Endovascular Treatment of a Sublcavian Artery Pseudoaneurysm in a Patient with a Pancoast Tumor

Endovascular Treatment of a Sublcavian Artery Pseudoaneurysm in a Patient with a Pancoast Tumor | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Endovascular Treatment of a Sublcavian Artery Pseudoaneurysm in a Patient with a Pancoast Tumor Samuel Mouyal, Xavier Guerra, Tom Boeken, Alessandro Di Gaeta, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6015192/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Jun, 2025 Read the published version in CVIR Endovascular → Version 1 posted 5 You are reading this latest preprint version Abstract Background: The authors report herein a rare case of an endovascular management of a giant subclavian artery pseudoaneurysm, revealed by a massive hemoptysis in a patient suffering from a Pancoast tumor. Case presentation: The endovascular procedure consisted of covering the subclavian artery rupture site with a stent graft after occluding the proximal segments of the ipsilateral internal thoracic and vertebral arteries. Conclusion: subclavian artery rupture was effectively managed using endovascular techniques via radial access. Pancoast tumor pseudoaneurysm hemoptysis subclavian artery endovascular interventional radiology stent graft Figures Figure 1 Figure 2 Figure 3 Background The Pancoast tumor, or superior pulmonary sulcus tumor, accounts for 3 to 5% of lung cancers (1). Tumor invasion of the thoracic outlet structures over the lung apex can lead to Pancoast-Tobias syndrome, which is characterized by a constellation of ipsilateral symptoms, including neuralgic pain in the upper limb and Horner’s syndrome (miosis, ptosis, anhidrosis), due to the invasion of the brachial plexus (C8, T1, T2 nerve roots) and the sympathetic nerve chains (stellate ganglion), respectively (2–4). When the subclavian vessels are invaded, it is not uncommon to observe stenoses or occlusions, which can result in manifestations of venous congestion or arterial ischemia of the limb. However, the occurrence of a subclavian artery (SCA) pseudoaneurysm caused by a Pancoast tumor appears to be atypical, as no cases have been described in the literature, which instead reports pseudoaneurysms of traumatic, iatrogenic (5, 6), infectious (7), and inflammatory (8) origins. The authors report a case of an endovascular management of a subclavian artery pseudoaneurysm, revealed by hemoptysis in a patient suffering from a Pancoast tumor. Case presentation The patient was a 36-year-old male with locally advanced large cell carcinoma of the right lung apex causing Pancoast-Tobias syndrome, in treatment for 6 months with radiation therapy and chemotherapy (Carboplatine, Pemetrexed and Avastin). He experienced a massive hemoptysis leading to hypoxic-induced cardio-respiratory arrest and was successfully resuscitated. After sedation, intubation and hemodynamic stabilization, a contrast enhanced chest CT-scan was performed (Fig. 1 ) which showed a 6 cm diameter pseudoaneurysm originating from the right SCA. The pseudoaneurysm was contained by the edges of excavated apical lung tumor. Moreover, the Pancoast tumor eroded the right lateral part of T1 vertebral body and encased the V1 segment of the ipsilateral vertebral artery (VA).After multidisciplinary discussion (intensive care physician, thoracic surgeon and interventional radiology) the patient was transferred by an air ambulance to our center for emergency interventional radiologic treatment. Intervention was performed using a right radial ultrasound guided approach via a 6-French (Fr) long sheath introducer. A digital subtraction angiography (DSA) of the right upper limb was conducted to safely navigate the angled diagnostic catheter to the SCA. DSA confirmed the perforation of the posteroinferior wall of the SCA a few millimeters upstream from the right vertebral artery ostium (Fig. 2 A). Additionally, a perforation of the proximal segment of the internal thoracic artery (ITA) was identified. Both rupture points contributed to the pseudoaneurysm blood inflow (Fig. 2 B). Our strategy consisted of covering the SCA rupture site with a stent graft after occluding the proximal segments of the right ITA and VA. A prior assessment of the posterior cerebral circulation was performed by angiography, which highlighted a convergence of the VAs into a basilar trunk with left vertebral dominance due to its lager diameter. The post-ostial segment of the right VA measured 4 mm and was occluded with a 6 mm diameter Amplatzer™ Vascular Plug 4 (Abbot, North