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Case Report

Vasc Specialist Int (2022) 38:30

Published online December 13, 2022 https://doi.org/10.5758/vsi.220031

Copyright © The Korean Society for Vascular Surgery.

Surgical Reconstruction of Traumatic Pseudoaneurysm of Palmar Arch Caused by Blunt Trauma

Nikolaos Papatheodorou1 , Konstantinos Dimitriadis2 , Damianos Doukas2 , Christos Argyriou2 , and George S. Georgiadis2

Departments of 1General Surgery and 2Vascular Surgery, Democritus University of Thrace, Alexandroupolis, Greece

Correspondence to:Christos Argyriou
Department of Vascular Surgery, Democritus University of Thrace, 22 Voulgaroktonou street, Alexandroupolis 68100, Greece
Tel: 30-2551351072
Fax: 30-6944359751
E-mail: argchristos@hotmail.com
https://orcid.org/0000-0003-3296-2303

Received: July 4, 2022; Revised: October 14, 2022; Accepted: November 6, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Although rare, pseudoaneurysms (PAs) of the palmar arch are mostly considered benign. However, they can cause severe complications if left untreated or misdiagnosed. There are a few data on traumatic PAs of the palmar arch, particularly those most commonly caused by penetrating hand injuries. However, PAs caused by blunt trauma are more insidious in onset, presenting as a painful pulsatile mass in the palmar area of the hand, and require prompt diagnosis and management to avoid catastrophic sequelae. Our case is the first study to describe a patient with traumatic PA of the palmar arch caused by blunt trauma that was treated with surgical reconstruction and venous bypass interposition.

Keywords: Palmar arch, Pseudoaneurysm, Blunt trauma, Surgical repair

INTRODUCTION

Pseudoaneurysms (PAs) of the palmar arch are rare but potentially fatal, especially if left untreated or underdiagnosed. They are mostly caused by penetrating or repetitive microtrauma [1], blunt trauma [2], and iatrogenic trauma, which occurs most commonly during orthopedic or other microsurgery procedures [3]. Patients usually present with a brief history of a gradually enlarging, tender, pulsatile mass or swelling, with sensory compromise or even ischemic skin changes [4]. Clinical examination and imaging are used to make a diagnosis [4,5]. We describe the first case of a 35-year-old male who suffered from a 3 cm in diameter symptomatic PA of the palmar arch after blunt trauma and was subsequently treated with open surgical reconstruction using a venous interposition graft. Approval from the Institutinal Review Board of the University General Hospital of Alexandroupolis was waived and informed consent was obtained by the patient.

CASE

A 35-year-old, right-hand-dominant male working as a carpenter was referred to our vascular clinic due to a pulsatile mass in the mid-palmar area of his left hand, causing excessive pain, especially during hand manipulation. The patient reported blunt trauma to his left palm with a hammer 3 months ago. Moreover, he complained of dysesthesia and numbness in his middle and ring fingers, and difficulty closing his fist because of the gradually expanding mass. On clinical examination, no motor deficits were detected, the Allen test was negative, and adequate vascularization of the digits was noted. Routine laboratory test results were within the normal range. Ultrasound examination revealed a false aneurysm in the superficial palmar arch of his left hand, measuring 3 cm in diameter, arising distally from the origin of the radial artery at the level of the wrist (Fig. 1). Past medical and family history, as well as overall clinical examination, did not reveal any signs or symptoms of connective tissue disorder (Marfan syndrome, Loeys-Dietz syndrome, Ehler-Danlos syndrome, or Neurofibromatosis type I) in the central nervous system or elsewhere. Routine laboratory tests were within the normal range, including c-reactive protein levels (0.25 mg/dL, normal <1 mg/dL).

Figure 1. Preoperative duplex ultrasonography with color Doppler images revealed a pseudoaneurysm. “Yin-yang” or Pepsi signs indicated bidirectional flow due to the swirling of blood within the false aneurysm.

