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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 5  |  Issue : 1  |  Page : 28-30

Brachial aneurysm caused by a long-term axillary crutch - A case and literature review


1 Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
2 Department of Vascular Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China

Date of Submission21-Nov-2021
Date of Decision28-Jan-2022
Date of Acceptance28-Jan-2022
Date of Web Publication22-Mar-2022

Correspondence Address:
Dr. Chuanqi Cai
Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022
China
Prof. Ping Lü
Department of Vascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2589-9686.340415

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  Abstract 


Brachial aneurysms are a rare disease, accounting for 0.5% of peripheral aneurysms. Using a long-term axillary crutch may be associated with arterial injury and induce upper extremity aneurysm formation. A 67-year-old woman had a history of using a long-term underarm crutch due to polio disease. Physical examination revealed edema of the left upper limb, pulseless of the brachial artery, and disappearance of distal radial pulse. The imaging examination revealed a brachial arterial aneurysm in the left upper limb, along with thrombosis. The aneurysm and mural thrombus were excised. The great saphenous vein graft was inserted to reconstruct occluded artery blood supply; the left brachial and radial arteries pulsed well after operation. This case report suggests that long-term use of axillary support for patients should be done with caution. Regular follow-up of upper extremity vascular morphology should be done. Timely anticoagulant therapy to prevent thrombosis and surgical resection of aneurysms are effective strategies for resolving complications.

Keywords: Axillary crutch, arterial thrombosis, brachial arterial aneurysm, transplantation of the great saphenous vein, polio


How to cite this article:
Ye P, Chen Y, Li Y, Gu Y, Cai C, Lü P. Brachial aneurysm caused by a long-term axillary crutch - A case and literature review. Vasc Invest Ther 2022;5:28-30

How to cite this URL:
Ye P, Chen Y, Li Y, Gu Y, Cai C, Lü P. Brachial aneurysm caused by a long-term axillary crutch - A case and literature review. Vasc Invest Ther [serial online] 2022 [cited 2022 May 24];5:28-30. Available from: https://www.vitonline.org/text.asp?2022/5/1/28/340415




  Introduction Top


Brachial aneurysm is unusual and it is even more rare when it occurs among the patient has a history of polio disease. We reported a rare case of a brachial aneurysm linked to the using a long-term due to polio disease. We successfully cured this patient by excising the aneurysm and reconstructing the brachial artery with the great saphenous vein graft.


  Case Presentation Top


A 67-year-old woman experienced upper limb pain for 1 year. The physical examination revealed numbness in the left upper limb and axillary sagged and swollen skin with slight tenderness. There was a pulseless fixed mass along with the radial arterial orientation. The brachial artery at the elbow fossa and radial artery were both pulseless. Compared to the right hand, the left hand had a lower temperature and a weaker grip strength. Medical history inquiry found that the patient had been using crutches for more than 36 years because of polio.

On admission, laboratory assays revealed no apparent abnormalities, including a normal D-dimer level of 0.38 mg/L (normal level: <0.5 mg/L). Moreover, no abnormalities were observed in her cardiac ultrasound detection and electrocardiogram. Next, she was scheduled for vascular color ultrasound detection. There was obvious embolization from the distal segment of the axillary artery to the distal brachial artery [Figure 1]a and [Figure 1]b.
Figure 1: Preoperative color ultrasound Doppler scan and computed tomography angiography imaging. (a-c) The brachial artery presented as a dilated aneurysm. There was no blood flow in the brachial artery

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Computed tomography angiography (CTA) confirmed the presence of a brachial arterial aneurysm (BAA) in the left upper limb, along with thrombosis, and BAA lesion was around 50 mm in length and 16 mm in diameter [Figure 1]c.

On day 3, surgery was performed under general anesthesia. There was obvious pigmentation of friction from the inner side of the left upper limb up to the axillae [Figure 2]a. The left distal axillary artery, brachial artery, and radial artery were explored intraoperatively. The left brachial artery had aneurysmal dilation with massive internal thrombosis [Figure 2]b, and no reflux blood flow was observed in the distal brachial artery. Following that, the BAA was dissected. Because the brachial artery presented as an inflammatory condition [Figure 2]b, we performed the left axillary artery–brachial artery bypass using a 6 cm in length great saphenous vein [Figure 2]c. Thrombectomy was performed using two 4F and 3F Fogarty catheters (Edwards Lifesciences, CA, USA) in the distal brachial and radial arteries [Figure 2]d, respectively. Subsequently, there was reflux blood flow from the distal segment of the brachial artery.
Figure 2: Intraoperative images. (a) There was obvious pigmentation of friction from the upper arm to the axillary area. (b) The brachial aneurysm was dissected. (c) The brachial aneurysm was excised, and one segment of the great saphenous vein was transplanted to reconstruct the blood flow. (d) The excised aneurysm and thrombectomy lesions

