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Asymptomatic Aneurysm of the Subclavian Vein
Abstract
Venous aneurysms are rare entities whose etiology remains unknown. We report an incidental observation of an asymptomatic, saccular aneurysm of the subclavian vein and discuss the possible origin and clinical impact, with special remarks on venous interventions.
... Upper extremity venous aneurysms and aneurysms of the neck region are rare, unlike the lower extremity venous aneurysms [1]. Only a few cases of venous aneurysms of the upper extremities are described in the literature [2][3][4]. Contrary to lower extremity venous aneurysms, they are mostly asymptomatic and have mild complications [5]. Clinically, they are mostly painless non-pulsatile masses in the neck region that increase with Valsalva maneuver [1]. ...
... There is currently no clear treatment protocol for venous aneurysms of the upper extremities and neck region. According to the available literature, some authors [3][4][5]12] surgically treated aneurysms, while in a small number of cases they were treated con-servatively [4]. Aneurysm resection theoretically eliminates the risk of serious complications, such as rupture and embolization. ...
Introduction. Upper extremity venous aneurysms and aneurysms of the neck are rare, unlike the lower extremity venous aneurysms. Only a few cases of upper extremity venous aneurysms have been described in the literature. The aim of the study was to find the best way to treat upper extremity venous aneurysms and the aneurysms of the neck region. Case Report. A 40-year-old female patient reported to the Emergency Center due to the swelling in the supraclavicular region. Color Doppler ultrasonography was performed and a saccular subclavian aneurysm was found, at the junction with the internal jugular vein, with signs of rupture presenting with locoregional hematoma spillage measuring 19 x 13 mm. Complete laboratory tests were performed, followed by computed tomography phlebography, where a partially thrombosed aneurysm was described in the angle between the internal jugular vein and subclavian vein, with a maximum diameter of 25 mm. The patient was hospitalized and treated conservatively. Six days after the onset of symptoms, magnetic resonance phlebography was performed, which did not show the previously described aneurysm of the left venous angle. Three months after the onset of symptoms, a control magnetic resonance phlebography was performed, which showed an aneurysm in the region of the junction of the left internal jugular vein and subclavian vein again, with a maximum diameter of 20 x 13 mm. Conclusion. Clinical examination and color Doppler ultrasound should certainly be the first-line of diagnosis, while magnetic resonance phlebography and computed tomography phlebography are the gold standard for aneurysm monitoring. Asymptomatic aneurysms and aneurysms with mild symptoms are best treated conservatively.
... A review of the literature revealed four reported cases of subclavian vein aneurysms. 2,[11][12][13] Two were asymptomatic and discovered incidentally, 11,12 whereas one presented as a symptomatic supraclavicular mass without a prior history of trauma. 2 Only one was a post-traumatic subclavian vein pseudoaneurysm that followed minor trauma to the shoulder, which was managed by surgical excision and patching of the defective vein. 13 Once a venous aneurysm is discovered, the initial diagnostic evaluation includes duplex ultrasonography, followed by CT with arterial and venous phases to delineate the exact anatomy. ...
... A review of the literature revealed four reported cases of subclavian vein aneurysms. 2,[11][12][13] Two were asymptomatic and discovered incidentally, 11,12 whereas one presented as a symptomatic supraclavicular mass without a prior history of trauma. 2 Only one was a post-traumatic subclavian vein pseudoaneurysm that followed minor trauma to the shoulder, which was managed by surgical excision and patching of the defective vein. 13 Once a venous aneurysm is discovered, the initial diagnostic evaluation includes duplex ultrasonography, followed by CT with arterial and venous phases to delineate the exact anatomy. ...
Subclavian and upper extremity venous pseudoaneurysms are rare and poorly understood. We present the case of a 45-year-old woman with a right subclavian vein pseudoaneurysm that formed after blunt trauma to the upper chest and shoulder. The patient was managed successfully with surgical excision through a supraclavicular approach. The case report is followed by a discussion on the etiology, clinical presentation, and management of venous pseudoaneurysms.
