Subclavian artery false aneurysm associated with brachial plexus palsy: a complication of parenteral drug addiction

[Rare variant of median nerve compression: compression by brachial artery false aneurysm combined with carpal tunnel syndrome. Case report and literature review]

BACKGROUND

The authors present severe compression of the median nerve by iatrogenic false aneurysm of the brachial artery combined with carpal tunnel syndrome.

MATERIAL AND METHODS

An 81-year-old woman developed acute anesthesia of fingers I-III of the left hand, impaired flexion of the thumb and forefinger, swelling of the hand and forearm, local pain in postoperative period after angiography. The patient was previously followed-up for transient numbness in both hands for 2 years with a diagnosis of carpal tunnel syndrome. Electroneuromyography and ultrasound of the median nerve at the level of shoulder and forearm were carried out. We visualized a pulsatile lesion with Tinel's sign within the elbow (false aneurysm of the brachial artery).

RESULTS

Resection of brachial artery aneurysm and neurolysis of the left median nerve were followed by regression of pain syndrome and improvement of motor function of the hand.

CONCLUSION

This case demonstrates a rare variant of acute high compression of the median nerve after diagnostic angiography. This situation should be considered in differential diagnosis with classical carpal tunnel syndrome.

Balloon-Assisted Percutaneous Thrombin Injection for Treatment of Iatrogenic Left Subclavian Artery Pseudoaneurysm in a Critically Ill COVID-19 Patient

Background

Central venous catheter represents an important tool in the management of critically ill patient. In this report, we described a COVID-19-positive case who had COVID-related complications and iatrogenic left subclavian artery pseudoaneurysm after central venous catheter insertion. Case Presentation. A 58-year-old male patient presented with a high-grade fever, myalgia, and shortness of breath due to COVID-19 infection. He required mechanical ventilation support and hemodialysis. He also developed uneventful deep vein thrombosis and myocardial infarction. As a complication of central line insertion, the patient developed pseudoaneurysm that originated from the subclavian artery with significant bleeding and large hematoma. Balloon-assisted percutaneous thrombin injection was done under ultrasound guidance. The patient was extubated 2 days later with no evidence of flow in the pseudoaneurysm. However, he lost movement in the left arm secondary to the compression of the brachial plexus from the pseudoaneurysm/hematoma, and therefore, 1.5 litres of the hematoma was evacuated in the operating room through a lateral left chest wall incision along the anterior axillary line to relieve the compression over the brachial plexus. The patient declined surgical reconstruction of the brachial plexus, and the flaccid paralysis of the arm did not recover during the follow-up.

Conclusion

This is a case of unusual complications of COVID infection and iatrogenic left subclavian artery pseudoaneurysm postcentral vein cannulation. Balloon-assisted percutaneous thrombin injection for treatment of left subclavian artery pseudoaneurysm is feasible; however, delayed diagnosis could be associated with long-term or permanent disability.

Avoiding peripheral nerve injury in arterial interventions

Although peripheral nerve injuries secondary to angiography and endovascular interventions are uncommon and usually not permanent, they can result in significant functional impairment. Most arteries used in access for angiography and endovascular therapies lie in close proximity to a nerve. The nerve may be injured by needle puncture, or by compression from hematoma, pseudoaneurysm, hemostasis devices, or by manual compression with incidence in literature ranging from as low as 0.04% for femoral access in a large retrospective study to 9% for brachial and axillary access. Given the increasing frequency of endovascular arterial procedures and the increasing use of nontraditional access points, it is important that the interventionalist have a working knowledge of peripheral nerve anatomy and function as it relates to relevant arterial access sites to avoid injury.

A Neglected Cause of Iatrogenic Brachial Plexus Injuries in Psychiatric Patients

BACKGROUND

Psychiatric patients are often kept immobilized during hospitalization to avoid self-inflicted injuries and danger to third parties. Inadequate positioning can lead to brachial plexus injuries (BPI).

OBJECTIVE

To present a series of 5 psychiatric patients with BPI after being left sedated and restrained for prolonged periods of time during hospitalization.

METHODS

We retrospectively reviewed the charts of 5 psychiatric patients with iatrogenic BPI referred by other institutions to our service. The restraint technique adopted by those institutions consisted of a high-thoracic restraint. All patients underwent complete clinical and neurological examination at our center. Information concerning patient demographics, BPI characteristics, treatment choice, and ultimate outcome was recorded.

RESULTS

Three patients were male. The age of our patients ranged from 25 to 61 years old (mean: 41.2; median: 43). Three patients had a diagnosis of bipolar disorder while 2 had schizophrenia. Duration of immobilization ranged from 5 to 168 h (mean: 77.8; median: 72). Four patients presented with a unilateral right-sided lesion. Time to presentation ranged from 1 to 9 mo (mean: 4.2; median: 4). All patients also had intense pain and axillary lesions. Four patients received conservative treatment with partial or full functional recovery and complete pain resolution. The remaining patients underwent surgical repair and experienced good functional outcome.