Chicago, Illinois, USA), delivered through a 0.038” guidewire-compatible catheter. ITA was then catheterized with a 2.7-Fr microcatheter (Progreat, Terumo, Tokyo, Japan) and embolized using the “sandwich technique”: coils (Azur CX-18, 6 x 20mm, Terumo, Tokyo, Japan) and MVP™-5Q MicroVascular Plug (Medtronic) downstream and upstream of the rupture point, respectively (Fig. 2 ). The final step was the deployment of a 7 x 37 mm balloon-expandable stent graft (BeGraft peripheral, Bentley, Germany) centered on the SCA perforation and covering the ostia of the right VA, ITA, thyrocervical trunk and superior thoracic artery. The apposition of the stent graft to the vascular wall was optimized using an 8 mm diameter balloon. Complete exclusion of the pseudoaneurysm was confirmed on control DSA (Fig. 2 ). Additional angiography of the posterior cerebral circulation through the left VA demonstrated the absence of cerebral perfusion defects and retrograde perfusion of the right VA to the occluded proximal segment (Fig. 2 ). Hemostasis of the puncture site was obtained using a radial compression device (TR Band®, Terumo, Tokyo, Japan). A contrast-enhanced chest CT angiography at one week (Fig. 3 ) showed the patency of the right SCA, no endoleak and no active bleeding. The pseudoaneurysm has given way to a pulmonary excavation of the right upper lobe. Three weeks later, patient suffered a fatal cardiac arrest with severe hypoxia. Discussion This case represents a rare subclavian artery rupture being effectively managed through endovascular intervention. This technique not only successfully controlled the acute hemorrhage but also maintained the integrity and patency of the vertebral artery, without any post-procedural complications. This approach further demonstrates the practical application of minimally invasive techniques in addressing complex vascular emergencies associated with cancer, showcasing the evolving capabilities of endovascular interventions. Endovascular treatment, in this instance, proved crucial for achieving hemostasis and ensuring the stability of nearby vascular structures through targeted embolization and the careful deployment of a covered stent. The success of this procedure highlights the significant role of refined interventional radiology techniques in addressing severe vascular challenges, particularly in patients with cancer, where traditional surgical interventions may pose heightened risks. Pancoast or superior sulcus tumors encompass a variety of neoplasms that invade the apical chest wall, leading to a distinct clinical entity known as Pancoast-Tobias syndrome. The superior sulcus, an anatomical pleuro-pulmonary groove, is shaped by the subclavian artery as it arches in front of the pleura and ascends laterally just beneath the lung apex. While not all superior sulcus tumors are located precisely in this groove, the term broadly refers to any tumor at the lung apices that manifests with the specific clinical signs and symptoms characteristic of Pancoast syndrome [ 1 ]. Pancoast-Tobias syndrome is defined by the constellation of severe shoulder and arm pain corresponding with the distribution of the C8, T1, and T2 nerve trunks, alongside Horner syndrome—which includes ipsilateral ptosis, miosis, and anhidrosis due to disruption of the sympathetic nerve chain traveling to the head—and muscle atrophy in the hands. In modern clinical practice, arterial complications directly caused by tumor invasion in Pancoast-Tobias syndrome are very rare. Advances in early detection and treatment, including chemotherapy and radiotherapy, have significantly reduced the incidence of such complications, which were more common in the past. Today, the more frequently observed vascular complication associated with thoracic tumors is superior vena cava syndrome, resulting from venous compression by the tumor. Literature is poor in instances of tumoral complications of subclavian artery (SCA) treated by endovascular approach. Among this cases, there is the stenosis of the SCA by a lung cancer, causing ischemic disturbances in the distal fingers [ 2 ]. While surgical interventions for apical lung tumors may necessitate treatments involving the subclavian artery or lead to related complications [ 3 , 4 ], there is no documented evidence of bleeding caused directly by tumor-induced rupture of the subclavian artery. This highlights a gap in the literature regarding such severe vascular events linked to tumor growth. Current management of SCA injury is predominantly through endovascular