PMC6056777_01
2D (a) and 3D (b) computed tomography (CT) angiogram demonstrates a
circumscript aneurysm of left subclavian artery measuring (4.1 x 3.3 cm) in
the intrathoracic retro-clavicular space. (arrow).
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In 2016, a routine computed tomography (CT) scan in an outside hospital revealed a newly developed circumscript aneurysm (4.1 x 3.3 cm) of the left subclavian artery (LSA) in the retro-clavicular intrathoracic space (Figure 1).
Intraoperative fluoroscopy images demonstrate: (a) 6F pigtail catheter
navigated to the aortic arch across the aneurysm of left subclavian artery
(LSA), arteriogram confirms a circumscript aneurysm (arrow). (b) A 0.035 in
guide wire was navigated across the aneurysm to the ascending aorta, and the
highly flexible self-expanding covered stent-graft (Viabahn 
9 x 100 mm) was advanced along the wire, positioned correctly and ready for
deployment (arrow). (c) LSA stent-graft has been successfully deployed from
just beyond the proximal branches of LSA, to the junction with the axillary
artery (arrow). (d) A completion arteriogram confirmed correct positioning
of LSA stent-graft, the aneurysm sac has been successfully excluded (arrow)
and the patency of axillary artery and left internal mammary artery.
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Then, a '0.035' J-tip guide-wire was navigated across the aneurysm to reach the ascending aorta, followed by a Viabahn stent-graft (9 x 100 mm) advanced safely over this wire and precisely deployed to exclude the aneurysm (Figure 2(a)-(c)). A completion angiogram confirmed correct positioning and absence of endoleak (Figure 2(d)); the brachial artery access was closed by manual compression for 30 min and then a large radial TR-band  for 3 h.
2D and 3D volume rendered computed tomography (CT) angiogram demonstrates:
(a) and (d) Pre-procedure, circumscript LSA aneurysm measuring
(4.1 x 3.3 cm). (b) and (e) Post-procedure; before hospital discharge, the
LSA aneurysm was completely excluded after deployment of Viabahn 
stent-graft (9 x 100 mm). (c) and (f) At 1-year follow-up, a CT scan showed
the LSA stent-graft that remains widely patent with no evidence of the
previous aneurysm. Immediately proximal to the stent and distal to the left
vertebral origin, there is a moderate concentring narrowing with an
estimated stenosis 30% (star).
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Before hospital discharge, a CT angiogram demonstrated that the LSA stent had been precisely deployed, not compromising vital side branches and completely excluding the aneurysmal sac (Figure 3(b) and (e)). The patient went home on a combination medication of Aspirin 75 mg, Bisoprolol 5 mg and Losartan 50 mg, and was followed for 1 year; at 1-year follow-up, a CT scan confirmed no endoleak, a completely thrombosed LSA aneurysm and eventually complete resolution of the aneurysmal sac (Figure 3(a)-(f)).