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Jornal Vascular Brasileiro

Print version ISSN 1677-5449On-line version ISSN 1677-7301

J. vasc. bras. vol.6 no.1 Porto Alegre Mar. 2007

http://dx.doi.org/10.1590/S1677-54492007000100010 

CASE REPORT

 

Lateral thoracic artery pseudoaneurysm due to blunt chest trauma

 

 

Artur José Rocha–LimaI; Marcus Vinícius MarquesII; Cláudio GabrieleIII

IVascular surgeon. Specialist in Angiology and Vascular Surgery, SBACV. Vascular ultrasonographer, Certificate in Vascular Doppler Ultrasonography, SBACV/CBR. Head, Vascular Surgery Service, Hospital de Base de Bauru, Bauru, SP, Brazil. Member, SBACV
IIVascular surgeon, Hospital de Base de Bauru, Bauru, SP, Brazil
IIIVascular surgeon. Specialist in Angiology and Vascular Surgery, SBACV. Hospital de Base de Bauru, Bauru, SP, Brazil

Correspondence

 

 


ABSTRACT

Pseudoaneurysm, or false aneurysm, is a clinical entity caused by arterial wall rupture, with blood extravasation contained by neighboring tissues. We report a case of a 64–year–old female patient, who was referred due to a rare right lateral thoracic artery lesion leading to pseudoaneurysm secondary to blunt trauma. The authors did not find a similar case in the literature.

Keywords: Pseudoaneurysm, surgery, complications, aneurysm, artery.


 

 

Introduction

Pseudoaneurysm, or false aneurysm, is a clinical entity caused by rupture of the arterial wall, with blood extravasation contained by neighboring tissues,1 or also described as the result of organization of the hematoma communicating with the arterial lumen.2 Penetrating bullet and knife wounds are the usual mechanism in most urban centers in Brazil and in the world, but iatrogenic etiology has been frequent.3 It often occurs in association with arterial catheterization procedures or other types of vascular trauma. The most frequently involved arteries in the formation of pseudoaneurysms are the humeral and femoral arteries.4 The authors report a case of blunt trauma, with lesion of the right lateral thoracic lesion leading to pseudoaneurysm, which apparently has no similar in the literature.

 

Case presentation

A 64–year–old female had fall from height on a stone when she was walking along an irregular path, suffering blunt chest trauma to the right. In the first assessment, fracture of costal archs was discarded, and the patient was discharged. She was followed for 3 months with pain in the right hemithorax, reduced strength in the right upper limb and progressive appearance of axillary mass when she was transferred to our service.

On clinical examination, she presented a large 15–cm, violet–colored mass located in the axillary and anterolateral region of the right hemithorax, with the following characteristics: nonpulsatile, increased temperature at the mass region, painful on palpation, hardened, with no murmur nor thrill, with paresis of the right upper limb and hemodynamically stable.

Ultrasound examination showed tumor with solid and cystic content and flow turbulence with image suggesting pseudoaneurysm. Arteriography is the examination that offers the best results, but it presents inconveniences and higher morbidity and mortality rates in traumatized patients.3 Digital arteriography revealed contrast extravasation at the axillary–humeral transition, with no accurate definition of the artery involved (Figure 1).

 

 

We chose the surgical treatment under general anesthesia. Proximal control was performed by dissecting the subclavian artery, and distal control by the distal humeral artery (Figure 2). At the axillary region, a direct approach of the tumor was performed, with incision on the tumoral mass, which showed organized thrombus in the periphery and more recent thrombus with liquefied hematoma in the central area (Figure 3), occupying the axillary fossa, compressing vessels and other local anatomical structures. The pseudoaneurysm had no origin in the axillary or subclavian arteries, but in the lateral thoracic artery, after a 0.5 cm laceration. This artery went longitudinally along the costal groove. The lesion was repaired using a polypropylene 6–0 separate–stitch suture. There was no involvement of vessels and nerves in this region. Absence of distal pulses was due to local compression caused by the tumoral mass.

 

 

 

 

The result of the surgery was satisfactory, obtaining the restoration of blood perfusion and return of humeral, radial and ulnar pulses. However, there was improvement in paresis.

 

Discussion

Axillary artery lesion is unusual in the general population4 and, when it occurs, it is usually caused by penetrating trauma. No case was found in which the origin of the pseudoaneurysm was the lateral thoracic artery.

