Case Report Stent-graft Repair of a True Internal Thoracic Artery Aneurysm Gabriele Piffaretti,1 Gianpaolo Carrafiello,2 Marco Franchin,1 Anna Maria Ierardi,2 Giovanni Mariscalco,3 Patrizio Castelli,1 and Santi Trimarchi,4 Varese and San Donato Milanese, Italy
We present the case of a 49-year-old woman diagnosed with Sneddon’s syndrome and previous endovascular embolization for cerebral and left renal artery aneurysms. The aneurysm was asymptomatic and incidentally detected as coin opacity at a preoperative X-ray performed for breast surgery. The 13-mm saccular left internal thoracic artery aneurysm engaged through a percutaneous left brachial artery access was successfully excluded with a stent graft. A 6-month follow-up computed tomography angiography confirmed the exclusion of the aneurysm, the patency of the internal thoracic artery, and the absence of endoleak or edge stenoses. True aneurysm of the internal thoracic artery is a rare entity. Stent-graft repair is a viable end effective alternative treatment for the exclusion of this lesion.
Aneurysm of the internal thoracic artery (ITA) is a rare entity; mainly, they have been identified as pseudoaneurysm following cardiac surgery, pacemaker implantation, or angiographic procedures.1 True aneurysms of the ITA have been reported more rarely, especially in association with connective tissue diseases or vasculitis.1e4
Traditionally, they have been treated with aneurysmectomy, while endovascular techniques have been successfully used but mainly in the form of coils embolization.4,5 We report the case of an ITA aneurysm successfully treated with stent graft (SG).
CASE REPORT Funding: None. Conflict of Interest: None. 1 Vascular Surgery, Department of Surgery and Morphological Sciences, Circolo University Hospital, University of Insubria School of Medicine, Varese, Italy. 2 Interventional Radiology, Department of Surgery and Morphological Sciences, Circolo University Hospital, University of Insubria School of Medicine, Varese, Italy. 3 Cardiac Surgery, University of Leicester, Glenfield Hospital, Leicester, UK. 4 Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy. Correspondence to: Gabriele Piffaretti, MD, PhD, Vascular Surgery, Department of Surgery and Morphological Sciences, Circolo University Hospital, University of Insubria School of Medicine, Via Guicciardini, 9, 21100 Varese, Italy; E-mail: [email protected]
Ann Vasc Surg 2015; -: 1–5 http://dx.doi.org/10.1016/j.avsg.2015.04.072 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: January 31, 2015; manuscript accepted: April 7, 2015; published online: ---.
A 49-year-old woman with a known diagnosis of Sneddon’s syndrome was admitted to our hospital for the management of an ITA aneurysm. Medical history was also notable for hypertension, pituitary adenoma, previous appendectomy, and colonic resection for diffuse acute peritonitis. In the past, she also underwent endovascular embolization of a left cerebral and left renal artery aneurysms; at that time, a preoperative computed tomography angiography (CTA) did not show enlargement of the ITA (Fig. 1A1). Three years later, she was admitted to our hospital for treatment of breast tumor as a result of screening program. A preoperative chest X-ray showed a left parasternal opacity which was further investigated with CTA. It revealed the presence of an intact 13-mm saccular aneurysm involving the proximal third of the left ITA (Fig. 1A2, B) and the dilatation of the ascending aorta (Fig. 1A3). A transthoracic echocardiography also showed the presence of a competent bicuspid aortic valve. A traditional open repair 1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Preliminary CTA showing the normal diameter (A1, arrow) of the ITA 3 years before the actual event (A2, arrow). Contextual ascending aortic enlargement
(A3). Volume rendering reconstruction (B) confirming the presence of the aneurysm (arrows) at the proximal one third of the artery.
versus an endovascular attempt was fully discussed and the informed consent was signed for an endovascular treatment attempt. We used local anesthesia, systemic heparinization (intravenous, 5000 IU), and a percutaneous left brachial artery approach. The ITA was engaged (Fig. 2A1) selectively with a 7F hockey stick guiding catheter (Cordis, Johnson & Johnson Corp., Miami Lakes, FL) and then crossed with a 0.014-inch stiff guidewire (Stabilizer Cordis, Johnson & Johnson Corp.). A 4.5 26 mm balloon-expandable SG (GraftMaster; Abbott, Santa Clara, CA) was deployed and insufflated at 11 atmospheres to achieve a diameter of 3.5 mm. The final angiogram showed the complete exclusion of the aneurysm and the patency of the ITA (Fig. 2A2). The postoperative course was uneventful; she was discharged on postoperative day 1 with clopidogrel 75 mg (Plavix; Sanofi Pharma Bristol-Myers Squibb SNC, Paris, France) plus acetylsalicylic acid 100 mg (Cardioaspirin; Bayer SpA, Milan, Italy). She was last seen 6 months later, asymptomatic when the follow-up CTA confirmed the complete exclusion of the aneurysm and the patency of the SG with no signs of endoleak or edge stenoses (Fig. 3).
