DEMOGRAPHICS: Subclavian artery mycotic aneurysms (SAMAs) are extremely rare, accounting for less than 5% of the total subclavian artery aneurysms in the past 30 years. Repair options are highly variable and dependent on aneurysm-specific characteristics such as size, morphology, etiology, and location. In such cases, intra-thoracic or extra-thoracic involvement may require sternotomy, thoracotomy, or supraclavicular incisions. Despite the poor general condition of patients with SAMA, more invasive methods of exposure such as thoracotomy or median sternotomy are still utilized today. Yet, an anatomical exposure using claviculectomy has remained underutilized and can be used as an alternative to the more invasive methods of exposure.
HISTORY: A 23-year-old male with a past medical history of intravenous drug use (IVDU) and subsequent infective endocarditis status post mitral valve replacement presented with left-hand weakness, intermittent rest pain, night sweats, and failure to thrive. Computed tomography angiography (CTA) of the left upper extremity revealed a 1.9 x 1.5 cm left subclavian artery aneurysm with a focal occlusion of the distal subclavian artery with reconstitution at the level of the axillary artery. The aneurysm's etiology was considered mycotic and secondary to intravenous drug use.
PLAN: A decision was made to move forward with the claviculectomy exposure due to the patient’s comorbidities and the complex and unique anatomical location involving both intrathoracic and extra-thoracic portions of the left subclavian artery. Intraoperatively, the medial two-thirds of the clavicle were removed. The mycotic aneurysm was resected, and the remaining thrombosed artery was excised. Successful treatment involved a left median claviculectomy, excision of the mycotic aneurysm, and a subclavian to axillary artery bypass using the great saphenous vein. A Doppler ultrasound after the operation ultimately showed a patent left axillary artery with a palpable left radial artery.
DISCUSSION: When managing patients with a SAMA, the size and the location of the aneurysm should be considered to ensure proper surgical and medical approaches to treatment. Claviculectomy can be used to aid subclavian artery exposure by avoiding possible sternotomy and/or thoracotomy, depending on the location of the aneurysm and involvement from intra- or extra-thoracic portions of the subclavian artery. This case presents that a claviculectomy method of exposure can produce satisfactory outcomes in patients with subclavian artery mycotic aneurysms while maintaining a full shoulder range of motion.
