A 65-yr-old female presented with hoarseness that began 3 weeks ago. She had no previous history of trauma, pulmonary and bronchial tuberculosis. On admission, her vital signs were normal and blood pressure was equal on both arms. The laboratory workup showed a white blood cell count of 6,500/microL, normal erythrocyte sedimentation rate and C-reactive protein. Syphilis serology, rheumatoid factor, and antinuclear antibody tests were negative. Chest radiograph (CXR) demonstrated a superior mediastinal mass (Fig. 1). Because laryngoscopy showed a fixed right vocal cord, hoarseness was considered to be due to recurrent laryngeal nerve palsy. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a 7 cm sized proximal right subclavian artery aneurysm (Fig. 2, 3). Thoracic and subclavian aortography revealed a tortuous right subclavian arterial anatomy with a saccular aneurysm beginning near the subclavian origin (Fig. 4). The preoperative diagnosis was atherosclerotic right subclavian artery aneurysm.
Repair of the aneurysm was performed through a median sternotomy. We dissected at the aneurysmal afferent loop and efferent loop. We made end-to-end anastomosis by Gore Tex (6 mm sized) graft interposition. In the operation field, we could not find the recurrent laryngeal nerve due to severe adhesions. After the debridement, a partially undetached aneurysm was left.
Cultures from the wall of the aneurysm and thrombus were negative. Pathology was consistent with an atherosclerotic aneurysm filled with thrombus (Fig. 5).
After one month follow-up, she still complains of hoarseness and laryngoscopic examination revealed right vocal cord palsy.