DISCUSSION Aneurysms of the ITA are rare entities mainly reported as pseudoaneurysm following sternotomy, endovascular procedures, or trauma.1 True aneurysms have been reported very rarely; since the first ever officially reported case in 1978,6 in the available literature we have found 19 cases including ours, being associated with a connective tissue disorder or vasculitis in nearly 60% of the cases (Table I).1e9 Other reports have classified this type of lesion as true aneurysm recognizing some typical aspect of degenerative aneurysm at the preliminary CTA in patients without previous cardiac surgery or trauma.10,11 Honestly, endovascular repair did not allow us to perform a definitive histological examination to also rule out an inflammatory or mycotic aneurysm; however, our patient did not have direct traumas, a pacemaker, or underwent cardiac surgery. On the other hand, she had a known diagnosis
Vol.
-,
No.
-, -
2015
Fig. 2. Operative findings. Selective ITA catheterization (A1) showing the location of the aneurysm (arrows) and final control angiography (A2) with the complete exclusion of the aneurysm and patency of the stent graft (ring).
of bicuspid aortic valve, received treatments for cerebral and renal artery aneurysms, and did not undergo previous arterial catheterization of the axillo-subclavian arteries. All these aspects led us to consider this aneurysm as a true aneurysm potentially related to a form of connective tissue disorder. Sneddon’s syndrome is a noninflammatory, occlusive arterial disease affecting small to medium caliber vessels predominantly affecting women in early middle age.12 Despite the fact that true aneurysms have not, so far, been recognized as a typical feature of Sneddon’s syndrome, we found 2 previous reports with aneurysmatic association similar to our patient.13 The new different aspect is the association with multiple aneurysmatic lesions though metachronous in clinical presentation. Worrying aspects of ITA aneurysms are the rapid growth and a high rupture risk. In fact, most of the treated cases were found incidentally during radiologic examinations shortly after previous negative examinations.1,2,6 In addition, 37% of the cases were ruptured aneurysms: they caused massive hemothorax, and potentially led to death.5,14 Even smaller aneurysm (e.g., 10e36 mm) did rupture.12,15 These are the main reasons to indicate repair for these aneurysms.
Case Report 3
Once diagnosed, repair is frequently indicated, but it remains to select the type of treatment. Traditionally, open repair required ligation and aneurysmectomy; this has been the type of treatment reported for the first cases ever and also for most of the ruptured lesions.5,7 However, the advent of endovascular techniques has made it an attractive target. Coils embolization has been preferred because angulations, tortuosity, and the frequent small pedicle of this artery make this treatment more straightforward.4,5,10,14 However, this means the ITA is occluded definitely. SG repair of the ITA has been published so far; although these lesions were pseudoaneurysms, SG proved to be an effective alternative strategy to preserve flow and maintain myocardial perfusion.16,17 In our case, we aimed to exclude the aneurysm and to preserve the patency of the ITA; this is the reason why we selected an SG which is generally implanted in coronary artery procedures. Although SG may be prone to thrombosis in smaller arteries especially in the long run, we believed that SG attempt could have been a viable and effective alternative. In a young woman, the preservation of the ITA patency could be helpful in the long followup, particularly in the presence of cardiac risk factors which could require surgical correction in the future; at that time, a patent ITA could be very useful.
