The document discusses aneurysms of the upper and lower extremity arteries. It defines an aneurysm as a permanent localized dilation of an artery with at least a 50% increase in diameter compared to normal. The most commonly affected vessel is the abdominal aorta. The document discusses the classification, presentation, diagnosis and treatment options for various types of peripheral artery aneurysms including femoral, popliteal, profunda femoris and persistent sciatic artery aneurysms. Treatment involves open or endovascular surgical repair depending on the location and size of the aneurysm.

1. Aneurysms of upper and lower
extremity arteries
Dr Rutvij Shah
DNB SS trainee
Vascular surgery
Sir Ganga Ram Hospital

2.  Greek word ANEURYSMA - “ a widening”
 Permanent localized dilation of artery having at least a 50 %
increase in diameter (1.5 times) compared with the
expected normal diameter (adjacent diameter of the same
artery).
 ECTASIA- Arterial dilation less than 50% above normal
 ARTERIOMEGALY– Diffuse arterial enlargement involving
several arterial segments with an increase in diameter
greater than 50% above normal.
 Most commonly affected vessel - AA
DEFINITION

3.  2000 B.C – PAPYRUS – Description of traumatic
aneurysms of the peripheral arteries.
 131 A.D – GALEN - Defined an aneurysms as a localized
pulsatile swelling that disappeared on pressure.
 1793 A.D – JOHN HUNTER - Operated for a pulsatile
mass in popliteal fossa.
 1991A.D - PARODI – Revolutionary minimally invasive
endovascular approach – 1st successful EVAR.
HISTORY

4.  Etiology
 Congenital
 Connective tissue disorders
 Degenerative
 Infection
 Inflammatory
 Trauma
 Location – based on the vessel it involves
 Morphology
 True/False
CLASSIFICATION

5. Lower extremity aneurysms

6.  Historically - typically mycotic, syphilitic, or traumatic
 Currently either degenerative aneurysms or post-
traumatic pseudo-aneurysms
 True aneurysms – men:women ; 30:1
 Association with AAA
 Bilaterality
 Clinical significance
INTRODUCTION

7.  CFA > SFA / PFA
 PSEUDO>TRUE
 Normal size – 1 cm (M), 0.8 cm(W)
FEMORAL ANEURYSMS

8.  CFA (57%) , SFA (26%), PFA (17%)
 Bilateral – 26%
 Associated with other aneurysms – 48%
 Predominantly in 70 years or older
 Associated with smoking and hypertension
 Majority are degenerative
True Aneurysms

9.  Asymptomatic – 30-40%
 Local symptoms – 30-40%
 Pain
 Compressive symptoms - neuropathic pain or leg edema
 Lower extremity ischemia – 60-65%
 Claudication or critical ischemia resulting from
embolization
 Rupture - rare - 4%
CLINICAL PRESENTATION

10.  Duplex ultrasound - modality of choice
 It is cost effective and accurate.
 CT ANGIOGRAPHY and MR ANGIOGRAPHY
 planning of endovascular repair - specific measurements
are needed to identify normal artery proximal and distal
to the identified aneurysm.
 To look for additional aneurysms such as aortic, iliac
artery, contralateral femoral artery, and popliteal artery
aneurysms.
DIAGNOSIS

11. CT ANGIOGRAM
MR ANGIOGRAM DSA
 Advantages vs disadvantages

12.  Symptomatic
 Asymptomatic femoral aneurysms more than 2.5 cm
diameter is indicated in “good-risk” patients.
 Not a lot of data, but one large study
TREATMENT

13.  Surgery of choice
 Aneurysm is excluded with an
interposition graft.
 To prevent injury to surrounding
structures that may be adherent to
it, the aneurysm sac is usually not
resected.
 PTFE/Dacron – better size match and
equivalent or better patency rates
then vein grafts at this position
Open repair

14. • An aneurysm
extending into the
PFA or SFA - complex
reconstruction with
an interposition graft
and a jump graft

15.  Stent graft via percutaneous approach
 Caution - Placement of a stent graft in the CFA, particularly
when it crosses the inguinal ligament, can cause stent
fracture or dislodgement.
 Role is limited
 1. Emergency situations like rupture
 2. Hybrid approach with an open surgical procedure
 3. Used as adjuncts to open procedures - proximal control
via a balloon placed under fluoroscopic guidance through
the opened aneurysm sac/contralateral CFA.
ENDOVASCULAR MANAGEMENT

16.  Causes –
 Iatrogenic causes (most common) -
instrumentation for cardiac or
peripheral catheterization.
 Infection that causes focal erosion of
the arterial wall, usually from external
sources such as contaminated needles
used during intravascular substance
abuse.
PSUEDOANERYMS

17.  Most common - Painful pulsating mass in the groin, usually with an
associated hematoma.
 Compressive symptoms - femoral neuropathic pain, paresis of hip
flexion, or edema.
 Skin ischemia and necrosis – if progressive enlargement.
 Femoral bruits - if an arteriovenous fistula.
 Distal embolization or limb ischemia - rare.
 Rupture (less common) - can lead to death from hemorrhagic shock
and is a surgical emergency
 EIA puncture - Significant bleeding without overt clinical findings -
occult bleeding into the retroperitoneal space.
CLINICAL PRESENTATION

