Neurovascular compromise due to true brachial artery aneurysm at the site of a previously ligated arteriovenous fistula: Case report and review of literature

True Brachial Artery Aneurysm in Patients with Previous Arterio-Venous Fistula Ligation and Immunosuppressant Therapy for Renal Transplantation: Case Report and Literature Review

BACKGROUND/OBJECTIVE

Brachial artery aneurysm (BAA) is a serious complication in patients with previous arterio-venous fistula (AVF), renal transplantation (RT), and immunosuppressive regimens. Until now, there has been no standard of care for these patients, especially for patients undergoing chronic dialysis and immunosuppressive treatment. The aim of this study was to investigate data from the literature regarding these patients and to suggest recommendations for the best approach to their treatment.

METHODS

A review of the literature was performed by searching the PubMed database in the English language. The review was accompanied by two case reports. A total of 24 articles with different variables-demographics, renal transplantation, aneurysm size, and type of surgery-were subjected to the review. In addition, two cases are reported.

CONCLUSION

This review suggests that the best treatment for these patients is open surgery, with aneurysmectomy and graft interposition.

RESULTS

All patients had RT. The age of patients ranged from 26-77 yo, with a male predominance. The majority had an AVF ligated after RT. The main clinical symptoms were pain, swelling, and pulsatile mass (66%). All patients, except one, were treated through open surgery. The first option for treatment was reversed saphenous vein graft interposition (36%), followed by ePTFE graft (16%).

True Brachial Aneurysm in an Older Female Patient. A Case Report and Review of Literature

INTRODUCTION

Brachial artery aneurysms constitute 0.5% of peripheral aneurysms. These can be true or secondary to trauma or arteriovenous fistulas. These present as an asymptomatic pulsatile mass or may cause symptoms due to compression of adjacent neurological structures.

CASE REPORT

We present a review of the literature on clinical, histological, and therapeutic characteristics of true brachial aneurysms, motivated by the case of a 67-year-old woman with an asymptomatic pulsatile mass dependent on the brachial artery of the left arm who underwent open surgical correction with resection of the aneurysmal sac and interposition of great saphenous vein graft with adequate postoperative results.

Giant Brachial Aneurysm after Arteriovenous Fistula Ligation: A Review of the Different Surgical Approaches

The aim of this paper is to describe the case of a patient successfully treated for left brachial arterial aneurysm occurring 15 years after renal transplantation and consequent 8 years after arteriovenous fistula (AVF) ligation. We describe our experience and our surgical approach. A 45-year-old man presented to our attention for a large pulsatile formation on the volatile face of the left forearm, which he reported to have enlarged in the last year. He had a history of chronic renal impairment in 2000, then AVF for dialysis was realized, and he was finally addressed to kidney transplantation in 2004. In 2011 the AVF was ligated. We observed absence of radial pulse and direct flow on the ulnar artery; a large pulsatile formation was evident along the course of the left brachial artery, associated with forearm venous dilatation. Doppler ultrasound showed fusiform aneurysm of the brachial artery with 3.5 cm diameter and longitudinal extension of 5 cm up to the brachial bifurcation. We removed the brachial aneurysm, with a venous bypass on the ulnar artery. The patient was discharged in good general condition on the second postoperative day. At 1- and 6-month follow-up he had complete recovery with graft patency, without any neurological impairment and with a good esthetic result. An open surgical repair with great saphenous vein interposition seems to be the best choice in terms of patency and perioperative morbidity.

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

Objective:

Chronic renal failure patients with arteriovenous hemodialysis access may exhibit pain and neurological complaints due to local nerve compression by the access conduit vessels of autogenous arteriovenous fistulas or the prosthesis of arteriovenous grafts. In this study, we have examined the results of surgical intervention for vascular access–related nerve compression in the upper extremity.

Methods:

A single center retrospective study was performed of all patients referred for persistent pain and neurological complaints after vascular access surgery for hemodialysis. There were four brachial-cephalic, three brachial-basilic upper arm arteriovenous fistulas, and three prosthetic arteriovenous grafts. All patients had pain and sensory deficits in a distinct nerve territory (median nerve: 6; median + ulnar nerve: 1; medial cutaneous nerve: 1), and two patients had additional motor deficits (median nerve).

Results:

A total of 10 patients (mean age: 59 years; range: 25–73 years; 2 men; 4 diabetics) were treated by surgical nerve release alone (2 patients) or in combination with access revision (8 patients). Mean follow-up was 23 months (range: 8–46 months). Direct complete relief of symptoms was achieved in six patients. Three patients had minor complaints, and one patient had a reoperation with good success.

Conclusion:

Vascular access–related nerve compression is an uncommon cause for pain, sensory and motor deficits after vascular access surgery. Surgical nerve release and access revision have good clinical outcome with relief of symptoms and maintenance of the access site in the majority of patients.