Clinical Research Hand and Wrist Arterial Aneurysms Gloria Esposito, MD, Enrico Maria Marone, MD, Davide De Dominicis, MD, Yamume Tshomba, MD, and Roberto Chiesa, MD, Milan, Italy

Hand and wrist aneurysms are a rare pathology, but recently the number of cases is increasing because of iatrogenic injuries such as catheter placement for endovascular procedures, invasive blood pressure monitoring, and arterial blood collection. In the period between January 1992 and January 2005, seven patients were treated at our institution for hand and wrist aneurysms. Five were true aneurysms and two were false aneurysms. All patients underwent surgery: four had aneurysmectomy and ligation of the arterial stumps and three had lesion removal, with arterial break suture in two cases and reconstruction with interposition of reversed autologous vein in the other case. In all cases, we did not have any postoperative ischemic or neurological complications. Symptoms like pain, paresthesia, and disesthesia combined with the minimal morbidity associated with repair suggest that operative repair of these aneurysms should be routinely performed.

INTRODUCTION

PATIENTS AND METHODS

Upper extremity arterial aneurysms involving palmar arch and radial arteries at the wrist are rare. Several causes of these uncommon lesions are known: atherosclerosis, recreational or occupational trauma, and iatrogenic injury. Actually, iatrogenic radial artery pseudoaneurysms are widely reported following artery cannulation. Most of them are false aneurysms. Surgical treatment is suggested to avoid any possible complication like paresthesia, distal embolization, severe pain (tenderness), cold intolerance, and rupture. Our purpose is to analyze causes, diagnosis, and treatment of patients admitted to our institution with this uncommon pathology.

Between January 1992 and January 2005, seven patients, all male, with a mean age of 60 years (range 23-72), were treated at our institution for an upper extremity aneurysm: five involving palmar arch and two involving radial artery at the wrist. Five were true aneurysms and two were false aneurysms. Etiology was traumatic in six cases: working trauma in four cases (one radial artery aneurysm and three palmar arch aneurysms), puncture by a rose in one case (palmar arch aneurysm), radial artery repetitive cannulation in one. A patient developed a palmar arch aneurysm for unknown reasons. In five cases, the right upper extremity was involved. Clinically, all the patients appeared with a pulsatile mass in the palm or at the wrist, painful in two cases. A patient complained of fifth hand finger paresthesia and disesthesia. All patients were investigated with ultrasonography. We found, in five cases, an aneurysmatic dilatation, partially thrombosed, of the ulnar artery in the palmar arch and of the radial artery at the wrist in two cases. Upper extremity angiography, with transfemoral catheterization, was performed in six cases (Fig. 1).

Department of Vascular Surgery, ‘‘Vita-Salute’’ University, Scientific Institute H. San Raffaele, Milan, Italy. Correspondence to: Enrico Maria Marone, MD, Department of Vascular Surgery, IRCCS H. San Raffaele, Via Olgettina 60, 20132, Milan, Italy, E-mail: [email protected] Ann Vasc Surg 2006; 20: 512-517 DOI: 10.1007/s10016-006-9045-8 Ó Annals of Vascular Surgery Inc. Published online: April 20, 2006 512

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AllenÕs test performed in all patients was negative for ischemia; continuous-wave Doppler did not show flow modification suggestive of low compensation from collateral circulation. All patients underwent surgical operation: five had aneurysmectomy and two had pseudoaneurysm resection. In one patient with pseudoaneurysm of the radial artery at the wrist, the vessel was reconstructed with interposition of a segment of autologous inverted saphenous vein (Fig. 2). In one case of pseudoaneurysm (Fig. 3) and in one case of true aneurysm of the palmar arch, the arterial lesion was repaired by a direct suture. In particular, in the true aneurysm of the palmar arch, we used a temporary intracoronary shunt of 1.8 mm diameter inserted in the artery during direct repair to reduce the risk of arterial occlusion with the suture (Fig. 4). In four cases, the aneurysm was ligated because the arterial stumps were inadequate to make anastomosis after collateral flow ability assessment. Histological finding confirmed five true aneurysms and two pseudoaneurysms.