CONCLUSION True aneurysms of the ITA are rare entities but frequently related to a connective tissue disorder. Although aneurysmectomy have been the most reported type of treatment, and coils embolization showed to be effective, SG repair appears a viable and effective alternative technical treatment. REFERENCES 1. Okura Y, Kawasaki T, Hiura T, et al. Aneurysm of the internal mammary artery with cystic medial degeneration. Intern Med 2012;51:2355e9. 2. Ishiwata S, Nishiyama S, Nakanishi S, et al. Coronary artery disease and internal mammary artery aneurysms in a young woman: possible sequelae of Kawasaki disease. Am Heart J 1990;120:213e7. 3. Common AA, Pressacco J, Wilson JK. Internal mammary artery aneurysm in Marfan syndrome: case report. Can Assoc Radiol J 1999;50:47e50. 4. Ohman JW, Charlton-Ouw KM, Azizzadeh A. Endovascular repair of an internal mammary artery aneurysm in a patient with Loeys-Dietz syndrome. J Vasc Surg 2012;55:837e40. 5. Rose JF, Lucas LC, Bui TD, et al. Endovascular treatment of ruptured axillary and large internal mammary artery aneurysms in a patient with Marfan syndrome. J Vasc Surg 2011;53:478e82. 6. Den Otter G, Stam J. Aneurysm of internal mammary artery. Thorax 1978;33:526e7.
4 Case Report
Annals of Vascular Surgery
Fig. 3. Follow-up CTA at 6 months showed the patency of the stent graft (A, arrow) with no recoil or edge stenoses (B, ring). Volume rendering reconstruction (C) confirming the aneurysm exclusion and patency of the ITA (arrows).
Table I. Literature summary: true ITA aneurysms reported in the literature Author (publication year)
Sex (age)
Associated syndrome
Den Otter and Stam6 (1978) Giles et al.7 (1990) Ishiwata et al.2 (1990) Wildhirt et al.11 (1994) Connery et al.18 (1995) Chan et al.19 (1996) Phan et al.8 (1998) Cohen et al.15 (1998) Common et al.3 (1999) Kim et al.12 (2005) Dell’Amore et al.10 (2006) Urso et al.20 (2007) Morimatsu et al.21 (2007) Rose et al.5 (2011)
Female (30) Female (39) Female (24) Female (62) Male (50) Female (38) Male (39) Male (42) Female (37) Female (45) Female (82) Male (63) Female (33) Male (68)
No Polyarteritis nodosa Kawasaki arteritis No No No EhlerseDanlos IV No Marfan Neurofibromatosis 1 No Neurofibromatosis 1 No Marfan
Okura et al.1 (2012) Ohman et al.4 (2012)
Female (61) Cystic medial degeneration Female (34) LoeyseDietz
Cooke et al.9 (2013)
Male (55)
Lindblom et al.14 (2013)
Male (57)
Segmental arterial mediolysis No
Other aneurysm (location)
Rupture
Treatment (type, outcome)
No No Coronary No No No Renal No No No No No No AscAA TAAA LSA No
No No No No No Yes Yes Yes No Yes No Yes Yes No
Ligation, alive Ligation, alive Ligation, alive Ligation, alive Ligation, alive Coils embolization, Ligation, alive Ligation Coils embolization, Coils embolization, Ligation, alive Ligation, dead Ligation, alive Coils embolization,
No
Ligation, alive
TAD TAAA Renals, celiac trunk No
No No
Coils/plug embolization, alive No
Yes
Coils embolization, alive
alive
alive alive
alive
AscAA, ascending aortic aneurysm; LSA, left subclavian artery; TAAA, thoracoabdominal aortic aneurysm; TAD, thoracic aortic dissection. 7. Giles JA, Sechtin AG, Waybill MM, et al. Bilateral internal mammary artery aneurysms: a previously unreported cause for an anterior mediastinal mass. AJR Am J Roentgenol 1990;154:1189e90.
8. Phan TG, Sakulsaengprapha A, Wilson M, et al. Ruptured internal mammary artery aneurysm presenting as massive spontaneous haemothorax in a patient with Ehlers-Danlos syndrome. Aust N Z J Med 1998;28:210e1.
Vol.
-,
No.