The diagnosis of the traumatic PA was established based on clinical and occupational grounds. The postoperative histopathologic report confirmed our initial clinical diagnosis of a traumatic PA (Supplementary Fig. 1). Due to the symptoms of persistent restrictive pain, location of the disease, and risk of peripheral embolization, prompt vascular reconstruction was planned. Despite adequate collateralization of the palmar area of the hand, we chose to revascularize rather than ligate and excise the PA. Our decision was primarily based on the occupational hazard of the patient bearing a future traumatic episode of arterial collaterals on the ulnar side or palmar arch, thus jeopardizing the perfusion of the hand.

A 4-cm length, Z-shaped incision was made in the palmar area of his left hand under local anesthesia. A PA of the superficial palmar arch was identified and dissected from the surrounding tissues (Fig. 2). The feeding and outflow arteries were clamped at both sides of the aneurysm, and the mass was dissected en bloc (Fig. 3) after 5,000 IU of unfractionated heparin was administered intravenously. Due to the difficulty in arterial end approximation, surgical reconstruction was performed using an autologous interposition graft (segment of the cephalic vein at the wrist level) rather than end-to-end arterial anastomosis (Fig. 4). A 6-0 vascular prolene suture was used to perform anastomoses. Finally, hemostasis was secured, and the wound was closed with interrupted 4-0 Prolene sutures. According to the treatment protocol, the patient received perioperative anticoagulation (tinzaparin 4,500 IU daily) and antibiotic prophylaxis (amoxicillin/clavulanic acid 875/125 mg), followed by acetylsalicylic acid 100 mg once daily for 1 month. He was discharged the following day. At 2 months follow-up, the patient had an uneventful recovery (Fig. 5) and remained completely asymptomatic with patent bypass according to ultrasound imaging after 1 year (Fig. 6).

Figure 2. Intraoperative view showed the pseudoaneurysm arising from the superficial palmar arch with afferent and efferent vessels controlled by vascular slings.
Figure 3. En bloc resection of the pseudoaneurysm.
Figure 4. Arterial reconstruction was done by an interposition graft with a reversed vein.
Figure 5. Two-month follow-up image of the left hand.
Figure 6. Duplex ultrasound at 1 year demonstrated patent bypass graft flow.

DISCUSSION

PAs of the palmar arch are uncommon but potentially fatal diseases that are scarcely described in the literature [1-8]. The superficial palmar arch was formed by the terminal branch of the ulnar artery and the superficial palmar branch of the radial artery. The arch crosses the palm and forms a curve. The superficial palmar branch of the ulnar nerve crosses above the ulnar branch of the superficial palmar arch. Therefore, excessive arterial exposure can result in inadvertent nerve injury. However, the deep palmar arch is located underneath, situated about 1.5 cm closer to the carpus, and is formed by the union of the terminal branch of the radial artery and the deep palmar branch of the ulnar artery [9]. PAs of the palmar area of the hand primarily affect the superficial rather than the deep palmar arch; the latter has been reported only once in the literature [10]. True aneurysms are usually fusiform in shape and involve all three layers of the arterial wall. However, false aneurysms are saccular in shape and are usually the result of penetrating injury to the vessel wall [11]. The arterial wall is disrupted, and arterial blood leaks into the surrounding tissue, slowly forming a hematoma surrounding the injured vessel. During the following weeks, the hematoma undergoes fibrotic transformation, and a PA persists [11,12].

The most common etiological factor for the development of PAs is trauma (blunt, penetrating, or iatrogenic) [1-8,12-20]. Differential diagnoses can include lipomas, fibromas, inclusion cysts, sarcomas, and abscess formation due to the retention of foreign bodies, especially after a previous trauma [4,5]. However, a pulsatile mass in the palm in a post-traumatic setting should always raise clinical suspicion of traumatic PA [12]. Although rare, PAs can be complicated by infection, abscess formation, arterial or venous occlusion, nerve compression [4,5,7,8,10,13], and arteriovenous fistula formation [8]. Slesarenko et al. [14] described a patient who presented with acute carpal tunnel syndrome due to a false aneurysm of the palmar arch. The patient underwent carpal tunnel decompression and mass excision. The risk of digital embolization from a partially thrombosed PA should be considered in all cases [15].