RESULTS The resection of the aneurysm was successfully performed in all cases, and no perioperative or postoperative complications were recorded. No patients developed distal ischemia or motor neurological deficits. The four patients in whom we performed ligation of the aneurysm without any arterial reconstruction did not have reduction of the distal blood flow or any ischemic complications, as was shown at the preoperative AllenÕs test. Intraoperative angiography performed in one case with reconstruction of the radial artery and in one case with suture of the arterial lesion of the palmar arch pseudoaneurysm showed patency of the treated vessels (Fig. 3). All preoperative symptoms resolved perioperatively except in one patient, in whom we observed the permanence of paresthesia of the IV and V fingers, completely reverted in 2 months. No patients experienced persistence of digital intolerance to cold postoperatively. The mean follow-up, performed only with colorcoded duplex ultrasonography, was 54 months (range 3-156). All patients showed satisfactory hand revascularization, and no one developed pseudoaneurysms of the reconstructed or ligated artery. Fig. 1. A Arteriography showed pseudoaneurysm of the palmar arch. B Preoperative angiography showing a saccular aneurysm of the ulnar artery in the palmar arch.

DISCUSSION Hippocrates made the first description of an upper extremity aneurysm in 460 B.C. In the third cen-

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Fig. 2. Pseudoaneurysm of the radial artery at the wrist (A). Aneurysmectomy and reconstruction with interposition of reversed autologous saphenous vein (B).

tury, Galeno differentiated between traumatic and occupational etiologies for hand and arm aneurysms. Even though these kinds of lesions were known for a long time, Guattani was the first who made an accurate description, in 1772, of an ulnar artery traumatic aneurysm, seen in a coachman who suffered repeated occupational injuries of the hand.1 In the modern age, Middleton,2 Smith,3 and Chapuis et al.4 described several upper extremity aneurysms. Usually, repetitive blunt trauma is the commonest cause of palmar aneurysm. Repetitive trauma related to occupational or recreational activities has been implicated.5 The mechanism of aneurysm formation is considered to be compression of the arterial wall, producing contusion of the media and subsequent weakness of the wall and

c Fig. 3. A Intraoperative image of pseudoaneurysm of the palmar arch. B Pseudoaneurysm resection and direct suture of the arterial lesion with 7/0 polypropylene and Teflon pledget. C Intraoperative angiography showing patency of the palmar arch after pseudoaneurysm resection and arterial repair.

fusiform dilatation.6 Aneurysms most commonly form in sites where the ulnar and radial arteries are less protected by cutaneous and muscular struc-

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Fig. 4. A Intraoperative image of an aneurysm of the palmar arch showing a temporary intracoronary shunt of 1.8 mm diameter inserted in the artery during direct repair to reduce the risk of arterial occlusion with the suture. B Intraoperative image of a true aneurysm of the palmar arch. To obtain adequate bleeding control during the reconstruction, minimizing arterial clamping damage, the proximal bleeding is controlled by manual compression of the ulnar artery at the wrist and the distal bleeding is stopped by insertion of a small occlusion catheter balloon (arrow).

tures; the ulnar artery is at particular risk at the ipotenar eminence because of its superficial location over the hook of the amate. The radial artery is also at risk at the wrist because of its superficial location over the trapezial ridge.7 True aneurysms can also be caused by atherosclerotic, metabolic, and congenital disorders8 and can be associated with diseases such as KawasakiÕs syndrome,9 KaposiÕs sarcoma,10 and cystic adventitial disease.11 The right hand is involved twice more frequently than the left. The reason depends on using the right hand for the majority of patients. Ninety percent of