approaches, particularly in post-traumatic or iatrogenic scenarios [ 5 , 6 ]. The first reported case of such endovascular treatment dates back to 1991 [ 7 ]. This technique has since been refined and widely adopted, offering a viable alternative to open surgery with benefits including minimized surgical risk and reduced recovery times [ 8 ]. There is one documented case of ruptured SCA aneurysm presenting as hemoptysis successfully treated using a covered stent [ 9 ]. However, this case was not of tumoral origin. Conclusion In summary, this case marks a rare instance where a tumor-induced subclavian artery rupture and pseudonaeursm being effectively managed using endovascular techniques via radial access. It shows also the importance of vascular analysis for irregularities or pseudo aneurysm in apical tumors. Abbreviations DSA digital subtraction angiography ITA internal thoracic artery SCA subclavian artery VA vertebral artery Declarations Funding: none. Authors' contributions: MAA, XG, CB and SM contributed to performing the case and writing the manuscript. All authors contributed and approved the final version for publication. Competing interests: The authors declare no conflict of interests. Ethics approval and consent to participate: Written informed consent was obtained for publication of this case report and accompanying images. Consent for publication: Written informed consent was obtained for publication of this case report and accompanying images. Availability of data and material: All data generated or analyzed during this study are included in this published article. Acknowledgements: not applicable References Gundepalli, S.G. and P. Tadi, Lung Pancoast Tumor , in StatPearls . 2024, StatPearls Publishing Copyright © 2024, StatPearls Publishing LLC.: Treasure Island (FL). Zhui, L., et al., Uncommon Presentation of Recurrent Lung Adenocarcinoma: A Finger Ulcer Induced by Subclavian Artery Invasion Successfully Healed With Viabahn VBX Treatment. Cureus, 2024. 16 (3): p. e55885. Lahon, B., et al., Subclavian artery resection and reconstruction for thoracic inlet cancer: 25 years of experience. Ann Thorac Surg, 2013. 96 (3): p. 983-8; discussion 988-9. Nomori, H., et al., Extended resection of lung cancer invading the left subclavian artery by using cardiopulmonary bypass. Ann Thorac Cardiovasc Surg, 2005. 11 (3): p. 211-3. Perri, M., et al., Endovascular repair of isolated post-traumatic subclavian artery false-aneurysm (FA) using gore viabahn vbx-balloon-expandable (BE) stent-graft: case report and literature review. Acta Biomed, 2022. 93 (S1): p. e2022080. Vierhout, B.P., et al., Changing profiles of diagnostic and treatment options in subclavian artery aneurysms. Eur J Vasc Endovasc Surg, 2010. 40 (1): p. 27-34. Becker, G.J., et al., Percutaneous placement of a balloon-expandable intraluminal graft for life-threatening subclavian arterial hemorrhage. J Vasc Interv Radiol, 1991. 2 (2): p. 225-9. Maskanakis, A., et al., Stenting of Subclavian Artery True and False Aneurysms: A Systematic Review. Ann Vasc Surg, 2018. 47 : p. 291-304. Kim, S.S., et al., Successful treatment of a ruptured subclavian artery aneurysm presenting as hemoptysis with a covered stent. Chonnam Med J, 2014. 50 (2): p. 70-3. Cite Share Download PDF Status: Published Journal Publication published 18 Jun, 2025 Read the published version in CVIR Endovascular → Version 1 posted Editorial decision: Minor revision 10 Mar, 2025 Reviewers agreed at journal 27 Feb, 2025 Reviewers invited by journal 27 Feb, 2025 Editor assigned by journal 23 Feb, 2025 First submitted to journal 21 Feb, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6015192","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":421772392,"identity":"d4f2bd76-f568-467b-a083-2e36c5939b11","order_by":0,"name":"Samuel Mouyal","email":"","orcid":"","institution":"Hôpital Europeen Georges-Pompidou: Hopital Europeen Georges Pompidou","correspondingAuthor":false,"prefix":"","firstName":"Samuel","middleName":"","lastName":"Mouyal","suffix":""},{"id":421772393,"identity":"f225a189-6abf-4ba4-ab6b-260cd8013901","order_by":1,"name":"Xavier Guerra","email":"","orcid":"","institution":"Hôpital Europeen Georges-Pompidou: Hopital Europeen Georges Pompidou","correspondingAuthor":false,"prefix":"","firstName":"Xavier","middleName":"","lastName":"Guerra","suffix":""},{"id":421772394,"identity":"768a23eb-9cb5-4fbc-aa44-a46637eb6ad1","order_by":2,"name":"Tom Boeken","email":"","orcid":"","institution":"Hôpital Europeen Georges-Pompidou: Hopital Europeen Georges