Physical examination and medical history were the cornerstones of diagnosis in these cases. Ultrasonography is sufficient to establish a diagnosis in most patients, whereas the presence of a foreign body can be excluded with plain radiographic imaging [5]. Other imaging modalities contributing to the diagnosis include computed tomography angiography, magnetic resonance angiography, and digital subtraction angiography. These imaging modalities can help to determine the anatomy of the PA, the presence of collaterals, the feasibility of performing endovascular therapy, and in cases where medical history is vague or inconclusive [3,5,10,14,16]. In our patient, the distinctive reported recent trauma and adequate vessel mapping on duplex ultrasound were considered sufficient for surgical decision-making.

According to the current literature, 19 studies have reported 22 patients with palmar arch aneurysms (Table 1). Among the studies, three were related to the children’s population. The underlying etiology was penetrating trauma in most cases (18/22, 81%), followed by blunt trauma in two cases (9%). Twenty patients (91%) presented with a pulsatile mass in their hands, and four patients (19%) had a bleeding episode at admission. However, the management of these lesions remains controversial. The treatment of small and uncomplicated false aneurysms could be conservative only by applying compressive bandages [7]. Traditionally, the treatment of choice is excision and ligation [4,2,6,11] or excision and arterial revascularization by primary repair [1,6,8,12,16,17], or vein graft interposition [18]. Our study is the first case report of a traumatic PA of the palmar arch managed with the interposition of an autologous vein graft in the literature. Regarding the non-autologous bypass option, only one study was reported by Lucchina et al. [19] describing the use of an artery graft interposition for the reconstruction of a digital artery PA, which remained patent during the 3-month follow-up period.

Table 1 . Studies reporting pseudoaneurysms of the palmar arch.

ReferenceMechanism of injuryTreatment
Lokey et al. (1978) [2]LacerationEL
Walsh and Conolly (1982) [6]Blunt traumaEEEA
LacerationEL
LacerationEL
Crush injuryLigation
Tyler and Stein (1988) [18]Repetitive blunt traumaExcision & interposition of vein graft
Yajima et al. (1995) [17]LacerationEEEA
Sterett (1996) [13]LacerationEL
Cromheecke et al. (1997) [15]Lacerationconsertavive
Simeonov (1998) [11]LacerationEL at its base
Slesarensko et al. (2007) [14]LacerationEL
Hughes et al. (2012) [5]Lacerationexcision & primary repair
Lucchina et al. (2011) [19]LacerationExcision & interposition of arterial graft
Gull et al. (2011) [3]Iatrogenic (carpal tunnel release)coil embolization
Fields et al. (1997) [7]Lacerationconservative with compression bandages
Sakamoto and Arai (2009) [8]LacerationEEEA
Franck et al. (2004) [1]LacerationEEEA
Schoretsanitis et al. (2015) [4]LacerationEL at its base
Sallihudin et al. (2015) [12]LacerationEEEA
Bosman et al. (2016) [10]LacerationUGPTI
Ferreira et al. (2017) [20]LacerationUGPTI
Sayit et al. (2017) [16]LacerationEEEA

EEEA, excision & end-to-end anastomosis; EL, excision and ligation; UGPTI, ultrasound-guided percutaneous thrombin injection..



Although surgical repair is currently considered the gold standard treatment, endovascular techniques such as coil embolization and ultrasound-guided thrombin injection have emerged as promising alternative minimally invasive solutions for treating superficial and deep palmar arch aneurysms [3,10,20]. These techniques are usually indicated in patients with increased surgical hemorrhagic risk and suitable anatomical characteristics of the lesions [20]. Thrombin injection should be continuously monitored via ultrasound and avoided in aneurysms with wide or non-visualized necks. In our case, we opted for surgical repair due to a non-visualized, superficially located, and surgically accessible PA neck lesion in a young, physically active patient.