CONCLUSION

Psychiatric patients who need to be sedated and immobilized must be monitored closely, as BPI can occur from high-thoracic restraints. When such an injury occurs, the patient must be referred to a center specialized in peripheral nerve surgery and rehabilitation.

Pseudoaneurysm of brachial artery: A rare cause of median nerve compression

Background

The authors present an unusual clinical case of high median nerve compression caused by an iatrogenic pseudoaneurysm of the brachial artery after an angiography with a follow up of 9 months.

Methods

A 73-year-old male was seen with progressive numbness, loss of opponency and diminution of strength of finger flexion in the left hand after an angiography with direct puncture of the left humeral artery. Physical examination revealed a hard consistency internal distal arm swelling with the size of a walnut, non-pulsatile and with a Tinel sign on percussion. Upper extremity arterial Doppler ultrasonography and magnetic resonance imaging didn't point to a pseudoaneurysm. Given the persistence and progressive worsening of symptoms, the patient was operated at 4 months after the beginning of symptoms through an anterior approach of the left elbow. The tumefaction corresponded to a brachial artery pseudoaneurysm completely thrombosed causing severe compression of the median nerve. Microsurgical neurolysis of the median nerve was performed and the pseudoaneurysm was removed.

Results

At 9 months of follow-up the patient had total recovery of flexion of the thumb and forefinger and recovery of opposition with slight hypoesthesia on the volar surface of the radial fingers of the hand.

Conclusions

This case represents a rare form of high median nerve compression after angiography. The increased use of endovascular procedures may cause a higher frequency of these neurological injuries, and if confirmed, the patient should be operated as soon as possible to avoid serious neurological sequelae.

Brachial plexus compression due to subclavian artery pseudoaneurysm from internal jugular vein catheterization

Internal jugular vein (IJV) catheterization has become the preferred approach for temporary vascular access for hemodialysis. However, complications such as internal carotid artery puncture, vessel erosion, thrombosis, and infection may occur. We report a case of brachial plexus palsy due to compression by right subclavian artery pseudoaneurysm as a result of IJV catheterization in a patient who was under maintenance hemodialysis.

Metachronous Giant Brachial Artery Pseudoaneurysms: A Case Report and Review of the Literature

Brachial artery pseudoaneurysms secondary to intravenous drug abuse represent a limb-threatening problem to patients and a technical challenge to the vascular surgeon. Here information is reported about a patient with metachronous bilateral giant brachial artery pseudoaneurysms secondary to intravenous drug use that were successfully treated with excision of the aneurysm and ligation of the brachial artery. Furthermore, a review of the current literature on the treatment of brachial artery aneurysm is presented.

Isolated anterior interosseous nerve deficit due to a false aneurysm of the humeral artery: an unusual complication of penetrating arm injury. Case report and literature review

Anterior interosseous nerve (AIN) injuries account for only 1% of all the nerve injuries at the upper limb. We report the case of a 22-year-old male who sustained a penetrating injury to the arm. No neurological deficit was found at the initial evaluation. However, 6 weeks later, he had a motor deficit confined to the territory of the AIN with weakness of the flexor pollicis longus and flexor digitorum longus to the index. He also reported paraesthesia. Tinel's test was positive over the pinpoint wound in the arm, where a painful swelling was felt. Electroneurophysiological testing indicated a deficit of the AIN. Surgical exploration identified a thrombosed false aneurysm of the humeral artery responsible for compression of the median nerve. One month later, the patient had achieved a full recovery. Immediate routine exploration of deep penetrating wounds, although mandatory, may fail to detect any lesions. Close monitoring must be provided subsequently, as gradual nerve compression can result in delayed neurological deficits.

Brachial plexus paralysis of a dominant arm due to hematoma associated with internal jugular vein cannulation

Paralysis and sensory loss of a dominant right arm developed as complications of cannulation of the right internal jugular vein (IJV) in a patient undergoing cardiac surgery. This sequela of IJV cannulation has not been previously reported at the time of this writing.

False aneurysm of the interosseous artery and anterior interosseous syndrome--an unusual complication of penetrating injury of the forearm: a case report

BACKGROUND

Palsies involving the anterior interosseous nerve (AIN) comprise less than 1% of all upper extremity nerve palsies.

OBJECTIVES

This case highlights the potential vascular and neurological hazards of minimal penetrating injury of the proximal forearm and emphasizes the phenomenon of delayed presentation of vascular injuries following seemingly obscure penetrating wounds.

CASE REPORT

We report a case of a 22-year-old male admitted for a minimal penetrating trauma of the proximal forearm that, some days later, developed an anterior interosseous syndrome. A Duplex study performed immediately after the trauma was normal. Further radiologic investigations i.e. a computer-tomographic-angiography (CTA) revealed a false aneurysm of the proximal portion of the interosseous artery (IA). Endovascular management was proposed but a spontaneous rupture dictated surgical revision with simple excision. Complete neurological recovery was documented at 4 months postoperatively.

