
Annals of Vascular Surgery
Kieffer et al.2 proposed an anatomic classification of aneurysms of the brachiocephalic artery. The classification includes 3 groups based on the extent of the aneurysmal disease: group A, no involvement of the origin of brachiocephalic artery; group B, involvement of the origin of brachiocephalic artery but not of the aorta; and group C, involvement of the brachiocephalic artery and aorta. Group A aneurysms are rare. Our patient had a group A aneurysm. Endovascular aneurysm repair by stent graft is indicated in patients in group A, because a landing zone can be secured. However, for group C, treatment by endovascular aneurysm repair is difficult, as these patients also have ascending aortic aneurysm. When patients in group B are treated by endovascular aneurysm repair, use of the applicable therapeutic method for aortic arch aneurysm (chimney technique, branched stent graft, and so forth) is necessary. In 1983, Stolf et al.1 reported 3 cases of ruptured brachiocephalic artery aneurysms. In this report, Stolf said, ‘‘The only form of treatment for aneurysms of the innominate artery is operative intervention.’’ However, the strategy for the treatment of brachiocephalic artery aneurysms has since changed dramatically. Stent-graft implantation for the brachiocephalic artery has evolved as an effective and safe treatment techniques since the 1990s.3,4 The use of an endovascular stent constitutes a treatment option for a less invasive treatment option for aortic disease and may be considered an alternative to conventional surgical treatment. The advantages of endovascular treatment over surgical correction of aortic diseases include avoiding thoracotomy and cardiopulmonary bypass and minimizing the complications associated with an open procedure.5 However, to our knowledge, endovascular treatment has been mainly described in individual case reports, with limited follow-up periods (Table I). In our case, open repair with removal of hematoma was considered the treatment of choice to directly relieve the symptoms related to the SVC obstruction; however, the patient’s multiple comorbidities prompted us to adopt a more palliative endovascular approach. Although cerebral and right arm ischemia is a major concern, coverage of the right subclavian artery after stent-graft repair of aneurysms involving the distal portion of the brachiocephalic artery is usually well tolerated. In the present case, because communication between the right and left vertebral arteries was confirmed by the intraoperative angiogram, reconstruction of the right subclavian artery was considered unnecessary.
Vol.
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No.
-, -
2014
Case Report 3
Fig. 2. Postoperative CT.
Table I. Follow-up study of endovascular repair for brachiocephalic artery aneurysm Author
Year
Type
Follow-up
Patency
Axisa et al.10 Puech-Leao and Orra11 Bush et al.12 Huang and Kao13 Angiletta et al.14
2000 2001 2002 2008 2012
Traumatic pseudoaneurysm True aneurysm Mycotic pseudoaneurysm Traumatic pseudoaneurysm True aneurysm due to Takayasu arteritis
18 months 21 months 6 months 1 year 8 years
O.K. O.K. O.K. O.K. O.K.
For selection of the stent-graft size, we select a stent graft that is w10e20% bigger in diameter than that of the landing zone in the artery. Because the brachiocephalic artery protruding the sacshaped aneurysm was 7 mm in diameter, a stent graft of 10 mm in diameter was selected. Nowadays, atherosclerosis is the most frequently cited etiology of the brachiocephalic artery aneurysm. Mycotic aneurysm, at one time more frequent because of the diffusion of syphilis, has decreased but not completely disappeared. Our patient was negative for syphilis tests and had no history of trauma. In addition, because he had no past history of diseases such as tuberculosis, Takayasu disease, Behcet disease, or connective tissue disorders, atherosclerosis was thought to be responsible for the aneurysm. SVC syndrome is characterized by a set of clinical signs and symptoms resulting from the obstruction of the SVC. The main causes include malignant tumors such as bronchogenic carcinoma, lymphoma, and mediastinal metastases. Lung cancer accounts for 80% of cases, mediastinal lymphomas for 15%
of cases, and other causes for 5% of cases.5 Acute compression and obstruction of the SVC is an unusual complication of isolated aneurysm with contained rupture of the brachiocephalic artery.6 Currently, endovascular stenting is frequently performed for SVC syndrome.7 However, the present patient did not undergo SVC stenting, because the patient had previously undergone pacemaker implantation. Although there have been some reports of percutaneous stent placement over permanent pacemaker wires in the treatment of SVC,8,9 the safety of the procedure is not established. Therefore, we chose a conservative approach. The patient’s symptoms resolved gradually, and he could be extubated within 5 days. We treated a case of SVC syndrome caused by a ruptured brachiocephalic artery aneurysm. Because the patient’s comorbidities precluded open repair, endovascular repair was chosen, leaving the hematoma compressing the SVC. Although the symptoms related to SVC syndrome persisted, they resolved in a week. Endovascular repair seemed to be a treatment option for the morbid patients.
4 Case Report
REFERENCES 1. Noedir AGS, Delmont B, Geraldo V, et al. Surgical treatment of ruptured aneurysms of the innominate artery. Ann Thorac Surg 1983;35:394e9. 2. Edouard K, Laurent C, Fabien K, et al. Aneurysms of the innominate artery: surgical treatment of 27 patients. J Vasc Surg 2001;34:222e8. 3. Queral LA, Criado FJ. The treatment of focal aortic arch branch lesions with Palmaz stents. J Vasc Surg 1996;23: 368e75. 4. Hadjipetrou P, Cox S, Piemonte T, et al. Percutaneous revascularization of atherosclerotic obstruction of aortic arch vessels. J Am Coll Cardiol 1999;33:1238e45. 5. Katsuro HJ, Rento GLB, Renata KBH. Aortic pseudoaneurysm as cause of superior vena cava syndrome: a case report. Rev Bras Cir Cardiovasc 2012;27:481e4. 6. James JM, Mark BK, Charles FB, et al. Superior vena cava syndrome caused by aneurysm of the innominate artery. Ann Thorac Surg 1995;59:227e9. 7. Jan MR, Jan AV, Wim JM, Wim JPB. Surgical management of superior vena cava syndrome after failed endovascular stenting. Interact CardioVasc Thorac Surg 2012;15:915e7.
Annals of Vascular Surgery
8. Suzanne MS, Charles PS, Daniel YS, et al. Placement of SVC stents over pacemaker wires for the treatment of SVC syndrome. J Vasc Interv Radiol 2000;215e9. 9. Garcia-San R K. Percutaneous treatment of superior vena cava syndrome after pacemakers electrodes implantation and/or surgical correction of congenital heart disease. Rev Esp Cardiol 2012;65:965e7. 10. Axisa BM, Loftus IM, Fishwick G, et al. Endovascular repair of an innominate artery false aneurysm following blunt trauma. J Endovasc Ther 2000;7:245e50. 11. Puech-Leao P, Orra HA. Endovascular repair of an innominate artery true aneurysm. J Endovasc Ther 2001;8:429e32. 12. Bush RL, Hurt JE, Bianco CC. Endovascular management of a ruptured mycotic aneurysm of the innominate artery. Ann Thorac Surg 2002;74:2184e6. 13. Huang CL, Kao HL. Endovascular management of posttraumatic innominate artery transection with pseudoaneurysm formation. Catheter Cardiovasc Interv 2008;72: 569e72. 14. Angiletta D, Marinazzo D, Guido G, et al. Eight-year followup of endovascular repair of a brachiocephalic trunk aneurysm due to Takayasu’s arteritis. J Vasc Surg 2012;56: 504e7.