... In our review of the literature, we found reports of only three patients with subclavian venous aneurysms and two patients with axillary venous aneurysms. [1][2][3] In contrast to venous aneurysms involving the abdomen or lower extremities, venous aneurysms in the head and neck region have a benign natural history. 4 Surgical excision of these aneurysms is usually undertaken for cosmetic purposes or for the development of symptoms. ...
... In our literature review, we found only three other cases of subclavian venous aneurysms. 1,2,9 Our patient and the one described by Yao et al were treated with surgical excision. The other two patients with subclavian venous aneurysms were treated conservatively without sequelae. ...
A case of a symptomatic 5.1-cm left subclavian venous aneurysm, which was treated with surgical excision, is presented. Most venous aneurysms in the head and neck region involve the internal or external jugular veins and are asymptomatic. Aneurysms involving the subclavian or axillary veins are rare. The natural history of these aneurysms is benign with no reported instances of rupture or thromboembolic events. Operative treatment is most often undertaken for cosmetic reasons or for the development of symptoms.
... 1 Asymptomatic patients with LBVC are incidentally diagnosed during routine chest radiography or chest CT, when a widened mediastinum is observed. 2,3 This was the exact scenario with our patient. In some cases, this anomaly can be symptomatic from complications including pulmonary embolus, 4 rupture, 5 and venous obstruction. ...
Brachiocephalic vein aneurysm is an extremely rare clinical entity, with a limited number of case reports in the literature. We report the case of a 74-year-old woman with a left brachiocephalic vein aneurysm (3 × 3 × 6.5 cm) that was discovered fortuitously by contrast-enhanced chest computed tomography. Surgical intervention was performed simultaneously during tricuspid valve surgery with coronary artery bypass grafting. This paper discusses the details of our case, the surgical treatment of brachiocephalic vein aneurysms, and the different treatment options.
... Patients with this condition usually have an asymptomatic subcutaneous mass that sometimes increases gradually in size and may be accompanied by the appearance of new symptoms [53]. The majority of upper extremity VA is initially noted due to aesthetic concerns regarding a soft mass that often enlarges with a Valsalva maneuver [54]. ...
... One of the possible complications is thromboembolism to the vertebral artery. These aneurysms may be symptomatic [1,2] or asymptomatic [3]. ...
We report on the case of a 56-year-old male patient who, after fainting, regained consciousness in hospital
in a confused state complaining of pain in the left arm. In the physical examination, the arm was seen to be
cold and without pulse, so an arteriography was performed which identified an aneurysm of the subclavian
artery with distal embolus of the upper limb. He was submitted to embolectomy of the limb but evolved
with degeneration of the neurological state and so was transferred to a university hospital which confirmed
the presence of thromboembolism of the vertebral artery. The upper limb had signs of distal ischaemia, so
anticoagulation with heparin was initiated. The patient presented with further deterioration of the neurological
condition and a transformation from ischaemic to hemorrhagic stroke was confirmed.
Key words: subclavian artery aneurysm, vertebral artery, thromboembolism, haemorrhage
... In a review of the literature, surgical intervention was selected as the treatment for two of the four reported primary subclavian vein aneurysms and all of the primary axillary aneurysms reported to date. [2][3][4][6][7][8][9] The majority of these were treated with simple excision. However, several were saccular in nature, suggesting an increased likelihood of thrombosis compared with fusiform venous aneurysms. ...
Spontaneous venous aneurysms of the upper extremities and neck are rare and typically asymptomatic. We present the first reported case of a symptomatic, primary upper extremity venous aneurysm in a patient who initially presented with pulmonary emboli. A 22-year-old patient was admitted with chest pain, dyspnea, and a right axillary mass. Computed tomography revealed diffuse, bilateral pulmonary emboli in addition to a thrombosed axillary vein. Venography confirmed the diagnosis, and also revealed a subclavian vein stenosis at the crossing of the first rib. Pharmacomechanical thrombolysis, catheter-directed thrombolysis, and venoplasty were performed with adequate flow restoration, also revealing the presence of a previously thrombosed proximal brachial/distal axillary venous aneurysm. Hematologic testing showed a positive and persistent lupus anticoagulant. The patient declined surgical reconstruction and opted for long-term anticoagulation. At 24 months, the patient continued to remain symptom-free.
