Iatrogenic Subtotal Stenosis of the Right Subclavian Artery Treated With Percutaneous Transluminal Angioplasty
This report describes a rare vascular complication of surgical placement of a marking clip and a possible approach to problem solving. A 55-year-old patient presented with loss of sensation in the fingers and loss of peripheral pulsations in the right arm 4 days after right upper lobectomy for a pT2N1 moderately differentiated adenocarcinoma of the lung. Duplex examination and computed tomography were performed the same day and showed a subtotal stenosis of the right subclavian artery, which was caused by the surgical placement of a metal clip to mark the surgical boundary. Selective angiography was subsequently performed. Percutaneous transluminal angioplasty (PTA) successfully dilated the stenosis and pushed the clip off. Flow in the right subclavian artery (RSA) was completely restored as were neurology and peripheral pulses. In conclusion, arterial stenosis by a surgical (marking) clip may be feasibly treated with PTA.
KeywordsArterial intervention Angioplasty/Angiogram Endovascular treatment Artery
Surgical clips are widely used in modern surgery. In addition to vascular and endoscopic clips, surgeons use metal clips liberally for marking purposes. Surgical boundaries are marked for future radiotherapy in various oncologic surgical procedures. To our knowledge, complications caused by placement of surgical marking clips have not been described before. This case report illustrates a complication of the placement of a surgical marking clip in the thoracic cavity and subsequent successful treatment.
A 55-year-old man presented with cold fingers and numbness of the right hand 4 days after undergoing right upper lobectomy for a pT2N1 moderately differentiated adenocarcinoma of the lung. The patient’s history did not show any vascular pathology.
Physical examination showed a significant temperature difference between the fingers of the right and the left hand. Radial, ulnar, and brachial artery pulses were absent, and a slight loss of sensation was noted. Motor functions were intact.
Arterial stenosis caused by placement of a surgical clip is an uncommon complication, with only one report in literature ; however, it did not involve a marking clip as in this case report. Usually, surgical marking clips are placed under direct vision. Fortunately, surgical marking clips are not applied as tightly as vascular clips, the purpose of which is to occlude blood vessels. This might have been the reason for the late onset of symptoms and mild clinical presentation in this case. Thus, it was assumed that the misplaced clip might be pushed off the RSA from within instead of performing a second thoracotomy to extract the clip. Of course, the backup plan would be a second thoracotomy to extrude the clip or, in the case of a complication by the endovascular procedure, to save the RSA.
The only case report on this topic describes a surgically obstructed left internal mammary artery graft by a clip after coronary bypass surgery. PTA successfully treated this complication. There are some more reports on vascular stenosis by medical devices, but these describe complications after vascular closing devices, such as the Starclose Closure device [2, 3, 4]. In these cases, the complication was treated surgically.
In the presented case, a surgical marking clip, placed in the upper boundary of the surgical resection of the upper pulmonary lobe, caused subtotal stenosis of the RSA. During the surgical procedure, the misplacement of the clip was not recognized because it was placed far up in the thoracic cavity. Thus, the origin of stenosis was thought to be atherosclerotic, and CTA was performed first instead of performing angiography directly. Of course, when thinking of an obstruction caused by corpora aliena, one could even have first performed CT with dual-energy imaging. CTA then unexpectedly showed the surgical marking clip on the RSA. Subsequently, a selective angiogram was performed, and the clip was successfully pushed away with use of an angioplasty balloon.
After this incident in our institution, we have discussed the use of surgical marking clips in oncologic upper thoracic surgery, but for now there are no other means for other marking techniques in our institution.
Arterial stenosis caused by a surgical marking clip may feasibly be treated first with an endovascular procedure, consisting of an angiogram with PTA, before performing a second surgery.
Conflict of interest
The authors declare that they have no conflict of interest.
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