Port Placement Produced Sizable Subclavian Pseudoaneurysm: Case Report

Purpose: Subclavian artery (SA) pseudoaneurysms are rare, accounting for less than 1% of all peripheral aneurysms. Most result from blunt trauma or iatrogenic causes (central line or tracheostomy tube placement). Treatment options include open surgical repair, endovascular repair, ultrasound-guided manual compression, or ultrasound-guided thrombin injection. Because there is little literature comparing these strategies, management must be tailored to each patient’s specific needs.

Materials and Methods: We present a 71-year-old woman with a history of endometrial carcinoma who was status post robotic hysterectomy and secondary debulking. She required adjuvant chemotherapy and presented to our community hospital to have a left subclavian vein port placed by gynecologic oncology. During the procedure, the left SA was inadvertently catheterized. The port was removed, and hemostasis achieved with manual pressure. Follow-up computed tomography angiography of the chest appeared to reveal active contrast extravasation into the mediastinum through a small arteriotomy defect in the proximal left SA, concerning for perforation and displacing the trachea anteriorly.

Results: Emergent angiography by the interventional radiology service revealed the pseudoaneurysm the left SA, with a narrow neck located 2.2 cm proximal to the origin of the left vertebral artery (VA). This location was crucial in determining which treatment to use for this patient. Ultrasound-guided compression would have also compressed the adjacent VA. Ultrasound-guided thrombin injection risks systemic embolization of the material. A recent review by Maskanakis et al estimated a 10.6% all-cause mortality incidence for emergency endovascular repair of SA true and false aneurysms, which is lower than the 13% mortality rate of open repair. For this patient, the team opted for covered stent placement. However, because of her complicated anatomy and infrastructural limitations at our institution, we transferred her to a tertiary care center, where she underwent successful stent placement.

Conclusions: Iatrogenic SA pseudoaneurysms are rare but can be life threatening. This case demonstrates the need for practitioners to be alert for this possibility and aware of the various treatment options because management often must be individualized for each patient.