... Most patients with thoracic venous aneurysms are asymptomatic, and the lesion is incidentally detected as a mediastinal mass by a chest radiograph in most cases. [1][2][3]5,[7][8][9] However, these aneurysms can cause chest pain or dyspnea, and they may sometimes be associated with rupture or pulmonary embolism. 4,10,11 Our patient complained of hoarseness and coughing caused by left recurrent laryngeal nerve paralysis, which is extremely rare. ...
Thoracic venous aneurysm is an extremely rare condition. This report describes the case of a 70-year-old woman with a left brachiocephalic venous aneurysm that caused recurrent nerve paralysis. Contrast-enhanced computed tomography and venography revealed a venous aneurysm, 4 cm in size, located adjacent to the venous angle. Anticoagulation therapy was started, and 1-1/2 months later, the aneurysm greatly decreased in size and showed marked calcification along its periphery. Venous aneurysms that shrink after anticoagulation therapy are exceptionally rare. The clinical features of this condition have been briefly reviewed.
... 1,2 VAs are classified according to their location and have been reported in association with the major veins of the neck, thorax, and abdomen as well as the deep and superficial veins of the upper or lower extremities. [3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] The natural history and clinical significance of VAs is related to their location and size. Neck and upper extremity VAs are usually asymptomatic and are most frequently treated because of their size and cosmetic appearance. ...
Although recognized with increasing frequency, the pathogenesis of venous aneurysms (VA) remains poorly understood. We evaluated 8 patients with 10 VA for the presence, localization and activity of metalloproteinases (MMPs).
Tissue specimens from VA (n=8), normal saphenous vein (NSV n=7) and varicose veins (VV n=7 were compared by histology and immunohistochemistry (IHC). Histologic sections were stained with H&E, Movats pentachrome and toluidine blue, and IHC specimens with antibodies to CD68, MMP2, MMP9, and MMP13. Protein expression and enzyme activity were determined by Western immunoblotting and zymography.
Three of 4 patients with popliteal VA presented with edema and leg pain and the remaining patient with deep venous thrombosis (DVT) and pulmonary embolism (PE). The 5 popliteal VA were treated by; excision and reanastomosis (n=2) lateral venorrhaphy (n=2) and spiral saphenous vein graft (n=1). The 3 patients with 4 upper extremity VA had discomfort over a compressible mass. Two of the VA were excised and the remaining patients aneurysm ruptured spontaneously. The mesenteric VA, an incidental finding at laparotomy was excised. Thrombus was present in 2 popliteal, 1 upper extremity and in the mesenteric aneurysm. Histologically, VA and VV were characterized by fragmentation of the elastic lamellae, loss of smooth muscle cells (SMCs) and attenuation of the venous wall when compared to NSV. Varicose veins and VA also demonstrated increased expression of MMP-2, MMP-9 and MMP-13 in endothelial cells (ECs), SMCs and adventitial microvessels compared to NSV. Both pro-MMP-2 and pro-MMP-9 were detected by zymography in VA,VV and NSV but only MMP-2 activity was demonstrable.
The structural changes in the venous wall in addition to the increased expression of MMP-2, MMP-9 and MMP-13 in VA compared to NSV and VV suggests a possible causal role for these MMPs in their pathogenesis.
A venous aneurysm, defined as a focal dilatation in a vein, is an uncommon vascular abnormality. It is to be distinguished from varicose veins, which are characterized by continuously dilated meandering and bending veins. A venous aneurysm can develop in all major veins, but multiple cervical venous aneurysms have rarely been reported, if ever. Herein, we report a case of venous aneurysms in the left external jugular vein and left subclavian vein.
