Brachial artery aneurysm rupture in a patient with neurofibromatosis: a case report

Presentation, Treatment and Outcomes of Brachial Artery Aneurysms

OBJECTIVE

Brachial artery aneurysms are rare entities that have typically been associated with trauma, infection, arterio-venous fistula creation or connective tissue disorders. These aneurysms are often asymptomatic, but they can also cause local tenderness or thrombo-embolic events. Due to the very low incidence of true brachial artery aneurysms, there are no standardized guidelines on their optimal management.

METHODS

From August 2000 to July 2022, all patients with a diagnosis of true brachial artery aneurysm were managed within our healthcare system. Demographic information, imaging findings, and operative details for these patients were collected.

RESULTS

Twenty-three patients with a diagnosis of true brachial artery aneurysm were identified. The median (range) age was 50.4 (1-75) years. Eighteen (78%) were male and the mean body mass index was 25.8±6.5 kg/m2. Concomitant risk factors included hypertension in 18 (79%), a smoking history in 12 (52%), hyperlipidemia in 9 (39%), and coronary artery disease in 5 (22%). Fifteen (65%) patients had a prior arterio-venous fistula created in the affected arm, 12 (52%) had a history of kidney transplant, and 10 (44%) were taking immunosuppressive medication. Four (18%) patients had a history of arterial aneurysm at other locations and 3 (13%) had been diagnosed with a connective tissue disorder. Thirteen patients (57%) presented with symptoms of local or exertional pain, while 10 (44%) were asymptomatic. Ultrasound or computed tomography imaging was performed in all patients, with an average aneurysm size of 2.9±2.0 cm. Eighteen (78%) patients underwent surgical repair (13 symptomatic and 5 asymptomatic). Surgical repair included resection of the aneurysm and brachio-brachial interposition/bypass graft placement with a reversed (8, 61.5%) or non-reversed (3, 23.1%) saphenous vein, ringed PTFE graft (1, 7.7%) or cryopreserved graft (1, 7.7%). Out of the 18 patients who underwent surgical repair, 2 (11%) experienced a postoperative complication. One patient had a superficial wound infection managed with antibiotics, and the other patient underwent hematoma evacuation. There were no nerve injuries or distal embolization. At a median (range) follow-up of 2.4 (0.1, 18.) years, 5 surgical patients were lost, and the remaining 10/13 (77%) grafts remained patent. Three patients developed asymptomatic graft occlusion, which were managed non-operatively. Among the five asymptomatic patients who did not undergo aneurysm repair, two died awaiting transplant and another 2 were lost to follow-up. One patient's aneurysm thrombosed at one year follow-up without causing symptoms.

CONCLUSIONS

Brachial artery aneurysm is diagnosed more commonly in male patients and in those who have a history of arterio-venous fistula creation or connective tissue disorder. Surgical repair of true brachial artery aneurysms should be recommended in all symptomatic patients. In asymptomatic patients, surgery was offered in the presence of aneurysms with intraluminal thrombus and diameter larger than 2.5 cm, with low morbidity. The type of repair is dictated by length of the aneurysm and presence of brachial artery redundancy, with patency of 81% at 2.4 years median follow-up.

Hybrid Approach of a Complex Aneurysm of the Subclavian-Axillary-Brachial Axis: A Case Report

BACKGROUND

Upper extremity arterial aneurysms are a rare, potentially limb-threatening disorder. Due to its rarity, the best treatment modality and outcomes are not entirely established; however, there is a consensus that open surgery is the first-line treatment. We present a complex case of an arterial aneurysm of the subclavian-axillary-brachial axis adequately treated using a hybrid surgical and endovascular treatment.

CASE PRESENTATION

A 59-year-old man presented to the emergency department with acute ischemia of the right upper limb. An extensive thrombosed aneurysm of the subclavian-axillary-brachial axis was identified. The treatment was carried out in two stages. In the first phase, urgent limb revascularization was performed using the great saphenous vein to perform a subclavian-brachial artery bypass. Later, the aneurysm was excluded using a vascular plug and multiple coils. Successful treatment was achieved with no morbidity for the patient.

CONCLUSIONS

Although the gold standard for treating upper limb aneurysms is open surgery, endovascular techniques can be a significant adjunct, reducing treatment morbidity and even mortality.

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.

Life-threatening brachial artery hemorrhage and a lethal outcome in patients with neurofibromatosis type 1: two case reports and a review of the literature

Neurofibromatosis type 1 (NF1) is an autosomal dominant disease characterized by neuorocutaneous lesions and multisystem involvement. Other notable features of NF1 include vasculopathy in the form of stenosis, occlusion, aneurysm, pseudoaneurysm, arteriovenous deformity, and rupture, which are difficult to manage and can have fatal outcomes. We describe two cases of extensive and progressive brachial artery hemorrhage following blunt trauma in patients with NF1. Management of these patients included combined endovascular and surgical treatment based on the patients' condition. The patients had a poor prognosis because of uncontrolled bleeding. While one patient died, the other survived, but the involved arm was amputated. Endovascular treatment is a widely used, popular, minimally invasive, and safe method to control the bleeding associated with NF1. However, this treatment can be challenging at times. Close collaboration between an interventional radiologist and surgeon is necessary for optimal treatment and careful follow-up for this condition.

Management of upper extremity aneurysms: a systematic review

INTRODUCTION

The aim of this paper is to provide recommendations for diagnosis and management of arterial or venous aneurysms of the upper extremity.

