Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 1  |  Page : 87-89

A case report of iatrogenic radial artery true aneurysm


Department of Surgery, Dhulikhel Hospital, Kavre, Nepal

Date of Submission02-Feb-2020
Date of Decision20-Feb-2020
Date of Acceptance28-Feb-2020
Date of Web Publication20-Feb-2021

Correspondence Address:
Pratima Thapa
Department of Surgery, Dhulikhel Hospital, Kavre
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_12_20

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  Abstract 


True aneurysm is dilatation of an artery which consists of all layers of the arterial wall. True radial artery aneurysms are very rare. The most common cause of radial artery aneurysm is iatrogenic trauma. Here, we report a case of iatrogenic true radial artery aneurysm. A 38-year-old male with a history of right radial artery cannulation for anticoagulant therapy to treat right leg deep venous thrombosis presented to our outpatient department with a complaint of swelling on the radial side of the volar aspect of the right arm. He was treated conservatively with steroids, but symptoms did not subside. Doppler ultrasound and computed tomography scan suggested true radial artery aneurysm. In view of pseudoaneurysm, surgical plan was made. During surgery, the aneurysm seemed to be involved in all the vessel layers. The aneurysm was excised, and ligation of both the ends was done. Anastomosis was not done owing to good flow in the distal part from the ulnar artery and damage to a long segment of the radial artery. Patients on anticoagulants are at a risk of aneurysm formation than patients who are not. It can be diagnosed clinically and radiologically.

Keywords: Iatrogenic aneurysm, Nepal, radial artery aneurysm, radial artery cannulation, true aneurysm


How to cite this article:
Thapa P, Karmacharya RM, Singh AK, Vaidya S, Dahal S, Dhakal P, Bhandari N, Bade S. A case report of iatrogenic radial artery true aneurysm. Indian J Vasc Endovasc Surg 2021;8:87-9

How to cite this URL:
Thapa P, Karmacharya RM, Singh AK, Vaidya S, Dahal S, Dhakal P, Bhandari N, Bade S. A case report of iatrogenic radial artery true aneurysm. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Feb 25];8:87-9. Available from: https://www.indjvascsurg.org/text.asp?2021/8/1/87/309696




  Introduction Top


True aneurysm is defined as dilatation of an artery which consists of all the layers of the arterial wall. A false aneurysm or pseudoaneurysm does not have all the layers of the arterial wall. Sometimes, when the pseudoaneurysm has existed for a long time, the wall gets fibrosed, and it starts to mature which resembles the arterial wall.[1] Following trauma, pseudoaneurysm is more common compared to true aneurysm.[1]

The most common cause of radial artery aneurysm is local trauma. Some other causes include mycosis, arteriosclerosis, idiopathic, underlying vasculopathy, local infection, and penetrating injuries such as bone fractures.[2] Iatrogenic damage is caused during diagnostic and therapeutic endovascular procedures, for example, radial artery cannulation such as during interventional procedures. Some of the most common risk factors are patients on anticoagulants or taking antiplatelet drugs. Radial artery aneurysm includes only 2.9% of upper-limb aneurysms and occurs most commonly at the level of the anatomical snuffbox.[2] According to the Laplace law, higher pressure causes enlargement of the arterial wall causing an aneurysm to form. Because the radial artery has a small lumen, aneurysm is less likely to form. Hence, true radial artery aneurysm is very rare. Only nine cases have been reported as true radial artery aneurysm so far.[3] Here, we present a case of radial artery aneurysm which was suspected to be a pseudoaneurysm but found to be true aneurysm during surgical intervention.


  Case Report Top


A 38 year old male smoker who was previously treated conservatively for right leg deep venous thrombosis presented to our outpatient department with complaints of swelling on the right hand for 2 weeks. He had a history of accidental right radial artery cannulation during the treatment for anticoagulation therapy. He was treated with intravenous(IV) and oral anticoagulants for the same. The swelling started from the 4th day of cannulation and started to grow gradually from about 1 cm × 1 cm to about 2 cm × 2cm on the lateral volar aspect of the right hand by 4 weeks.

The initial diagnosis made was vasculitis, and he was treated with steroids for about 3 weeks after which he complained that his symptoms did not subside despite the medications. Doppler ultrasound showed 12.3 mm × 8.6 mm distal radial artery pseudoaneurysm with Yin Yang pattern on color Doppler. Computed tomography (CT) scan of the right arm done in 4weeks time reported radial artery aneurysm of about 3.38 cm × 3.02 cm × 1.97 cm and had some features of pseudoaneurysm as shown in [Figure 1]. By then the size of the swelling was already about 3× 3cm as shown in [Figure 2]. On re evaluation using Doppler ultrasonography, aneurysmal thrombosed segment of the radial artery was present in the distal forearm with reversed distal flow. The patient was planned for operative management due to the risk of thrombus extension and rupture. Warfarin was discontinued 3 days before surgery, and heparin was given for 3 days which was stopped just a day before surgery. Under general anesthesia, incision over aneurysm was given, and aneurysm was identified and dissected as shown in [Figure 3]. The aneurysm, however, was involving all the layers and thus was true aneurysm. Owing to damage of a long segment of the radial artery, end to end anastomosis was not planned. Proximal control was taken, and sac was resected. Distal and proximal radial arteries were transfixed and reinforced by Prolene as shown in [Figure 4]. Hemostasis was maintained and the skin closed in layers. Postoperative event was uneventful, and he was discharged on the 3rd postoperative day. During follow up visits, there was good wound healing and no issues on perfusion of digits.
Figure 1: Preoperative computed tomography showing aneurysm of the right radial artery

