A Case of Giant Subclavian Artery Aneurysm Compressing the Recurrent Laryngeal Nerve

A Case of Giant Subclavian Artery Aneurysm Compressing the Recurrent Laryngeal Nerve | 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 Case Report A Case of Giant Subclavian Artery Aneurysm Compressing the Recurrent Laryngeal Nerve Zelong Qian, Han Xiao, YuZhu Wu, Junjian Tang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6805684/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Giant subclavian artery aneurysms are relatively uncommon, and the occurrence of symptoms resembling Horner's syndrome due to compression of the sympathetic nerve is even rarer. In such cases, open surgery is associated with more favorable outcomes compared to conventional endovascular treatment. This report introduces a 72-year-old male patient and discusses the characteristics of giant subclavian artery aneurysms and the surgical approaches employed. Figures Figure 1 Figure 2 Figure 3 Case Presentation A 72-year-old male was admitted to the hospital with the chief complaint of "hoarseness for more than 10 days." The patient had experienced hoarseness without any apparent precipitating factors 10 days prior to admission. He also reported experiencing aspiration while drinking water but denied symptoms of chest tightness, dyspnea, headache, or dizziness. He initially consulted the Department of Respiratory Medicine in our hospital, where a preliminary diagnosis of "mediastinal mass and pulmonary inflammation" was made. Subsequently, a chest CT scan revealed a large aneurysm of the right subclavian artery, prompting his transfer to our department. The patient had a history of hypertension for over 15 years, which was well-controlled with oral administration of 80 mg of valsartan-hydrochlorothiazide once daily. On physical examination, the heart rate was 84 beats per minute. The patient was alert and in good spirits. A palpable mass was noted on the right thoracic wall. Additionally, right-sided ptosis was observed, although enophthalmos was not evident. Anhidrosis was noted on the right side of the face. Muscle strength was grade 5 bilaterally. Upon admission, blood pressure measurements were as follows: 176/81 mmHg in the left upper limb and 179/90 mmHg in the right upper limb. The patient did not report any dizziness or discomfort. Sublingual administration of 10 mg of nifedipine was administered, and subsequent blood pressure measurements were 169/83 mmHg on the left and 155/77 mmHg on the right. Laboratory investigations revealed no significant abnormalities in blood, urine, or stool routine examinations. Biochemical analysis indicated elevated blood glucose levels and an increased procalcitonin level. Cervical Computed Tomography Angiography (CTA): Aneurysm of the right subclavian artery, with the maximum diameter of the aneurysm sac approaching 54 mm (Fig. 1 , A); occlusion of the right vertebral artery (Fig. 1 , B), with proximal lumen compression and stenosis. Mixed plaques were observed at the bifurcation of the bilateral common carotid arteries, resulting in moderate stenosis of the lumen. The aneurysm sac was reconstructed from multiple angles (Fig. 1 , C). Magnetic Resonance Imaging (MRI) revealed an acute cerebral infarction in the right parietal lobe. The preoperative electrocardiogram (ECG) demonstrated high voltage in both the left and right ventricles, complete right bundle branch block, ST-T changes, and leftward axis deviation. Subsequent coronary CTA showed moderate stenosis in the mid-segment of the left anterior descending artery (LAD); severe stenosis in the second diagonal branch (D2); mild stenosis in the mid-to-distal segment of the left circumflex artery (LCX); severe stenosis in the distal segment of the right coronary artery (RCA); and severe stenosis in the right posterior descending artery. Figure 2 presents the comparison of preoperative(Fig. 1 , D), 1-week postoperative(Fig. 1 , E), and 1.5-month(Fig. 1 , F) postoperative CT follow-up, demonstrating significant improvement in the compression of surrounding tissues and nerves. The patient has provided consent for the publication of this case report, and the study has been approved by the hospital’s ethics committee. Therapeutic Protocol On January 17, 2025, under tracheal intubation anesthesia, a median sternotomy was performed, and the sternal edges were meticulously sealed with bone wax to achieve hemostasis. Intravenous heparin (210 mg) was administered. The right subclavian vein, innominate artery, right common carotid artery, and right subclavian artery were carefully dissected, and vascular occlusion tapes were placed. A right subclavian artery aneurysm, approximately 5 cm in diameter, was identified, characterized by significant tortuosity and compression of the right recurrent laryngeal nerve(Figure 1 , A). The recurrent laryngeal nerve and the proximal and distal ends of the aneurysm were meticulously dissected. After vascular occlusion, the aneurysmal wall was incised, and atherosclerotic plaques and thrombi, approximately 2 cm × 2 cm in