CASE 9705 Published on 09.12.2011

Unusual lesion of the left subclavian artery and unusual endovascular repair


Interventional radiology

Case Type

Clinical Cases


Fabio Pozzi Mucelli, Sandro Pulvirenti, William Toscano, Stefano Cernic, Maria Cova

Struttura Complessa di Radiologia,
Az. Ospedaliero-Universitaria
Ospedali Riuniti di Trieste, Italy;

70 years, male

Area of Interest Cardiovascular system, Thorax, Arteries / Aorta ; Imaging Technique Catheter arteriography, Conventional radiography, CT-Angiography
Clinical History
70-year-old, male, smoker, recent haemoptysis. Plain-film shows left mediastinic enlargement (Fig. 1a) confirmed by PET-CT (left hypercaptating paramediastinic mass suggestive for lung tumour). CT-angiography did not confirm neoplastic nature, however, showed a large left subclavian artery aneurysm (SAA), partially thrombosed (Fig. 1a). Surgery was considered contraindicated for poor general condition; endovascular treatment was attempted.
Imaging Findings
Double femoral approach was done (left side: 7F sheath; right side: 10F). Preliminary angiogram confirmed the left SAA at the origin (Fig. 1b). Distally to the aneurysm the artery was occluded and recanalised through ipsilateral vertebral artery. The aneurysm was catheterised with a 5F catheter while using the contralateral approach a large (28x100mm) self-expandable bare-stent (Sinus-XL-Optimed) was advanced and deployed with distal markers at the origin of brachio-cephalic trunk (Fig. 2a). Once deployed the stent the aneurysm was filled with coils (MReye-Cook) for a total of 200cm of coils.
Final check shows good filling of the sac and correct stent position (Fig. 2b, c). Both femoral accesses were closed using an Angioseal 8F device (see case n.9702). At the end of procedure patient reported aphasia which resolved spontaneously in few days. CT done one month later shows almost complete filling of the sac and regular flow through the stent (Fig. 3).
The most common aetiology of SAAs is atherosclerosis, constituting of approximately 60% of the reported causes, followed by infectious aneurysms (syphilis, tuberculosis, mycotic, or bacterial infections). Congenital arterial anomalies, such as Marfan syndrome and cystic medial necrosis, constituted 10% of the causes. Among recent reports, it was found that true SAAs in intrathoracic lesions were mainly due to atherosclerosis, whereas in the case of extrathoracic lesions, thoracic outlet syndrome was the main cause of SAAs [1, 2]. A differential diagnosis to consider is penetrating aortic ulcer; however, usually this is located in a more distal location [3]. This case has not a definite diagnosis: PET-CT suggests a neoplastic origin, however, no neoplastic cells were found at cytologic evaluation during broncoscopy and the short follow-up available does not show significant progression of the lesion. Nevertheless we believe this case is original for the modality of treatment proposed. Surgery was considered contraindicated for general condition but due to repeated haemoptysis episodes a treatment of the SAA was considered mandatory. The first option was a custom-made stent-graft deployment with a "scalop" in the site of the brachiocephalic trunk [4], however, the landing zone was too short and the company producing these stent-grafts refused the case. For this reason we decided to adopt a sort of "jailing technique" derived from neuroradiologic endovascular techniques of intracranial aneurysm embolisation [5]. In cases of wide-neck intracranial aneurysm different options are available: a stent is deployed at the level of the neck to avoid the risk of coils protrusion into the parent vessel. After stent deployment a microcatheter is advanced though the mesh of the stent and "coiling" of the aneurysm is obtained ("stent through" technique). The other option is to advance the microcatheter in the sac before stent deployment. Once in the sac the stent is deployed in the parent vessel and microcatheter is stabilised and coiling of the sac can be performed. This technique is named "jailing technique". We decided to use in this case the same technique. To our knowledge we didn't find other reports of SAA treated in this way. The only disappointing aspect observed is low flexibility of the self-expandable stent with a kinking in the central part (Fig. 3b). Maybe the stent chosen was too long for this lesion. A further follow-up is scheduled at 6 months.
Differential Diagnosis List
Endovascular treatment of left subclavian artery pseudoaneurysm
Penetrating aortic ulcer
Final Diagnosis
Endovascular treatment of left subclavian artery pseudoaneurysm
Case information
DOI: 10.1594/EURORAD/CASE.9705
ISSN: 1563-4086