CASE 14459 Published on 11.09.2017

Subclavian vein aneurysm - Case presentation and discussion

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Manuel David Torres Guzmán MD, Alejandro Romero MD

San Ignacio,Carrera 7 # 40-62; Carrera 7-C Bis, # 141-A - 27, Casa 70 110121 Bogota; Email:macrosdavtorres@gmail.com

Patient

64 years, female

Categories

Area of Interest Head and neck, Interventional vascular, Vascular ; Imaging Technique CT-Angiography, Catheter venography, Digital radiography, Fluoroscopy, Ultrasound, Ultrasound-Colour Doppler, Ultrasound-Power Doppler, Ultrasound-Spectral Doppler

Procedure Diagnostic procedure, Catheters, Embolisation, Intraoperative ; Special Focus Aneurysms, Oedema ;

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Clinical History

A 64-year-old female patient suffers from a progressive dyspnea for 2 months. The patient indicates pleuritic pain in the the left hemithorax with a 8/10 intensity. She also notes a 24 hour-long oedema and pain in the left lateral neck region and the ipsilateral supraclavicular region. She denies other symptoms.

Imaging Findings

A CT-bodyscan is requested on the suspicion of a lymphoma presence.

Saccular dilatation of the proximal third of the left subclavian vein measuring 14.8x16x14.6 mm is documented [Fig. 1a, b and c] with an aneurysm/vein ratio of 16/9.5 mm = 1.68. Angiography confirms an aneurysm in the subclavian vein [Fig. 2a and b]. Doppler exploration confirms an aneurysm on the cephalad side of the vein, and in its interior partial thrombosis can be seen [Fig. 3a, b and c].

Endovascular therapy with coils is indicated due to the presence of oedema and pain in the lower left neck. After signing the informed consent, (explaining possible complications such as vein thrombosis or rupture and coil migration) the procedure is performed without complications, excluding the aneurysm from the systemic vascularisation, evidenced in phlebography [Fig. 4]. Two detachable coils were used, (5x150mm, and 6x200mm). Doppler insonation shows an acoustic shadow artefact (coils) and permeability [Fig. 5a and b].

Discussion

Venous aneurysms typically consist of real aneurysms, mostly saccular, appearing as isolated soft tissue masses or as a component of arteriovenous malformations, reaching a size two to three times greater than the calibre of the main vessel and its aetiology is generally unknown, although focal defects in the development of the tunica media are suggested as a possible explanation [1, 2, 3]. They're more common in the jugular veins, central thoracic veins and visceral veins, affecting any age and gender [3, 4]. When they occur in the head and neck, they often manifest as asymptomatic masses that increase in size with Valsalva manoeuvres [1, 2, 3, 5].

There are 3 types of venous aneurysms: congenital (neurofibromatosis or Menkes disease), traumatic and acquired (for example arterialised vein grafts.) [5].

Possible complications include: thromboembolism, rupture, venous obstruction and compression of adjacent structures [1, 6, 7]. When these entities occur in the legs or abdomen, surgical resection is recommended due to higher risk for these complications. There are reports of up to a 71% incidence of deep vein thrombosis and pulmonary embolism in popliteal or femoral vein aneurysms, and 41% in intra-abdominal veins [1]. The treatment indications of a venous aneurysm that does not correspond to these anatomical areas are: complications, sustained growth and cosmetic alteration [2].

In our review of the literature there's report of 5 cases of subclavian vein aneurysms and only one of these cases presented a pulmonary thromboembolism as a complication [1, 3, 8].

Doppler Duplex ultrasonography and computed tomography with intravenous injection of non-ionic water-soluble iodinated contrast are the best way to evaluate this disease. Alternatively MRI angiography or phlebography can be performed [2, 3, 9]. Nevertheless, given the benign nature of these diseases when they occur in the mediastinum or neck, very invasive procedures are not recommended unless the patient presents any of the mentioned indications [2].

Venous aneurysms have been treated with conservative management and monitoring, open surgery and also endovascular techniques, which are favoured since they are minimally invasive. Among the latter, the use of coils, glue, stents or thrombin can be included. Regarding the use of stents, embolisation of the aneurysm can be carried out with the stent in place or aneurysm exclusion can be performed by placement of a stent-graft. The stent with the ends positioned at least 15 mm on either side of the aneurysm, serves as a scaffold for intra-aneurysmatic coils implantation, preventing herniation to more proximal vessels allowing denser packing [8].

Differential Diagnosis List

Aneurysm of the left subclavian vein.