In conclusion, palmar arch PAs are rarely diagnosed or described in the literature. In most cases, they follow an insidious and silent course; however, they may progress to a symptomatic status with serious sequelae to the patient, especially if they are diagnosed late or undertreated. Clinical examination is considered the essential modality for diagnosis, and ultrasonography can confirm the diagnosis in most cases. Although minimally invasive endovascular solutions have emerged as attractive alternative treatment options, surgical repair of palmar arch PAs with or without bypass surgery is currently considered the traditional choice of treatment, especially in young, physically active patients.

SUPPLEMENTARY MATERIAL

Supplementary Figure can be found via https://doi.org/10.5758/vsi.220031.

vsi-38-30-supple.pdf

FUNDING

None.

CONFLICTS OF INTEREST

The authors have nothing to disclose.

AUTHOR CONTRIBUTIONS

Concept and design: NP, KD, CA. Analysis and interpretation: NP, KD, DD. Data collection: NP, KD, DD. Writing the article: NP, KD, CA. Critical revision of the article: CA, GSG. Final approval of the article: all authors. Overall responsibility: CA.

Fig 1.

Figure 1.Preoperative duplex ultrasonography with color Doppler images revealed a pseudoaneurysm. “Yin-yang” or Pepsi signs indicated bidirectional flow due to the swirling of blood within the false aneurysm.
Vascular Specialist International 2022; 38: https://doi.org/10.5758/vsi.220031

Fig 2.

Figure 2.Intraoperative view showed the pseudoaneurysm arising from the superficial palmar arch with afferent and efferent vessels controlled by vascular slings.
Vascular Specialist International 2022; 38: https://doi.org/10.5758/vsi.220031

Fig 3.

Figure 3.En bloc resection of the pseudoaneurysm.
Vascular Specialist International 2022; 38: https://doi.org/10.5758/vsi.220031

Fig 4.

Figure 4.Arterial reconstruction was done by an interposition graft with a reversed vein.
Vascular Specialist International 2022; 38: https://doi.org/10.5758/vsi.220031

Fig 5.

Figure 5.Two-month follow-up image of the left hand.
Vascular Specialist International 2022; 38: https://doi.org/10.5758/vsi.220031

Fig 6.

Figure 6.Duplex ultrasound at 1 year demonstrated patent bypass graft flow.
Vascular Specialist International 2022; 38: https://doi.org/10.5758/vsi.220031

Table 1 . Studies reporting pseudoaneurysms of the palmar arch.

ReferenceMechanism of injuryTreatment
Lokey et al. (1978) [2]LacerationEL
Walsh and Conolly (1982) [6]Blunt traumaEEEA
LacerationEL
LacerationEL
Crush injuryLigation
Tyler and Stein (1988) [18]Repetitive blunt traumaExcision & interposition of vein graft
Yajima et al. (1995) [17]LacerationEEEA
Sterett (1996) [13]LacerationEL
Cromheecke et al. (1997) [15]Lacerationconsertavive
Simeonov (1998) [11]LacerationEL at its base
Slesarensko et al. (2007) [14]LacerationEL
Hughes et al. (2012) [5]Lacerationexcision & primary repair
Lucchina et al. (2011) [19]LacerationExcision & interposition of arterial graft
Gull et al. (2011) [3]Iatrogenic (carpal tunnel release)coil embolization
Fields et al. (1997) [7]Lacerationconservative with compression bandages
Sakamoto and Arai (2009) [8]LacerationEEEA
Franck et al. (2004) [1]LacerationEEEA
Schoretsanitis et al. (2015) [4]LacerationEL at its base
Sallihudin et al. (2015) [12]LacerationEEEA
Bosman et al. (2016) [10]LacerationUGPTI
Ferreira et al. (2017) [20]LacerationUGPTI
Sayit et al. (2017) [16]LacerationEEEA

EEEA, excision & end-to-end anastomosis; EL, excision and ligation; UGPTI, ultrasound-guided percutaneous thrombin injection..


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