size, were removed(Figure 1 , B). End-to-end anastomosis was performed between the proximal and distal ends using 5/0 Prolene suture, and the aneurysmal remnants were obliterated(Figure 1 , C). A single mediastinal chest tube was placed. After neutralization of heparin with protamine sulfate, meticulous hemostasis was achieved. The sternum was securely approximated with steel wire, and the surgical incision was closed in layers. The procedure was completed without complications, and the patient was transferred to the intensive care unit (ICU) for further management. Intraoperatively, 300 ml of autologous blood was retransfused. Discussion Subclavian artery aneurysm (SAA) is relatively uncommon, accounting for only 1% of peripheral artery aneurysms [ 1 ]. The occurrence of giant subclavian artery aneurysms is particularly rare. When the volume of SAA is small, it typically presents without significant symptoms or signs. However, as the aneurysm enlarges, approximately one-fourth of the cases may manifest symptoms [ 2 ]. In the present case, magnetic resonance angiography (MRA) of the brain revealed an acute cerebral infarction in the right parietal lobe. After multidisciplinary team (MDT) discussion, it was concluded that the infarction was likely caused by mural thrombus dislodgement from the aneurysm into the cerebral vasculature. Currently, the patient does not exhibit clinical manifestations of cerebral infarction. Cervical computed tomography angiography (CTA) showed near-occlusion of the right vertebral artery, yet the patient does not present with symptoms such as dizziness, tinnitus, or visual disturbances. Relevant literature suggests that collateral compensation may occur via the classic circle of Willis and the pathway involving the external carotid artery, occipital artery, muscular branch of the vertebral artery, and vertebral artery. Therefore, even with right vertebral artery occlusion, the patient may not experience neurological complications [ 3 ]. SAA can be classified into true aneurysms and false aneurysms. The common etiology of true aneurysms includes atherosclerosis and thoracic outlet syndrome, whereas false SAAs are often caused by trauma or iatrogenic injury. It has been reported that mural thrombi in the right subclavian artery can embolize through the right vertebral artery, basilar artery, left posterior cerebral artery, left posterior communicating artery, and distal left middle cerebral artery due to thoracic outlet syndrome [ 4 ]. Based on the anterior scalene muscle as a boundary, SAA can be categorized into three types: proximal, middle, and distal. Studies have indicated that proximal and middle types of SAA have a higher incidence of rupture, while distal type has a higher risk of thrombus embolization [ 5 ]. Notably, in conjunction with the coronary CTA findings, the patient was found to have severe coronary atherosclerotic heart disease, with multiple branches of the coronary arteries showing significant stenosis. The initial surgical plan was to perform right subclavian artery aneurysm resection combined with coronary artery bypass grafting. However, after considering the patient's vital signs from multiple perspectives, only the right SAA resection was performed. Research has shown that high-density lipoprotein cholesterol (HDL-C) in blood lipids is an important predictive indicator. In atherosclerotic cardiovascular disease (AS-CVD), approximately one-tenth of patients with low HDL-C levels also present with subclavian artery stenosis. Considering the nearly 20 mmHg difference in blood pressure between the left and right sides, as well as the cervical CTA findings of proximal stenosis of the right subclavian artery, mixed plaques at the bifurcation of the bilateral common carotid arteries, and moderate stenosis of the lumen, subclavian steal syndrome should be considered. However, the patient currently does not exhibit clinical symptoms of upper limb ischemia or posterior circulation ischemia. The treatment methods for SAA include open surgery, endovascular intervention, and hybrid surgery. Distal type SAAs are often compressed by the clavicle and first rib, and the inserted covered stent is prone to twisting or fracture. Therefore, open surgery is frequently chosen for these locations [ 6 ]. Currently, endovascular treatment is predominantly selected [ 7 ], with the advantages of minimal invasiveness and better patient tolerance. Special location SAAs refer to those involving multiple arterial lesions. Treating such lesions poses numerous challenges, as it is necessary to not only manage the aneurysm itself but also to consider the aortic arch, vertebral artery, and carotid artery to prevent severe complications caused by cerebral ischemia [ 8 ]. Although the patient's SAA was of the proximal type, the decision was made to perform right SAA resection with end-to-end anastomosis of the right subclavian artery, considering the large size of the aneurysm, the acute phase of nerve compression, and the inability of the stent to cover the entire aneurysm. Although