Untreated pseudoaneurysm may lead to major complications, such as compression of neighboring structures, hemorrhage and infection. When there is delay in suspecting the lesion and also in the treatment of lesions affecting subclavian and axillary arteries, there may be compression of the humeral plexus,5 with consequent neurological sequelae, and may evolve with significant and permanent neurological deficit.5 Lesions associated with the brachial plexus are found in 35% of cases and present significant long–term morbidity.6 Venous involvement in this region is possible due to proximity of other structures. Knowing the anatomy of this anatomical region is very important to suspect vascular lesion.

Due to the fact that some cases do not initially present signs and symptoms, some authors4 support the need of performing arteriography in all patients with penetrating wound near subclavian and axillary vessels, even if there are no signs of arterial insufficiency. Ultrasound examination has the advantage of being noninvasive and available, but also the limitation of being examiner–dependent and of not reaching the whole local arterial extension, because some vessels pass under the bone. A diagnostic possibility is arteriography by retrograde injection through humeral artery, which is an easy, fast and ideal examination for situations of vascular trauma in that region.7 In our case, there was no humeral pulse, which made this specific form of diagnosis impossible. The fact that examinations such as ultrasound and arteriography did not perform an accurate diagnosis of the affected artery was due to the difficulty in precisely identifying all the arteries in this thoracic region, which, besides the lateral thoracic artery, presents other arteries nearby, such as the thoracodorsal and subscapular artery, which have a more posterior course.

Lesions caused by penetrating trauma in this region are often associated with lesions of the brachial plexus. In closed trauma, the most frequent association is with lesions of the brachial plexus and with fracture of clavicle and/or first rib. These lesion associations should raise a high suspicion level of subclavian artery lesion. In anterior luxation of the shoulder or in fracture of the humeral neck, axillary artery lesion should be considered. Due to extensive collateral circulation in the shoulder, many complex vascular lesions may go unnoticed, due to absence of ischemia or minimal pulse alteration.8

Arteriographic assessment is crucial, in asymptomatic cases and in those with signs of ischemia and hematoma in the supraclavicular or low cervical region, but it is not always effective, as in this case, in which arteriography did not diagnose the affected artery. It is possible that other diagnostic methods, such as angiographic resonance or tomographic angiography, are more sensitive, but we did not find reports in the literature using those methods in similar cases.

The definition of the true affected artery was only possible after detailed study of the region anatomy during the surgery, since only the lateral thoracic artery presents close proximity with costal groove.

This case is peculiar due to the type of trauma and involvement of the lateral thoracic artery. There is no similar report in the literature.

 

Acknowledgement

We thank Prof. Dr. Winston Bonetti Yoshida for his technical and scientific support to the publication of this paper.

 

References

1. Miyamotto M, Moreira RCR, Erzinger FL, França GJ, Cunha AGP. Pseudo-aneurisma idiopático da artéria poplítea. J Vasc Bras. 2004;3:169-72.         [ Links ]

2. Burihan E. Traumatismos vasculares. In: Maffei FHA, ed. Doenças vasculares periféricas. Rio de Janeiro: Medsi; 1995. p. 1127-42.         [ Links ]

3. Medeiros CAF, Landim RM, Castro AM, et al. Condutas no trauma penetrante da artéria axilar. J Vasc Bras. 2003;2:225-8.         [ Links ]

4. Mariné L, Mertens R, Valdes F, Kramer A. Pseudoaneurysm of the braquiocefalic trunk and bullet trauma. J Vasc Bras. 2005;4:169-73.         [ Links ]

5. McCready RA, Procter CD, Hyde GL. Subclavian-axillary vascular trauma. J Vasc Surg. 1986;3:24-31.         [ Links ]

6. Raju S, Carner DV. Brachial plexus compression: complication of delayed recognition of arterial injuries of the shoulder girdle. Arch Surg. 1981;116:175-8.         [ Links ]

7. Graham JM, Mattox KL, Feliciano DV, DeBakey ME. Vascular injuries of the axilla. Ann Surg. 1982;195:232-8.         [ Links ]

8. Aerts N, Lopes H, Kiss E, Paiva HD. Arteriografia retrograda no diagnóstico de trauma vascular no segmento subclávio-axilar. Cir Vasc Angiol. 2001;17(Supl 5):S105.        [ Links ]

 

 

Correspondence:
Artur José Rocha–Lima
Rua João Croce, 4/85, Jardim Shangri–lá
CEP 17054–638 – Bauru, SP, Brazil
Tel.:(14) 3214.4747, (14) 8122.7172
Fax:(14) 3227.8786
Email: arochalima@gmail.com

Manuscript received August 10, 2006, accepted September 27, 2006.

 

 

This case report was presented at VIII Pan American Congress on Vascular and Endovascular Surgery.

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