Recently, endovascular aortic aneurysm repair has made remarkable progress, and it is becoming increasingly common for the access to originate in the upper extremity for complicated aortic aneurysmal cases.
In such cases, a left brachial artery approach is commonly chosen. Since we often encounter asymptomatic left subclavian artery occlusion (LSAO), it is an important consideration when planning the operations.
Here, we report two cases of a poor access route from the left brachial artery because of asymptomatic axillary artery occlusion (AAO), despite no preoperative upper arm blood pressure laterality, a normal ankle brachial pressure index, and no preoperative occlusion of the subclavian artery on CT scan.
Case 1 (Fig. 1)
A 76-year-old woman (height 156 cm, weight 47 kg) had previously undergone intestinal resection procedures because of superior mesenteric artery occlusion and carotid artery stenting for bilateral internal carotid artery stenosis. As a result, she had a past medical history of old cerebral infarction.
We planned endovascular aneurysm repair (EVAR) for para-renal abdominal aortic aneurysm using the snorkel technique for the renal artery, but we failed to pass through the left subclavian artery when approaching from the left brachial artery because of AAO.
Before the operation, her pulse was palpable and there was no difference between the left and right upper extremity. Her upper arm blood pressure at that time exhibited no laterality (HR 87/min, BP right 149/90 mmHg, BP left 148/84 mmHg).
Preoperative enhanced computed tomography (CT) imaging revealed a para-renal abdominal aortic aneurysm with a maximum diameter of 58 × 63 mm. The axillary artery was densely calcified, but the AAO was not obvious since the contrast medium was injected from the left upper extremity during preoperative enhanced CT, and this caused severe halation at the axillar/subclavian vein, which made visualization of the adjacent left subclavian artery difficult or impossible.
We planned EVAR for her para-renal abdominal aortic aneurysm using the snorkel technique in the renal arteries. We attempted cannulation of the renal artery approaching from the left brachial artery, but failed to pass through the left subclavian artery because of AAO. Therefore, we decided to compromise the EVAR by landing the proximal stent in the short neck without the snorkel technique. Since the completion angiogram showed the absence of endoleak and complete exclusion of the aneurysm, we did not access the right upper extremity to perform the originally planned snorkel technique.
Case 2 (Fig. 2)
A 73-year-old woman (height 155 cm, weight 49 kg) had right renal arterial embolism, chronic kidney disease, and pleurisy in her past history.
Preoperatively, her upper arm blood pressure exhibited no laterality (HR 76/min, BP right 120/80 mmHg, BP left 123/75 mmHg).
Preoperative enhanced computed tomography (CT) imaging revealed a thoracic aortic aneurysm with a maximum diameter of 52 × 50 mm, but the left AAO was not obvious because the left innominate vein’s enhancement concealed LSAO findings.
We planned zone 2 thoracic endovascular aneurysm repair (TEVAR) for thoracic aortic aneurysm and embolization of the left subclavian artery via the left brachial artery, but we failed to pass through the left subclavian artery because of AAO, and therefore, we simply covered the orifice of the left subclavian artery using a stent graft without embolization. No endoleak was observed postoperatively.