endovascular treatment for SAA is less invasive to the patient and can offer more benefits when the indications are strictly followed, open surgery may provide greater benefits in certain special circumstances. Declarations Conflict of interest All authors declare that there is no conflict of interest. Author contribution statement Zelong Qian : article writing and revision ; Han Xiao : data collection and mapping ; Junjian Tang : research design, article review. Funding statement There is no funding for this study. Author Contribution Zelong Qian : article writing and revision ; Han Xiao : data collection and mapping ; YuZhu Wu:Collect photos; Junjian Tang : research design, article review. References Maskanakis A, Patelis N, Moris D, et al. Stenting of Subclavian Artery True and False Aneurysms: A Systematic Review. Ann Vasc Surg. 2018;47:291–304. Lou Z, Jin Y, Yang J, et al. Images in Vascular Medicine: Subclavian steal syndrome induced by subclavian artery aneurysm. Vasc Med. 2020;25(6):598–9. Zhang T, Li QL, Zhang XM, et al. Impact of left subclavian artery occlusion during thoracic endovascular aortic repair on ischemic stroke [J]. Chin J Gen Surg. 2019;34(2):113–7. Schleifer L, Vogel S, Arun A, et al. Stroke Caused by Arterial Thoracic Outlet Syndrome in an Adolescent. Child Neurol Open. 2022;9:2329048X221105743. NAZ I, ZIA-UR-REHMAN AZIZM et al. Subclavian artery aneu rysms: management implications in a resource-limited setting [J].Vascular, 2012, 20(6) : 301–5. Zhang P, Zhao HM, Sun DJ, et al. Endovascular exclusion of a giant subclavian artery aneurysm using a covered stent: A case report [J]. J Clin Surg. 2023;31(08):722–3. Zhao YB, Hua ZH, Jiao ZY, et al. Endovascular treatment of subclavian artery aneurysms [J]. Henan Med Res. 2021;30(13):2350–3. Li Y, Li F, Chen HJ, et al. Influence factors on early prognosis in patients with acute terminal internal carotid artery occlusion and their relationship with intracranial blood supply [J]. Chin J Practical Neurol Dis. 2023;26(06):699–703. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted 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. 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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-6805684","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":501396101,"identity":"bcf06fda-e0d0-4629-811c-c9b12548f3ae","order_by":0,"name":"Zelong Qian","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYBACNvnHBw7/qKjhYWPv//ggoaKGsBY+hrTExwxnjsnw8RwwNnhw5hhhLXIMOcrGjC3MNnISCWaSD1uYiXAYwxk26cIGNh42hoS0isQGNgb+9u4E/FoYe49Jz9whA9Ry4NiNxB0yDBJnzm7Ar4WZL02C9wzQFsbGthuJZ9gYDCRyCWhh4zGT4G1j5mFjZmYrSGxjJkILD4+xMVgLEDAQp0WCLfHhjDPHeIB6mSUSgAyCfpGfwXzgwIeKGnv5+W8YPwLjVI6/vRe/FgzAQ5ryUTAKRsEoGAVYAQDrxUJPg217lQAAAABJRU5ErkJggg==","orcid":"","institution":"Affiliated Hospital of Jiangnan University","correspondingAuthor":true,"prefix":"","firstName":"Zelong","middleName":"","lastName":"Qian","suffix":""},{"id":501396102,"identity":"b0d3c1d6-90ab-40fa-868f-35275133d39b","order_by":1,"name":"Han Xiao","email":"","orcid":"","institution":"Affiliated Hospital of Jiangnan University","correspondingAuthor":false,"prefix":"","firstName":"Han","middleName":"","lastName":"Xiao","suffix":""},{"id":501396103,"identity":"5f89df57-9d00-4150-9618-66b7b4056754","order_by":2,"name":"YuZhu Wu","email":"","orcid":"","institution":"Affiliated Hospital of Jiangnan University","correspondingAuthor":false,"prefix":"","firstName":"YuZhu","middleName":"","lastName":"Wu","suffix":""},{"id":501396104,"identity":"4a37e24a-d026-42c1-8ca3-505f871a89eb","order_by":3,"name":"Junjian Tang","email":"","orcid":"","institution":"Affiliated Hospital of Jiangnan University","correspondingAuthor":false,"prefix":"","firstName":"Junjian","middleName":"","lastName":"Tang","suffix":""}],"badges":[],"createdAt":"2025-06-03 00:38:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6805684/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6805684/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89979072,"identity":"07fec1a1-705f-47e6-95a6-8d9d8aaf4c39","added_by":"auto","created_at":"2025-08-27 06:17:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1427174,"visible":true,"origin":"","legend":"\u003cp\u003eMaximum diameter of the aneurysm sac on thoracic computed tomography (CT) (A); Preoperative thoracic aorta computed tomography angiography (CTA) (B); Reconstruction of the aneurysm sac from various angles (C).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6805684/v1/76bf1e9ec1cf308b85c8614b.png"},{"id":89979063,"identity":"2f0c8ea2-cce9-49ee-a0c9-3afe0c28b49e","added_by":"auto","created_at":"2025-08-27 06:17:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":57332,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative thoracic computed tomography (CT) at an approximate equivalent level (D); Thoracic CT at 1 week postoperatively (E); Cervical computed tomography angiography (CTA) at 1.5 months postoperatively (F).