Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 6  |  Issue : 2  |  Page : 129-131

Anastomotic pseudoaneurysm of brachioradial artery


Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka, India

Date of Web Publication6-Jun-2019

Correspondence Address:
Dr. S Roshan Rodney
Jain Institute of Vascular Sciences, A Unit of Bhagwan Mahaveer Jain Hospital, Bengaluru, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_94_18

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  Abstract 


Brachioradial (BR) artery also known as “radial artery of high origin” is the most common anatomical variation in the upper extremity arterial system. However, the clinical significance of this variation is rarely recognized in daily practice. This article reports the case of a 40-year-old male patient who presented with anastomotic pseudoaneurysm of an arteriovenous fistula, which had been created between the BR artery and median cubital vein in the antecubital fossa. The patient underwent aneurysm excision with repair of BR artery. Postoperative period was uneventful.

Keywords: Anastomotic, antecubital, brachioradial artery, pseudoaneurysm


How to cite this article:
Rodney S R, Anand V, Vishnu M, Raj S, Chaudhari H, Sravan C P, Lende V, Vishal H, Krishna K S, Nishan B. Anastomotic pseudoaneurysm of brachioradial artery. Indian J Vasc Endovasc Surg 2019;6:129-31

How to cite this URL:
Rodney S R, Anand V, Vishnu M, Raj S, Chaudhari H, Sravan C P, Lende V, Vishal H, Krishna K S, Nishan B. Anastomotic pseudoaneurysm of brachioradial artery. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Jun 25];6:129-31. Available from: http://www.indjvascsurg.org/text.asp?2019/6/2/129/259665




  Introduction Top


Aneurysmal dilatation of arteriovenous fistula (AVF) created for hemodialysis is one of the frequently known complications, with an incidence rate of 5%–8%.[1] There is a 12% incidence of a high brachial bifurcation so that the ulnar and radial arteries are both present in the cubital fossa. The larger of the two arteries should be used for the anastomosis, but nevertheless, the overall patency may be less than that of standard brachiocephalic AVFs.[2]


  Case Report Top


A 40-year-old male, smoker, known diabetic, hypertensive and chronic kidney disease on maintenance hemodialysis, presented with a pulsatile mass in his right cubital fossa for 5 years. The patient had a history of an AVF created in the right antecubital fossa before 6 years, and after maturation, it had been accessed for hemodialysis for 6 months. Later, he was undergoing ayurvedic treatment for his kidney disease for the next 4 years. For the past 1 year, the patient is undergoing hemodialysis through contralateral brachiocephalic AVF, currently nonaneurysmal, created 14 months before in an outside hospital as there was pulsatile swelling in right antecubital fossa with no thrill in the right arm. Physical examination showed a pulsatile mass in the right antecubital fossa [Figure 1]. The hands were well perfused, with palpable ulnar artery and good signals in radial artery at the level of the wrist. We first performed an arterial Doppler of right upper limb which revealed an aneurysm of size about 4.5 cm × 4.5 cm at the anteromedial aspect of the right elbow compressing brachial artery with pulsatile flow in both cephalic and basilic veins although we were unable to determine whether this was an aneurysm or pseudoaneurysm [Figure 2]. Preoperative computed tomography (CT) angiography showed the high bifurcation of brachial artery with a large aneurysm with peripheral thrombus of size about 5.9 cm × 5.3 cm × 6.4 cm noted at the level of right elbow arising from the AVF or adjacent radial artery [Figure 3]. The aneurysm is seen compressing and narrowing adjacent radial artery anteromedially. The patient was planned for surgery under general anesthesia. Under tourniquet control, a S-shaped incision was made across the cubital fossa for complete visualization of the aneurysm [Figure 4]. After complete dissection, the aneurysm sac was incised and all clots evacuated. After the aneurysmal segment was excised, the medially pushed brachioradial (BR) artery was repaired with 5–0 polypropylene sutures. Wound was closed after confirmation that no other bleeding was present. The patient was discharged home on the next day and was followed up. The incision healed well and no flap necrosis was encountered. The excised aneurysm sac which was sent for histopathological analysis revealed it as pseudoaneurysm.
Figure 1: Right antecubital fossa pulsatile swelling

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Figure 2: Ultrasound image demonstrating the aneurysm

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Figure 3: Preoperative computed tomography angiography with three-dimensional reconstruction showing high bifurcation of brachial artery with brachioradial artery aneurysm

