Emergency (****); * (*): *-* This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2015 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 75 Emergency (2015); 3 (2): 75-77 CASE REPORT Brachial Artery Aneurysm as a Limb Threatening Condition; a Case Report Farhad Heydari, Mehrsa Taheri*, Mehrdad Esmailian 1Department of Emergency Medicine, Al-Zahra Hospital, Isfahan University of Medical Sciences, Isfahan, Iran. *Corresponding Author: Mehrsa Taheri: Department of Emergency Medicine, Al-Zahra Hospital, Soffeh Blvd, Isfahan, Iran Tel: 989133172474 Ext 2082; Email: mehrsa_taheri@yahoo.com Received: October 2014; Accepted: November 2014 Abstract Brachial artery aneurysms are rare but potentially limb threatening condition. The presented case here is a 52 - year old male referred to the emergency department complaining a sudden onset and progressive pain with cold- ness of his right upper extremity during brushing. The right upper extremity was pulseless and three-dimensional computed tomography showed an aneurysm of the proximal right brachial artery associated with arterial occlusion in its distal branch. Embolectomy was done, the aneurysm resected, and the artery successfully revascularised by interposing a saphenous vein graft. Key words: Brachial artery; aneurysm, dissecting; peripheral arterial disease; vascular grafting; limb salvage Cite this article as: Heydari F, Taheri M, Esmailian M. Brachial artery aneurysm as a limb threatening condition; a case report. Emergency. 2015;3(2):75-7. Introduction: ocalized balloon-like bulge in an artery wall is called aneurysm that classified as true, pseudo, and mycotic types. True aneurysm is the local- ized dilation involving all three layers (intima, media, and adventitia) of the arterial wall, but a false type o r pseudoaneurysm is a collection of flowing blood that communicates with the arterial lumen and is filled only by the adventitia or surrounding soft tissue (1). Aneurysms can manifest in all arteries but peripheral artery aneurysms in the upper extremities are rare so that brachial artery aneurysms have an overall preva- lence of 0.5% (2-4). Also, mycotic and post-traumatic are more common than true aneurysm (3, 5). There are few reports in this regard and the following presentation described a patient referred to the emer- gency department (ED) with signs and symptoms of arterial insufficiency and final diagnosis of brachial artery aneurysm. Case Report: A 52-year-old male referred to the ED with complaining of sudden onset and progressive pain with coldness of his right upper extremity when he was brushing. The subject had no other complaint such as chest pain, palpi- tation, or shortness of breathing. He had no history of trauma, injection, dialysis, arteriography, intravenous drug abuse, or surgery in his right upper extremity. The patient’s history was negative regarding hypertension, ischemic heart diseases, diabetes mellitus, hyper- lipidemia, etc. On physical examination, he had a swell- ing on his right axilla without pigmentation. Palpation revealed a 2 × 2.5 centimetre pulsatile, compressible mass with no tenderness and the temperature equal to the surrounding skin. Supraclavicular and axillary lymph nodes were not bilaterally palpable. Pulse of the axillary artery was palpable, but brachial and radial arteries were pulseless. The capillary refill time was in normal range and sensory and motor functions were intact. Car- diac examination revealed no murmurs, lungs sounded clear, and abdomen was soft with no tenderness. The re- mainder of the systemic examination was unremarkable. Paraclinic investigation showed 6800/mm3 white blood cell (WBC) count , 14gram/decilitre haemoglobin level, 13 millimetres/hour erythrocyte sedimentation rate (ESR), 13 seconds Prothrombin time (PT), and 33 sec- onds partial thromboplastin time (PTT). Color Doppler ultrasonography of right upper extremity arteries showed an anechoic, pulsatile, 25 × 22 millimetres mass with turbulent flow seen along the brachial artery. Com- puted tomoangiography showed an aneurysm of the proximal right brachial artery associated with arterial occlusion in distal radial branch (Figures 1 and 2). Em- bolectomy was done, the aneurysm resected, and the brachial artery successfully re-vascularised by interpos- ing a saphenous vein graft. The resected aneurysm dis- played a true aneurismal sac filled with internal throm- bus. Finally, the patient was discharged, under warfarin anticoagulation therapy, without any complication on the fifth days after surgery. L This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2015 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com Heydari et al 76 Figure 1: Computed tomoangiography of the proximal right bra- chial artery (axial cuts). Figure 2: Three-dimensional computed tomoangiography of the proximal right brachial artery, white arrow shows the location of aneurysm. Discussion: The usual manifestation of peripheral aneurism is inci- dentally finding of a pulsatile, painless and asympto- matic mass, which becomes symptomatic when compli- cations arise. Thrombosis in the sac, vascular collapse which throws emboli into peripheral circulation, and also disruption caused the profuse bleeding are among these complications (5). Atherosclerotic aneurysms, which commonly develop in advanced ages, are often seen in large arteries, while pseudoaneurysm may be ob- served in any location and age. Aneurysms are generally revealed in infrequent locations due to Marfan’s syn- drome, syphilis, and major trauma. Familial history of aneurysm, connective tissue disorders, and atheroscle- rotic risk factors (hypertension, hyperlipidemia, smok- ing, and age) are considered as it’s risk factors (1, 4, 6). Without proper management, hemorrhage, extremity venous edema, cutaneous erosion, and especially adja- cent neurological structure compression can develop due to enlargement of the aneurysm. The first symptom of upper extremity aneurysms can be nerve injury due to adjacent nerve compression (2). Prompt diagnosis and treatment of true peripheral artery aneurysms are nec- essary to minimize the complication rate and serious long-term squeal (7, 8). Differential diagnosis include pulsating tumours (such as bone sarcoma, osteoclas- toma), arterio-venous malformation, lymphadenopathy, lipoma, hematoma, and abscess. The diagnosis should be confirmed by a duplex ultrasonography, show the arte- rial blood flow into the aneurysm. Computed tomogra- phy or magnetic resonance angiography can also be used for diagnosis (9). In spite of all above-mentioned, the gold standard tool is a selective upper extremity arteri- ography. However, the first choices in investigation are often color Doppler ultrasonography and subtraction image angiography (2). The defect in the artery is usually small and easily identified by a transient release of the proximal clamp (5). Close observation, thrombin injec- tion, ultrasound-guided compression, and operative re- pair are treatment options. Conclusion: Aneurysms of the brachial artery are not common, but could be potentially limb threatening. Prompt diagnosis and proper treatment may prevent from irreversible squeal. The best therapeutic option is immediate opera- tive repair. Acknowledgments: The authors appreciate the insightful cooperation of staffs of the Emergency Department of Al-Zahra Hospi- tal. Conflict of interest: None Funding support: None This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Copyright © 2015 Shahid Beheshti University of Medical Sciences. All rights reserved. Downloaded from: www.jemerg.com 77 Emergency (2014); 3 (2): 75-77 Authors’ contributions: All authors passed four criteria for authorship contribu- tion based on recommendations of the International Committee of Medical Journal Editors. References: 1. Hall HA, Minc S, Babrowski T. Peripheral artery aneurysm. Surgical Clinics of North America. 2013;93(4):911-23. 2. Yetkin U, Gurbuz A. Post-traumatic pseudoaneurysm of the brachial artery and its surgical treatment. 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