-, -
2015
9. Cooke DL, Meisel KM, Kim WT, et al. Serial angiographic appearance of segmental arterial mediolysis manifesting as vertebral, internal mammary and intra-abdominal visceral artery aneurysms in a patient presenting with subarachnoid hemorrhage and review of the literature. J Neurointerv Surg 2013;5:478e82. 10. Dell’Amore A, Sanna S, Botta L, et al. Giant atherosclerotic aneurysm of left internal mammary artery. Eur J Cardiothorac Surg 2006;30:557e8. 11. Wildhirt S, Eckel L, Beyersdorf F, et al. Atherosclerotic aneurysm of the right internal mammary artery presenting as a mediastinal mass. J Thorac Cardiovasc Surg 1994;107:1535e6. 12. Kim SJ, Kim CW, Kim S, et al. Endovascular treatment of a ruptured internal thoracic artery pseudoaneurysm presenting as a massive hemothorax in a patient with type I neurofibromatosis. Cardiovasc Intervent Radiol 2005;28:818e21. 13. Killeen T, Wanke I, Mangiardi J, et al. Ruptured, fusiform, distal lenticulostriate aneurysm causing intraventricular haemorrhage in a patient with antiphospholipid-negative Sneddon’s syndrome. Clin Neurol Neurosurg 2014; 116:80e2. 14. Lindblom RP, Zemgulis V, Lilieqvist A, et al. Even small aneurysms can bleed: a ruptured small idiopathic aneurysm of the internal thoracic artery. Interact Cardiovasc Thorac Surg 2013;17:583e5.
Case Report 5
15. Cohen JD, Sahar G, Singer P, et al. Massive spontaneous hemothorax as a presenting sign of aneurysmal rupture of the internal thoracic artery. A case report. J Cardiovasc Surg (Torino) 1998;39:383e5. 16. Cheung PK, Philipp RK, Freed DH. Endovascular stenting for treatment of a left internal mammary artery pseudoaneurysm following redo-sternotomy: a case report. Catheter Cardiovasc Interv 2013;82:778e81. 17. Callaway MP, Wilde P, Angelini G. Treatment of a false aneurysm of an intercostal artery using a covered intracoronary stent-graft and a radial artery puncture. Br J Radiol 2000;73:1317e9. 18. Connery CP, Cramer SF, Cheeran D. Multiple aneurysms of the internal thoracic artery. Ann Thorac Surg 1995;59: 1561e3. 19. Chan LW, Fermanis CG. Spontaneous haemothorax caused by an internal mammary artery aneurysm. Aust N Z J Surg 1996;66:332e3. 20. Urso S, Carballo J, Greco E, et al. Ruptured aneurysm of the mammary artery in a patient with neurofibromatosis type I. J Card Surg 2007;22:229e31. 21. Morimatsu Y, Koga T, Akiyoshi H, et al. Massive hemothorax due to rupture of internal thoracic artery aneurysm after vaginal delivery. Acta Obstet Gynecol Scand 2007;86: 504e5.
We present the case of a 49-year-old woman diagnosed with Sneddon’s syndrome and previous endovascular embolization for cerebral and left renal artery aneurysms. The aneurysm was asymptomatic and incidentally detected as coin opacity at a preoperative X-ray performed for breast surgery. The 13-mm saccular left internal thoracic artery aneurysm engaged through a percutaneous left brachial artery access was successfully excluded with a stent graft. A 6-month follow-up computed tomography angiography confirmed the exclusion of the aneurysm, the patency of the internal thoracic artery, and the absence of endoleak or edge stenoses. True aneurysm of the internal thoracic artery is a rare entity. Stent-graft repair is a viable end effective alternative treatment for the exclusion of this lesion.
Aneurysm of the internal thoracic artery (ITA) is a rare entity; mainly, they have been identified as pseudoaneurysm following cardiac surgery, pacemaker implantation, or angiographic procedures.1 True aneurysms of the ITA have been reported more rarely, especially in association with connective tissue diseases or vasculitis.1e4
Traditionally, they have been treated with aneurysmectomy, while endovascular techniques have been successfully used but mainly in the form of coils embolization.4,5 We report the case of an ITA aneurysm successfully treated with stent graft (SG).
CASE REPORT Funding: None. Conflict of Interest: None. 1 Vascular Surgery, Department of Surgery and Morphological Sciences, Circolo University Hospital, University of Insubria School of Medicine, Varese, Italy. 2 Interventional Radiology, Department of Surgery and Morphological Sciences, Circolo University Hospital, University of Insubria School of Medicine, Varese, Italy. 3 Cardiac Surgery, University of Leicester, Glenfield Hospital, Leicester, UK. 4 Thoracic Aortic Research Center, IRCCS Policlinico San Donato, San Donato Milanese, Italy. Correspondence to: Gabriele Piffaretti, MD, PhD, Vascular Surgery, Department of Surgery and Morphological Sciences, Circolo University Hospital, University of Insubria School of Medicine, Via Guicciardini, 9, 21100 Varese, Italy; E-mail: [email protected]
Ann Vasc Surg 2015; -: 1–5 http://dx.doi.org/10.1016/j.avsg.2015.04.072 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: January 31, 2015; manuscript accepted: April 7, 2015; published online: ---.
