Introduction

Upper extremity arterial aneurysm is not a common scenario. This entity may discuss under two major categories such as true aneurysm and pseudoaneurysm. Most of the true aneurysm causes by both penetrating injury or blunt trauma and degenerative disease¹,². The pseudoaneurysm mostly caused by the iatrogenic factor includes puncture for angiography or arterial blood drawing³,⁴. The common characteristics of both types of upper extremity aneurysms are that most of them seen in the brachial and radial arteries, in contrast, the subclavian and axillary arteries are less affected due to their anatomical localization. The actual incidence of such aneurysms in the general population is unknown, as there is no comprehensive study in the literature.

Aneurysms originating from the upper extremity arteries cause complications related to thromboembolism on the hands and fingers. In that case limb loss rate seen quite higher compared with the lower extremity arterial aneurysms, so early diagnosis and adequate treatment is essential²,⁵. In this study, we aimed to investigate the etiology, our treatment strategy, and long-term outcome in the light of 10 years of experiences.

Materials and methods

Results

The pulsatile mass was the most common clinical findings for aneurysmal dilalations. True aneurysmal dilatations more often localized at brachial region, whereas the pseudoaneurysms mostly seen at the radial artery; this is because of the radial artery is favored for coronary angiogram access. Majority of the true aneurysmal dilatation (58%) found to be caused by blunt trauma in the case series. Degenerative arterial disease (16%) such as Behçets disease and adventitial cystic necrosis was the main etiology of the idiopathic aneurysmal dilatation. Four (21%) patients who had true brachial aneurysm underwent emergency intervention due to limb ischemia (Table 1).

In 16 (84%) patients who had true aneurysmal dilation, autologous saphenous vein graft used for repair (Fig. 1). One of the applied saphenous vein grafts was occluded at 9^th day after operation, embolectomy was performed, and the graft flow was restored. Embolectomy failed in one patient who had no flow in the interposed saphenous vein to the distal radial artery at postoperative 7^th month. Any further intervention was considered for that patient because there was no ischemic complication. The primary and secondary patency of the saphenous graft was 87.5% and 93.8% consecutively after 43 ± 18 months of follow-up.

Figure 1 Radial artery aneurysm repair with autologous saphenous vein. A: aneurysm exposure. B: saphenous vein interposition. C: aneurysm material. 

The rest of 3 (16%) patients deprived autogen graft due to absence of saphenous vein or severe varicosity on saphenous vein again. In these patients, 6 mm PTFE ringed graft was used (Fig. 2). Graft infection occurred after 2 weeks in one of this patient who was a drug-abuser. The PTFE graft was removed, and bovine jugular vein was used after tissue debridement. Graft thrombosis was found in other patient at 3^rd postoperative day and embolectomy successfully performed. The patient was given warfarin and ASA daily as treatment.

Figure 2 Brachial artery aneurysm repair with PTFE ring graft. A: aneurysm exposure. B: graft interposition. C: aneurysm material. 

In this series, the incidence of the pseudoaneurysm was found to be higher than the true aneurysmal dilatation (64.5% vs. 35.5%). All the pseudoaneurysms were developed by iatrogenic causes (Table 2). 30 (84%) of the pseudoaneurysm repaired by primary technique, and 6 (16%) patients required patch plasty to avoid involved segment stenosis after repair. Two brachial and one radial pseudoaneurysm ruptured and underwent emergency surgery. All the pseudoaneurysm repaired without complication and long-term results did not found stenosis or occlusion. No limb loss or aneurysm reoccurrence observed during the follow-up period.

Discussion

The incidence of the upper extremity arterial aneurysms is much less than the lower extremity. Etiology includes iatrogenic, idiopathic, penetrating injury, and blunt trauma. Iatrogenic factors include puncture for angiography and blood sample drawing. Most of the pseudoaneurysm causes by iatrogenic injury³,⁴. Uncontrolled hypertension, anticoagulations, and inadequate compression after arterial blood drawing may play important role of its formation. Pseudoaneurysms occur in a shorter period and have a higher risk of rupture, and most of them can be preventable according to the nature of its formation⁷,⁸. The incidence found in our series is around 65%. In our series, we performed primary repair technique under local anesthesia or axillary nerve blockage according to the patient’s willingness in pseudoaneurysm treatment. Long-term results are excellent after repair, and the length of hospital stay is limited to 1 or 2 days. In contrast with that, true aneurysm mostly caused by penetrating injury or blunt trauma and degenerative arterial disease¹,². Our investigation revealed that true aneurysms after injury occurred in a longer period.