Pompidou","correspondingAuthor":false,"prefix":"","firstName":"Tom","middleName":"","lastName":"Boeken","suffix":""},{"id":421772395,"identity":"a43878fe-e828-4d5c-830c-2383922dd301","order_by":3,"name":"Alessandro Di Gaeta","email":"","orcid":"","institution":"Hôpital Europeen Georges-Pompidou: Hopital Europeen Georges Pompidou","correspondingAuthor":false,"prefix":"","firstName":"Alessandro","middleName":"Di","lastName":"Gaeta","suffix":""},{"id":421772396,"identity":"e9342d75-bae6-4cfa-99e1-e524e642111b","order_by":4,"name":"Crina Bordeianu","email":"","orcid":"","institution":"Hôpital Europeen Georges-Pompidou: Hopital Europeen Georges Pompidou","correspondingAuthor":false,"prefix":"","firstName":"Crina","middleName":"","lastName":"Bordeianu","suffix":""},{"id":421772397,"identity":"53ed4bc3-7209-40b5-ae92-f7a09d934be3","order_by":5,"name":"Manuel Gargiulo","email":"","orcid":"","institution":"Hôpital Europeen Georges-Pompidou: Hopital Europeen Georges Pompidou","correspondingAuthor":false,"prefix":"","firstName":"Manuel","middleName":"","lastName":"Gargiulo","suffix":""},{"id":421772398,"identity":"667f3528-f06a-4773-93f3-fb073eabfa28","order_by":6,"name":"Olivier Pellerin","email":"","orcid":"","institution":"Hôpital Europeen Georges-Pompidou: Hopital Europeen Georges Pompidou","correspondingAuthor":false,"prefix":"","firstName":"Olivier","middleName":"","lastName":"Pellerin","suffix":""},{"id":421772399,"identity":"69cb55c7-2d73-427d-82dc-735317d8e524","order_by":7,"name":"Marc Sapoval","email":"","orcid":"","institution":"Hôpital Europeen Georges-Pompidou: Hopital Europeen Georges Pompidou","correspondingAuthor":false,"prefix":"","firstName":"Marc","middleName":"","lastName":"Sapoval","suffix":""},{"id":421772400,"identity":"76f8a0f0-d0e6-4404-80e7-946eb961816f","order_by":8,"name":"Marc Al Ahmar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYNCCAoYEIMn4AEjw8BGnxQCshdkApIWNFC1sEiA2QS267WcffvhhYJcHZDyr/JpjJ8PGwPzw0Q08WszOpBtL9hgkFwMZZrdltyUDHcZmbJyDT8uBNDYGHgPmxG1Axm3JbcxALTxs0ni1nH/GxvjHoD5xG5BRLLmtnggtN9LYmHkMDiduAzIYP247TIyWZ8zSMgbHgVqADMZtx3nYmAn55Xwa48c3FdVAhwEZP7dV2/OzNz98jE8LCmDmAZPEKgcBxh+kqB4Fo2AUjIIRAwC3+ETZUrBKaQAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0003-3017-2455","institution":"HEGP: Hopital Europeen Georges Pompidou","correspondingAuthor":true,"prefix":"","firstName":"Marc","middleName":"Al","lastName":"Ahmar","suffix":""}],"badges":[],"createdAt":"2025-02-12 12:35:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6015192/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6015192/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s42155-025-00572-9","type":"published","date":"2025-06-18T15:57:33+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":77747754,"identity":"9e41cba7-c8c0-43ec-99e0-828820ebe560","added_by":"auto","created_at":"2025-03-05 06:56:51","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":387160,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePrior chest CT-scan angiography\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThoracic CT angiography in the arterial phase after contrast agent injection, coronal slice (1-A), axial slices (1-B and 1-C), and volume rendering (1-D). Pseudoaneurysm of the right pulmonary apex (1-A, 1-B and 1-D, asterisk) contained by the edges of the Pancoast tumor, due to rupture of the posterior-inferior wall of the right SCA (1-A and 1-B, solid arrow). Tumor invasion of the mediastinum with thrombosis of the superior vena cava (1-A, dotted arrow), invasion of the right lateral part of the T1 vertebral body (1-C, hollow arrowhead), and encasement of the V1 segment of the right VA (1-C, solid arrowhead).\u003c/p\u003e","description":"","filename":"1.tiff.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6015192/v1/c8b359e7b633e1c202d65925.jpg"},{"id":77747756,"identity":"43e3f007-c465-4488-bca8-4f0ca85033c5","added_by":"auto","created_at":"2025-03-05 06:56:51","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":664276,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProcedural angiographies\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDSA of the right SCA showing pseudo-aneurysmal extravasation (2-A: early phase, 2-B: late phase) in proximity to the right VA (2-A, solid arrow) and the right ITA (2-A, dotted arrow). Selective arteriography of the right ITA revealing extravasation from the proximal segment (2-C, dotted circle). Occlusion of the right ITA downstream of the rupture point with coils (2-D, black arrowhead) and with a micro-plug upstream (2-D and 2-E, solid white arrowhead). Occlusion of the V1 segment of the right VA with a plug (2-E, hollow arrowhead). Arteriography of the SCA after occlusion of the VA and ITA identifying the rupture point feeding the pseudoaneurysm (black arrow). Covered stent deployed in the right SCA (2-G, proximal and distal ends of the stent marked by white arrows) allowing complete exclusion of the pseudoaneurysm without residual extravasation (2-H). Angiography of the posterior cerebral circulation via the left VA showing no embolic complications (2-I).