Chapter 84 - Upper extremity aneurysm

Question 1

Usual age at which aneurysm degeneration occur in aberrant right subclavian

Answer 1

> 50 years

Question 2

Define Kommerell’s diverticulum

Answer 2

Degenerative aneurysmal change in proximal portion of aberrant subclavian artery

Question 3

Rate of Kommerell’s diverticulum in aberrant right subclavian

Answer 3

60%

Question 4

Astley Cooper 1805, 1808 on arch vessel aneurysm

Answer 4

CCA aneurysm ligation

Question 5

Mott 1818 on arch vessel aneurysm

Answer 5

Innominate artery ligation for subclavian artery aneurysm

dead in 1 month from necrotic aneurysm

Question 6

1864 Smyth in New Orleans on subclavian artery aneurysm

Answer 6

first successful treatment by ligating CCA and innominate artery

recurred and ruptured 10 years later

Question 7

Halsted 1892 John Hopkins on arch vessel aneurysm

Answer 7

Successful resection of subclavian artery aneurysm

Question 8

Matas 1913 on arch vessel aneurysms

Answer 8

7 cases of subclavian aneurysm endoaneurysmorrhaphy

Question 9

% of arch aneurysms that were degenerative

Answer 9

63%

Question 10

Demographic of arch vessel aneurysms

Answer 10

men > 60 years

Question 11

Causes of arch vessel aneurysms

Answer 11

1) degenerative
2) trauma
3) FMD
4) syphilis
5) cystic medial necrosis
6) vasculitis
7) contiguous tuberculous lymphadenitis
8) idiopathic congenital cause

Question 12

Arch aneurysms as a percentage of all peripheral aneurysms

Answer 12

1%

Question 13

Percentage of patients with arch aneurysms to have other peripheral aneurysms

Answer 13

30-50%

Question 14

Subclavian aneurysm as percentage of all arch aneurysms

Answer 14

50%

Question 15

Innominate aneurysm as percentage of arch aneurysms

Answer 15

2-5%

Question 16

Causes of true aneurysms in the CCA

Answer 16

1) degenerative
2) FMD
3) marfan
4) Behcet
5) takayasu

Question 17

Chance of bilateral CCA aneurysm

Answer 17

very rare

1) takayasu
2) cogan syndrome

Question 18

Cogan syndrome

Answer 18

Multisystemic disease with vestibuloauditory dysfunction, inflammatory eye disease and vasculitis

Can cause recurrent aortic and carotid aneurysms

Mimic Marfans

Question 19

Symptoms of arch vessel aneurysm

Answer 19

1) chest/neck/shoulder pain
2) UE ischemic symptoms
3) UE pain/neurologic dysfunction
4) hoarseness
5) respiratory insufficiency
6) TIA/stroke
7) dysphagia
8) hemoptysis
9) supraclavicular bruit
10) Horner syndrome

Question 20

Risk of ligation in causing ischemia in arch aneurysms

Answer 20

25%

Question 21

Kieffer et al innominate artery types

Answer 21

Type A: confined to innominate artery distal to origin
Type B (most common): innominate and origin
Type C: innominate artery and ascending aorta

Question 22

Subclavian artery aneurysm classification

Answer 22

Proximal (degenerative): stenotomy

Distal (TOS): supra and infraclavicular incision

Question 23

Relative contraindication to open repair of arch aneurysms

Answer 23

1) severely compromised pulmonary function
2) prior sternotomy
3) prior left thoracotomy
4) hemodynamic instability due to poly trauma

Question 24

Mortality of open arch aneurysm repair

Answer 24

11%

Question 25

What to do if needing to cover vertebral artery

Answer 25

1) contralateral needs to be adequate 2) carotid vertebral bypass first if needed 3) coil embolize vert if not ligated to limit endoleak

Question 26

Hybrid approach to subclavian and innominate aneurysms

Answer 26

Carotid-subclavian bypass or transposition | Proximal plug or endograft in innominate into CCA

