Idiopathic radial artery aneurysm: case report

Meira Jr., Luiz Ernani; Gouvêa, Thalis Marcelo; Macedo, Thiago Jardim de

doi:10.1590/S1677-54492011000400011

Abstracts

Radial artery aneurysms are extremely rare. Post-traumatic pseudoaneurysms are the vast majority. True radial artery aneurysms can be idiopathic, congenital, poststenotic, or associated with some pathologies, such as vasculitis and conjunctive tissue diseases. We report a case of an idiopathic aneurysm of the radial artery in a three-year-old child who was submitted to surgical resection after a complete diagnostic approach.

aneurysm; radial artery; child

Os aneurismas da artéria radial são extremamente raros. Em sua maioria, consistem de pseudoaneurismas pós-traumáticos. Os aneurismas da artéria radial verdadeiros podem ser idiopáticos, congênitos, pós-estenóticos ou associados a patologias, tais como vasculites e doenças do tecido conjuntivo. Foi relatado um caso de aneurisma idiopático de artéria radial em uma criança de três anos, que, após completa investigação diagnóstica complementar, foi submetida à ressecção cirúrgica.

aneurisma; artéria radial; criança

CASE REPORT

^IVascular and Endovascular Surgeon at the Hospital Regional João Penido from FHEMIG - Juiz de Fora (MG), Brazil

^IIAttending Medicine at Universidade Presidente Antônio Carlos (UNIPAC) - Juiz de Fora (MG), Brazil

Correspondence

ABSTRACT

Radial artery aneurysms are extremely rare. Post-traumatic pseudoaneurysms are the vast majority. True radial artery aneurysms can be idiopathic, congenital, poststenotic, or associated with some pathologies, such as vasculitis and conjunctive tissue diseases. We report a case of an idiopathic aneurysm of the radial artery in a three-year-old child who was submitted to surgical resection after a complete diagnostic approach.

Keywords: aneurysm; radial artery; child.

Introduction

The upper limbs are considered less vulnerable to arterial diseases, especially those of aneurysmatic nature. Due to their low incidence, such aneurysms are diagnostic and therapeutic challenges. In this area, the arteries most frequently affected by the aneurysmatic process are, in decreasing order: subclavian, brachial, ulnar and radial arteries^1,2.

Radial artery aneurysms are mostly pseudoaneurysms associated with iatrogenic conditions resulting from invasive procedures for endovascular diagnosis and/or therapy, invasive monitoring of mean arterial pressure and repeated punctures in the intensive care unit or in drug users. Blunt traumas are another cause of radial artery pseudoaneurysms, especially those related to fracture with vascular injury, as well as penetrating traumas caused by cold weapon³.

In contrast, the main cause of true aneurysms in arteries of the upper limbs, below the axillary artery and specifically the radial artery, is repeated blunt trauma, which is followed by idiopathic causes, atherosclerosis, metabolic and congenital diseases or associated with disorders such as neurofibromatosis and vasculitis such as Buerger's disease, Kawasaki's disease, Bechet's disease and polyarteritis nodosa⁴. Aneurysmatic formations have also been reported, associated with arteriovenous fistulas created for hemodialysis, poststenotic dilatations, one case related to hemophilia A and one case related to severe anemia^4-9.

The purpose of this study is to present the case report of a three-year-old child with true idiopathic radial aneurysm.

Case description

A healthy three-year-old male patient, no history of comorbidities. According to the mother, pre-natal period without occurrences, normal delivery, proper vaccination and no history of admissions, traumas or surgical interventions.

Around two months ago, a pulsatile nodular injury was observed, in middle third, anterior face of the right forearm. The arterial echo Doppler exam was performed in the right upper limb, and radial artery aneurism was identified (Figure 1).

The patient was sent to the Vascular Surgery Service of Hospital Regional Dr. João Penido, Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), in the city of Juiz de Fora, Minas Gerais, in May 2009. The patient complained of pain on palpation and reported mild intermittent swelling in the right hand and did not present any ischemic sign, neurological alteration or local or systemic infectious sign. In addition, the patient did not have history of trauma or invasive procedure in the right upper limb. The Allen's test result was bilaterally negative.

The diagnosis of vasculitis or metabolic diseases was ruled out, based on clinical and laboratorial exams. The patient was sent to imaging propedeutics, and the following exams were performed: abdominal ultrasound, lower extremity ultrasound, transthoracic echocardiogram, multislice helical angiotomography of upper limbs, aortic arch and great vases, from thoracic and abdominal aorta to femoral vessels. No other aneurysmatic lesions were identified besides the focal dilatation of proximal right radial artery, with the largest diameter of 1.1 cm and 1.5 cm length. The aneurysm started around 2.0 cm from the origin of radial artery, which had 0.33 cm proximal diameter, distal to the dilatation (Figures 2a and 2b).