18.  Duplex ultrasound
 Modality of choice
 The sensitivity and specificity of
DUS for femoral false aneurysms
are 94% and 97%, respectively.
 Important information on
diameter, morphology, and
anatomy of the neck and location
of the femoral artery defect.
DIAGNOSIS

19.  Ultrasound-Guided Compression.
 Less invasive alternative to surgery
 Compression is maintained for 10 to 20 minutes –
reassessed - If flow persists - the procedure is
repeated
 Bed rest for 6 hours, re-evaluated with DUS at 24 and
48 hours after the procedure to rule out recurrence.
 Success rates - 66% to 86%, with required compression
times averaging 30 to 44 minutes.
 Recurrence - 4%
 The presence of anticoagulation - reduces the
likelihood of success to less than 40%.
TREATMENT

20.  Limitations
 Contraindicated in patients with ischemic skin changes or
infection and when the puncture site originates above the
inguinal ligament.
 Not usually possible in patients with severe pain and very
large hematomas.
 Technically more difficult in obese patients
 Time-consuming, operator and patient fatigue
 Complications
 Aneurysm rupture
 Femoral vein thrombosis
 Limb ischemia from femoral arterial thrombosis
 Hypotension from vasovagal events

21.  Cope et al (20 years ago) -
Angiographically directed thrombin
injection via percutaneous access into
the aneurysm cavity
 Kang et al - Modified the technique by
performing direct percutaneous
aneurysm puncture under duplex
ultrasound guidance.
 Thrombin directly converts fibrinogen
to fibrin.
 Consequently, thrombin injection is
effective even in patients receiving
anticoagulation.
 Thrombin are commercially available
Ultrasound-guided Thrombin
Injection

22.  Quick, simple, and relatively painless.
 Critical step - Identification of the needle within the
aneurysm sac.
 Inject slowly and to stop immediately once
thrombosis has occurred
 Thrombin (1000 IU/mL) is injected slowly through a
3-mL syringe for a period of about 10 to 15 seconds,
until flow within the cavity ceases.
 Approximately 1000 units of thrombin is required
to induce thrombosis.
 Patients are given bed rest for 1 hour.
 Duplex ultrasound is repeated 24 hours later to
confirm permanent thrombosis of the aneurysm.
 UGTI has a success rate of 96% to 100%.

24.  Contraindications to thrombin –
 Relative contraindication - short, wide channel or “neck”,
higher incidence of embolization of thrombus
 Cochrane review compared multiple non-surgical
treatments
 Compression was effective in achieving pseudoaneurysm
thrombosis.
 Ultrasound-guided application did not confer additional
benefit.
 Percutaneous thrombin injection was more effective than a
single session of ultrasound-guided compression

25.  Indications
 Ruptured pseudoaneurysms
 Failures of or contraindications to UGC
or UGTI
 Pseudoaneurysms associated with an
arteriovenous fistula.
Open Surgical Repair
 Direct repair with polypropylene sutures
 If there is extensive damage to the femoral arterial wall -
patch angioplasty with autologous or synthetic tissue
 Autologous tissue is preferred, because pseudoaneurysms
may be associated with latent infections.

26.  Isolated aneurysms - Less common than CFA.
 More commonly manifest as proximal
extensions of popliteal artery aneurysms.
 An extensive review by Leon et al –
 61 reported cases of isolated SFA aneurysms.
 Average age of 75.7 years
 Location - middle third of the artery
 Mean diameter of 8.4 cm at diagnosis.
 Most common manifestation - pulsatile tender
thigh mass
 Rupture was more common manifestation
(42%) than distal ischemia (13%)
SFA ANEURYSMS

27.  Duplex ultrasound scan – accurate - smaller
asymptomatic aneurysms.
 CT/MRI/DSA - to evaluate the inflow and outflow
vessels
DIAGNOSIS

28.  Indications to treatment
 2.5 cm or more in diameter
 Grow over time
• Focal aneurysms - opening of the sac, evacuation of thrombus,
and creation of an end-to-end interposition graft
• More extensive aneurysms - proximal and distal ligation
followed by placement of a bypass graft
• Saphenous vein or prosthetic graft can be used.
• Limb salvage rate is reported at greater than 90%.
• Endovascular repair has been reported – No long-term data on
the effectiveness
TREATMENT

29.  < 3% of all femoral artery aneurysms
 Most cases - unilateral
 Synchronous aneurysms - 70% of cases (MC - popliteal aneurysms)
 Clinical Presentation
 Limb-threatening ischemia from distal embolization of thrombus,
particularly if there is concomitant SFA occlusive disease.
 Rupture
 Large size at presentation because of their deep anatomic
location
PFA ANEURYSMS

30.  Repair – No clear criteria of diameter , but is
always recommended (high rate of
complications and unknown natural history.)
 Surgical repair - aneurysmectomy with an
interposition graft of either saphenous vein
or prosthetic material
 Principles
 SFA evaluation pre operatively
 Large branches of the profunda femoral artery
should be preserved whenever possible.
 Carefully preserve deep femoral vein and
femoral nerve
 Proximal control - CFA
TREATMENT

31.  Aneurysms confined to the distal branches of
the deep femoral artery - Simple ligation OR
Selective embolization
 Proximal PFA ligation - in patients with
rupture, especially when the SFA is patent
 Endovascular management of PFA aneurysms
has been reported. Stent-grafts- good short-
term results.
 Considered in - In patients without major
compressive symptoms.

