Save
Download PDF

A 36-year-old man with a history of hypertension presented with sudden-onset dyspnea and chest pain. He reported no trauma, headache, or transient ischemic attack. His blood pressures were 140/100 mmHg (right arm) and 132/100 mmHg (left arm). A chest radiograph showed bilateral soft-tissue opacities in the superior mediastinum (Fig. 1). A bruit was heard over the right subclavian artery (SCA). The bilateral lower-limb pulses were barely palpable. An electrocardiogram indicated no acute coronary syndrome.

Fig. 1. Chest radiograph shows 2 dense soft-tissue opacities (arrows) causing widening of the superior mediastinum.Fig. 1. Chest radiograph shows 2 dense soft-tissue opacities (arrows) causing widening of the superior mediastinum.Fig. 1. Chest radiograph shows 2 dense soft-tissue opacities (arrows) causing widening of the superior mediastinum.
Fig. 1. Chest radiograph shows 2 dense soft-tissue opacities (arrows) causing widening of the superior mediastinum.

Citation: Texas Heart Institute Journal 44, 5; 10.14503/THIJ-15-5413

Cross-sectional imaging was performed. Multislice computed tomographic and magnetic resonance angiograms showed large fusiform bilateral SCA aneurysms causing a mass effect upon the trachea, with evidence of a dissection flap in the right SCA (Fig. 2). A left middle cerebral artery aneurysm was seen at the bifurcation (Fig. 3). Tight aortic coarctation with mild poststenotic dilation was noted at the origin of the left SCA (Fig. 4).

Fig. 2. A) Computed tomographic and B) magnetic resonance angiograms show bilateral fusiform subclavian artery aneurysms (An) compressing the trachea (*) with evidence of a dissection flap in the right subclavian artery (arrows).Fig. 2. A) Computed tomographic and B) magnetic resonance angiograms show bilateral fusiform subclavian artery aneurysms (An) compressing the trachea (*) with evidence of a dissection flap in the right subclavian artery (arrows).Fig. 2. A) Computed tomographic and B) magnetic resonance angiograms show bilateral fusiform subclavian artery aneurysms (An) compressing the trachea (*) with evidence of a dissection flap in the right subclavian artery (arrows).
Fig. 2. A) Computed tomographic and B) magnetic resonance angiograms show bilateral fusiform subclavian artery aneurysms (An) compressing the trachea (*) with evidence of a dissection flap in the right subclavian artery (arrows).

Citation: Texas Heart Institute Journal 44, 5; 10.14503/THIJ-15-5413

Fig. 3. A) Coronal computed tomographic and B) magnetic resonance time-of-flight angiograms show a left middle cerebral artery (MCA) aneurysm (*) at the branching point.Fig. 3. A) Coronal computed tomographic and B) magnetic resonance time-of-flight angiograms show a left middle cerebral artery (MCA) aneurysm (*) at the branching point.Fig. 3. A) Coronal computed tomographic and B) magnetic resonance time-of-flight angiograms show a left middle cerebral artery (MCA) aneurysm (*) at the branching point.
Fig. 3. A) Coronal computed tomographic and B) magnetic resonance time-of-flight angiograms show a left middle cerebral artery (MCA) aneurysm (*) at the branching point.

Citation: Texas Heart Institute Journal 44, 5; 10.14503/THIJ-15-5413

Fig. 4. A) Magnetic resonance angiogram and B) postoperative volume-rendered computed tomogram show tight juxtaductal coarctation of the aorta (arrows). / DA = descending aorta; LSCA = left subclavian arteryFig. 4. A) Magnetic resonance angiogram and B) postoperative volume-rendered computed tomogram show tight juxtaductal coarctation of the aorta (arrows). / DA = descending aorta; LSCA = left subclavian arteryFig. 4. A) Magnetic resonance angiogram and B) postoperative volume-rendered computed tomogram show tight juxtaductal coarctation of the aorta (arrows). / DA = descending aorta; LSCA = left subclavian artery
Fig. 4. A) Magnetic resonance angiogram and B) postoperative volume-rendered computed tomogram show tight juxtaductal coarctation of the aorta (arrows). DA = descending aorta; LSCA = left subclavian artery

Citation: Texas Heart Institute Journal 44, 5; 10.14503/THIJ-15-5413

To relieve the patient's respiratory distress, we resected the right SCA aneurysm and performed graft repair. Further surgery was planned to repair the coarctation and resect the left SCA aneurysm.