\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6805684/v1/be18803cf3785e203aa33c82.png"},{"id":89983329,"identity":"9593ee1d-bdfd-40ce-ad24-ac13d6aa84c3","added_by":"auto","created_at":"2025-08-27 06:33:22","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2882451,"visible":true,"origin":"","legend":"\u003cp\u003eIncision of the aneurysmal wall and dissection of the compressed recurrent laryngeal nerve (A); Resection of a portion of the aneurysm with suture approximation of the distal and proximal ends (B); Complete apposition of the proximal and distal ends, with reestablishment of blood flow in the right subclavian artery (C).\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6805684/v1/b7299d456e336baea8279ab4.png"},{"id":105897522,"identity":"281152d1-2cd8-43a8-9850-4ecd5a7a25e4","added_by":"auto","created_at":"2026-04-01 08:57:17","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6068380,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6805684/v1/7233283d-d993-47aa-ada5-37fe68f6ccac.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Case of Giant Subclavian Artery Aneurysm Compressing the Recurrent Laryngeal Nerve","fulltext":[{"header":"Case Presentation","content":"\u003cp\u003eA 72-year-old male was admitted to the hospital with the chief complaint of \"hoarseness for more than 10 days.\" The patient had experienced hoarseness without any apparent precipitating factors 10 days prior to admission. He also reported experiencing aspiration while drinking water but denied symptoms of chest tightness, dyspnea, headache, or dizziness. He initially consulted the Department of Respiratory Medicine in our hospital, where a preliminary diagnosis of \"mediastinal mass and pulmonary inflammation\" was made. Subsequently, a chest CT scan revealed a large aneurysm of the right subclavian artery, prompting his transfer to our department. The patient had a history of hypertension for over 15 years, which was well-controlled with oral administration of 80 mg of valsartan-hydrochlorothiazide once daily. On physical examination, the heart rate was 84 beats per minute. The patient was alert and in good spirits. A palpable mass was noted on the right thoracic wall. Additionally, right-sided ptosis was observed, although enophthalmos was not evident. Anhidrosis was noted on the right side of the face. Muscle strength was grade 5 bilaterally. Upon admission, blood pressure measurements were as follows: 176/81 mmHg in the left upper limb and 179/90 mmHg in the right upper limb. The patient did not report any dizziness or discomfort. Sublingual administration of 10 mg of nifedipine was administered, and subsequent blood pressure measurements were 169/83 mmHg on the left and 155/77 mmHg on the right. Laboratory investigations revealed no significant abnormalities in blood, urine, or stool routine examinations. Biochemical analysis indicated elevated blood glucose levels and an increased procalcitonin level. Cervical Computed Tomography Angiography (CTA): Aneurysm of the right subclavian artery, with the maximum diameter of the aneurysm sac approaching 54 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, A); occlusion of the right vertebral artery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, B), with proximal lumen compression and stenosis. Mixed plaques were observed at the bifurcation of the bilateral common carotid arteries, resulting in moderate stenosis of the lumen. The aneurysm sac was reconstructed from multiple angles (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, C). Magnetic Resonance Imaging (MRI) revealed an acute cerebral infarction in the right parietal lobe. The preoperative electrocardiogram (ECG) demonstrated high voltage in both the left and right ventricles, complete right bundle branch block, ST-T changes, and leftward axis deviation. Subsequent coronary CTA showed moderate stenosis in the mid-segment of the left anterior descending artery (LAD); severe stenosis in the second diagonal branch (D2); mild stenosis in the mid-to-distal segment of the left circumflex artery (LCX); severe stenosis in the distal segment of the right coronary artery (RCA); and severe stenosis in the right posterior descending artery. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the comparison of preoperative(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, D), 1-week postoperative(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, E), and 1.5-month(Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, F) postoperative CT follow-up, demonstrating significant improvement in the compression of surrounding tissues and nerves. The patient has provided consent for the publication of this case report, and the study has been approved by the hospital\u0026rsquo;s ethics committee.