32.  Persistent sciatic artery (PSA) is a rare
vascular congenital embryological anomaly -
in 0.01% to 0.05% of the population.
 PSA is the primary lower limb artery; the
femoral artery is hypoplastic
 No clear data on the average size, etiology or
natural history
 Prone to aneurysmal degeneration - 40%
 Clinical presentation –
 Enlarged pulsatile buttock mass
 Local compressive symptoms – sciatic
neuropathy, skin changes
 Distal ischemia.
PSA ANEURYSMS

33.  TREATMENT - Surgical repair - with an
interposition graft
 Surgical dissection - not recommended -
Potential damage to the adjacent sciatic nerve
 Endovascular stent placement - effective method
of repair for PSA aneurysm (provided that there
are no compressive symptoms)
 Case report - Embolization of a ruptured PSA
aneurysm with Amplatzer plugs (St. Jude
Medical, Minnesota) in a hemodynamically
unstable patient - Successfully controlled the
hemorrhage but was complicated by footdrop,
likely secondary to sciatic nerve ischemia and a
buttock abscess.

34.  The popliteal artery, by definition - extends from the
adductor canal to the origin of the anterior tibial
artery below the knee.
 Popliteal artery - differs in diameter from proximal to
distal
 Most PAAs - proximal or mid portion of the artery.
 Controversy –
 Some writers - A diameter of 1.5 cm or greater in an
“average” patient to be an aneurysm
 Clinical practice - most surgeons use 2 cm as the
threshold diameter
POPLITEAL ARTERY ANEURYSMS

35.  Most common peripheral artery aneurysms (70%)
 Almost - Exclusively in men.
 50% - bilateral PAAs
 30% - 50% - associated abdominal aortic aneurysm (AAA)
 In patients treated for isolated popliteal aneurysms, the
likelihood of development of another aneurysm at a
remote site over a 10-year period - 50%.
 Majority of PAAs - true degenerative aneurysms
 The anatomic location at a high flexion point and repetitive
stresses on the artery in this location may be additional
causative factors
ETIOLOGY

36.  The mean growth rate –
 1.5 mm/year for < 20 mm
 3 mm/year for 20 to 30 mm
 3.7 mm/year for > than 30 mm
 Hypertension - most common risk factor
 Szilagyi et al - over a 5-year period, only 32% of
observed PAAs remained without lower extremity
complications.
 Dawson et al - 71 PAAs, 25 - treated non surgically and
complications developed in 57%
 The probability of development of complications
increased with time up to 74% within 5 years
NATURAL HISTORY

37.  >50 % - SYMPTOMATIC
 Most common - Lower extremity ischemia
 Usually - chronic ischemic symptoms - chronic emboli occlude the
outflow vessels and collaterals develop
 Chronic symptoms with a non-pulsatile popliteal mass
 Compressive symptoms - which may include vein (leg swelling,
deep venous thrombosis) or nerve compression
 Rupture - unusual complication - 0% to 7% (Hemorrhagic shock
– rare – close confines of the popliteal space)
CLINCAL
PRESENTATION

38.  May be found incidentally
 Suspected anytime a prominent or widened popliteal
artery pulse
 Men with known AAA, femoral artery aneurysm, or
contralateral PAA

39.  Duplex ultrasound - modality of choice
 It is cost effective and accurate.
 CT ANGIOGRAHY and MR ANGIOGRAPHY
 planning of endovascular repair - specific
measurements are needed to identify normal
artery proximal and distal to the identified
aneurysm.
 To look for additional aneurysms such as aortic,
iliac artery, contralateral femoral artery, and
popliteal artery aneurysms.
 DSA - can be misleading because of non
visualization of mural thrombus or missing of a
thrombosed PAA.
DIAGNOSIS

40.  Outcomes - best in asymptomatic patients and progressively
worse in those with either chronic ischemic symptoms or
advanced acute limb ischemia
 Controversy –
 All symptomatic PAAs and those 2.0 cm or more in diameter
should be considered for treatment - justified, given the
associated 30% to 40% risk for development of acute ischemic
complications
 Popliteal aneurysms should be repaired once found, regardless
of size,
 because of high complication and limb loss rates
 high limb salvage and patency rates and low operative mortality
 Galland et al - evaluated 95 PAAs. Of those that were
asymptomatic, less than 3 cm, and without distortion, none
became thrombosed.
TREATMENT

41.  Conclusion –
 The decision must be individualized, careful weighing
of the risks and benefits
 Symptomatic PAA - repair
 Asymptomatic but is at least 2.0 to 2.5 cm in diameter
and contains thrombus - repair
 In older patients with multiple comorbidities,
observation of even a larger aneurysm may be
warranted.
 Extensive thrombus or asymptomatic occlusion of
tibial vessels may be indications for intervention.

42.  OPTIMIZE
 Antiplatelets and statins - ideally at least 1 month prior
to the procedure
 Evaluation for other aneurysms
 Type of repair - depends on the patient’s anatomy,
age, and comorbidities – open / endovascular / hybrid

43.  No RA/GA , less risk
 Percutaneous puncture or a small cutdown to expose
either the SFA or CFA.
ENDOVASCULAR REPAIR

44.  Anatomic selection criteria for endovascular repair of PAAs
 Normal proximal and distal segment (landing zones) of at least 2 cm
 No large discrepancy in size between proximal and distal landing zones
 Lack of extensive vessel tortuosity/extremely large aneurysm- stent-graft
prone to kinking and displacement
 Patients who frequently flex their knees to more than 90 degrees
(laborers, farmers, carpenters, etc) - risk of stent deformation and
thrombosis.
 If antiplatelet therapy is contraindicated, an endovascular approach is not
recommended
 Patients with single-vessel outflow - higher stent-graft thrombosis rate
than patients with two- or three-vessel outflow
 Post procedure antiplatelet-
 If no contraindication - clopidogrel is prescribed indefinitely.
 A minimum of 4 to 6 weeks of dual antiplatelet therapy is recommended
 Unless there is a known hypercoagulable state, anticoagulation is not
routinely used.