\u003c/p\u003e","description":"","filename":"2.tiff.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6015192/v1/0d36b4eba8e10989bde73fc1.jpg"},{"id":77749011,"identity":"71b4651c-2862-4061-bdf1-cbef26c03811","added_by":"auto","created_at":"2025-03-05 07:12:51","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":415499,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003e1-week post-procedure chest CT-scan angiography\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChest CT-scan in the arterial phase after contrast agent injection, coronal (3-A and 3-C), sagittal view (3-B). Right SCA with regular caliber and patency of the stent graft (3-A and 3-B, arrow), adjacent to the upper pole of the right apical pulmonary excavation where the pseudoaneurysm was located (3-A and 3-B, asterisk). Occlusion of the proximal segments of the right ITA with a microvascular plug (3-C, solid arrowhead) and coils (3-C, hollow arrowhead), and of the right VA (3-C, dotted arrow).\u003c/p\u003e","description":"","filename":"3.tiff.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6015192/v1/b589d53cba1d3b6a08e55ee2.jpg"},{"id":85231368,"identity":"010e76c2-193f-4965-a60d-4fb57d8ec0b2","added_by":"auto","created_at":"2025-06-23 16:06:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1936783,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6015192/v1/0d0e4655-2f52-416a-ad2d-f825217a633c.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eEndovascular Treatment of a Sublcavian Artery Pseudoaneurysm in a Patient with a Pancoast Tumor\u003c/p\u003e","fulltext":[{"header":"Background","content":"\u003cp\u003eThe Pancoast tumor, or superior pulmonary sulcus tumor, accounts for 3 to 5% of lung cancers (1). Tumor invasion of the thoracic outlet structures over the lung apex can lead to Pancoast-Tobias syndrome, which is characterized by a constellation of ipsilateral symptoms, including neuralgic pain in the upper limb and Horner\u0026rsquo;s syndrome (miosis, ptosis, anhidrosis), due to the invasion of the brachial plexus (C8, T1, T2 nerve roots) and the sympathetic nerve chains (stellate ganglion), respectively (2\u0026ndash;4). When the subclavian vessels are invaded, it is not uncommon to observe stenoses or occlusions, which can result in manifestations of venous congestion or arterial ischemia of the limb. However, the occurrence of a subclavian artery (SCA) pseudoaneurysm caused by a Pancoast tumor appears to be atypical, as no cases have been described in the literature, which instead reports pseudoaneurysms of traumatic, iatrogenic (5, 6), infectious (7), and inflammatory (8) origins.\u003c/p\u003e \u003cp\u003eThe authors report a case of an endovascular management of a subclavian artery pseudoaneurysm, revealed by hemoptysis in a patient suffering from a Pancoast tumor.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eThe patient was a 36-year-old male with locally advanced large cell carcinoma of the right lung apex causing Pancoast-Tobias syndrome, in treatment for 6 months with radiation therapy and chemotherapy (Carboplatine, Pemetrexed and Avastin).\u003c/p\u003e \u003cp\u003eHe experienced a massive hemoptysis leading to hypoxic-induced cardio-respiratory arrest and was successfully resuscitated. After sedation, intubation and hemodynamic stabilization, a contrast enhanced chest CT-scan was performed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) which showed a 6 cm diameter pseudoaneurysm originating from the right SCA. The pseudoaneurysm was contained by the edges of excavated apical lung tumor. Moreover, the Pancoast tumor eroded the right lateral part of T1 vertebral body and encased the V1 segment of the ipsilateral vertebral artery (VA).After multidisciplinary discussion (intensive care physician, thoracic surgeon and interventional radiology) the patient was transferred by an air ambulance to our center for emergency interventional radiologic treatment.