Idiopathic radial aneurysm in the anatomical snuffbox: case report

CASE REPORT

Idiopathic radial aneurysm in the anatomical snuffbox: case report

Aline Cristine Barbosa Santos^I; Fabrício Mascarenhas de Oliveira^I; José Guilherme de Oliveira^II; Edgard Bolanho^II; Tasso Roberti^II; Ulisses Ubaldo Matosinho Mathias^II; Regina de Faria Bittencourt da Costa^III; Nelson Fernandes Júnior^IV

^IFormer resident, Vascular Surgery Service, Hospital Heliópolis, São Paulo, SP, Brazil.

^IIAssistant physician, Vascular Surgery Service, Hospital Heliópolis, São Paulo, SP, Brazil.

^IIIPhD, Universidade Federal de São Paulo – Escola Paulista de Medicina (UNIFESP-EPM), São Paulo, SP, Brazil. Director, Surgical Clinics, Hospital Heliópolis, São Paulo, SP, Brazil. Assistant physician, Vascular Surgery Service, Hospital Heliópolis, São Paulo, SP, Brazil. Member, SBACV.

^IVHead, Vascular Surgery Service, Hospital Heliópolis, São Paulo, SP, Brazil. Specialist, Angiology and Vascular Surgery, Conselho Federal de Medicina. Specialist, Angiographic Radiology and Endovascular Surgery, Sociedade Brasileira de Radiologia Intervencionista e Cirurgia Endovascular – Colégio Brasileiro de Radiologia (SoBRICE-CBR).

ABSTRACT

We report a case of a 73-year-old female, laundress/farmer, hypertensive, with symptomatic pulsatile lump of 1.5 x 0.5 cm at the right anatomical snuffbox of the right hand, with slow and progressive growth and local pain in the past 10 years. The patient presented no neurological symptoms, cyanosis, infection or local trauma history. Allen’s test was negative, and color Doppler ultrasound confirmed presence of radial artery aneurysm in the anatomical snuffbox. Surgical treatment via aneurysmectomy of radial artery in the snuffbox with proximal and distal ligation was carried out. She had good operative course with no signs of digital ischemia. Histopathological test confirmed diagnosis of arterial wall (true aneurysm). She remains asymptomatic in outpatient follow-up. There is no definition as to which aneurysms distal to the axillary artery could be followed without a surgical procedure. As the patients had normal Allen’s test and local pain, proximal and distal ligation was chosen and had good outcome.

Keywords: Aneurysm, idiopathic, radial artery, hand.

RESUMO

Paciente do sexo feminino, 73 anos, negra, lavadeira/lavradora, hipertensa, apresentava tumor pulsátil de 1,5 x 0,5 cm em região de tabaqueira anatômica da mão direita há 10 anos, de crescimento lento e progressivo, associado a dor local. Não apresentava alterações neurológicas, cianose de extremidades, sinais de infecção ou trauma local. O teste de Allen resultou negativo, e o Eco-Doppler colorido demonstrou aneurisma de artéria radial na tabaqueira anatômica. Procedeu-se a aneurismectomia de artéria radial na tabaqueira anatômica com ligadura dupla proximal e distal. Houve boa evolução operatória, sem sinais de isquemia digital. O exame anatomopatológico confirmou diagnóstico de parede arterial (aneurisma verdadeiro). O paciente encontra-se em acompanhamento ambulatorial, no momento assintomático. Não há definição de quais aneurismas distais à artéria axilar possam ser acompanhados sem conduta cirúrgica. Como a paciente, neste caso, apresentava teste de Allen normal e dor local, optou-se pela ligadura proximal e distal, com bom resultado.

Palavras-chave: Aneurisma, idiopático, artéria radial, mão.

Introduction

Radial artery true aneurysms are extremely rare, especially when located at the hand.^1,2 The main cause of true aneurysms in upper limb arteries, below the axillary artery, is repetitive blunt trauma,³ followed by idiopathic etiology; other causes include atherosclerotic and iatrogenic disease, metabolic and congenital diseases or associated with neurofibromatosis, Buerger's disease, Kaposi's sarcoma or Kawasaki syndrome.^1,4,5 Arterial aneurysms of the upper limbs rarely have rupture, thrombosis and embolism being their main complications.

Treatment of radial artery aneurysms remains controversial and dependent on factors such as collateral circulation, presence of infection, evidence of distal embolization or thrombus in the aneurysmal sac and associated symptoms.^6,7 We report on a case of idiopathic aneurysm of the radial artery in the anatomical snuffbox.

Case description

A 73-year-old black female patient, laundress/farmer, hypertensive, was admitted to the service in July 2006 with pulsatile lump of 1.5 x 0.5 cm at the anatomical snuffbox of the right hand, with slow and progressive growth and local pain in the past 10 years, irradiating to the hand extremity and fingers (Figure 1A).

She had no neurological changes, distal pallor and/or cyanosis, signs of infection and did not report history of local trauma, although her work activities required intensive and repetitive use of her hands. Right and left upper limb pulses were 4+/4+.

Allen's test resulted negative bilaterally. Color Doppler ultrasound of the right upper limb and hand showed aneurysmal dilatation of the radial artery in the anatomical snuffbox of 1.3 x 1.0 x 0.7 cm, without mural thrombi, absence of other proximal or distal vascular changes (Figure 2).

Surgical exploration showed radial artery aneurysm measuring approximately 1.3 x 0.6 cm. Aneurysmectomy and proximal and distal ligation of the artery were chosen (Figure 1B) based on evaluation of hand circulation. The material sent for anatomopathological study (hematoxylin, eosin and Verhoff) was compatible with morphological diagnosis of arterial vessel with all layers (Figure 3).