45.  Viabahn endoprosthesis (W.L Gore & Associates, Newark,
Delaware)
 PTFE with a nitinol exoskeleton.
 Prevents tissue ingrowth
 Extremely flexible
 Lengthens and foreshortens easily
 Heparin bonded surface
 Contoured proximal edge – improve flow dynamics
 Lengths – 2.5/5/7.5/10/15/25 cm
 Diameters – 5 to 13 mm

47.  Principles
 Usually oversized - 10% to 15% more than the internal diameter
 Up to an 8-mm graft - 7F sheath using and 0.018-inch guide wire.
 9- to 13-mm graft - 9 F to 12 F sheath and 0.035-inch guide wire.
 Vascular access - appropriate sheath is placed - angiogram -
proximal and distal landing zones as well as the runoff vessels are
confirmed.
 The patient is systemically heparinized
 Discrepancy in proximal and distal landing zones - A maximum of 1
mm of size differential if more than one stent-graft is required
 The stent-grafts are deployed from small to large with minimum 2-
to 3-cm overlap
 Post-dilate to “iron out” any kinks or stenosis.
 Completion angiogram - endoleak and preservation of runoff
without embolization
 An angiogram is performed again with the knee bent

48.  Avoid landing the distal end of the
graft at the bend of the popliteal
artery, which is usually a few
centimeters above the actual knee
joint and can be located by
performing an angiogram with the
knee bent.

50.  Primary objective - exclude them from the circulation.
 In 1785, John Hunter ligated the popliteal artery with a large
popliteal aneurysm
 In the modern era, arterial bypass with ligation or interposition
grafting has replaced simple ligation and remains the - gold
standard
 Pre op planning based on imaging – imperative
 Frequently - size discrepancy between the vein graft and the
popliteal arteries - thus - end-to-side technique preferable.
 Saphenous vein preferred, prosthetic grafts – good short term
results.
OPEN REPAIR

51.  Small or fusiform aneurysms - best approached medially
and treated with conventional bypass and aneurysm
ligation.
PRINCIPLES OF MEDIAL APPROACH

52.  A tunnel - created from the above-knee to the below
knee popliteal space between the heads of the
gastrocnemius muscle.
 Numerous studies - even with proximal and distal
ligation - 30% of aneurysms do not ultimately undergo
thrombosis
 Thus most writers are proponents of opening all
popliteal aneurysms in order to suture-ligate back-
bleeding side branches.

53.  Advantage –
 Only logical option for bypass grafts that must extend to the
distal tibial or pedal vessels.
 Familiar to all vascular surgeons
 Providing easy access to the entire great saphenous vein.
 Procedure is performed at some distance from the aneurysm,
thus reducing the likelihood of operative injury to structures
adherent to the surface of the popliteal aneurysm.
 Disadvantage –
 Generally used in conjunction with aneurysm ligation but without
decompression.

54.  Preferred in
 Large aneurysms
 Compressive symptoms
 Confined to popliteal space and causing
distortion of the normal anatomy –
distortion/kinking/elongation
 Interposition grafting from within the sac is
preferable
 Aneurysm sac opened – thrombus removed –
back bleeders ligated
 Circulation restored by interposition graft /
bypass
 Requires less dissection of popliteal artery
PRINCIPLES OF POSTERIOR
APPROACH

55.  30% of PAA - acute ischemic symptoms at initial evaluation.
 There is a high rate of limb loss
 In an acutely symptomatic PAA patient – which CAT?
 RUTHERFORD CAT 1
 preoperative imaging (CT/MRI) done
 systemic heparin given
 If the diagnosis of PAA is already made - angiography directly -
can give additional information about the status of the runoff
vessels. (DSA - gold standard)
 RUTHERFORD CAT 2A AND 2B
 directly to the operating room.
EMERGENCY REPAIR

56. OPEN APPROACH
 If the aneurysm is fully occluded and a patent distal
outflow vessel is identified on arteriography - a vein bypass
to the patent outflow vessel
 If no outflow vessel is identified – Decide if patient’s limb is
immediately threatened –
 If Yes - intra-arterial thrombolysis
 If No – immediate surgery
 If no outflow vessel was identified on the arteriogram,
thromboembolectomy of the distal popliteal or tibial vessels
(or both) should be attempted.
 Trifurcation of the popliteal artery – preferred site to gain
access to all three arteries.
 A No. 2 Fogarty balloon embolectomy catheter