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIntervention was performed using a right radial ultrasound guided approach via a 6-French (Fr) long sheath introducer. A digital subtraction angiography (DSA) of the right upper limb was conducted to safely navigate the angled diagnostic catheter to the SCA. DSA confirmed the perforation of the posteroinferior wall of the SCA a few millimeters upstream from the right vertebral artery ostium (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). Additionally, a perforation of the proximal segment of the internal thoracic artery (ITA) was identified. Both rupture points contributed to the pseudoaneurysm blood inflow (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eOur strategy consisted of covering the SCA rupture site with a stent graft after occluding the proximal segments of the right ITA and VA. A prior assessment of the posterior cerebral circulation was performed by angiography, which highlighted a convergence of the VAs into a basilar trunk with left vertebral dominance due to its lager diameter. The post-ostial segment of the right VA measured 4 mm and was occluded with a 6 mm diameter Amplatzer\u0026trade; Vascular Plug 4 (Abbot, North Chicago, Illinois, USA), delivered through a 0.038\u0026rdquo; guidewire-compatible catheter. ITA was then catheterized with a 2.7-Fr microcatheter (Progreat, Terumo, Tokyo, Japan) and embolized using the \u0026ldquo;sandwich technique\u0026rdquo;: coils (Azur CX-18, 6 x 20mm, Terumo, Tokyo, Japan) and MVP\u0026trade;-5Q MicroVascular Plug (Medtronic) downstream and upstream of the rupture point, respectively (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The final step was the deployment of a 7 x 37 mm balloon-expandable stent graft (BeGraft peripheral, Bentley, Germany) centered on the SCA perforation and covering the ostia of the right VA, ITA, thyrocervical trunk and superior thoracic artery. The apposition of the stent graft to the vascular wall was optimized using an 8 mm diameter balloon. Complete exclusion of the pseudoaneurysm was confirmed on control DSA (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Additional angiography of the posterior cerebral circulation through the left VA demonstrated the absence of cerebral perfusion defects and retrograde perfusion of the right VA to the occluded proximal segment (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Hemostasis of the puncture site was obtained using a radial compression device (TR Band\u0026reg;, Terumo, Tokyo, Japan).\u003c/p\u003e \u003cp\u003eA contrast-enhanced chest CT angiography at one week (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) showed the patency of the right SCA, no endoleak and no active bleeding. The pseudoaneurysm has given way to a pulmonary excavation of the right upper lobe. Three weeks later, patient suffered a fatal cardiac arrest with severe hypoxia.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis case represents a rare subclavian artery rupture being effectively managed through endovascular intervention. This technique not only successfully controlled the acute hemorrhage but also maintained the integrity and patency of the vertebral artery, without any post-procedural complications. This approach further demonstrates the practical application of minimally invasive techniques in addressing complex vascular emergencies associated with cancer, showcasing the evolving capabilities of endovascular interventions.\u003c/p\u003e \u003cp\u003eEndovascular treatment, in this instance, proved crucial for achieving hemostasis and ensuring the stability of nearby vascular structures through targeted embolization and the careful deployment of a covered stent. The success of this procedure highlights the significant role of refined interventional radiology techniques in addressing severe vascular challenges, particularly in patients with cancer, where traditional surgical interventions may pose heightened risks.\u003c/p\u003e \u003cp\u003ePancoast or superior sulcus tumors encompass a variety of neoplasms that invade the apical chest wall, leading to a distinct clinical entity known as Pancoast-Tobias syndrome. The superior sulcus, an anatomical pleuro-pulmonary groove, is shaped by the subclavian artery as it arches in front of the pleura and ascends laterally just beneath the lung apex. While not all superior sulcus tumors are located precisely in this groove, the term broadly refers to any tumor at the lung apices that manifests with the specific clinical signs and symptoms characteristic of Pancoast syndrome [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePancoast-Tobias syndrome is defined by the constellation of severe shoulder and arm pain corresponding with the distribution of the C8, T1, and T2 nerve trunks, alongside Horner syndrome\u0026mdash;which includes ipsilateral ptosis, miosis, and anhidrosis due to disruption of the sympathetic nerve chain traveling to the head\u0026mdash;and muscle atrophy in the hands.