Brachial arteriomegaly and true aneurysmal degeneration: case report and literature review

Vascular Medicine 2002; 7: 25±27 Brachial arteriomegaly and true aneurysmal degeneration: case report and literature review Christian D Schunna and Timothy M Sullivanb Abstract: While brachial artery aneurysms are rare and usually of infectious, post-traumatic or iatrogenic etiology, true aneurysms of the brachial artery are even more unusual. We report on a large brachial artery aneurysm complicated by chronic contained rupture and partial outow obstruction. This was observed 19 years after ligation of a radiocephalic (Brescia–Cimino) arteriovenous Žstula for hemodialysis that had existed for 2 years. Of 581 brachial artery reconstructions performed at the Cleveland Clinic Foundation between January 1989 and December 2000, only three involved repairs of brachial artery aneurysms; only the reported case was a true aneurysm of degenerative origin for an incidence of 0.17% (1/581). The management of brachial artery aneurysms is described and the pertinent literature was reviewed. Key words: brachial arteriomegaly; brachial artery aneurysm; cimino arteriovenous Žstula Brachial artery aneurysms are relatively rare and usually of infectious, post-traumatic or iatrogenic1 ± 5 etiology. True aneurysms of the brachial artery are even more unusual. We report on a large fusiform aneurysm of the brachial artery complicated by chronic contained rupture and partial out¯ow obstruction. A 52-year-old black female presented with a 6-month history of progressive swelling and pain in her left antecubital fossa and exercise-induced ischemia of the forearm and hand. A grape-sized mass in this location had been stable and non-tender for 2 years prior to presentation. Her past history was signi®cant for severe hypertension requiring hospitalization for hypertensive encephalopathy and acute renal failure 21 years prior to this presentation. She had been on chronic hemodialysis for 1 year via a left radiocephalic arteriovenous ®stula (Brescia±Cimino), when her renal function rebounded and she was able to discontinue hemodialysis. One year later, the ®stula was ligated at her request. Renovascular hypertension had been excluded by arteriography via femoral puncture. She denied previous angiographic or angioaccess procedures via her left antecubital fossa, con®rmed by diligent review of her medical records. There was no history of local trauma, local in¯ammatory process, intravenous drug abuse, fever or chills. There was no family history of aneurysm or connective tissue disease. On physical examination, a widely pulsatile mass was present, extending from the distal medial upper arm to the antecubital fossa (Figure 1), which measured 14 ´ 7 cm on color duplex examination (Figure 2). There was no evidence of embolization to the digits, although pulses were not palpable distal to the aneurysm. The remainder of her physical examination was normal. Non-invasive laboratory examination of the upper extremities identi®ed reduced pulse volume waveforms and a 70 mmHg reduction in arterial pressure at the wrist when compared with the right upper extremity. Angiography documented a tortuous, arteriomegalic left brachial artery with poor opaci®cation of the larger brachial aneurysm. The proximal radial artery appeared chronically occluded, with run-off via a diffusely diseased ulnar and a small interosseous artery (Figure 3). Evaluation of the abdominal aorta and femoro-popliteal arteries with duplex ultrasound identi®ed no other aneurysms. The patient underwent uneventful resection of a dumbbell-shaped, densely ®brosed aneurysm, the distal part of which appeared to be an organized, contained rupture. Arterial continuity was re-established with a reversed median vein of the forearm interposition graft from normal proximal brachial artery to the con¯uence of the ulnar and interosseous arteries. Adequacy of revascularization was documented by intraoperative arteriography. Histological evaluation of the vessel wall con®rmed the diagnosis of true brachial aneurysm, with all three layers of the arterial wall intact. Her postoperative course was uneventful, and her hand remained well perfused at the 2-year follow-up. a Discussion Address for correspondence: Christian D Schunn, Section of Vascular Surgery, Department of Surgery, Robert C Byrd Health Sciences Center, West Virginia University, Morgantown, WV 26506-9238, USA. Tel: +1 304 293 2367; Fax: +1 304 293 8881; E-mail: cschunnKhsc.wvu.edu True brachial artery aneurysms are a rare entity. Of 581 procedures involving the brachial artery performed at the Cleveland Clinic Foundation between January 1989 and December 2000, only three were repairs of brachial artery aneurysms. Two were iatrogenic false aneurysms following cardiac intervention; only the reported case was a true aneu- Case report Section of Vascular Surgery, Department of Surgery, Robert C Byrd Health Sciences Center, West Virginia University, Morgantown, WV, USA; bDepartment of Surgical Education and Vascular Surgery Service, Greenville Hospital System, SC, USA Ó Arnold 2002 Downloaded from vmj.sagepub.com by guest on April 24, 2016 10.1191/1358863x02vm411cr 26 CD Schunn and TM Sullivan Figure 1 Left arm brachial artery aneurysm. rysm of degenerative origin (1/581; 0.172%), as supported by arteriomegaly of the entire brachial artery on arteriography and by the histologic appearance of the operative specimen. The in¯uence of the radial AV ®stula on the brachial artery in this patient remains speculative. While the distal ®stula may have increased ¯ow through the native brachial artery, this effect had lasted only 2 years ± assuming successful ®stula ligation 19 years prior. Furthermore, true cause-and-effect have not been previously reported. Peripheral aneurysms in hemodialysis patients generally involve the arterial anastomoses of bridge ®stulas or are found at the site of repetitive punctures of these grafts. Although direct accidental puncture of the brachial artery during dialysis is a recognized cause of brachial artery aneurysm formation,6 it does not seem to be a plausible etiology in this patient, where the aneurysm formed 20 years after her last hemodialysis. In addition, she did not ®t the pro®le for any of the multitude of described etiologies for peripheral aneurysm formation of the congenital,7 ,8 connective tissue disorder, in¯ammatory or primary degenerative syndromes.9 ± 1 2 Among the complications related to peripheral aneurysm formation, rupture is less frequently seen than symptoms referable to compression of surrounding structures. The most frequent event is distal embolization,1 3 ,1 4 which in the upper extremity may go unnoticed and remain well compensated for long periods of time. Functionally, the brachial artery is similar to the popliteal artery in the lower limb. Popliteal artery aneurysms are more likely to thrombose or embolize, while rupture is quite uncommon. Conclusion Figure 2 Preoperative duplex scan of left brachial artery demonstrates tortuosity and aneurysmal degeneration (white arrow). Vascular Medicine 2002; 7: 25±27 True aneurysmal degeneration of the brachial artery is a rare occurrence which may lead to contained rupture. Successful repair requires precise preoperative anatomic and functional de®nition of the disease process and intraoper- Downloaded from vmj.sagepub.com by guest on April 24, 2016 Brachial arteriomegaly and true aneurysmal degeneration 27 ative assessment of revascularization with arteriogram. Recommendations for repair should parallel those for popliteal aneurysms, with elective operation (exclusion and bypass) considered for aneurysms greater than one and a half to two times the diameter of the normal adjacent artery, or for those aneurysms which contain thrombus regardless of size. References 1 Cakalagaoglu C, Keser N, Alhan C. Brucella-mediated prosthetic valve endocarditis with brachial artery mycotic aneurysm. J Heart Valve Dis 1999; 8: 586±90. 2 Yellin AE. Ruptured mycotic aneurysm: a complication of parenteral drug abuse. 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(B) Preoperative arteriogram, left forearm, demonstrates thrombosis of brachial artery at the elbow joint (black arrow) with reconstituted ulnar (white arrow) and interosseous arteries. Vascular Medicine 2002; 7: 25±27 Downloaded from vmj.sagepub.com by guest on April 24, 2016