Comment

Among patients with peripheral aneurysms, the prevalence of SCA aneurysms is 1%.1 The chief causes are atherosclerosis1 and thoracic outlet syndrome2; rarer causes are infection and trauma.3 Extrathoracic aneurysms present as pulsatile masses, whereas intrathoracic aneurysms cause compressive symptoms. The aneurysms can rupture or cause thromboembolization. Surgery is recommended, especially in patients who present with obstructive symptoms.3 The association between intracranial aneurysms and aortic coarctation has been described4; hypertension and hemodynamic changes in cerebral perfusion are possible causes.5

Authors have reported unilateral SCA aneurysm with aortic coarctation,6 aneurysms of congenital cause,7 and bilateral SCA aneurysms associated with aortic pseudocoarctation.8 To our knowledge, ours is the first report of the triad of bilateral SCA aneurysms, intracranial aneurysm, and true coarctation of the aorta. We suggest that patients who present with SCA aneurysm also be examined for associated aneurysms and aortic coarctation.

References

  • 1.

    Witz M
    ,
    YahelJ
    ,
    LehmannJM.
    Subclavian artery aneurysms. A report of 2 cases and a review of the literature. J Cardiovasc Surg1998;39(
    4
    ):429–32.

  • 2.

    Davidovic LB
    ,
    MarkovicDM
    ,
    PejkicSD
    ,
    KovacevicNS
    ,
    ColicMM
    ,
    DoricPM.
    Subclavian artery aneurysms. Asian J Surg2003;26(
    1
    ):7–12.

  • 3.

    Bin HG
    ,
    KimMS
    ,
    KimSC
    ,
    KeunJB
    ,
    LeeJH
    ,
    KimSS.
    Intrathoracic aneurysm of the right subclavian artery presenting with hoarseness: a case report. J Korean Med Sci2005;20(
    4
    ):674–6.

  • 4.

    Connolly HM
    ,
    HustonJ3rd
    ,
    BrownRDJr
    ,
    WarnesCA
    ,
    AmmashNM
    ,
    TajikAJ.
    Intracranial aneurysms in patients with coarctation of the aorta: a prospective magnetic resonance angiographic study of 100 patients. Mayo Clin Proc2003;78(
    12
    ):1491–9.

  • 5.

    Singh PK
    ,
    MarzoA
    ,
    StaicuC
    ,
    WilliamMG
    ,
    WilkinsonI
    ,
    LawfordPV
    , et al. The effects of aortic coarctation on cerebral hemodynamics and its importance in the etiopathogenesis of intracranial aneurysms. J Vasc Interv Neurol2010;3(
    1
    ):17–30.

  • 6.

    Inan K
    ,
    GokselOS
    ,
    AlpI
    ,
    ErdenT
    ,
    UsMH
    ,
    YilmazAT.
    Coarctation of the aorta associated with left subclavian artery aneurysm: a case report. Heart Surg Forum2007;10(
    3
    ):E175–6.

  • 7.

    Stahl RD
    ,
    LawrencePF
    ,
    BhirangiK.
    Left subclavian artery aneurysm: two cases of rare congenital etiology. J Vasc Surg1999;29(
    4
    ):715–8.

  • 8.

    Argotte AF
    ,
    GironF
    ,
    BilfingerTV.
    Bilateral subclavian artery aneurysms with pseudocoarctation of the aorta. Case report and review of the literature. J Cardiovasc Surg (Torino)1998;39(
    6
    ):747–50.

  • Download PDF
Fig. 1.
Fig. 1.

Chest radiograph shows 2 dense soft-tissue opacities (arrows) causing widening of the superior mediastinum.

Fig. 2.
Fig. 2.

A) Computed tomographic and B) magnetic resonance angiograms show bilateral fusiform subclavian artery aneurysms (An) compressing the trachea (*) with evidence of a dissection flap in the right subclavian artery (arrows).

Fig. 3.
Fig. 3.

A) Coronal computed tomographic and B) magnetic resonance time-of-flight angiograms show a left middle cerebral artery (MCA) aneurysm (*) at the branching point.

Fig. 4.
Fig. 4.

A) Magnetic resonance angiogram and B) postoperative volume-rendered computed tomogram show tight juxtaductal coarctation of the aorta (arrows).

DA = descending aorta; LSCA = left subclavian artery

Contributor Notes

Section Editor: Raymond F. Stainback, MD, Department of Adult Cardiology, Texas Heart Institute, 6624 Fannin St., Suite 2480, Houston, TX 77030

From: Department of Cardiac Radiology, All India Institute of Medical Sciences, New Delhi 110029, India

Address for reprints: Priya Jagia, MD, Department of Cardiac Radiology, Cardiothoracic Sciences Centre, AIIMS, New Delhi 110029, India, E-mail: drpjagia@yahoo.com