A 49-year-old woman with a known diagnosis of Sneddon’s syndrome was admitted to our hospital for the management of an ITA aneurysm. Medical history was also notable for hypertension, pituitary adenoma, previous appendectomy, and colonic resection for diffuse acute peritonitis. In the past, she also underwent endovascular embolization of a left cerebral and left renal artery aneurysms; at that time, a preoperative computed tomography angiography (CTA) did not show enlargement of the ITA (Fig. 1A1). Three years later, she was admitted to our hospital for treatment of breast tumor as a result of screening program. A preoperative chest X-ray showed a left parasternal opacity which was further investigated with CTA. It revealed the presence of an intact 13-mm saccular aneurysm involving the proximal third of the left ITA (Fig. 1A2, B) and the dilatation of the ascending aorta (Fig. 1A3). A transthoracic echocardiography also showed the presence of a competent bicuspid aortic valve. A traditional open repair 1
2 Case Report
Annals of Vascular Surgery
Fig. 1. Preliminary CTA showing the normal diameter (A1, arrow) of the ITA 3 years before the actual event (A2, arrow). Contextual ascending aortic enlargement
(A3). Volume rendering reconstruction (B) confirming the presence of the aneurysm (arrows) at the proximal one third of the artery.
versus an endovascular attempt was fully discussed and the informed consent was signed for an endovascular treatment attempt. We used local anesthesia, systemic heparinization (intravenous, 5000 IU), and a percutaneous left brachial artery approach. The ITA was engaged (Fig. 2A1) selectively with a 7F hockey stick guiding catheter (Cordis, Johnson & Johnson Corp., Miami Lakes, FL) and then crossed with a 0.014-inch stiff guidewire (Stabilizer Cordis, Johnson & Johnson Corp.). A 4.5 26 mm balloon-expandable SG (GraftMaster; Abbott, Santa Clara, CA) was deployed and insufflated at 11 atmospheres to achieve a diameter of 3.5 mm. The final angiogram showed the complete exclusion of the aneurysm and the patency of the ITA (Fig. 2A2). The postoperative course was uneventful; she was discharged on postoperative day 1 with clopidogrel 75 mg (Plavix; Sanofi Pharma Bristol-Myers Squibb SNC, Paris, France) plus acetylsalicylic acid 100 mg (Cardioaspirin; Bayer SpA, Milan, Italy). She was last seen 6 months later, asymptomatic when the follow-up CTA confirmed the complete exclusion of the aneurysm and the patency of the SG with no signs of endoleak or edge stenoses (Fig. 3).
DISCUSSION Aneurysms of the ITA are rare entities mainly reported as pseudoaneurysm following sternotomy, endovascular procedures, or trauma.1 True aneurysms have been reported very rarely; since the first ever officially reported case in 1978,6 in the available literature we have found 19 cases including ours, being associated with a connective tissue disorder or vasculitis in nearly 60% of the cases (Table I).1e9 Other reports have classified this type of lesion as true aneurysm recognizing some typical aspect of degenerative aneurysm at the preliminary CTA in patients without previous cardiac surgery or trauma.10,11 Honestly, endovascular repair did not allow us to perform a definitive histological examination to also rule out an inflammatory or mycotic aneurysm; however, our patient did not have direct traumas, a pacemaker, or underwent cardiac surgery. On the other hand, she had a known diagnosis
Vol.
-,
No.
-, -
2015
Fig. 2. Operative findings. Selective ITA catheterization (A1) showing the location of the aneurysm (arrows) and final control angiography (A2) with the complete exclusion of the aneurysm and patency of the stent graft (ring).
of bicuspid aortic valve, received treatments for cerebral and renal artery aneurysms, and did not undergo previous arterial catheterization of the axillo-subclavian arteries. All these aspects led us to consider this aneurysm as a true aneurysm potentially related to a form of connective tissue disorder. Sneddon’s syndrome is a noninflammatory, occlusive arterial disease affecting small to medium caliber vessels predominantly affecting women in early middle age.12 Despite the fact that true aneurysms have not, so far, been recognized as a typical feature of Sneddon’s syndrome, we found 2 previous reports with aneurysmatic association similar to our patient.13 The new different aspect is the association with multiple aneurysmatic lesions though metachronous in clinical presentation. Worrying aspects of ITA aneurysms are the rapid growth and a high rupture risk. In fact, most of the treated cases were found incidentally during radiologic examinations shortly after previous negative examinations.1,2,6 In addition, 37% of the cases were ruptured aneurysms: they caused massive hemothorax, and potentially led to death.5,14 Even smaller aneurysm (e.g., 10e36 mm) did rupture.12,15 These are the main reasons to indicate repair for these aneurysms.