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Figure 4: Intraoperative view of the aneurysm

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  Discussion Top


There are many variants in arterial anatomy of the upper limb. Of all the variants, the BR artery defined as a high bifurcation of the brachial artery giving rise to the radial artery above the antecubital fossa is the most common [3] and holds the greatest clinical importance to the vascular surgeon [Figure 5].
Figure 5: Photograph (a) and illustration (b) of brachioradial artery or superficial brachial artery. Superficial brachial artery continues as the radial artery in the forearm. AA: Axillary artery, BA: Brachial artery, LC: Lateral cord, MC: Medial cord, M: Median nerve, SBA: Superficial brachial artery, RA: Radial artery, UA: Ulnar artery. Reproduced from Kirskey et al

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A detailed description of upper-limb vascular variability has been described by Rodríguez-Niedenführ et al.[4] in their study of 384 upper limbs found BR artery in 20.3% of cadavers. BR artery originates more frequently from the brachial than the axillary and specifically from the upper third of the brachial, followed by the middle and inferior thirds, respectively. Variations of the branching pattern of the brachial artery have been the subject of many anatomical studies because of their high incidence. There is only limited data within the vascular surgery literature regarding the clinical importance of this anatomic variant on dialysis access outcomes. Pseudoaneuryms, near the AVF site, are either due to leak from the anastomotic site or late sutural dehiscence. Repeated and inadvertent punctures lead to extravasations of blood from the artery, formation of hematoma, and further development of pseudoaneuryms. Anastomotic AVF pseudoaneurysms associated with high bifurcation of brachial artery is most commonly due to inadvertent cannulation of the BR artery.[5] In most of the cases, BR artery lies superficially throughout its course and more vulnerable to cannulation injury leading to aneurysm formation requiring surgical intervention.[6],[7]

Any variant of the brachial artery should be identified before surgery. However, a full workup by CT angiography for every single patient is neither feasible nor cost effective. Hence, we urge surgeons to be aware of this possibility and do a preoperative Doppler evaluation as a routine before any dialysis access creation.


  Conclusion Top


In summary, the high bifurcation of the brachial artery, or BR variant, is an important and common anatomical finding with significant clinical implications. It represents an unappreciated cause of fistulae nonmaturation, prosthetic bridge graft failure, and vascular steal syndrome. It is the responsibility of dialysis access surgeons and nephrologists to become familiar with this anatomic variant and its implications for access planning. Preoperative vascular imaging protocols should be modified to facilitate identification of this finding. The dialysis surgeon should develop an algorithm for managing aberrant brachial artery anatomy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Haładaj R, Wysiadecki G, Dudkiewicz Z, Polguj M, Topol M. The high origin of the radial artery (Brachio-radial artery): Its anatomical variations, clinical significance, and contribution to the blood supply of the hand. Biomed Res Int 2018:11. Article ID 1520929.  Back to cited text no. 1
    
2.
Kian K, Shapiro JA, Salman L, Khan RA, Merrill D, Garcia L, et al. High brachial artery bifurcation: Clinical considerations and practical implications for an arteriovenous access. Semin Dial 2012;25:244-7.  Back to cited text no. 2
    
3.
Kirksey L. Unrecognized high brachial artery bifurcation is associated with higher rate of dialysis access failure. Semin Dial 2011;24:698-702.  Back to cited text no. 3
    
4.
Rodríguez-Niedenführ M, Vázquez T, Nearn L, Ferreira B, Parkin I, Sañudo JR, et al. Variations of the arterial pattern in the upper limb revisited: A morphological and statistical study, with a review of the literature. J Anat 2001;199:547-66.  Back to cited text no. 4
    
5.
Noguchi M, Hazama S, Tsukasaki S, Eishi K. Iatrogenic pseudoaneurysm in a hemodialysis patient: The hidden hazard of a high radial artery origin. Heart Vessels 2004;19:98-100.  Back to cited text no. 5
    
6.
Lioupis C, Mistry H, Junghans C, Haughey N, Freedman B, Tyrrell M, et al. High brachial artery bifurcation is associated with failure of brachio-cephalic autologous arteriovenous fistulae. J Vasc Access 2010;11:132-7.  Back to cited text no. 6
    
7.
Al Talalwah W. A case report of a high brachial artery bifurcation in relation to clinical significance of artificial arteriovenous fistula. Acta Med Int 2017;4:22-4.  Back to cited text no. 7
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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