57.  25% to 45% of acutely ischemic patients have thrombosis of the
aneurysm with either no visible runoff vessel or with severely
compromised runoff
 Ultimately, the decision to perform thrombolysis must be
individualized - patient factors, clinical circumstances, contra-
indications
 Infusion rate - 2 mg/hr of t-PA
 APTT-- Should be less than therapeutic to prevent bleeding
complications (< 50 sec)
 Fibrinogen level - above 200 mg/dL, lytic therapy is continued.
 Options - bypass can be performed if a target vessel opens, lytic
therapy can be continued, or the patient can undergo an attempt at
urgent thrombectomy/ bypass if the leg is acutely threatened.
 Alternatively, if the thrombus lyses and anatomy permits (as
described earlier), and there is more than one outflow vessel, an
endovascular stent-graft can be placed as previously described.
ENDOVASCULAR APPROACH

58.  Intra-arterial thrombolysis fails - Open
thrombectomy
 Open thrombectomy fails - intraoperative lytic
therapy and pharmocomechanical thrombectomy
HYBRID APPROACH

59.  True aneurysms – extremely rare
 Description limited primarily to case
reports.
 Commonly - penetrating trauma, fractures,
or iatrogenic injury (including thrombo-
embolectomy of the tibial vessels with
balloon catheters)
 Symptomatic - should be repaired with
autologous vein bypass grafts
 If other tibial arteries are patent, treatment
with simple ligation will suffice
 Coil embolization has been reported as an
effective treatment of tibial artery
aneurysms.
TIBIAL AND PEDAL ARTERY
ANUERYSMS

60. UPPER EXTREMITY
ANEURYSMS
Dr Rutvij Shah
DNB SS trainee
Vascular surgery
Sir Ganga Ram Hospital

61.  Uncommon
 Most common type - Arch vessel aneurysms
 1805 and 1808 - Common carotid aneurysm ligations by Astley
Cooper
 1818 - Ligation of the innominate artery by Valentine Mott for
the treatment of a subclavian artery aneurysm.
 1864 - Smyth - The first successful treatment of a subclavian
artery aneurysm - ligated the right common carotid and
innominate artery -The aneurysm recurred and ruptured 10
years later.
 1892, Halsted at the Johns Hopkins Hospital - First to combine
ligation with resection of a subclavian artery aneurysm
INTRODUCTION

62. • Arch vessel aneurysms - 1%
 Most commonly - Degenerative disease
• Other causes
• Trauma, fibromuscular dysplasia, syphilis, cystic medial necrosis,
vasculitis, tuberculous lymphadenitis, etc
• Cury et al reported – series of 74 arch vessel aneurysms
 63% were degenerative
 vast majority in men older than 60 years of age.
• 30% to 50% degenerative arch vessel aneurysms –
associated with aorto-iliac or other peripheral
aneurysms
ARCH VESSEL ANEURYSMS
EPIDEMIOLOGY

63.  SCA aneurysms - most common - 50% of the cases
 Innominate artery aneurysms - 2% to 5% of cases
 Carotid artery aneurysms – extremely rare
 Bilateral CCA aneurysms - associated with Takayasu’s
arteritis
 Pseudo aneurysms
 Considerably more frequent
 Complications of blunt or penetrating trauma - inadvertent
cannulation while accessing the adjacent vein, operative
dissections, or infection.

64.  75 % - Asymptomatic
 Presenting symptoms include
 Local
 Chest, neck, and shoulder pain from acute expansion or rupture
 Upper extremity pain and neurologic dysfunction from brachial plexus
compression
 Thrombo-embolization
 Upper extremity acute and chronic ischemic symptoms
 Transient ischemic attacks and stroke ( vertebral and carotid circulations)
 Compressive
 Hoarseness from compression of the right recurrent laryngeal nerve
 Horner’s syndrome
 Respiratory insufficiency from tracheal compression
 Dysphagia from esophageal compression in cases of aberrant right
subclavian artery
 Hemoptysis from erosion into the apex of the lung.
CLINICAL PRESENTATION

65.  Supraclavicular pulsatile mass (? tortuous and elongated
common carotid and subclavian arteries)
 Supraclavicular bruit
 Absent or diminished pulses in the upper extremity
 Signs of micro-embolization (“blue finger” syndrome)
 Sensory and motor signs of brachial plexus compression
 Vocal cord paralysis
 Horner’s syndrome resulting from compression of the
stellate ganglion
SIGNS

66.  DUS – can diagnose, has anatomical limitations
 Conventional angiography / MR / CT angiography
 extent of the aneurysm,
 assess the sites of vascular occlusion in cases
complicated by thromboembolism
 to note the competency of the contralateral vertebral
circulation if the ipsilateral vertebral artery originates
from an aneurysmal vessel
 assess anatomic suitability for endovascular repair.
DIAGNOSIS

67.  Resection or endo-aneurysmorrhaphy and
reestablishment of arterial continuity
 more commonly, an interposition prosthetic graft.
 with an end-to-end anastomosis (for very small aneurysms)
 Ligation without direct or extra-anatomic reconstruction
- ischemic symptoms in 25%
TREATMENT – OPEN REPAIR

68.  INNOMINATE ARTERY
 Median sternotomy extended into the right neck.
 Proximal control - obtained at the aortic arch.
 The right subclavian and right common carotid
arteries - dissected for distal control.
 The aneurysm is resected, and reconstruction with a
prosthetic graft.

69.  An anatomic classification -
Kieffer et al to guide the
surgical repair
 For type A and B aneurysms,
the proximal graft anastomosis
- To native ascending aorta
proximal to the innominate
origin.
 The graft is then anastomosed
to the uninvolved distal
innominate artery
 The origin of the innominate
artery - oversewn or patch
angioplasty of the aorta may
occasionally be required.