\u003c/p\u003e \u003cp\u003eIn modern clinical practice, arterial complications directly caused by tumor invasion in Pancoast-Tobias syndrome are very rare. Advances in early detection and treatment, including chemotherapy and radiotherapy, have significantly reduced the incidence of such complications, which were more common in the past. Today, the more frequently observed vascular complication associated with thoracic tumors is superior vena cava syndrome, resulting from venous compression by the tumor.\u003c/p\u003e \u003cp\u003eLiterature is poor in instances of tumoral complications of subclavian artery (SCA) treated by endovascular approach. Among this cases, there is the stenosis of the SCA by a lung cancer, causing ischemic disturbances in the distal fingers [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While surgical interventions for apical lung tumors may necessitate treatments involving the subclavian artery or lead to related complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], there is no documented evidence of bleeding caused directly by tumor-induced rupture of the subclavian artery. This highlights a gap in the literature regarding such severe vascular events linked to tumor growth.\u003c/p\u003e \u003cp\u003eCurrent management of SCA injury is predominantly through endovascular approaches, particularly in post-traumatic or iatrogenic scenarios [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. The first reported case of such endovascular treatment dates back to 1991 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This technique has since been refined and widely adopted, offering a viable alternative to open surgery with benefits including minimized surgical risk and reduced recovery times [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. There is one documented case of ruptured SCA aneurysm presenting as hemoptysis successfully treated using a covered stent [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, this case was not of tumoral origin.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn summary, this case marks a rare instance where a tumor-induced subclavian artery rupture and pseudonaeursm being effectively managed using endovascular techniques via radial access. It shows also the importance of vascular analysis for irregularities or pseudo aneurysm in apical tumors.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003edigital subtraction angiography\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eITA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003einternal thoracic artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSCA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003esubclavian artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003evertebral artery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003eFunding: none.\u003c/li\u003e\n \u003cli\u003eAuthors\u0026apos; contributions: MAA, XG, CB and SM contributed to performing the case and writing the manuscript. All authors contributed and approved the final version for publication.\u003c/li\u003e\n \u003cli\u003eCompeting interests:\u0026nbsp;The authors declare no conflict of interests.\u003c/li\u003e\n \u003cli\u003eEthics approval and consent to participate: \u0026nbsp;\u003cstrong\u003eWritten informed consent was obtained for publication of this case report and accompanying images.\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eConsent for publication: \u0026nbsp;\u003cstrong\u003eWritten informed consent was obtained for publication of this case report and accompanying images.\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eAvailability of data and material:\u0026nbsp;All data generated or analyzed during this study are included in this published article.\u003c/li\u003e\n \u003cli\u003eAcknowledgements: not applicable\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGundepalli, S.G. and P. Tadi, \u003cem\u003eLung Pancoast Tumor\u003c/em\u003e, in \u003cem\u003eStatPearls\u003c/em\u003e. 2024, StatPearls Publishing Copyright \u0026copy; 2024, StatPearls Publishing LLC.: Treasure Island (FL).