Question 27

Subclavian stent graft patency

Answer 27

83-100% over 7-29 months

Question 28

Aberrant subclavian artery prevalence

Answer 28

0.5-1% of population

Question 29

Aberrant subclavian artery first described by

Answer 29

Hunauld 1735

Question 30

Dysphagia lusoria first described by

Answer 30

Impingement of aberrant vessel on esophagus Bayford 1794

Question 31

Track of the anomalous right subclavian

Answer 31

Distal to left subclavian origin Posterior and inferior on arch 80% cross midline between esophagus and spine less likely cross between esophagus and trachea or anterior to trachea

Question 32

Embryology, left fourth arch becomes

Answer 32

Part of aortic arch

Question 33

Embryology, right fourth arch becomes

Answer 33

root of right subclavian artery

Question 34

Embryologic cause of aberrant subclavian

Answer 34

Right fourth aortic arch and rigth dorsal aorta involute cranial to 7th intersegmental artery

Question 35

What is aberrant subclavian artery associated with

Answer 35

Non-recurrent right laryngeal nerve

Question 36

Epidemiology of aberrant subclavian aneurysm

Answer 36

1) Age > 50 | 2) either sex

Question 37

Indication to repair aberrant artery aneurysm

Answer 37

Repair > 3cm in good risk patients

Question 38

Kommerell Diverticulum define

Answer 38

Proximal aberrant subclavian artery aneurysm Described by Kommerell 1936

Question 39

Rate of Kommerell in aberrant subclavian

Answer 39

60%

Question 40

Who first called attention to the significance of aneurysm change in aberrant subclavian

Answer 40

McCallen and Schaff 1956

Question 41

Aberrant subclavian Classification by Kiefer

Answer 41

Group 1: nonaneurysmal aberrant right subclavian artery Group 2: occlusive disease of nonaneurysmal ARCA Group 3: aneurysmal dilation of ARSA without aortic involvement Group 4: aneurysmal ARSA with aortic involvement

Question 42

Aberrant subclavian artery aneurysm presented as rupture or dissection in this % of patients

Answer 42

14-53%

Question 43

% of patients with aberrant subclavian aneurysm also have AAA

Answer 43

20%

Question 44

Mortality of open repair of Kommerell diverticulum

Answer 44

Up to 30%

Question 45

Hybrid approach to bilateral subclavian revasc and endo TEVAR - mortality

Answer 45

10% in 36 months

Question 46

Causes of axillary artery aneurysm

Answer 46

1) trauma: repetitious forceful extension of UE - abduction, external rotation and downward displacement of humeral head 2) congenital (Rare) baseball pitchers

Question 47

Rob and Standeven 1956 on axillary artery aneurysms

Answer 47

Crutch-induced blunt trauma first described Thickened walls and wrinkled roughed intima loss of brachial pulse or emboli after prolonged crutch use

Question 48

Histological signs of chronic trauma

Answer 48

1) Fragmentation of medial elastic fibers | 2) periadventitial fibrosis

Question 49

Symptoms of axillary artery aneurysm

Answer 49

1) emboli | 2) brachial plexus compression

Question 50

Patency of open interpositional grafting of axillary artery

Answer 50

100% 3.2 years

Question 51

Patency of Endovascular treatment of axillary artery aneurysm

Answer 51

84.4% up to 70 months

Question 52

Causes of brachial artery aneurysm

Answer 52

1) traumatic (including IVDU injection and infecdtion) 2) Congenital aneurysm 3) idiopathic 4) Type IV Ehlers-Danlos 5) Kawasaki 6) Buerger 7) Kaposi sarcoma 8) cystic adventitial disease 9) dissection

Question 53

Symptoms of brachial artery aneurysm

Answer 53

1) median nerve compression | 2) digital ischemia (thrombosis or emboli)

Question 54

Patency of brachial artery aneurysm open repair

Answer 54

100% 16 months

Question 55

Rate of brachial artery pseudoaneurysm and thrombosis after percutaneous access

Answer 55

Pseudoaneurysm 0.3% | Thrombosis 1-7%

Question 56

Thrombin injection for brachial artery pseudoaneurysm

Answer 56

1) too superficial 2) usually short neck Can be done but usually not suitable