Case Report 3
Once diagnosed, repair is frequently indicated, but it remains to select the type of treatment. Traditionally, open repair required ligation and aneurysmectomy; this has been the type of treatment reported for the first cases ever and also for most of the ruptured lesions.5,7 However, the advent of endovascular techniques has made it an attractive target. Coils embolization has been preferred because angulations, tortuosity, and the frequent small pedicle of this artery make this treatment more straightforward.4,5,10,14 However, this means the ITA is occluded definitely. SG repair of the ITA has been published so far; although these lesions were pseudoaneurysms, SG proved to be an effective alternative strategy to preserve flow and maintain myocardial perfusion.16,17 In our case, we aimed to exclude the aneurysm and to preserve the patency of the ITA; this is the reason why we selected an SG which is generally implanted in coronary artery procedures. Although SG may be prone to thrombosis in smaller arteries especially in the long run, we believed that SG attempt could have been a viable and effective alternative. In a young woman, the preservation of the ITA patency could be helpful in the long followup, particularly in the presence of cardiac risk factors which could require surgical correction in the future; at that time, a patent ITA could be very useful.
CONCLUSION True aneurysms of the ITA are rare entities but frequently related to a connective tissue disorder. Although aneurysmectomy have been the most reported type of treatment, and coils embolization showed to be effective, SG repair appears a viable and effective alternative technical treatment. REFERENCES 1. Okura Y, Kawasaki T, Hiura T, et al. Aneurysm of the internal mammary artery with cystic medial degeneration. Intern Med 2012;51:2355e9. 2. Ishiwata S, Nishiyama S, Nakanishi S, et al. Coronary artery disease and internal mammary artery aneurysms in a young woman: possible sequelae of Kawasaki disease. Am Heart J 1990;120:213e7. 3. Common AA, Pressacco J, Wilson JK. Internal mammary artery aneurysm in Marfan syndrome: case report. Can Assoc Radiol J 1999;50:47e50. 4. Ohman JW, Charlton-Ouw KM, Azizzadeh A. Endovascular repair of an internal mammary artery aneurysm in a patient with Loeys-Dietz syndrome. J Vasc Surg 2012;55:837e40. 5. Rose JF, Lucas LC, Bui TD, et al. Endovascular treatment of ruptured axillary and large internal mammary artery aneurysms in a patient with Marfan syndrome. J Vasc Surg 2011;53:478e82. 6. Den Otter G, Stam J. Aneurysm of internal mammary artery. Thorax 1978;33:526e7.
4 Case Report
Annals of Vascular Surgery
Fig. 3. Follow-up CTA at 6 months showed the patency of the stent graft (A, arrow) with no recoil or edge stenoses (B, ring). Volume rendering reconstruction (C) confirming the aneurysm exclusion and patency of the ITA (arrows).
Table I. Literature summary: true ITA aneurysms reported in the literature Author (publication year)
Sex (age)
Associated syndrome
Den Otter and Stam6 (1978) Giles et al.7 (1990) Ishiwata et al.2 (1990) Wildhirt et al.11 (1994) Connery et al.18 (1995) Chan et al.19 (1996) Phan et al.8 (1998) Cohen et al.15 (1998) Common et al.3 (1999) Kim et al.12 (2005) Dell’Amore et al.10 (2006) Urso et al.20 (2007) Morimatsu et al.21 (2007) Rose et al.5 (2011)
Female (30) Female (39) Female (24) Female (62) Male (50) Female (38) Male (39) Male (42) Female (37) Female (45) Female (82) Male (63) Female (33) Male (68)
No Polyarteritis nodosa Kawasaki arteritis No No No EhlerseDanlos IV No Marfan Neurofibromatosis 1 No Neurofibromatosis 1 No Marfan
Okura et al.1 (2012) Ohman et al.4 (2012)
Female (61) Cystic medial degeneration Female (34) LoeyseDietz
Cooke et al.9 (2013)
Male (55)
Lindblom et al.14 (2013)
Male (57)
Segmental arterial mediolysis No
Other aneurysm (location)
Rupture
Treatment (type, outcome)
No No Coronary No No No Renal No No No No No No AscAA TAAA LSA No
No No No No No Yes Yes Yes No Yes No Yes Yes No
Ligation, alive Ligation, alive Ligation, alive Ligation, alive Ligation, alive Coils embolization, Ligation, alive Ligation Coils embolization, Coils embolization, Ligation, alive Ligation, dead Ligation, alive Coils embolization,
No
Ligation, alive
TAD TAAA Renals, celiac trunk No
No No
Coils/plug embolization, alive No
Yes
Coils embolization, alive
alive
alive alive
alive
AscAA, ascending aortic aneurysm; LSA, left subclavian artery; TAAA, thoracoabdominal aortic aneurysm; TAD, thoracic aortic dissection. 7. Giles JA, Sechtin AG, Waybill MM, et al. Bilateral internal mammary artery aneurysms: a previously unreported cause for an anterior mediastinal mass. AJR Am J Roentgenol 1990;154:1189e90.