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Figure 2: Pulsatile, globular mass of 3 cm × 3 cm in the right forearm in the ventrolateral surface

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Figure 3: True aneurysm of the radial artery which is thrombosed

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Figure 4: Ligation of both the proximal and distal parts of the radial artery with excision of the aneurysm

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  Discussion Top


We report a case of a 38-year-old male with iatrogenic true radial artery aneurysm. The patient had a history of failed IV access in the same area, followed by mild pain for a day in the radial part of the distal right forearm. There were pain, swelling, and pulsatile mass in the right lateral part of the distal forearm 2 weeks after the injury. We initially managed the patient conservatively with steroids with the suspicion of vasculitis, but due to failure of management, surgical intervention was planned. Proper treatment is necessary as aneurysm carries the risk of rupture, thromboembolism, or nerve compression.[2] However, owing to persistence of symptoms, we planned for further evaluation. Doppler ultrasonography as well as CT angiogram suggested pseudoaneurysm of the radial artery. The uniqueness about this case is that although the evaluation suggested pseudoaneurysm, intraoperatively it was found to be true aneurysm as all the layers of the vessel wall were seen, and there was no neck as of pseudoaneurysm. Another feature of this case is that the long segment of the radial artery was involved and thus not amenable for bypass.

There are few case reports of radial artery aneurysm following catheterization of the radial artery for coronary angiogram. In a case series, it was found that five radial artery aneurysms occurred out of 16,808 catheterizations; however, they were pseudoaneurysms.[4] We could not find any case report of the radial artery aneurysm from our country. Furthermore, we could not find case reports of true radial artery aneurysm due to trauma while attempting IV access. However, a case report done by Kongunattan reports a case of an aneurysm after a blunt trauma to the right hand diagnosed by Doppler ultrasound.[5] In a meta-analysis done by Hossami Shaabi using the terms “radial artery” and “aneurysm” and “radial artery” and “pseudoaneurysm,” 68 and 46 articles were found, respectively, published until May 2013. Among all 102 reported cases, only eight cases of idiopathic true radial artery aneurysms were reported.[6]

The most common cause of a radial artery aneurysm is trauma, iatrogenic being the most common. Anticoagulants remain a major risk factor for the formation of aneurysm. Since our patient had a history of left leg deep venous thrombosis, he was taking warfarin and IV heparin. Diagnosis is based on clinical examination and radiology.

The treatment of an aneurysm varies on the type of lesion. In our case, had it been uncomplicated pseudoaneurysm, it could be treated conservatively with compression and observation.[7],[8] There have been cases reported about the successful management of pseudoaneurysm with local compression. One of such cases has been reported by Ghanavati[7] who was managed conservatively with no complications. Ultrasound-guided thrombin injection is another preferable and effective treatment in patients taking anticoagulants like our patient. However, it carries the risk of thrombosis distal to the aneurysm causing distal end ischemia if circulation is not adequate.

Surgical management is the only reliable option so far in case of true aneurysm or pseudoaneurysm that has failed to respond to conservative management. Hence, surgical excision is advantageous. Furthermore, it decreases the risk of complications and is the better option for patients who have failed conservative management for pseudoaneurysm.


  Conclusion Top


There are very few cases reported for true radial artery aneurysm as shown in Figures 3 and 4. The use of anticoagulants is a risk factor for it. Aneurysms are often misdiagnosed which may affect the proper management. True aneurysm along with complicated pseudoaneurysm usually needs surgical management. In case of healthy proximal and distal part of aneurysm, interposition graft can be done. However, if the residual artery wall is not healthy and good flow is noted from the ulnar artery, excision of the aneurysm with ligation of the distal end of the radial artery can be done without the risk of limb ischemia.

Consent

Written consent has been taken from the patient regarding this case report publication. The data and figures published are included in the consent.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ho PK, Weiland AJ, McClinton MA, Shaw Wilgis EF. Aneurysms of the upper extremity. J Hand Surg 1987;12:39-46.  Back to cited text no. 1
    
2.
Maalouly J, Aouad D, Saidy E, Tawk A, Baaklini G, Cortbawi C. Atraumatic left distal radial artery aneurysm. Case Rep Orthop 2019;2019:1-4.  Back to cited text no. 2
    
3.
Al-Zoubi NA. Idiopathic true aneurysm of distal radial artery: Case report. Vasc Health Risk Manag 2018;14:279-81.  Back to cited text no. 3
    
4.
Nieddu ME. Post-traumatic aneurysm of the radial artery: A case report. J Ultrasound 2012;15:174-5.  Back to cited text no. 4
    
5.
Kongunattan V, Ganesh N. Radial artery pseudoaneurysm following cardiac catheterization: A nonsurgical conservative management approach. Heart Views 2018;19:67-70.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Zegrí I, García-Touchard A, Cuenca S, Oteo JF, Fernández-Díaz JA, Goicolea J. Radial artery pseudoaneurysm following cardiac catheterization: Clinical features and nonsurgical treatment results. Rev Esp Cardiol (Engl Ed) 2015;68:349-51.  Back to cited text no. 6
    
7.
Ghanavati R, Arab Ahmadi M, Behnam B. Successful nonsurgical treatment of a radial artery pseudoaneurysm following transradial coronary angiography. J Tehran Heart Cent 2017;12:82-4.  Back to cited text no. 7
    
8.
Madia C. Management trends for postcatheterization femoral artery pseudoaneurysms. JAAPA 2019;32:15-8.  Back to cited text no. 8
    


    Figures

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



 

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