70.  For lesions extending into the
origins of the right subclavian or
common carotid artery, a bifurcated
graft, or a branch graft.
 Type C innominate artery aneurysms
usually require aortic arch and
innominate artery prosthetic graft
replacement using cardiopulmonary
bypass and hypothermic circulatory
arrest

71.  SUBCLAVIAN ARTERY ANEURYSMS
 Proximal (typically degenerative) or
distal (usually related to thoracic outlet
syndrome)
 For proximal right SCA -median
sternotomy with extension into the
supraclavicular fossa
 Supraclavicular and infraclavicular
incisions / Resection of the clavicle - for
exposure of the subclavian artery.
 For proximal left subclavian aneurysms -
left thoracotomy combined with
supraclavicular exposure.
 For mid and the distal subclavian artery -
a supraclavicular incision

72.  Endovascular alternative - for proximal and distal
control with balloon occlusion angiographically.
 Vertebral artery - reconstruction by re-implantation,
particularly if this is the dominant vertebral artery or
for cases in which the contralateral vertebral artery is
hypoplastic or diseased.

73.  Aneurysm resection with graft replacement - excellent long-
term results.
 In one of the largest reported series,
 normal upper extremity circulation was maintained
 no procedure-related complications during a mean follow-up of
9.2 years
 Since many patients - unfit for open repair because of their
advanced age and multiple comorbidities - careful patient
selection is mandatory
 Relative contraindications to open repair - severely
compromised pulmonary function, prior sternotomy or
thoracotomy, and hemodynamic instability
RESULTS

74.  Attractive option for patients unfit for open
repair
 Endovascular treatment can be especially
helpful in cases of actively bleeding
coagulopathic patients with iatrogenic,
catheter-induced, or other penetrating
injury of the arch vessels.
 Aneurysms secondary to connective tissue
disorders - more suitable for endovascular
repair (to avoid direct resection and
anastomoses to diseased vessels)
ENDOVASCULAR REPAIR

75.  The proximal portion and mid portion - most amenable to
endovascular
 The distal portion - located between the clavicle and the first rib,
and endografts are subject to compression, deformation, and
fracture.
 However, several anatomic limitations exist.
 Unusual for true subclavian or innominate aneurysms to have
adequate proximal and distal landing zones.
 Coverage of branch vessels, such as the right carotid, vertebral
arteries, and left internal mammary when it has been used for coronary
bypass, may not be feasible.
 Endograft placement in the right subclavian artery - stroke from
embolic debris dislodged into the right common carotid artery.
 The vertebral artery - vulnerable - may be covered during stent-graft
deployment - Posterior circulation stroke may occur, when the
contralateral vertebral artery is highly stenotic, hypoplastic, or
occluded.
 Whenever the origin of the vertebral artery is involved by the
aneurysm, coil embolization of the ipsilateral vertebral artery is
desirable to prevent future branch vessel endoleaks.

76.  Approach - Transbrachial or transfemoral approach.
 Both balloon-mounted and self-expandable endografts
have been used
 Most frequently used endografts - Wallgraft (Boston
Scientific), Viabahn (Gore), or Fluency (Bard)
 Most endografts - 7F to 9F delivery sheaths
 Because of discrepancy in proximal and distal landing
zone diameters, a combination of endografts of different
sizes may be necessary.
 Mid- and long-term results of these techniques not
reported

77.  A flexible, self-expanding vascular prosthesis
 Diameters – 6/7/8/9/10/12/ 13.5 m
 Length – 40/60/80/100/120 mm
 Comprised of expanded polytetrafluoroethylene (ePTFE)
encapsulating a Nitinol stent framework, except the flared
stent graft ends with the four radiopaque Tantalum
markers
 The inner lumen - is carbon impregnated.
 The length of the uncovered portion of the stent graft is
approximately 2 mm at each end.
FLUENCY

78.  Embolization with coils or a vascular
plug of a proximal subclavian artery
aneurysm + subclavian artery
transposition or carotid-subclavian
bypass
 Complete exclusion of the subclavian
aneurysm is facilitated by ligation of
the subclavian artery proximal to the
distal anastomosis of the carotid-
subclavian bypass.
 Vertebral artery and LIMA– must be
taken care of
HYBRID

79.  Another technique - endograft into the innominate artery in
a retrograde fashion via carotid-subclavian bypass limb
 Cerebral embolization - minimized by occluding antegrade
carotid flow
 Long-term durability of endografts, in arch vessels is
unknown.
 Short term patency for subclavian stent grafts ranges from
83% to 100% over a mean follow-up of 7 to 29 months.
 Deformation, and fracture and stenosis from intimal
hyperplasia have been reported and may limit the
applicability of endovascular repair in this location.

