Vascular trauma is an important cause of disability and death in civilian or battlefield environments. Moreover, vascular trauma represents 3% of traumatic injuries, and in approximately 15% of vascular trauma cases, the upper extremity is affected [1,2]. The mechanism is related to the environment and can range from vasospasm with contusion to complete transection of the artery with significant hemorrhage [3].

Brachial artery aneurysms represent 0.17% of all peripheral aneurysms and are generally associated with traumatic injuries [4,5]. The most common clinical manifestation is a pulsatile mass or symptoms derived from the local compression of neural structures [6], and the diagnosis is usually confirmed by imaging studies [7]. Complications occur in 33% of the cases and include pain, ischemia, embolization, aneurysm rupture, and limb loss [8]. True aneurysms in the brachial artery are uncommon. Traumatic injuries to this vessel usually manifest as pseudoaneurysms; however, case reports exist documenting true traumatic aneurysms [9]. In this report, we present a case of successful surgical management of a true traumatic brachial artery aneurysm secondary to a gunshot wound.

The study was approved by the Institutional Review Board (IRB) of the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (IRB no. SCI-4828-23-24-1).

A 47-year-old male was referred to our clinic with claudication in the right arm. He had a history of a gunshot wound on the posterolateral distal aspect of the right arm 16 years before our evaluation, for which he had undergone an unspecified surgical repair at another hospital. The surgery proceeded without complications; however, during the postoperative period, he reported the development of a pulsatile mass in the right antecubital fossa, which, according to him, remained unchanged, pulsatile, and asymptomatic for 16 years; therefore, he never sought medical attention. Last year, the patient suffered from a sudden onset of paresthesia and claudication in the right arm. Three months after the symptomatology started, he visited a local hospital, where he was diagnosed with a thrombosed aneurysm of the right brachial artery. Anticoagulation therapy was initiated without clinical improvement, and he was subsequently referred to our institution for specialized vascular intervention.

During physical examination, a pulsatile mass on the right antecubital fossa was noted, with no thrill, associated with the absence of a pulse in the ipsilateral ulnar artery and weakness in the radial artery. Computed tomographic angiography (CTA) revealed an 18×13×52 mm thrombosed true aneurysm in the distal brachial artery (Fig. 1). Distal recanalization was observed through the deep brachial branch, with thrombosis affecting the distal two-thirds of the ipsilateral ulnar artery. The arterial phase revealed no opacification of the venous system, ruling out the presence of a traumatic arteriovenous fistula (Fig. 1). Given the aforementioned findings and the absence of acute ischemia, anticoagulation treatment was continued, and elective open surgical revascularization was performed.

Figure 1. (A) Computed tomographic angiography, three-dimensional reconstruction demonstrated occlusion of the distal brachial artery (dotted arrow) and distal two-thirds of the ulnar artery (white arrow). (B) Axial image displayed the thrombosed true aneurysm of distal brachial artery. M, medial; L, lateral.

During the surgical procedure, the right upper extremity was abducted to a 90-degree angle (Fig. 2). Under general anesthesia, a 15 cm incision was made in the distal third of the upper arm, antecubital crease, and proximal third of the forearm. The brachial artery was carefully exposed, revealing an aneurysmal lesion with no abnormal communication between the artery and vein (Fig. 3A). After achieving proximal and distal vascular control, the aneurysm was excised. Arterial inflow and backbleeding were adequate, obviating the necessity for Fogarty catheter thrombectomy or distal revascularization. Arterial flow was restored with an autologous reverse saphenous vein graft. Proximal and distal anastomoses in the brachial artery were performed by running 5-0 Prolene sutures (Fig. 3B). Using continuous-wave Doppler, the patency of the graft and distal arteries was verified. Unfortunately, during the procedure, a 1×1 cm aneurysm wall segment intended for histopathological study was mistakenly discarded during sample transport. The postoperative period was uneventful. One year later, the graft was patent, and the patient was asymptomatic with the extremity in full range of motion.

Figure 2. Preoperative photograph displayed a fusiform lesion at the level of the right antecubital fossa (white arrow).