8. Phan TG, Sakulsaengprapha A, Wilson M, et al. Ruptured internal mammary artery aneurysm presenting as massive spontaneous haemothorax in a patient with Ehlers-Danlos syndrome. Aust N Z J Med 1998;28:210e1.
Vol.
-,
No.
-, -
2015
9. Cooke DL, Meisel KM, Kim WT, et al. Serial angiographic appearance of segmental arterial mediolysis manifesting as vertebral, internal mammary and intra-abdominal visceral artery aneurysms in a patient presenting with subarachnoid hemorrhage and review of the literature. J Neurointerv Surg 2013;5:478e82. 10. Dell’Amore A, Sanna S, Botta L, et al. Giant atherosclerotic aneurysm of left internal mammary artery. Eur J Cardiothorac Surg 2006;30:557e8. 11. Wildhirt S, Eckel L, Beyersdorf F, et al. Atherosclerotic aneurysm of the right internal mammary artery presenting as a mediastinal mass. J Thorac Cardiovasc Surg 1994;107:1535e6. 12. Kim SJ, Kim CW, Kim S, et al. Endovascular treatment of a ruptured internal thoracic artery pseudoaneurysm presenting as a massive hemothorax in a patient with type I neurofibromatosis. Cardiovasc Intervent Radiol 2005;28:818e21. 13. Killeen T, Wanke I, Mangiardi J, et al. Ruptured, fusiform, distal lenticulostriate aneurysm causing intraventricular haemorrhage in a patient with antiphospholipid-negative Sneddon’s syndrome. Clin Neurol Neurosurg 2014; 116:80e2. 14. Lindblom RP, Zemgulis V, Lilieqvist A, et al. Even small aneurysms can bleed: a ruptured small idiopathic aneurysm of the internal thoracic artery. Interact Cardiovasc Thorac Surg 2013;17:583e5.
Case Report 5
15. Cohen JD, Sahar G, Singer P, et al. Massive spontaneous hemothorax as a presenting sign of aneurysmal rupture of the internal thoracic artery. A case report. J Cardiovasc Surg (Torino) 1998;39:383e5. 16. Cheung PK, Philipp RK, Freed DH. Endovascular stenting for treatment of a left internal mammary artery pseudoaneurysm following redo-sternotomy: a case report. Catheter Cardiovasc Interv 2013;82:778e81. 17. Callaway MP, Wilde P, Angelini G. Treatment of a false aneurysm of an intercostal artery using a covered intracoronary stent-graft and a radial artery puncture. Br J Radiol 2000;73:1317e9. 18. Connery CP, Cramer SF, Cheeran D. Multiple aneurysms of the internal thoracic artery. Ann Thorac Surg 1995;59: 1561e3. 19. Chan LW, Fermanis CG. Spontaneous haemothorax caused by an internal mammary artery aneurysm. Aust N Z J Surg 1996;66:332e3. 20. Urso S, Carballo J, Greco E, et al. Ruptured aneurysm of the mammary artery in a patient with neurofibromatosis type I. J Card Surg 2007;22:229e31. 21. Morimatsu Y, Koga T, Akiyoshi H, et al. Massive hemothorax due to rupture of internal thoracic artery aneurysm after vaginal delivery. Acta Obstet Gynecol Scand 2007;86: 504e5.