Immunohistochemistry with smooth muscle-specific antibody was performed, being compatible with the vessel wall. The histological status associated with the immunohistochemical panel confirmed diagnosis of true aneurysm. The patient progressed with no postoperative complications and no signs of distal ischemia. In outpatient follow-up, she had a healed operative wound, unaltered active and passive hand movement, absence of signs of ischemia and pain.

Discussion

Radial artery aneurysms of the hand are extremely rare; upper limb aneurysms are less frequent.^1,2,4 Most of them consist of pseudoaneurysms associated with penetrating or iatrogenic traumas. True and pseudoaneurysms may occur after catheterization for endovascular procedure, invasive monitoring of the blood pressure; their incidence is six per 12,500 procedures and can be associated with infection.^1,2 Other risk factors predisposing to formation of radial artery pseudoaneurysms include old age, abnormal status of the vessel wall (atherosclerosis), multiple attempts of puncture, hematoma and collagen vascular disease.⁴ True aneurysms have been related to atherosclerosis and neurofibromatosis.⁵ The true, idiopathic aneurysm is the rarest.^1-3

Diagnosis of radial artery true aneurysm is suggested by complaint and physical examination. Differential diagnosis includes synovial cyst, ganglion, abscess, neural tumors, and fibromas.⁶ Radial artery aneurysm complications include ischemia and distal embolization, rupture being less frequent.^4,5

Color Doppler ultrasound can be used to diagnose and evaluate not only aneurysms, but also hand circulation; Allen's test can be associated with a dynamic examination.⁷

Arteriography provides preoperative anatomical details for lesions proximal to the forearm, but can be used more selectively for lesions distal to that region.⁶

Treatment of radial artery aneurysms depends on location, evaluation of distal circulation (hand) using arteriography and/or color Doppler ultrasound and intraoperative findings.^6,8

Treatment method is still controversial. Options include simple ligation of the vessel and sac excision, ligation of the main artery maintaining the other forearm vessels intact, primary anastomosis (terminoterminal) and revascularization with venous graft.^4,5,9,10 In this case the patient had no evident history of local trauma; despite her work activity, repetitive strain injury was not characterized; in addition, there was no history of local puncture or catheterization. She had no risk factors for aneurysm formation and no history of vasculopathy. Color Doppler ultrasound showed radial artery aneurysm with no evidence of thrombi or other distal vascular changes. Allen's test did not show any changes. Although the patient did not have embolic phenomena or aneurysm thrombi, resection was chosen due to associated symptomatology and to avoid complications. During surgical exploration, presence of radial artery aneurysm was confirmed, with no digital branches originating from it, and absence of changes in hand perfusion after interruption of arterial flow. Arterial ligation and excision of the aneurysmal sac were performed, with excellent postoperative result.

In the literature there are few cases described as radial artery aneurysm in the anatomical snuffbox; most aneurysms in hand arteries occur in the ulnar artery and are associated with repetitive strain, local trauma.^3-5 In some cases clinical follow-up was performed,^4.5, due to risk of hand and finger ischemia. Surgical repair of the aneurysm (ligation and resection or resection with revascularization) is indicated to prevent this risk.^9,10.

As the patient had normal Allen's test, evaluation of hand circulation by color Doppler ultrasound with no changes and absence of aneurysm thrombi, aneurysmectomy and proximal and distal ligation of the artery were performed, with efficient result. In the preoperative evaluation, imaging examinations did not show aneurysms in other locations or cardiovascular changes. Preoperative and anatomopathological examinations did not show disease etiology, and the lesion was considered a true aneurysm of the radial artery in the anatomical snuffbox of an idiopathic nature.

References

• 1. Brito CJ. Aneurismas arteriais periféricos. In: Maffei FH. Doenças vasculares periféricas. Rio de Janeiro: Medsi; 2002. p. 1149-67.
• 2. Brito CJ, Azevedo Jr. AC, Schulze GC. Aneurismas periféricos. In: Brito CJ. Cirurgia vascular. Rio de Janeiro: Revinter; 2002. p. 534-50.
• 3. Behar JM, Winston JS, Knowles J, Myint F. Radial artery aneurysm resulting from repetitive occupational injury: Tailor"s thumb. Eur J Vasc Endovasc Surg. 2007;34:299-301.
• 4. Yaghoubian A, de Virgilio C. Noniatrogenic aneurysm of the distal radial artery: a case report. Ann Vasc Surg. 2006;20:784-6.
• 5. Walton NP, Choudhary F. Idiopathic radial artery aneurysm in the anatomical snuff box. Acta Orthop Belg. 2002;68:292-4.
• 6. Gray RJ, Stone WM, Fowl RJ, Cherry KJ, Bower TC. Management of true aneurysms distal to the axillary artery. J Vasc Surg. 1998;28:606-10.
• 7. Ruengsakulrach P, Brooks M, Hare DL, Gordon I, Buxton BF. Preoperative assessment of hand circulation by means of Doppler ultrasonography and the modified Allen test. J Thorac Cardiovasc Surg. 2001;121:526-31.
• 8. Al-Omran M. True ulnar artery aneurysm of the hand in an 18-month-old boy: a case report. J Vasc Surg. 2007;45:841-3.
• 9. Hattori N, Furuta Y, Shiraishi K, Nakayama T, Isobe K, Tanaka T. The radial artery aneurysm within the anatomical snuffbox. Jpn J Vasc Surg. 2004;13:597-601.
• 10. Miura S, Kigawa I, Miyari T, Fukuda S. A surgically treated case of true radial arterial aneurysm in the anatomical snuffbox. Jpn J Vasc Surg. 2004;13:687-690.

Correspondence

Publication Dates

• Publication in this collection
  12 Dec 2008
• Date of issue
  Dec 2008

History

• Received
  31 Mar 2008
• Accepted
  14 Oct 2008