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2012 46: 492 originally published online 4 June 2012VASC ENDOVASCULAR SURGSydney Sek Ning Wong and Graham Roche-Nagle

Giant True Brachial Artery Aneurysm  

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Giant True Brachial Artery Aneurysm

Sydney Sek Ning Wong, MD1 andGraham Roche-Nagle, MD, MBA, FRCSI, EBSQ-VASC1

AbstractTrue brachial artery aneurysms (BAAs) are uncommon peripheral vessel aneurysms that typically occur in the setting of injury.While its relationship with trauma and infectious etiologies are well defined, the association between arteriovenous fistulas(AVFs) and BAA is less well understood. We present a case of a giant true BAA that presented several years post-AVF ligation.A review of BAA, its association with AVF, and its management follows.

Keywordsbrachial artery, peripheral aneurysm, arteriovenous fistula, arteriomegaly, hemodialysis, degenerative aneurysm

Introduction

True brachial artery aneurysms (BAAs) are uncommon periph-

eral vessel aneurysms that are typically associated with trauma

or infectious etiologies. An association with arteriovenous

fistulas (AVFs) has also been noted. They typically present

in the setting of a mass in the upper extremity with a history

consistent with local injury or inflammation. The natural his-

tory of this disease is not well understood, but once diagnosed,

treatment is recommended to prevent possible complications

from thrombosis or emboli.

Case Report

A 37-year-old gentleman presented to the vascular surgery

clinic following an incidental finding of a giant left BAA. Sev-

eral years previously the patient had a radiocephalic fistula

ligated following a successful renal transplant. The radial

artery had been tied off during this procedure as the graft

appeared quite aneurysmal. Unfortunately, the transplant even-

tually failed necessitating resumption of hemodialysis, through

a dialysis central line.

Despite this large pulsatile mass in the patient’s left upper

arm, he was relatively asymptomatic and had not suffered any

complications. The distal arm and hand were viable and an

ulnar pulse was palpable. There had been no history of trauma

or recent intravenous insertion in the area.

Following confirmation with duplex ultrasonography, a

computed tomography angiography scan was performed on the

upper extremity to delineate the anatomy (Figure 1). The

images revealed that the patient had an ectatic brachial artery

extending proximally to the axilla. The fusiform aneurysm

measured 4.4 cm in maximal diameter and extended 8 cm in

length. In addition, the aneurysm appeared mostly thrombosed.

Due to the risk of emboli to the remaining perfusing vessel

to the hand, operative repair was recommended. Vein mapping

identified suitable venous bypass grafts for the procedure. The

aneurysm was resected and reconstruction consisted of a bra-

chial to ulnar artery bypass with reverse saphenous vein graft

(Figures 2–4). An end-to-side anastamosis was required proxi-

mally as the brachial artery was quite ectatic. An end-to-end

anastamosis was fashioned distally at the ulnar artery.

Postoperatively, the patient did well, with a palpable ulnar

pulse throughout his stay. During 3 months follow-up, the

patient continued to have good function.

Discussion

Brachial artery aneurysms are uncommon1 and typically occur

in the setting of trauma, intravenous drug use, endocarditis,

congenital syndromes, or vasculitis.2-7 True BAA represent

an even smaller proportion of all aneurysms occurring in the

upper extremity. In a review by the Cleveland clinic, only 1

of 581 procedures done on the brachial artery was for a true

aneurysm.8 The Mayo clinic did a similar review that identified

only 2 cases over a 20-year period.9 Because of its low inci-

dence, the natural history of an untreated brachial aneurysm

is difficult to discern. Therefore, management principles are

often drawn from recommendations for popliteal aneurysms,

which have a high rate of complications if untreated.10

Interestingly, while popliteal aneurysms are highly associ-

ated with synchronous aneurysms elsewhere, aneurysms in the

upper extremity do not appear to have the same association.

1 Department of Vascular Surgery, Toronto General Hospital, Toronto, ON,

Canada

Corresponding Author:

Sydney Sek Ning Wong, The Banting Institute, University of Toronto, Toronto,

ON M5G 1L5, Canada

Email: sydney.wong@utoronto.ca

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The Mayo clinic study showed only an 8% incidence of concur-

rent aneurysm in 12 cases of true upper extremity aneurysm.9

This may represent a difference in pathogenesis as aneurysms

in this region are related to local vascular injury such as trauma

rather than systemic atherosclerotic disease.

An association between BAA and AVFs has been observed

for some time.11 Most cases involve the site of anastamosis or

are venous in nature, related to repetitive punctures. Few are

true degenerative aneurysms with arteriomegaly as illustrated

by our case. A current theory of pathogenesis in this setting

involves adaptive arterial wall expansion in the face of sheer

forces from increased flow.12 This may result in tears through

the elastic fibers in the internal transverse membrane, predis-

posing to aneurysm development.13,14 Interestingly, the pro-

cess may not be fully arrested by fistula closure,15-18 leading

to the permanent nature of this transformative process.

Renal transplantation, as was the case in our patient, may

also be associated with aneurysm progression. Eugster et al fol-

lowed patients post-AVF and renal transplantation over a

period of 10 years with ultrasound. The study concluded that

arterial dilatation was time dependent and also showed a trend

for higher arterial diameters in transplanted compared with

nontransplanted patients.19 There is some evidence that immu-

nosuppression and corticosteroids increase the progression and

development of aneurysmal disease.20,21

Figure 1. Three-dimensional reconstruction of a computed tomogra-phy angiography scan showing fusiform aneurysm at mid to distalbrachial artery (lined arrow). Note significantly ectatic proximal bra-chial artery and axillary artery (arrow head).

Figure 4. Aneurysm resected and reconstruction with reverse saphe-nous vein graft. Note ligation of brachial artery stump and end-to-sideanastamosis proximally. Distally, the graft is anastamosed to the ulnarartery in an end-to-end fashion.

Figure 2. Intraoperative photograph of exposed aneurysm.

Figure 3. Opening of aneursym and evacuation of thrombus.

Wong and Roche-Nagle 493

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The presentation of BAA is similar to that of other periph-

eral artery aneurysms. Most commonly, they present as an

asymptomatic mass. However, pain and paresthesias from local

compression can be observed as well. Much less common are

ischemic presentations including distal embolization and a low

risk of rupture. Physical examination should involve neurolo-

gic evaluation as well as signs of distal embolic disease.

Duplex ultrasonography is the initial diagnostic test of

choice. Computed tomography angiography may be performed

for operative planning, and limited conventional angiography

can be employed in selective cases.

Management of BAA remains consensus based and is most

often surgical. In uncommon cases such as endocarditis and vas-

culitis, medical therapy may be tried initially. Surgical recon-

struction is generally recommended for aneurysms that are 1.5

to 2 times the normal arterial diameter.8 Usually this consists

of excision and ligation with reconstruction bypass grafts. Vein

patches may be used in anatomically suitable cases. Endovascu-

lar techniques have been explored and successfully employed in

the treatment of pseudoaneurysms related to vascular access22—

however, their use in true BAA has not been validated.

Conclusion

True BAAs are uncommon entity and are typically a result of local

vascular injury. They are associated with AVFs and there is some

evidence that closure of the fistula does not preclude future aneur-

ysm formation. Immunosuppression may also have an impact on

its development. Currently, surgical therapy is the mainstay of

therapy with medical management in few select cases. Endovas-

cular treatment has not yet been validated for this disease.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to

the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, author-

ship, and/or publication of this article.

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