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Therapeutic Protocol ","content":"\u003cp\u003eOn January 17, 2025, under tracheal intubation anesthesia, a median sternotomy was performed, and the sternal edges were meticulously sealed with bone wax to achieve hemostasis. Intravenous heparin (210 mg) was administered. The right subclavian vein, innominate artery, right common carotid artery, and right subclavian artery were carefully dissected, and vascular occlusion tapes were placed. A right subclavian artery aneurysm, approximately 5 cm in diameter, was identified, characterized by significant tortuosity and compression of the right recurrent laryngeal nerve(Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, A). The recurrent laryngeal nerve and the proximal and distal ends of the aneurysm were meticulously dissected. After vascular occlusion, the aneurysmal wall was incised, and atherosclerotic plaques and thrombi, approximately 2 cm \u0026times; 2 cm in size, were removed(Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, B). End-to-end anastomosis was performed between the proximal and distal ends using 5/0 Prolene suture, and the aneurysmal remnants were obliterated(Figure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, C). A single mediastinal chest tube was placed. After neutralization of heparin with protamine sulfate, meticulous hemostasis was achieved. The sternum was securely approximated with steel wire, and the surgical incision was closed in layers. The procedure was completed without complications, and the patient was transferred to the intensive care unit (ICU) for further management. Intraoperatively, 300 ml of autologous blood was retransfused.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSubclavian artery aneurysm (SAA) is relatively uncommon, accounting for only 1% of peripheral artery aneurysms [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The occurrence of giant subclavian artery aneurysms is particularly rare. When the volume of SAA is small, it typically presents without significant symptoms or signs. However, as the aneurysm enlarges, approximately one-fourth of the cases may manifest symptoms [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In the present case, magnetic resonance angiography (MRA) of the brain revealed an acute cerebral infarction in the right parietal lobe. After multidisciplinary team (MDT) discussion, it was concluded that the infarction was likely caused by mural thrombus dislodgement from the aneurysm into the cerebral vasculature. Currently, the patient does not exhibit clinical manifestations of cerebral infarction. Cervical computed tomography angiography (CTA) showed near-occlusion of the right vertebral artery, yet the patient does not present with symptoms such as dizziness, tinnitus, or visual disturbances. Relevant literature suggests that collateral compensation may occur via the classic circle of Willis and the pathway involving the external carotid artery, occipital artery, muscular branch of the vertebral artery, and vertebral artery. Therefore, even with right vertebral artery occlusion, the patient may not experience neurological complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eSAA can be classified into true aneurysms and false aneurysms. The common etiology of true aneurysms includes atherosclerosis and thoracic outlet syndrome, whereas false SAAs are often caused by trauma or iatrogenic injury. It has been reported that mural thrombi in the right subclavian artery can embolize through the right vertebral artery, basilar artery, left posterior cerebral artery, left posterior communicating artery, and distal left middle cerebral artery due to thoracic outlet syndrome [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Based on the anterior scalene muscle as a boundary, SAA can be categorized into three types: proximal, middle, and distal. Studies have indicated that proximal and middle types of SAA have a higher incidence of rupture, while distal type has a higher risk of thrombus embolization [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNotably, in conjunction with the coronary CTA findings, the patient was found to have severe coronary atherosclerotic heart disease, with multiple branches of the coronary arteries showing significant stenosis. The initial surgical plan was to perform right subclavian artery aneurysm resection combined with coronary artery bypass grafting. However, after considering the patient's vital signs from multiple perspectives, only the right SAA resection was performed. Research has shown that high-density lipoprotein cholesterol (HDL-C) in blood lipids is an important predictive indicator. In atherosclerotic cardiovascular disease (AS-CVD), approximately one-tenth of patients with low HDL-C levels also present with subclavian artery stenosis. Considering the nearly 20 mmHg difference in blood pressure between the left and right sides, as well as the cervical CTA findings of proximal stenosis of the right subclavian artery, mixed plaques at the bifurcation of the bilateral common carotid arteries, and moderate stenosis of the lumen, subclavian steal syndrome should be considered. However, the patient currently does not exhibit clinical symptoms of upper limb ischemia or posterior circulation ischemia.