Theoretically, as a result of blunt trauma, the vascular structure trapped between the trauma object and the bone or joint, and there is no significant bleeding other than ecchymosis due to the flexibility of the artery after trauma. In penetrating injury traumas, due to the regional anatomical proximity of the neurovascular bundle, the development of functional neural losses always exists with the traumatic aneurysm²,⁵. Most of the limb loss happens when the severe trauma causes adjacent nerve and more considerable surrounding tissue injury and concomitant necrosis or contamination⁵. In our series, no severe neurological consequences encountered except the temporary loss of motor function in a left subclavian artery aneurysm and sensory function in a brachial artery aneurysm. Some studies showed that degenerative arterial diseases such as Behcets disease and adventitial cystic necrosis may cause peripheral arterial aneurysm⁹,¹⁰. In our series, two patients with Behcets disease have brachial artery aneurysm; the ascending aortic aneurysm co-exists in one of them. Adventitial cystic necrosis was found in one patient with axillary artery aneurysm.

Due to its superficial localization, the upper extremity arterial aneurysms can be diagnosed easily than the lower extremity aneurysms. In the most comprehensive study of the upper extremity aneurysms, the presence of pulsatile mass was the most common. In our series, the most common symptom was ischemic complaints such as intermittent pallor and cooling in addition to the presence of pulsatile mass¹¹. If the upper extremity arterial aneurysms are not treated, complications of thrombosis, bleeding, and a-v fistula are likely to develop¹². Although endovascular techniques or similar procedures are increasingly used for upper extremity arterial aneurysms, due to lack of long-term results, we remain to prefer surgical approach¹²-¹⁴. Surgical approach is based on the excision of the aneurysm sac and the maintenance of arterial flow. Continuous arterial flow should be ensured by end-to-end anastomosis with autologous saphenous vein graft, if possible. Reconstruction of the arterial structure with autologous vein graft is an appropriate approach for the preservation of the distal extremity, especially at brachial and more proximal arterial aneurysms⁵,¹⁵. We did not prefer the upper extremity adjacent veins in our patients because of the risk of aneurysm formation during long-term follow-up¹⁶.

Our study showed the saphenous vein and PTFE ring graft to the brachial artery showed excellent patency due to adequate run-off. The debate of repair or ligation of the radial artery has been continuing for more than two decades¹⁷,¹⁸. Studies are suggesting that the long-term patency of the saphenous vein anastomosed to the radial artery is unsatisfactory leads to ligation of the radial artery. Our opinion is to repair the proximal radial artery and provides blood flow if there is an on-site facility and experienced operators. The most distal radial artery might be ligated because the vein graft patency at this level is not satisfying.

Endovascular therapy may also be considered as an option. However, we did not choose it because the cost of endovascular treatment was higher and the surgical results were satisfactory. In the presence of suitable conditions, endovascular treatment can be applied and more studies can be done.

Conclusion

Upper extremity aneurysms are mostly seen as iatrogenic pseudoaneurysms. Surgical treatment consists of simple suturing and patch plasty. Most of the true aneurysms occur in the later period after blunt trauma, aneurysms due to degenerative disease are much less common. Long-term results of aneurysm resection and saphenous graft interposition are excellent. It may be reasonable to ligate aneurysms in the distal radial artery.

Synopsis

This retrospective study revealed that the majority of upper extremity arterial aneurysms are pseudoaneurysms and can be preventable. Blunt trauma might cause true aneurysm in a longer period. Autologous vein graft is the best choice for true aneurysm repair.

Author contribution

EC Ata conducted data analysis, critically revised manuscript, and approved final version. MO Beyaz and I Demir participated in study design, data analysis, interpretation, wrote manuscript, and approved final version.

Ethics approval

This is a retrospective study, so it was exempted from ethics committee approval. The study results were endorsed by the Ethics Committee of Istanbul Medipol University.