80.  Most common congenital anomaly of the aortic arch
 0.5% to 1% of the population
 Arises from the proximal descending thoracic aorta, distal to
the left SCA
 Typically – arises posterior and inferior on the arch, 80% -
crosses the midline between the esophagus and the spine
 Less commonly, between the esophagus and trachea or
anterior to the trachea.
 Most patients – asymptomatic
 A non recurrent right laryngeal nerve is associated with this
anomaly
ABBERENT
SUBCLAVIAN ARTERY

81.  Either gender
 Age > 50 years
 The majority of these require intervention,
owing either to symptoms or to the risk of
rupture.
 Clear size criteria have not been established
 Cina et al - proposed repair of aneurysms larger
than 3 cm in size in good-risk patients
ABBEREBT SUBCLAVIAN ARTERY
ANEURYSM

82.  Degenerative aneurysmal changes - up to 60% of patients
in the proximal portion of the aberrant subclavian artery.
 1936 – Kommerell described a diverticulum of the aorta at
the origin of the anomalous subclavian artery.
 1956 - McCallen et al, first called attention to the clinical
significance of aneurysmal change in an anomalous right
subclavian artery
 Kieffer et al, reported largest cases - 55
 surgically treated 33 adults with aberrant subclavian arteries,
17 of whom had a Kommerell’s diverticulum or aneurysmal
change of the thoracic aorta at the origin of the aberrant
subclavian artery.
KOMMERELL’S DIVERTICULUM

84.  Based on clinical presentation
and anatomy - proposed by
Kieffer et al.
 Group 1: Non-aneurysmal ARSA
causing compressive symptoms.
 Group 2: Occlusive disease of a
non-aneurysmal ARSA.
 Group 3: Aneurysmal dilatation
of the ARSA without aortic
involvement
 Group 4: Aneurysmal ARSA with
aortic involvement.
CLASSIFICATION

85.  According to Kieffer et al,
 22 patients – aneurysmal degeneration
 11 of 33 patients without aneurysmal degeneration presented
with dysphagia
 5 developed upper right limb ischemia
 Stone et al reported
 24 patients diagnosed with an aberrant right subclavian artery
 66% were asymptomatic at the time of presentation
 34% presented with various symptoms of dysphagia, upper
extremity ischemia, or findings of aneurysmal degeneration
CLINICAL PRESENTATION

86.  Sometimes diagnosed incidentally,
 Usually present with
 dysphagia from esophageal compression
 dyspnea and coughing from tracheal
compression
 chest pain from expansion or rupture
 symptoms of right upper extremity
ischemia
 emergently with aneurysm rupture or
dissection.
 Aneurysm rupture in these cases seems to
be unrelated to the size of the aneurysm.
 Approximately one fifth of reported
patients with this anomaly - associated
abdominal aortic aneurysm.

87.  ABBERENT SCA
 Open repair - usually – right supraclavicular incision.
 The aberrant right subclavian artery - Ligation to the left of
the esophagus relieves local pressure symptoms.
 The distal end of the subclavian is then transposed and
anastomosed end-to-side to the right common carotid
artery.
 This approach is satisfactory when proximal aberrant
subclavian is not aneurysmal
TREATMENT

88.  Aberrant Subclavian Artery Aneurysm
 Repair recommended - Propensity to cause symptoms/ lethal
rupture
 Resection or exclusion of the aneurysmal artery with vascular
reconstruction of the subclavian artery
 Multiple procedures
 The best approach depends on the anatomic characteristics of the
lesion, patient fitness, and acuity of presentation.
 In the elective setting - A staged approach with right carotid-
subclavian bypass or transposition (end-subclavian to side-
carotid) preceding left thoracotomy and aneurysm resection with
oversewing of the origin from the aortic arch is attractive because
the risk of cerebral and right upper extremity embolization is
minimized.
 Simple side-biting clamp exclusion may be possible, although
interposition graft repair of the aorta itself may be necessary in up
to 30% of patients with aortic involvement.

89.  Limitations of open repair
 High rates of neurologic complications
 High morbidity and mortality, particularly in patients unfit
for open major vascular reconstructions.
 Previous thoracotomy
 Combination of aortic endografting and extra-anatomic
bypass is a particularly appealing combination for
treatment of this condition.

90.  Endovascular occlusion (plug/coils) of aberrant right
subclavian artery combined with distal ligation is an
alternative to open repair.
 Right SCA to be re-vascularized - ?
HYBRID PROCEDURE

91.  A thoracic endograft can effectively exclude antegrade flow into
an aberrant right subclavian artery aneurysm , needs carotid –
right SCA anastomosis
 Majority of cases - the orifices of the aberrant right and left
subclavian arteries are situated at the same level or in close
proximity. To effectively occlude the origin of the aberrant vessel
with a thoracic endograft, its placement usually requires exclusion of
both subclavian arteries.
 Bilateral occlusion - not recommended (subclavian steal syndrome or
upper-limb ischemia, spinal ischemia or stroke)
 Therefore thoracic aortic endografting usually needs to be combined
with revascularization of one or both subclavian arteries
 Hence bilateral subclavian transposition or carotid-subclavian bypass
procedures may need to be performed before endovascular
treatment

92.  Significantly reduces morbidity and mortality of the
repair of these aneurysms
 Could become standard treatment.
 Long term outcomes of such therapy are not established
 Unclear whether covering the aortic origin of the
aneurysm using an aortic endograft can effectively
relieve compressive symptoms of the diverticulum and
prevent rupture.

