Cardiovascular Center, Taichung Veterans General Hospital, Taichung, Taiwan, ROC.
J Chin Med Assoc. 2012 Sep;75(9):474-8. doi: 10.1016/j.jcma.2012.06.019. Epub 2012 Aug 21.
Mycotic subclavian artery pseudoaneurysms are rare. There are controversies over the surgical or endovascular approach as the treatment of choice for these lesions. The standard surgical debridement might not be a choice for poorly surgically reachable lesions or for patients with multiple comorbidities. Endovascular aneurysm repair may be an effective alternative in selected cases. This treatment was rarely reported previously. Herein, we present a high-surgical-risk case with a highly suspected left subclavian arterial mycotic pseudoaneurysm, which, although difficult to approach surgically, was successfully managed with stent grafting and a complete antibiotic treatment course. An 89-year-old male was admitted due to intermittent fever and hemoptysis for 2 months. Salmonella group B was cultured from his sputum, and a 3.5 cm pseudoaneurysm was identified by chest multidetector-row computed tomography (MDCT) angiogram. Endovascular treatment with a graft stent was chosen due to high surgical risk and difficult surgical access to the lesion. The intervention was well planned ad hoc, based on MDCT images and meticulously performed by dual endovascular approaches. Antibiotics were continued after the procedure, and the patient was discharged from the hospital. As MDCT disclosed near-complete regression of the pseudoaneurysms 2 months later and the patient was in healthy status, antibiotics were continued for 6 months. He was readmitted 11 months later due to lacunar infarction with minor pneumonia over the left lower lung in which Salmonella enteritis was also diagnosed. After this acute event, he was again hospitalized 14 days later due to sepsis with adult respiratory distress syndrome and shortly expired despite all emergent treatment measures. No evidence of local subclavian infection recurrence was noted throughout or related to subsequent events. In conclusion, endovascular treatment of an infected subclavian artery pseudoaneurysm could be a choice in selected patients, but treatment of underlying infection determines the clinical outcome.
感染性锁骨下假性动脉瘤较为罕见。对于这些病变，手术或血管内治疗作为首选治疗方法存在争议。对于难以手术治疗的病变或合并多种合并症的患者，标准的手术清创术可能不是一种选择。血管内动脉瘤修复术在某些情况下可能是一种有效的替代方法。此前这种治疗方法很少有报道。在此，我们报告了一例高手术风险的疑似左侧锁骨下动脉感染性假性动脉瘤患者，尽管手术难度较大，但通过支架置入术和全程抗生素治疗成功治疗。一名 89 岁男性因间歇性发热和咯血 2 个月入院。从他的痰中培养出乙型沙门氏菌，胸部多层螺旋 CT（MDCT）血管造影显示 3.5 厘米假性动脉瘤。由于手术风险高，病变手术难度大，选择血管内治疗用移植物支架。根据 MDCT 图像进行了专门的术前精心计划，并通过双血管内途径进行了精心操作。介入治疗后继续使用抗生素，患者出院。2 个月后 MDCT 显示假性动脉瘤几乎完全消退，患者状况良好，继续使用抗生素 6 个月。11 个月后，他因左侧下肺小肺炎合并腔隙性梗死再次入院，同时也诊断出沙门氏肠炎。在这一急性事件之后，他因成人呼吸窘迫综合征合并败血症再次住院 14 天，尽管采取了所有紧急治疗措施，但他很快去世。整个过程中或与随后的事件相关，均未发现局部锁骨下感染复发的证据。总之，对于选定的患者，感染性锁骨下动脉假性动脉瘤的血管内治疗可能是一种选择，但潜在感染的治疗决定了临床结果。