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patients are men, and this is connected with harsh jobs and recreational activity. False aneurysms are typically the result of penetrating injuries that perforate the vessel wall, causing hemorrhage and pulsatile hematoma. Subsequently, the hematoma is infiltrated by inflammatory cells and fibroblasts. These cells habitually form a thick capsule in 2 or 3 weeks, and the shape is determined by the surrounding structures. Pseudoaneurysms can develop several hours or even months after an injury. Percutaneous arterial cannulation is systematically used in intensive care units for hemodynamic monitoring. Risk factors for occurrence of radial aneurysm after catheterization may include advanced age, long duration of catheterization, hospital duration, and general infection with Staphylococcus aureus.12 In histological findings, true arterial aneurysms contain all elements of the layers of the arterial wall.13 The tunica media is damaged as a result of blunt trauma or repetitive injuries. Gradually, the vessel dilated, assuming a fusiform aspect of the artery. False aneurysms have a saccular appearance, and histological tests show disruption of the vessel layers with absence or discontinuity of elastic fibers.14 Usually, clinical appearance includes a mass growing at the palm or at the wrist. The mass may or may not be pulsatile and looks like other kinds of bulging masses such as neural tumors, muscular fibromas, and dermoid cysts. Diagnosis is suspected when a pulsatile mass arises progressively. Clinical symptoms can include a painful growth on the palm as well as paresthesia and numbness if nerves are compressed. The pain is usually increased by pressure. RaynaudÕs phenomenon may develop as a consequence of microembolisms caused by thrombosis.15 The diagnosis of upper extremity aneurysm is suggested at physical examination. Ultrasonography is generally the first examination to be performed.16 A Doppler scan will assess the flow and color Doppler scan can establish the morphology of the mass and the nature of the blood supply; digital blood flow can also be analyzed. AllenÕs test was performed to assess patency of the vessels and palmar arch function. Arteriography was helpful in five patients on whom it was performed because it gave further information on hand and wrist vascularization. Its need once diagnosis has been made is debated. Commonly, arteriography provides valuable preoperative anatomic details locating the afferent vessels to plan surgery accurately.

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Some authors have reported good results with radionuclide imaging of upper extremity arterial aneurysms.17 Operative interventions have long been the management of choice for upper extremity arterial aneurysms since the first report by Griffith in 1879.18 Rupture is a remote possibility, and morbidity is linked to distal embolization. Because of the symptoms, complications, and minimal morbidity associated with repair, routine surgical treatment should be performed. Type of treatment of hand and wrist aneurysms remains controversial; in fact, it is possible to remove the aneurysm and ligate or reconstruct the artery. Ligature without reconstruction is possible when the collateral circulation is adequate. Gage19 recommend delaying surgery after diagnosis for at least 2-3 months to allow an adequate collateral circulation to develop. Instead, Spittel20 proposes immediate surgery to obviate the risk of complications such as rupture, nerve damage, or distal embolization. About the technique, some surgeons suggest resecting the aneurysm and reconstructing the blood vessels with an end-to-end suture.21 In these procedures, to obtain adequate bleeding control during the reconstruction, minimizing arterial clamping damage, we found it helpful to control the proximal bleeding with manual compression of the artery at the wrist and the distal bleeding with insertion of a small occlusion catheter balloon (Fig. 4B). We also found it helpful to use temporary intracoronary shunts inserted in the artery to reduce the risk of arterial occlusion with the suture. Alternatively, in cases of more extensive arterial lesions, bypass with interposition of inverted autologous saphenous vein or synthetic graft has been reported.21 A few experiments have been made using tiny grafts in synthetic materials (expanded polytetrafluoroethylene) 4 mm in diameter with encouraging results.21 It is useful to remember that if angiography shows a good distal perfusion and AllenÕs test is negative, ischemic damage is highly unlikely. In our patients, good vascularization revealed by color-coded duplex ultrasonography, AllenÕs test, and arteriography allowed us to ligate the afferent and efferent arteries without consequences. Our decision to reconstruct the artery was taken intraoperatively, only when the favorable anatomy allowed us to perform a safe, fast, handy, and inexpensive repair such as a direct suture (two cases). Our experience confirmed that, in more complex cases, if the preoperative AllenÕs test is negative, usually a ligature may be performed safely and should be the first choice. In one case of

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our series, in an extensive pseudoaneurysm of the radial artery, aneurysmectomy was exceptionally followed by a reconstruction with interposition of reversed autologous saphenous vein because of the occupational requirements of the patient (piano player). The role of alternative techniques of repair, such as endovascular procedures or percutaneous occlusion by means of fibrin adhesive injection described for distal aneurysms of the lower limb,22,23 has to be assessed in the upper extremities. However, these techniques are related to an increased risk of peripheral ischemia and, in our opinion, are not adequate in cases so easy to approach with open surgery.