\u003c/li\u003e\n\u003cli\u003eZhui, L., et al., \u003cem\u003eUncommon Presentation of Recurrent Lung Adenocarcinoma: A Finger Ulcer Induced by Subclavian Artery Invasion Successfully Healed With Viabahn VBX Treatment.\u003c/em\u003e Cureus, 2024. \u003cstrong\u003e16\u003c/strong\u003e(3): p. e55885.\u003c/li\u003e\n\u003cli\u003eLahon, B., et al., \u003cem\u003eSubclavian artery resection and reconstruction for thoracic inlet cancer: 25 years of experience.\u003c/em\u003e Ann Thorac Surg, 2013. \u003cstrong\u003e96\u003c/strong\u003e(3): p. 983-8; discussion 988-9.\u003c/li\u003e\n\u003cli\u003eNomori, H., et al., \u003cem\u003eExtended resection of lung cancer invading the left subclavian artery by using cardiopulmonary bypass.\u003c/em\u003e Ann Thorac Cardiovasc Surg, 2005. \u003cstrong\u003e11\u003c/strong\u003e(3): p. 211-3.\u003c/li\u003e\n\u003cli\u003ePerri, M., et al., \u003cem\u003eEndovascular repair of isolated post-traumatic subclavian artery false-aneurysm (FA) using gore viabahn vbx-balloon-expandable (BE) stent-graft: case report and literature review.\u003c/em\u003e Acta Biomed, 2022. \u003cstrong\u003e93\u003c/strong\u003e(S1): p. e2022080.\u003c/li\u003e\n\u003cli\u003eVierhout, B.P., et al., \u003cem\u003eChanging profiles of diagnostic and treatment options in subclavian artery aneurysms.\u003c/em\u003e Eur J Vasc Endovasc Surg, 2010. \u003cstrong\u003e40\u003c/strong\u003e(1): p. 27-34.\u003c/li\u003e\n\u003cli\u003eBecker, G.J., et al., \u003cem\u003ePercutaneous placement of a balloon-expandable intraluminal graft for life-threatening subclavian arterial hemorrhage.\u003c/em\u003e J Vasc Interv Radiol, 1991. \u003cstrong\u003e2\u003c/strong\u003e(2): p. 225-9.\u003c/li\u003e\n\u003cli\u003eMaskanakis, A., et al., \u003cem\u003eStenting of Subclavian Artery True and False Aneurysms: A Systematic Review.\u003c/em\u003e Ann Vasc Surg, 2018. \u003cstrong\u003e47\u003c/strong\u003e: p. 291-304.\u003c/li\u003e\n\u003cli\u003eKim, S.S., et al., \u003cem\u003eSuccessful treatment of a ruptured subclavian artery aneurysm presenting as hemoptysis with a covered stent.\u003c/em\u003e Chonnam Med J, 2014. \u003cstrong\u003e50\u003c/strong\u003e(2): p. 70-3.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Pancoast tumor, pseudoaneurysm, hemoptysis, subclavian artery, endovascular interventional radiology, stent graft","lastPublishedDoi":"10.21203/rs.3.rs-6015192/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6015192/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u0026nbsp;\u003c/strong\u003eThe authors report herein a rare case of an endovascular management of a giant subclavian artery pseudoaneurysm, revealed by a massive hemoptysis in a patient suffering from a Pancoast tumor.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u0026nbsp;\u003c/strong\u003eThe endovascular procedure consisted of covering the subclavian artery rupture site with a stent graft after occluding the proximal segments of the ipsilateral internal thoracic and vertebral arteries.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u0026nbsp;\u003c/strong\u003esubclavian artery rupture was effectively managed using endovascular techniques via radial access.\u003c/p\u003e","manuscriptTitle":"Endovascular Treatment of a Sublcavian Artery Pseudoaneurysm in a Patient with a Pancoast Tumor","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-05 06:56:46","doi":"10.21203/rs.3.rs-6015192/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2025-03-10T04:23:45+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2025-02-27T22:30:41+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-02-27T12:13:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-24T04:01:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"CVIR Endovascular","date":"2025-02-21T08:48:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"796baf62-0d2d-4a96-95d6-0328447a0bcc","owner":[],"postedDate":"March 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-23T16:01:23+00:00","versionOfRecord":{"articleIdentity":"rs-6015192","link":"https://doi.org/10.1186/s42155-025-00572-9","journal":{"identity":"cvir-endovascular","isVorOnly":false,"title":"CVIR Endovascular"},"publishedOn":"2025-06-18 15:57:33","publishedOnDateReadable":"June 18th, 2025"},"versionCreatedAt":"2025-03-05 06:56:46","video":"","vorDoi":"10.1186/s42155-025-00572-9","vorDoiUrl":"https://doi.org/10.1186/s42155-025-00572-9","workflowStages":[]},"version":"v1","identity":"rs-6015192","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6015192","identity":"rs-6015192","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}