The patient was then submitted to aneurysm resection. The selected procedure was radial artery ligature, due to a satisfactory reflux from the distal stump, reduced arterial caliber and the resected segment length (around 3 cm). The surgical specimen was sent for anatomopathological and culture exam. The histological exam showed arterial vessel wall with all layers and negative culture for infectious agents (Figures 3 and 4).

The procedure included a 30-day follow-up and the patient presented good post-operative progress, with no ischemic or neurological deficit.

Discussion

The true radial artery aneurysm is a diagnostic and therapeutic challenge. The diagnosis is defined through complaint and physical examination. The main manifestation is local pain, followed by symptoms and signs of distal ischemia, secondary to episodes of thrombosis or distal microembolization. Symptoms resulting from the compression process are also described, such as hand swelling and neurological symptoms, such as paresthesias^5,9. Rupture is not described in any published series. Aneurysms can be asymptomatic and are presented only as a pulsatile mass, with fremitus and blow in the physical exam. The differential diagnosis includes synovial cyst, ganglions, lipomas and neuromas. In a case of radial artery aneurysm, complete anamnesis and rigorous physical examination are essential. After traumatic or iatrogenic events are ruled out, the rare causes of true aneurysms should be investigated. For such purpose, laboratorial and imaging exams should be performed, as well as investigations for collagenosis, vasculitis and metabolic diseases, before considering the lesion is congenital or idiopathic. Imaging propedeutics includes echo Doppler exam, abdominal ultrasound, echocardiogram, angiotomography, angioresonance and arteriography^3,4,10.

The echo Doppler exam is used not only for the diagnosis, but also to assess the hand circulation, always combined with the Allen's test. The echocardiogram can be useful while assessing children to rule out coronary artery aneurysms, such as in Kawasaki's disease cases. Today, angiotomography has replaced the golden standard arteriography in the diagnosis of other associated lesions and surgical planning, providing a better evaluation of the aneurysm, the proximal and distal bed to the lesion. Children with peripheral aneurysm should be submitted to pan-computed angiotomography before any treatment is started¹⁰.

The treatment of radial artery aneurysms is still controversial; it is dependent on the etiology, location, presence of thrombi, associated symptoms and mainly the circulation status collaterally and distally to the lesion. The surgical options range from proximal and distal ligature of the vessel combined with the aneurysmatic sac resection to revascularization procedures, with termino-terminal primary anastomosis or bypass with venous graft^10-12. There is no definition regarding the clinical follow-up without any surgical treatment; therefore, due to the risk of thrombotic and microembolic complications that can lead to distal ischemia, the surgical correction of aneurysm is always indicated.

References

1. De Luccia N. Aneurismas nos Membros Superiores. In: Leão PP, Kauffman P (org.). Aneurismas Arteriais. São Paulo: Fundo Editorial Bik; 1998. v.1.
2. Brito CJ, Azevedo Jr AC, Silva RM. Aneurismas dos membros superiores. In: Brito CJ. Cirurgia Vascular: Cirurgia Endovascular, Angiologia. São Paulo: Revinter; 2008; p. 605-8.
3. Santos ACB, Oliveira FM, Oliveira JG, Bolanho E, Roberti T, Mathias UUM, et al. Aneurisma idiopático de artéria radial na região da tabaqueira anatômica: relato de caso. J Vasc Bras. 2008;7(4):380-3.
4. Yaghoubian A, Virgílio C. Noniatrogenic Aneurysm of Distal Radial Artery: A case report. Ann Vasc Surg. 2006;20:784-6.
5. Walton NP, Choudhary F. Idiophatic radial artery aneurysm in anatomical snuff box. Acta Orthop Belg. 2002;68(3):292-4.
6. Filis K, Arhontovassilis F, Theodorou D, Theodossiades G, Manouras A. True radial artery aneurysm in a mild haemophilia A patient. Haemophilia. 2007;13(4):440-2.
7. Grey AC, Vallelly SR. Spontaneous false aneurysm of the radial artery in neurofibromatosis. Clin Radiol. 1999;54(3):185-6.
8. Singh S, Riaz M, Wilmshurst AD, Small JO. Radial artery aneurysm in a case of neurofibromatosis. Brit J Plast Surg. 1998;51:564-5.
9. Hattori N, Furuta Y, The radial artery aneurysm within the anatomical snuff box. J Vasc Surg. 2004;13:597-601.
10. Pagès ON, Alicchio F, Keren B, Diallo S, Lefebvre F, Valla JS, et al Management of brachial artery aneurisms in infants. Pediatr Surg Int. 2008;24:509-13.
11. Gray RJ, Stone WM, Fowl RJ, Cherry KJ, Bower TC. Management of true aneurysms distal to the axillary artery. J Vasc Surg. 1998;28(4):606-10.
12. Miura S, Kigawa I, Miyari T, Fukuda, S. A surgically treated case of true radial aneurysm in the anatomical snuff box. J Vasc Surg. 2004;13:687-90.