368 c© 2012 Wiley Periodicals, Inc.

SURGICAL TECHNIQUE

Ministernotomy with SubclavianExtension for the Management of aLarge Intrathoracic PseudoaneurysmSalvatore Lentini, M.D., Domenico Spinelli, M.D., Narayana Pipito, M.D.,

Mafalda Massara, M.D., Filippo Benedetto, M.D., and Francesco Spinelli, M.D.

Cardiovascular and Thoracic Department, Policlinico G. Martino, University of Messina,Messina, Italy

ABSTRACT We report on the management of a large intrathoracic subclavian pseudoaneurysm treated using

an upper J ministernotomy with subclavian extension. This approach allows exposure of the supraaortic

vessels and upper portion of the thoracic cavity and may be of help in selected cases. doi: 10.1111/j.1540-8191.2012.01450.x (J Card Surg 2012;27:368-370)

Different surgical approaches have been pro-posed for the treatment of lesions affecting thecervicothoracic region. We describe a surgical ap-proach through an upper J ministernotomy with sub-clavian extension for treating a subclavian arterypseudoaneurysm presenting as a large intrathoracicmass.

CLINICAL SUMMARY

A 57-year-old female was presented with a large in-trathoracic mass due to a pseudoaneurysm of the rightsubclavian artery, causing respiratory distress and clin-ical signs of superior vena cava (SVC) syndrome. Thepatient had a past history of breast cancer treated withsurgery, chemotherapy, and radiation, for which sherequired central venous cannulation. Iatrogenic punc-ture of the subclavian artery was thought to be thecause of the pseudoaneurysm. The patient had re-ceived multiple endovascular treatments for treatingthe pseudoaneurysm: she had stenting of the rightsubclavian artery to cover the opening of the arterialfalse aneurysm and extension of stenting to the rightcarotid artery (Chimney technique). A CT scan nowshowed a large right intrathoracic mass (6.5 cm ×8 cm), with compression of the trachea. (Figs. 1and 2).

Conflict of interest: None.

Address for correspondence: Salvatore Lentini, M.D., F.E.S.C., Cardio-vascular and Thoracic Department, Policlinico G Martino, Universita diMessina, Viale Gazzi, 98100 Messina, Italy. Fax: +(39) 090 2217086;e-mail: salvolentini@alice.it

Surgical technique

Under general anaesthesia, the patient was posi-tioned in the dorsal decubitus position, with hyperex-tension of the right cervical region with the head turnedon the left side, the right axillary region gently raisedwith a block, and the right arm positioned on the lateralside of the chest wall. The right cervical, subclavian,and sternal areas were draped. An upper J shaped in-cision was performed, with the sternum incised fromthe sternal notch vertically to the third right intercostalspace. From the sternal notch, the incision was thenlaterally extended to the right subclavian region (Fig. 3).Through the supraclavicular incision, both the rightcarotid artery and the right subclavian artery were ex-posed (Fig. 4A). Through the sternal incision the aorticarch and the intrapericardial structures were exposedto allow central cannulation should emergency extra-corporeal circulation be needed. After careful surgicaldissection, the subclavian artery was clamped distal tothe pseudoaneurysm. The right common carotid arteryand the brachiocephalic artery next to the aortic archwere clamped. After vessel incision, the previously in-serted stents were removed and the subclavian arterywith the neck of the pseudoaneurysm completely ex-cised (Fig. 4B). Then, through the sternal incision, theright pleural cavity was entered. The large vascularmass was visualized and opened, the thrombotic ma-terial removed, and the residual cavity was washedwith saline and poviodine solution. The right subclavianartery was then reconstructed with an 8 mm diameterGORE-TEX

R©(W. L. Gore & Assoc., Flagstaff, AZ, USA)

vascular interposition graft.The postoperative course was uneventful with

recovery from the respiratory and SVC syndrome

J CARD SURG2012;27:368-370

LENTINI, ET AL.MINISTERNOTOMY WITH SUBCLAVIAN EXTENSION

369

Figure 1. CT scan showing the intrathoracic mass compress-ing the trachea and displacing the supra-aortic vessels to theleft.

Figure 2. CT angiography. (A) White arrow shows leakage ofcontrast medium from the stented subclavian artery (∗). (B)The subclavian artery (∗) and the carotid artery (C.A.) with thepreviously implanted stents.

symptoms. CT angiography at three-month follow-upshowed normal patency of the subclavian and carotidarteries and absence of tracheal compression. At12 months follow-up, the patient remained well, withno recurrence of symptoms.

Figure 3. Drawing illustrating the surgical incision.

Figure 4. Intraoperative findings. (A) Ministernotomy andpreparation of the supraaortic vessels on the right side. (B)Opening of the pseudoaneurysm.

DISCUSSION

Aneurysms or pseudoaneurysms of the subclavianartery are rare and may expand into the cervical re-gion intrathoracically. Choosing the surgical exposurefor pathologies affecting the subclavian vessels withintrathoracic extension represents a challenge.

370 LENTINI, ET AL.MINISTERNOTOMY WITH SUBCLAVIAN EXTENSION

J CARD SURG2012;27:368-370

Antero-superior approaches are an important strat-egy in the surgical access to the cervical thoracicregion.1 Following the previous works by Cormier,who in 1970 described an anterior surgical access tothe subclavian pedicle, Dartevelle et al. in 1993 de-scribed a transclavicular approach for radical resectionof lung tumors invading the thoracic inlet with vascularinvolvement.2,3 However, clavicular resection resultedin reduced function of the upper limb. Therefore,Grunenwald et al. modified this surgical approach,maintaining clavicle integrity, and described an an-terior transmanubrial approach (Cormier–Dartevelle–Grunenwald approach).4 The anterior cervical transster-nal approach described by Ladas in 1999 and theunilateral cervicosternal thoracotomy (hemiclamshell)enable exposure of the cervicothoracic region and ofthe pulmonary hilum.5,6 For intrathoracic aneurysmsof the proximal left subclavian artery, a lateral thora-cotomy with partial cardiopulmonary bypass has beenproposed.7 An approach through a full sternotomy hasbeen reported to treat large true aneurysms of theproximal right subclavian artery.8

In the present case, we used a reduced sternal ap-proach through an upper J ministernotomy to the thirdright intercostal space, with a supraclavicular exten-sion to expose the subclavian artery up to its distalportion. Upper ministernotomy is currently used forsurgery on the aortic valve and ascending aorta.9,10 Itcan be used both for first time and for redo surgery.11

Cardiopulmonary bypass (CPB) may be needed dur-ing surgery for large intrathoracic aneurysms or pseu-doaneurysms.12 In this case, ministernotomy wouldenable the exposure of intrapericardial structures forcentral cannulation, allowing CPB. Through the mini-sternotomy, the upper portion of the pleural cavity canbe easily exposed to evacuate the aneurysm cavity. Onthe other hand, the supraclavicular incision would allowthe exposure of the subclavian artery up to its distalportion, including its branches. In our patient, we leftthe sternocleidomastoid muscle in place without anyfiber resection, therefore we created a tunnel behindthis muscle to reconstruct the arterial tree. This incisionalso allows exposure of the common carotid artery, asin the present case. The precise surgical exposure ofthe subclavian artery branches is of help before open-ing the aneurysm to reduce blood loss. The upper Jministernotomy with subclavian extension would al-low the exposure of the intrathoracic structures thatneed to be visualized, without need for a complete

sternotomy adding to the procedure the advantages ofa minimally invasive sternal approach.9-11

In conclusion, we suggest this type of incision forvascular lesions where exposure of supraaortic ves-sels and the upper portion of the pleural cavity isneeded.

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