Figure 3. (A) Intraoperative photograph displayed a true aneurysm in the distal brachial artery. Note the morphology of the aneurysmal dilation, anatomically, which suggested the presence of a true brachial artery aneurysm (white arrow). (B) Surgical image illustrated the interposition graft using a reversed saphenous vein (black arrow).

True brachial artery aneurysm is an unusual vascular lesion commonly associated with a previous traumatic event. Due to its rarity, much of the available information is derived from case reports [5,6]. Currently, the most extensive series on true upper extremity arterial aneurysms was reported by Gray et al. [8] at the Mayo Clinic. Over a span of 20 years, only two cases involving the brachial artery have been described: the first case was secondary to repetitive trauma and manifested as an asymptomatic pulsatile mass, while the second was idiopathic and presented with an acute thrombotic event. Both patients underwent surgery with excellent results. Approximately, more than 50% of the cases are attributed to blunt trauma [10,11]. In our case, the aneurysmal lesion was also derived from the trauma caused by a firearm projectile, though determining if the bullet had directly injured the brachial artery was difficult.

The most common clinical presentation of a brachial artery aneurysm is an asymptomatic pulsatile mass [5]. In a small proportion of cases, they present with complications such as rupture, thrombosis, embolization, acute ischemia, or nerve compression due to the mass effect. Shaban et al. [12] established that surgical intervention was justified in all patients, including asymptomatic patients. In addition, Gray et al. [8] reported a substantial series of upper extremity true aneurysms, in which symptomatic or complicated aneurysms constituted the presenting clinical manifestation in half of the cases, irrespective of size. In our case, the vascular lesion remained asymptomatic for 16 years. However, the aneurysm eventually became thrombosed, leading to ischemic complications. Therefore, repairing these aneurysms may be beneficial, regardless of symptoms.

The initial diagnosis is evident after a detailed physical examination and clinical history; however, for precise surgical planning, imaging is required. We used Doppler ultrasound as the initial study, which allowed us to visualize the thrombosed aneurysm during the first visit of the patient to our clinic. We performed CTA as an additional imaging modality to completely delineate the vascular anatomy.

Hall et al. [7] mentioned that nonsurgical treatment can be considered when the aneurysm is small and asymptomatic; however, they also established that surgical repair is the best option. In contrast, Tadayon et al. [13] proposed open surgery with autogenous vein graft as the treatment of choice. Senarslan et al. [14] reported that endovascular techniques are a viable management option. However, most lesions are not anatomically suitable for this treatment modality. Recently, percutaneous placement of stent grafts has been proposed and this alternative approach, mainly in the lower extremities, has demonstrated acceptable primary and secondary patency [15]. However, the endovascular management of brachial artery aneurysms has rarely been reported. Maynar et al. [16] reported a case of distal true brachial artery aneurysm in a candidate deemed unfit for surgery. The case was managed successfully with an endovascular stent graft that was patent with no kinking at the 8-month follow-up. In our case, the aneurysm was located precisely on the elbow crease, and no stent graft with manufacturer indications for this anatomical site was available. Considering the patient’s favorable status as a suitable candidate for surgery and the generally superior long-term patency associated with open procedures in this population, we decided that the best approach is an interposition graft with saphenous vein.

In conclusion, traumatic true brachial artery aneurysms are infrequent vascular pathologies, and their clinical presentation with a complete thrombosis is rare. Surgical repair is indicated in all cases, and open surgery with the placement of an interposition vein graft is the most durable option, as in the reported case. Endovascular therapy is currently under evaluation, and its indications depend on anatomical suitability.

None.

The authors have nothing to disclose.

Concept and design: RGG, CAH, JEAA. Analysis and interpretation: RGG, CAH, JEAA, LBG. Data collection: RGG, LBG. Writing the article: RGG, LBG, JEAA. Critical revision of the article: RGG, JEAA, LBG, RV, HLE, AVA, MCI, CAH. Final approval of the article: all authors. Statistical analysis: none. Obtained funding: none. Overall responsibility: CAH.