\u003c/p\u003e\u003cp\u003eThe treatment methods for SAA include open surgery, endovascular intervention, and hybrid surgery. Distal type SAAs are often compressed by the clavicle and first rib, and the inserted covered stent is prone to twisting or fracture. Therefore, open surgery is frequently chosen for these locations [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Currently, endovascular treatment is predominantly selected [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], with the advantages of minimal invasiveness and better patient tolerance. Special location SAAs refer to those involving multiple arterial lesions. Treating such lesions poses numerous challenges, as it is necessary to not only manage the aneurysm itself but also to consider the aortic arch, vertebral artery, and carotid artery to prevent severe complications caused by cerebral ischemia [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Although the patient's SAA was of the proximal type, the decision was made to perform right SAA resection with end-to-end anastomosis of the right subclavian artery, considering the large size of the aneurysm, the acute phase of nerve compression, and the inability of the stent to cover the entire aneurysm.\u003c/p\u003e\u003cp\u003eAlthough endovascular treatment for SAA is less invasive to the patient and can offer more benefits when the indications are strictly followed, open surgery may provide greater benefits in certain special circumstances.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eConflict of interest\u003c/h2\u003e\u003cp\u003eAll authors declare that there is no conflict of interest.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eAuthor contribution statement\u003c/h2\u003e\u003cp\u003eZelong Qian : article writing and revision ; Han Xiao : data collection and mapping ; Junjian Tang : research design, article review.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding statement\u003c/h2\u003e\u003cp\u003eThere is no funding for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eZelong Qian : article writing and revision ; Han Xiao : data collection and mapping ; YuZhu Wu:Collect photos; Junjian Tang : research design, article review.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMaskanakis A, Patelis N, Moris D, et al. Stenting of Subclavian Artery True and False Aneurysms: A Systematic Review. Ann Vasc Surg. 2018;47:291\u0026ndash;304.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLou Z, Jin Y, Yang J, et al. Images in Vascular Medicine: Subclavian steal syndrome induced by subclavian artery aneurysm. Vasc Med. 2020;25(6):598\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang T, Li QL, Zhang XM, et al. Impact of left subclavian artery occlusion during thoracic endovascular aortic repair on ischemic stroke [J]. Chin J Gen Surg. 2019;34(2):113\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSchleifer L, Vogel S, Arun A, et al. Stroke Caused by Arterial Thoracic Outlet Syndrome in an Adolescent. Child Neurol Open. 2022;9:2329048X221105743.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNAZ I, ZIA-UR-REHMAN AZIZM et al. Subclavian artery aneu rysms: management implications in a resource-limited setting [J].Vascular, 2012, 20(6) : 301\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhang P, Zhao HM, Sun DJ, et al. Endovascular exclusion of a giant subclavian artery aneurysm using a covered stent: A case report [J]. J Clin Surg. 2023;31(08):722\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhao YB, Hua ZH, Jiao ZY, et al. Endovascular treatment of subclavian artery aneurysms [J]. Henan Med Res. 2021;30(13):2350\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi Y, Li F, Chen HJ, et al. Influence factors on early prognosis in patients with acute terminal internal carotid artery occlusion and their relationship with intracranial blood supply [J]. Chin J Practical Neurol Dis. 2023;26(06):699\u0026ndash;703.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-6805684/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6805684/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eGiant subclavian artery aneurysms are relatively uncommon, and the occurrence of symptoms resembling Horner's syndrome due to compression of the sympathetic nerve is even rarer. In such cases, open surgery is associated with more favorable outcomes compared to conventional endovascular treatment. This report introduces a 72-year-old male patient and discusses the characteristics of giant subclavian artery aneurysms and the surgical approaches employed.\u003c/p\u003e","manuscriptTitle":"A Case of Giant Subclavian Artery Aneurysm Compressing the Recurrent Laryngeal Nerve","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 06:17:15","doi":"10.21203/rs.3.rs-6805684/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3ab2c05f-b995-44ce-8920-5fd7db4d9141","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-01T08:53:17+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-27 06:17:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6805684","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6805684","identity":"rs-6805684","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}