Swelling in the upper arm: the presentation and management of an isolated brachial artery aneurysm

Abstract

True aneurysms of the brachial artery are uncommon. We describe the presentation and surgical management of an isolated, brachial artery aneurysm in a 64-year-old woman. Excision of the aneurysm and long saphenous venous interposition grafting was performed with no postoperative complications and histology demonstrated true aneurysmal degeneration. case history A 64-year-old woman presented with a 2-month history of progressive swelling in the medial aspect of her left upper arm. This was associated with paraesthesia in the lateral three fingers of her left hand. She did not report a history of pain, pyrexia, preceding trauma, intravenous drug use or previous catheterisation of her vasculature. Her previous medical history included well controlled hypertension, with an angiotensin-converting enzyme inhibitor and a thiazide diuretic, and mild asthma. There was no family history of connective tissue disorders or aneurysmal disease. Ann R Coll Surg EnglA physical examination demonstrated a 3cm x 5cm pulsatile mass that was mobile in the transverse plane and fixed in the longitudinal plane. The brachial and radial pulses were normal on palpation and no evidence of distal vascular insufficiency was noted. A neurological examination demonstrated altered sensation in the distribution of the median nerve. Ultrasonography revealed a large pulsatile aneurysm and the diagnosis of a secular proximal brachial artery aneurysm was confirmed by a computed tomography angiogram (Fig 1). Transthoracic echocardiography and duplex ultrasonography of the remaining vasculature did not identify any other abnormalities. The patient's blood tests were unremarkable with normal inflammatory markers.The surgical management of the aneurysm was performed under general anaesthetic. Dissection of the aneurysm revealed the sac to be adherent and compressing the median nerve (Fig 2). Complete dissection and mobilisation of the sac confirmed its saccular morphology. An approximately 3cm segment of the affected artery was excised and a reversed short segment of the long saphenous vein from the patient's left thigh was used as an interposition graft, anastomosed proximally and distally with 7/0 polypropylene. A gentamicin-collagen sponge (Collatamp ® , EUSA Pharma, Oxford, UK) was left in situ prior to closure. The patient was discharged two days later after an uneventful recovery with complete resolution of paraesthesia in the median nerve distribution. No complications were noted after four months of follow-up.The aneurysm histology demonstrated age-related degenerative changes with intimal thickening and thinning of the media consistent with aneurysmal degeneration (Fig 3). discussionThe aetiology of brachial artery aneurysms includes infections (mycotic), trauma, congenital conditions and atherosclerosis. True aneurysms affecting the brachial artery are very rare. The Cleveland Clinic identified only 1 of 581 procedures on brachial arteries over an 11-year period as involving true aneurysms.1 The Mayo clinics at Rochester and Arizona ide...

Surgical intervention for upper extremity nerve compression related to arteriovenous hemodialysis accesses

“…Repetitive blunt vascular trauma was held responsible for aneurysm formation in five patients. 6 , 7 Upper limb false aneurysms are usually caused by penetrating trauma, a disrupted arteriovenous anastomosis, or develop after miscannulation of an AVF. The surgical procedures are aneurysmorrhaphy, excision with end-to-end arterial anastomosis, excision, and artery ligation with subsequently reversed autogenous vein interposition graft.…”