Brachiocephalic aneurysm: the case for early recognition and repair.

Over a 40 year period (1950-1990) only 73 patients were treated surgically for brachiocephalic aneurysms. An operation was performed for 38 subclavian, 25 extracranial carotid, six innominate, three aberrant right subclavian, and one vertebral artery aneurysm. Twenty-three other associated aneurysms occurred in 14 patients. Five patients had an additional untreated brachiocephalic aneurysm, and nine patients had 18 aneurysms located in different anatomic regions. There were 40 men and 33 women with a mean age of 50.5 years (range 16 to 82 years). Forty patients (54.8%) presented with potentially life- or limb-threatening signs or symptoms, including stroke or transient ischemic attacks (31.5%), upper extremity ischemia (19.2%), and rupture (4.1%). Atherosclerosis was most common in innominate aneurysms (66.7%) but also occurred in subclavian (34.1%) and carotid aneurysms (12.0%). Thoracic outlet compression was a common etiology for subclavian aneurysms while trauma or spontaneous dissection was more frequent for carotid aneurysms. Six deaths (8.2%) occurred within 30 days of operation: two from rupture, three in association with concomitant cardiovascular operations, and one from emergency carotid ligation. There were no deaths with elective isolated surgical repair. Overall five and 10 year survival in patients with brachiocephalic aneurysms was 80.8% and 61.4%, respectively. The majority of brachiocephalic aneurysms present with life- or limb-threatening complications and are associated with a high mortality for emergency or concomitant repair. Early elective isolated surgical repair remains the optimal therapy.