93.  Davidian et al reported - intraluminal placement of an
endograft confined to the aberrant vessel.
 Hoppe et al - occluded an aberrant subclavian artery
aneurysm with two Amplatzer septal occluders at the
proximal and distal ends of the aneurysm.
 The eventual need for revascularization of the right
upper extremity could be assessed after the procedure.
 Paucity of data regarding pure endovascular procedures.
ENDOVASCULAR APPROACH

94.  Rare
 Usually caused by blunt or penetrating
trauma
 Most posttraumatic axillary aneurysms -
young men involved in athletic activities
that are associated with repetitious,
forceful extension of the upper extremity.
 Probably related to the repeated
abduction and external rotation of the
upper extremity with downward
displacement of the humeral head.
AXILLARY ARTERY ANEURYSMS
ETIOLOGY

95.  The circumflex humeral arteries that usually arise
from the third portion of the axillary artery encircle
the surgical neck of the humerus - creating a tethering
effect on the axillary artery, which is in a fixed
position relative to the humerus - repeated
compression of the axillary artery can lead to intimal
damage, thrombosis and aneurysm formation of the
circumflex humeral arteries or the axillary artery.

96.  Usually occur with penetrating trauma, but they also may occur
with blunt trauma in the form of humeral fractures and anterior
dislocation of the shoulder.
 Excellent collateral circulation in this area - distal perfusion may
be adequate despite extensive axillary artery injury.
 Present late – chronic psuedoaneurysms – local symptoms
 Can lead to serious and permanent neurologic disability
because of hemorrhage into the axillary sheath and
compression of the brachial plexus.
 Suspect in blunt trauma with normal pulse examination but
brachial plexus palsy, because the likelihood of concomitant
vascular injury is high in these cases.
 Diagnosis
AXILLARY PSEUDOANEURYSMS

97.  Crutch-induced blunt trauma producing aneurysmal dilatation
of the axillary artery usually occurs in older patients – chronic
trauma.
 Thrombus, usually loosely adherent to the damaged intima,
may become dislodged by further trauma from crutches and
is the source of acute, chronic, or repetitive emboli.
 Suspected when a patient who has been using crutches for a
prolonged period presents with an absent brachial pulse.

98.  Surgical treatment - resection of the aneurysm and interposition vein
grafting.
 The brachial plexus and surrounding vascular structures should be
protected during dissection of the aneurysm.
 Autogenous vein grafts in upper extremity reconstructions are
preferred because of improved patency rates with these conduits
 Occasionally, an adjacent segment of the axillary or brachial vein has
been used to reconstruct the artery. However, this vein - extremely
thin walled and may itself become aneurysmal with time
 For this reason, a segment of saphenous vein is the conduit of
choice.
 Long-term results are excellent.
TREATMENT

99.  Endograft placement is sufficient to obtain complete
exclusion of the aneurysm cavity.
 Occasionally, embolization with microcoils of branch vessels to
isolate the sac and prevent retrograde endoleak
 Review of literature by DuBose et al - overall patency during
the follow-up period was reported at 84.4%.
 Endovascular repair of axillary aneurysms and
pseudoaneurysms should be considered an alternative to
surgical treatment in patients with major comorbidities and
high surgical risk.
ENDOVASCULAR

101.  Most - false aneurysms secondary to repetitive trauma, or iatrogenic
complications.
 Intravenous drug abuse is currently a frequent cause of infected
pseudoaneurysms in the antecubital fossa.
 Arteriovenous access creation can lead to aneurysmal degeneration of
donor arteries as well.
 Uncommon causes of true aneurysms of the brachial artery
 Congenital connective tissue abnormalities, such as those found in
association with type IV Ehlers-Danlos syndrome
 Kawasaki’s syndrome
 Buerger’s disease
 Kaposi’s sarcoma
 Cystic adventitial disease
BRACHIAL ARTERY
ANEURYSMS

102.  Most - Symptoms of median nerve compression or local pain
 Other symptoms include
 hand and digital ischemia as a result of thrombosis of the
aneurysm and/or distal embolization.
 Diagnosis - physical examination.
 Duplex ultrasonography can establish the diagnosis.
 Upper extremity arteriography - necessary to delineate the
extent of the aneurysm, to assess the sites of vascular occlusion
and to determine whether anatomic variants are present that
might affect reconstruction.
 Simple iatrogenic brachial artery false aneurysms can usually be
repaired without the need for angiography
CLINICAL PRESENTATION

103.  Because of the high incidence of symptoms and
complications and the minimal morbidity associated
with operative treatment, aneurysm repair should be
offered to all patients.
TREATMENT

104.  Open surgical repair - Preferred method of treatment,
 Local, regional, or general anesthesia
 Resection with either patch or interposition vein
grafting / resection and primary anastomoses, or in
the case of iatrogenic false aneurysms, simple suture
repair.
 Patency at a mean follow-up of 16 months was 100%.
OPEN REPAIR

105.  Only two case reports have described use of endograft in the
treatment of brachial artery aneurysms.
 In one case, a mycotic brachial pseudoaneurysm developed
secondary to a methicillin-resistant Staphylococcus aureus (MRSA)
wound infection that occurred after an emergency brachial artery
bypass grafting using greater saphenous vein. This pseudoaneurysm
was successfully treated with an endograft and antibiotics.
 In a second case, a brachial artery aneurysm was treated with an
endograft in a patient that had sustained a gunshot wound to the left
arm.97 This patient had a complex open humerus fracture and
brachial plexus injury, initially treated with wound debridement, skin
grafting, external fixation, and physical therapy. Two months after
the initial injury, the patient developed acute left arm pain and a
pulsatile mass in the upper arm. Arteriography demonstrated near
total transaction of the proximal left brachial artery. The origin of the
pseudoaneurysm was successfully excluded with an endograft.
ENDOVASCULAR REPAIR

106. THANK YOU