EVIDENCE ACQUISITION

A systematic review of the Medline and Cockrane databases was performed from 1988 to 2019 by a combined strategy of MeSh terms.

EVIDENCE SYNTHESIS

One-hundred-forty-four publications were identified: 111 addressing arterial aneurysms and 33 addressing venous aneurysms. A total of 162 cases of arterial aneurysms, mostly brachial aneurysms (34.0% of cases) and 40 cases of venous aneurysms, mostly located in the forearm (60.0% of cases) were reported. For both types of aneurysms, most common presentation was the perception of a mass (56.3% for arterial one and 87.5% for venous one), but thromboembolic complication (46.7%), paresthesia (16.5%) or rupture (6.4%) could be observed in the setting of arterial aneurysms, while arm swelling (27.5%), neurological symptoms (12.5%), pulmonary embolism (10.0%) or rupture (2.5%) could occur in the setting of venous aneurysms. DUS was performed as first imaging modality for both settings, followed but CTA and MRA, especially in arterial aneurysms, to evaluate distal emboli and surrounding vasculature. Surgical treatment was mostly based on excision of the aneurysms with revascularization for arterial aneurysms (77.2%) and resection without reconstruction for the venous one (85.0%). Complications occurred in 10.5% of the cases of arterial aneurysms, none occurred after venous aneurysm resection.

CONCLUSIONS

Prompt diagnosis and appropriate preoperative imaging are mandatory in order to offer the best treatment modality. Open resection with revascularization seems to be the treatment of choice for arterial aneurysms, although endovascular procedures became more popular. Venous aneurysms require excision without revascularization.

Successful Repair of a Vasculopathic Aneurysmal Brachial Artery in a Patient with Type 1 Neurofibromatosis

Vasculopathy is a well-recognized abnormality associated with neurofibromatosis type 1(NF1) and may cause stenoses, aneurysms, and arteriovenous malformations. We report a challenging case of a woman with NF1, who presented with spontaneous rupture of a brachial aneurysm around her right elbow, on a background of previous debulking and soft tissue reconstructive surgery in the same arm. She underwent successful delayed reconstruction of the brachial artery using an autologous great saphenous vein graft.

Successful Surgical Reconstruction of a Ruptured Brachial Artery Aneurysm in a Patient With Type 1 Neurofibromatosis

Introduction

The vascular pathology of patients with type 1 neurofibromatosis (NF-1) is known. Aneurysms of the brachial artery in NF-1 patients are rare and surgical treatment remains a challenge.

Report

A patient known to have NF-1 presented with swelling of the left arm. Computed tomography angiography showed a ruptured aneurysm of the brachial artery. Operative reconstruction was performed using reversed saphenous vein.

Discussion

Up to now four cases had been published describing brachial aneurysms in NF-1 patients. This case describes the successful reconstruction of a ruptured brachial aneurysm, using a saphenous vein.

Neurofibromatosis 1 vasculopathy manifesting as a peripheral aneurysm in an adolescent

Arterial vasculopathy is a well-recognized but uncommon manifestation of neurofibromatosis type 1 (NF-1). It can manifest as stenoses, aneurysms or arteriovenous malformations. NF-1 vasculopathy typically involves the aorta, visceral arteries or carotid-vertebral circulation. Aortic and visceral vasculopathy typically presents as stenotic lesions, while aneurysms have been reported primarily in the subclavian/vertebral arteries. Aneurysms of the peripheral/extremity arteries are an extremely rare complication of NF-1 that may present as a mass or spontaneous rupture. We present the case of a teenage boy with an arm mass secondary to an aneurysm. We hope this case will increase recognition of the variable clinical manifestations of NF-1 vasculopathy among radiologists.

[Involvement of peripheral arteries in Von Recklinghausen neurofibromatosis]

Arterial lesions are relatively rare in neurofibromatosis type I but can have potentially serious consequences for the patient. We report two clinical cases of peripheral arterial involvement in neurofibromatosis type 1. The first case was a 25-year-old female with Von Recklinghausen disease who developed a swollen tender mass around her left arm. The arterial CT scan revealed a false aneurysm of the brachial artery. The surgical procedure involved repair of the false aneurysm, and ligation of the brachial artery. Intra- and postoperative bleeding was severe, leading to hemodynamic instability and impaired hemostasis. The patient died on day 2, postoperatively. The second case involved a 17-year-old male with Von Recklinghausen disease who presented stage II arteritis of the right lower limb. Arteriography revealed a long stenosis of the right superficial femoral artery extending to the popliteal artery and an important collateral circulation in the leg arteries. Medical treatment with regular clinical supervision was recommended in this patient.

Multiple serial aneurysms of brachial artery with multiple arteriovenous malformations of forearm

Brachial arterial aneurysm is a rare entity. We present a case of multiple serial aneurysms of the brachial artery with associated multiple arteriovenous malformations of the forearm, along with symptoms of distal ischemia and its surgical management.

Ruptured brachial artery aneurysm in a patient with type 1 neurofibromatosis

Vascular lesions associated with neurofibromatosis type 1 (NF1) are rare but can lead to catastrophic complications if disrupted. Ruptured aneurysms in NF1 patients are difficult to treat surgically because of vascular wall fragility. We describe a female NF1 patient with a ruptured aneurysm of her brachial artery. This is the first published case of successful reconstruction of a ruptured brachial aneurysm associated with NF1, using a saphenous vein graft.