CONCLUSIONS/SUMMARY

After every penetrating injury of the proximal forearm we propose routinely a detailed neurological and vascular status and a CTA if Duplex evaluation is negative.

Axillary Artery to Contralateral Axillary Vein Graft Fistula in Chronic Hemodialysis Patients

BACKGROUND

Vascular access failure is a severe and common complication for hemodialysis patients. The possible vascular access sites are limited in dialysis patients. Axillary artery to contralateral axillary vein arteriovenous fistula (AVF) is one of the possibilities. However, the clinical outcome of this procedure is still un-defined.

OBJECT

The purpose of this study is to review the clinical outcome of axillary artery to contralateral axillary vein AVF as a hemodialysis vascular access.

PATIENTS AND METHODS

We retrospectively reviewed native or graft arteriovenous fistula records for chronic hemodialysis patients at Chang Gung Memorial Hospital in Kaohsiung, Taiwan, from January 1986 to March 2001. Records were reviewed for all chronic hemodialysis patients, with more than 2000 individuals receiving more than 10,000 fistulas. Eight patients received axillary artery to contralateral axillary vein AVF.

RESULTS

The mean age for these patients was 61.7 +/- 16.3 year-old at time of surgery. All patients had received multiple native or graft arteriovenous fistula creation. The 2-year and 4-year AVF graft survival is 87.5% and 43.8% respectively. One patients developed brachial plexopathy after operation. Another patient had venous hypertension distal to the AVF site. Both patients were managed conservatively. There is no AVF-related mortality in these patients.

CONCLUSION

We conclude that axillary artery to contralateral axillary vein graft fistula may be a feasible alternative choice for chronic hemodialysis access.

Arterial Consequences of Recreational Drug Use

BACKGROUND

Recreational drug use is becoming an increasing problem throughout the world. Many of the drugs used and their routes of administration have the potential to cause damage to the vascular system. Intravenous drug administration with the risk of arterial puncture predisposes to the formation of infected pseudoaneurysms. Inadvertent intra-arterial injection predisposes to distal limb ischaemia. Cocaine has numerous effects not only on the heart, but also potentially on any vascular bed.

METHODS

A systematic review of published literature with regard to the arterial consequences of recreational drug abuse was undertaken by undergoing an electronic search.

RESULTS

Most of the available literature is in the form of case reports and case series. Pseudoaneurysm formation is a serious consequence for intravenous drug users. For femoral aneurysms vessel ligation is the safest option with a low amputation risk. A high proportion of patients do have symptoms of claudication in the long term. Intra-arterial injections can result in limb threatening ischaemia. Systemic anticoagulation forms the mainstay of treatment. Cocaine has significant effects upon both the myocardium and the arterial tree in general. Arterial problems must always be considered in cocaine users who present acutely.

CONCLUSION

The consequences of recreational drug use will result in an increased exposure of vascular surgeons to its associated complications posing unique and challenging problems.

False aneurysm with median nerve palsy after iatrogenic brachial artery puncture

We report on a case in which a patient on oral anticoagulation for her aortic valve replacement, with an International Normalised Ratio of 2.13, developed a false aneurysm of the brachial artery after a routine arterial puncture, despite direct pressure to the aspiration site. The false aneurysm was complicated by the development of median nerve palsy.

Diagnosis and Management of Complications of Self-Injection Injuries of the Neck

When IVDUs who lose peripheral access turn to their necks, they invite a spectrum of unique complications that require particular management and treatment. While many of these complications are infectious, other possibilities include vocal cord paralysis and needle fragment foreign bodies. Work-up of these patients must include a very thorough history and physical exam, particularly of the head and neck, complete with a laryngeal exam. All patients should undergo imaging studies, including plain films, CT or MRI of the neck, and other studies as appropriate. Laboratory studies should include HIV and hepatitis serologies. Because of the risks to the surgical team, neck explorations, when indicated, should be performed under general anesthesia with strict adherence to universal precautions. Further management includes early referrals to methadone clinics, although unfortunately poor patient compliance is usual. Public campaigns aimed at prevention are useful, although limited, and should be encouraged.

Inadvertent subclavian artery puncture in an intravenous drug abuser

Arterial complications from inadvertent arterial puncture in intravenous drug abusers are well recognised. Most reports describe injury to the femoral artery with occasional reports of brachial and radial artery injury. A case of subclavian artery injury is described in this paper, and the pathophysiology and treatment of intraarterial drug injection discussed.

Pseudoaneurysm in injecting drug abusers: cases from India

Pseudoaneurysm, a known complication of arterial needle puncture, is also an uncommon complication of parenteral drug abuse. India is currently witnessing an upsurge of abuse of injectable drugs. Five cases of pseudoaneurysm developing as a complication of intra-arterial drug abuse are reported. The need for early recognition and proper timely intervention is highlighted.