A 64-year-old man was referred to our department from a general physician with a left supraclavicular mass. The mass was soft and painless, and increased in size when the patient performed the Valsalva maneuver. There was no prior history of trauma to that area. Doppler ultrasonography, dynamic computed tomography and magnetic resonance imaging revealed two aneurysms of the left external jugular vein and an aneurysm of the subclavian vein, and suggested the presence of a thrombus in one of the external jugular vein aneurysms. We resected the external jugular lesions with the aim of preventing pulmonary embolism, as well as for esthetic reasons. The resection was performed successfully, with no postoperative complications. Following the surgery, the patient has remained asymptomatic for 4 months. Histopathologically, one of the aneurysms contained a thrombus.
Venous aneurysm of the neck is usually asymptomatic, and is most frequently treated only for esthetic reasons. However, there are a few reports of pulmonary embolism arising from thrombus formation in the jugular and subclavian veins. We consider that surgery should be performed if the patient is deemed to be at the risk of developing pulmonary embolism from the thrombus. In the present patient, we did not resect the subclavian lesion because it was asymptomatic. Careful follow up is important considering the possibility of thrombus formation and rupture.
A 27-year-old Korean male complained of chest pain and dyspnea that began after he had squeezed a mass on the medial side of his right upper arm. Computed tomography (CT) angiography and venous Doppler ultrasonography revealed a right basilic vein aneurysm with an organized thrombosis causing pulmonary emboli. After 1 month of anticoagulation, the aneurysm was ligated and resected. During the operation, multiple venous aneurysms filled with organized thrombi were observed. This is the first reported case of a thrombotic primary venous aneurysm of an upper extremity causing pulmonary emboli after it was squeezed.
Copyright © 2015 Elsevier Inc. All rights reserved.
Mediastinal widening in an adult is mostly nodal in origin. Occasionally vascular aneurysms may be the underlying cause, in which case the aorta or its branches are most frequently involved. Thoracic venous aneurysms, on the other hand, have been reported only in anecdotes, with fusiform aneurysm of the superior vena cava being the commonest. Isolated aneurysms involving the brachiocephalic/innominate vein are extremely rare. We describe detection of a saccular aneurysm of the innominate vein, as the underlying cause of mediastinal widening seen on a chest radiograph in a 42-year-old asymptomatic woman. The characteristic radiological findings of thoracic venous aneurysms are described with particular reference to the importance of multiplanar computed tomography in such settings. Also discussed is the role of imaging in the diagnosis and guiding the management of this rare entity.
Few cases of venous aneurysm involving the subclavian vein have been reported in the literature to date, and all were treated conservatively or with surgical excision. The present report describes a 73-year-old woman with a pulmonary thromboembolism that likely originated from a large right subclavian vein aneurysm that was treated by percutaneous endovascular means. The technique involved placement of a self-expanding stent in the parent vein across the aneurysm, followed by filling of the lumen of the aneurysm with coils through a microcatheter. The patient has remained symptom-free at 18-month follow-up.
Thoracic venous aneurysms are extremely rare conditions. Only 14 innominate venous aneurysms have been reported in the literature. We report a case of a 13-year-old girl who presented with a mediastinal mass on chest roentgenogram, which was performed because the patient was postoperatively tachypneic after a routine appendectomy. Further investigations revealed a large left innominate venous aneurysm that was growing rapidly. The patient underwent aneurysmectomy and reconstruction of the innominate vein. The patient's postoperative course was uneventful, and her respiratory symptoms resolved.
Thoracic vein aneurysms are very rare vascular lesions, usually detected as incidental findings. We describe the case of a patient with an advanced atrioventricular block who underwent definitive pacemaker implantation. In order to explain the difficult advancement of a pacemaker lead, vein angiography was performed during the procedure and a large innominate vein aneurysm was observed. Successful lead placement was then performed without further complications.
A case of left brachiocephalic venous aneurysm is presented. Thoracic venous aneurysms are rare with only 27 previous cases in the medical literature, the majority involving the superior vena cava. There are only two previous reports of isolated brachiocephalic venous aneurysm. Venous aneurysms are usually first detected as mediastinal widening on a chest radiograph and can be further defined using CT, MRI or angiography. The aetiology is uncertain. Management is usually conservative, but surgical correction has been performed.