Cystic hygroma

Pancoast tumour

Paraganglioma

Goitre

Lymphoma

Final Diagnosis

Aneurysm of the left subclavian vein.

References

[1] Robert A. McCready, MD, M. Ann Bryant, RN, Janet L. Divelbiss, RN, et al (2007) Robert A. McCready, MD, M. Ann Bryant, RN, Janet L. Divelbiss, RN, et al (2007) Inflammatory carcinoma of the breast. J Vasc Surg 45:1080-2. J Vasc Surg 45:1080-2 (PMID: 17466806)

[2] G. Pedersen, E. Laxdal, S.R. Amundsen (2005) SHORT REPORT, Aneurysm of the Subclavian Vein. EJVES Extra 10, 89–91

[3] Nina C. A. Vermeer, MD, Jan Willem M. Elshof, MD, and Patrick W. H. E. Vriens, MD, PhD (2014) Clinical presentation, diagnosis, and treatment of venous aneurysms. J Vasc Surg 2:349-53 (PMID: 26993399)

[4] Ilijevski NS, Radak S, Vucurevic G, Sagic D, Otasevic P, Tasic N, et al (2008) Jugular vein aneurysm. Vascular 16:291-4 (PMID: 19238873)

[5] J.S.T. Yao, B. van Bellen, W.R. Flinn, J.J. Bergan (1982) Aneurysms of the venous system. Aneurysms: diagnosis and treatment, Grune and Stratton, New York 1: 515–530

[6] El Husseiny M, Benhaiem N, Vayssairat M, Allaire E. (2011) Masson’s vegetant intravascular hemangioendothelioma in an external jugular vein aneurysm with recurrent thrombosis. J Vasc Surg 53:1723-5 (PMID: 21609803)

[7] Ioannou CV, Kostas T, Tsetis D, Georgakarakos E, Gionis M, Katsamouris AN (2010) External jugular vein aneurysm: a source of thrombotic complications. Int Angiol 29:284-5 (PMID: 20502418)

[8] Enrique M. San Norberto, MD, Vicente M. Gutiérrez, MD, Álvaro Revilla, MD, et al (2010) Subclavian Venous Aneurysm: Endovascular Treatment. J Vasc Interv Radiol 21:1306–1308 (PMID: 20537560)

[9] Chaoyang Wen, Runqiu Liu, Mei Liu, et al (2009) Saccular neck venous aneurysm on color duplex sonography: an analysis of 12 cases. Clinical Imaging 33(6):424-9 (PMID: 19857801)

Case information

URL:	https://eurorad.org/case/14459
DOI:	10.1594/EURORAD/CASE.14459
ISSN:	1563-4086

License

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.

Figure 1

Neck and thoracic inlet CT

Neck and thoracic inlet CT with intravenous contrast media in axial projection, a saccular aneurysm of the upper edge of the left subclavian vein can be seen (arrow), without evidence of rupture.

Neck and thoracic inlet CT with intravenous contrast media in coronal reconstruction, in which a saccular aneurysm of the upper edge of the left subclavian vein can be seen (arrow), without evidence of rupture.

Neck and thoracic inlet CT with intravenous contrast media in sagittal reconstruction, in which a saccular aneurysm of the upper edge of the left subclavian vein can be seen (arrow), without evidence of rupture.

Figure 2

Venography of the left subclavian vein

Venography of the left subclavian vein after catheterization and subsequently of the aneurysm, shows filling of the venous dilatation after the injection of contrast media, with preserved patency of the subclavian vein.

Venography of the left subclavian vein after catheterization and subsequently of the aneurysm, shows filling of the venous dilatation after the injection of contrast media. The dimensions of the lesion are noted.

Figure 3

Duplex Doppler

Gray scale and Color Doppler exploration demonstrates the aneurysm and an echogenic image attached to a wall in its interior, compatible with mural thrombus.

Gray scale and Color Doppler exploration, orthogonal to Fig. 3a, demonstrates the aneurysm and an echogenic image attached to a wall in its interior, compatible with mural thrombus.

Gray scale and Color Doppler exploration, showing evidence of the patency of the subclavian vein adjacent to the aneurysm.

Figure 4

Venography of the left subclavian vein

Venography of the left subclavian vein after endovascular therapy with coils within the aneurysm. Complete exclusion of aneurysm from the venous circulation and patency of the veins is observed.

Figure 5

Doppler ultrasound

Power Doppler demonstrates irregular echogenic image which generates acoustic shadowing, corresponding to embolisation material within the aneurysm. There is adequate bloodflow within the subclavian vein.