CONCLUSIONS Upper extremity aneurysm is a rare pathology. Iatrogenic injuries, such as catheter placement and arterial blood collection, are important interventions in hospitalized patients. Recently, the number of cases is increasing also because of the increased number of radial access for diagnostic and endovascular procedures. Radial percutaneous access provides a more direct approach; it is clinically safe and could become an attractive alternative access site for patients at high risk for bleeding complications. On the other hand, ulnar or radial true aneurysms are usually due also to direct or repetitive blows to the vessels, as in occupational or recreational traumas. Surgery is the treatment of choice for hand and forearm aneurysms. Complete diagnostic assessment is important before planning surgery in order to achieve good results. AllenÕs test is an essential part of the physical examination, to assess the vascular supply to the hand. REFERENCES 1. Guattani C. De extremis aneurismatibus manu chirurgica methodice penetrandis. Rome, 1772. Erichsen JE (trans). London: Syndenham Society, 1844, 268 pp. 2. Middleton DS. Occupational aneurysms of the palmar arteries. Br J Surg 1933;21:215. 3. Smith JW. True aneurysms of traumatic origin in the palm. Am J Surg 1962;104:7-11. 4. Chapuis Y, Barrat J, Charron E. Aneurysmes arteriels de la paume de la mains. Chirurgie 1976;102:447-457. 5. Clark ET, Mass DP, Bassiouny HS, Zarins CK, Gevertz BL. True aneurysmal disease in the hand and upper extremity. Ann Vasc Surg 1991;5:271-285. 6. Ho PK, Weiland AJ, McClinton MA, Wilgis EFS. Aneurysms of the upper extremity. J Hand Surg [Am.] 1987;12:19-46. 7. Kleinert HE, Buyet GC, Morgan JA, Kutz JE, Atasay E. Aneurysms of the hand. Arch Surg 1973;106:554-557. 8. Malt S. An atherosclerotic aneurysm of the hand. Arch Surg 1978;113:762-763.

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9. Nitsure MY, Hiremath MS, Grant PK, Galati MR, Wadia RS. Kawasaki syndrome with multiple arterial aneurysms. Indian Pediatr 1988;25:881-888. 10. Baxt S, Mori K, Hoffman S. Aneurysm of the hand secondary to KaposiÕs sarcoma. J Bone Joint Surg Am 1975; 57:995-997. 11. Durham JR, McIntyre KE. Adventitial cyst disease of the radial artery. J Cardiovasc Surg 1989;30:517-520. 12. Jayle C, Corbi P, Lanquetot H, Godet C, Menu P. Radial artery aneurysm: an unusual complication of catheterisation. Ann Chir 2002;127:631-633. 13. Smith JW. True aneurysms of traumatic origin in the palm. Am J Surg 1962;104:7-13. 14. Kleinert HE, Burget GC, Morgan JA. Aneurysms of the hand. Arch Surg 1973;106:554. 15. Kerr CD, Duffey TP. Traumatic false aneurysm of the radial artery. J Trauma 1988;28:1603-1604. 16. Dooley TW, Welsh CF, Puckett CL. Noninvasive assessment of microvessels with the duplex scanner. J Hand Surg [Am.] 1989;14:670-673.

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17. Maurer AH, Holder LE, Espinols DA, Rupani HD, Wilgis EF. Three phase radionuclide scintigraphy of the hand. Radiology 1983;146:761-775. 18. Carniero RDS. Aneurysms of the wrist. Plast Surg 1974;54:482-489. 19. Gage M. Traumatic arterial aneurysms of the peripheral arteries. Am J Surg 1943;59:210–231. 20. Spittel JA. Aneurysms of the hand and wrist. Med Clin North Am 1958;42:1007-1010. 21. Lanzetta M, Fox U. Aneurysms of the palmar arch and proper digital artery: case report and literature review. J Reconstr Microsurg 1992;59:210-231. 22. Corso R, Carrafiello G, Intotero M, Solcia M. Large iatrogenic pseudoaneurysm of the posterior tibial artery treated with sonographically guided thrombin injection. AJR Am J Roentgenol 2003;180:1479-1480. 23. Schneider PA, Abcarian PW, Leduc JR, Ogawa DY. Stentgraft repair of mycotic superficial femoral artery aneurysm using a Palmaz stent and autologous saphenous vein. Ann Vasc Surg 1998;12:282-285.