During the last 20 years we diagnosed five cases of venous aneurysm of the jugular (n = 4) and basilic (n = 1) veins. The purpose of this report was to determine the natural history and indications for surgery of venous aneurysms.
Our five cases were included in an English-language literature review performed through August 1993.
In our series two aneurysms (one external jugular vein, one basilic vein) were excised for cosmetic reasons. Three internal jugular vein aneurysms were followed up for up to 4 years without complications with serial color duplex ultrasonography. Of 32 patients with abdominal venous aneurysms (18 portal, seven inferior vena cava, four superior mesenteric, two splenic, one internal iliac), 13 (41%) had major complications including five deaths. Of 31 patients with deep venous aneurysms of the extremity (29 popliteal, two common femoral), 22 (71%) had deep vein thrombosis or pulmonary embolism and in 17 recurrent deep vein thrombosis or pulmonary embolism developed when patients were treated with anticoagulation alone.
Prophylactic surgery is cautiously recommended for low-risk patients with venous aneurysms of the abdomen and strongly recommended for most patients with lower extremity deep venous aneurysms. Other venous aneurysms should be excised only if they are symptomatic, enlarging, or disfiguring.
A case of true venous aneurysm with saccular dilation of the proximal half of the superior vena cava, the right innominate vein, and the distal two thirds of the left innominate vein in an 18-year-old white woman is presented. At surgery part of the aneurysmal wall was resected, and subsequently the mediastinal venous system was reconstructed with use of the rest of the aneurysmal wall. The postoperative course was uneventful. Operative treatment of mediastinal venous aneurysms is indicated to prevent possible major complications. We strongly suggest performance of this surgery only by means of a heart-lung machine.
We present a case of azygos vein continuation with aneurysm of the azygos vein simulating a tumor in the right upper mediastinum. The dynamic CT examination initially showed a structure of malignant appearance during the early arterial phase. Further dynamic CT revealed marked enhancement of the mass during the late venous phase, suggesting a vascular structure. Confirmation of diagnosis was made by MRI using a fast gradient echo imaging technique in cine mode, showing turbulent flow in the azygos aneurysm, and contrast-enhanced MR angiography, demonstrating a dilated azygos vein. Dynamic CT has a potential pitfall in the diagnosis of vascular structures.
Venous aneurysms are infrequent vascular alterations. Their origin is not well known, but pathologic study reveals probably a similar natural history than the arterial aneurysms. Their clinical significance arises from the complications they can originate, specially in certain locations, which include pulmonary embolism, and, on the other hand, differential diagnosis with certain malignant pathologies may be necessary, depending upon the clinical context. A patient is presented whose radiographic findings, in association with clinical factors, led to surgical exploration to rule out malignant lung tumor. A left subclavian vein aneurysm was finally diagnosed using magnetic resonance imaging.
This article has no abstract; the first 100 words appear below.
SUBCUTANEOUS masses may present a problem in differential diagnosis. Aneurysmal dilatation of a localized segment of a vein occurring in the absence of associated varicose veins is a rare phenomenon but, when present, may be mistaken for other tumors in the subcutaneous tissues. The purpose of this report is to emphasize the clinical patterns in 5 cases of venous aneurysm in an attempt to aid in accurate preoperative diagnosis. In addition, the histologic features in 4 of these cases are discussed. Case Reports Case 1. A 49-year-old white assembly-line worker (H.F.H. 755656) was seen on June 12, 1961, because of . . .
*From the Section of Peripheral Vascular Diseases, Division of Cardiovascular Disease, and the Department of Pathology, Henry Ford Hospital.
§Performed by C. Leslie Mitchell, M.D., head, Division of Orthopaedic Surgery, Henry Ford Hospital.
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DETROIT, MICHIGAN
† Head, Section of Peripheral Vascular Diseases, Division of Cardiovascular Disease, Henry Ford Hospital.
‡ Senior associate pathologist, Department of Pathology, Henry Ford Hospital.