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Immediate postoperative vascular pulsation was observed in the transplanted vessel and left brachial artery [Figure 2]c. Two days later, the numbness and pain of the left upper limb disappeared, and the skin temperature increased significantly. Before her discharge on day 5 following surgery, the left finger activity was improved considerably. Moreover, we conducted another CTA scan to follow-up on the brachial artery. The bypass vessel presented patent flow [Figure 3]a.
Figure 3: Postoperative computed tomography angiography and morphometry result. (a) Postoperative computed tomography angiography confirmed no brachial aneurysm, and the bypass vessel was patent. (b) Representative hematoxylin and eosin slide showed that there was broken elastic fiber, and there were abundant infiltrated cells in the aneurysm accompanied with extensive thrombosis in the intimal layer

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Finally, we analyzed the aneurysm lesion's morphometry. As expected, cellular infiltration occurred in the intimal and medial layers. The elastic fibers were broken, accompanied by abundant thrombosis in the intimal area [Figure 3]b.


  Discussion and Conclusions Top


Aneurysms in the axillary or brachial arteries are rarely reported, especially in people who have used crutches for many years.[1] Compared to lower limb aneurysms, upper limb aneurysms were less common, accounting for 0.5% of all peripheral aneurysms.[1],[2] As demonstrated by morphometry in [Figure 3]b, perennial use of underarm crutch resulted in abundant cellular infiltration in the whole vessel wall accompanied by destroyed vascular homeostasis. When patients underwent long-term axillary crutches, the brachial artery suffered from chronic repeated abrasions and compression injuries, which could induce the degeneration of intima and media of arteries, resulting in a narrowed lumen.[3],[4] The above injury could result in arterial aneurysm formation and subsequent thromboembolism several years later.[1],[5],[6] Although ischemia can occur due to a BAA, this lesion is generally curable through surgical excision and reconstruction of the brachial artery.

Patients who use crutches are common worldwide, but brachial aneurysms are uncommon,[7] and insufficient cases can be accumulated to conduct meaningful statistical analysis. The keyword “crutch-induced” was used to search PubMed, retrieving 73 articles about crutch-induced injury of upper limb artery. Using the keywords “brachial artery aneurysm” and “crutch” retrieval, we found 12 articles that adhere to the standard of using crutches for BAAs. The most common symptom was chills in the affected limb (62.5%), followed by pain (50%) and numbness (37.5%). They were predominantly male and ranged in age from 42 to 83 years, with an average of 63. The duration of axillary crutches ranged from 36 to 67 years, accounting for 70%–85% of life cycle. One case was reported as a 64-year-old male with a 45-year smoking history.[7] Therefore, the prevalence of brachial aneurysms increased with age and crutch duration, and the main risk factors could include advanced age (>63 years), male gender, previous medical history, duration of crutch use, and smoking history.

To sum up, we presented a patient with a BAA and thrombosis caused by years of crutch history, which was successfully treated with open surgery. We came up with a clinical practice approach. A routine color ultrasound Doppler scan is recommended for patients with sustained upper limb crutch history to screen the brachial artery aneurysm. Surgical treatment should be performed actively to prevent more severe consequences such as limb ischemia or gangrene. In the future, a biomimetic walking crutch stick may be beneficial in reducing this aneurysm.

Declarations

Informed consent was obtained from this patient.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her 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

This research was supported by National Natural Science Foundation of China (No. 81670512 to P.L., and No. 82000729 to C.C.).

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Moon IS, Hwang JK, Kim JI. Recurrent upper extremity embolism due to a crutch-induced arterial injury: A different cause of upper extremity embolism. Ann Vasc Surg 2010;24:554.e7-12.  Back to cited text no. 1
    
2.
Shaban Y, Elkbuli A, Geraghty F, Boneva D, McKenney M, De La Portilla J. True brachial artery aneurysm: A case report and review of literature. Ann Med Surg (Lond) 2020;56:23-7.  Back to cited text no. 2
    
3.
Furukawa K, Hayase T, Yano M. Recurrent upper limb ischaemia due to a crutch-induced brachial artery aneurysm. Interact Cardiovasc Thorac Surg 2013;17:190-2.  Back to cited text no. 3
    
4.
Morisaki K, Kuma S, Okazaki J. Recurrent brachial artery embolism caused by a crutch-induced axillary artery aneurysm: Report of a case. Surg Today 2014;44:1355-8.  Back to cited text no. 4
    
5.
Konishi T, Ohki S, Saito T, Misawa Y. Crutch-induced bilateral brachial artery aneurysms. Interact Cardiovasc Thorac Surg 2009;9:1038-9.  Back to cited text no. 5
    
6.
Forte AJ, Yeager TE, Boczar D, Broer PN, Manrique OJ, Parrett BM. Pediatric ulnar artery pseudoaneurysm of the wrist after glass laceration: A case report and systematic review of the literature. Microsurgery 2021;41:84-94.  Back to cited text no. 6
    
7.
Wigley FM. Clinical practice. Raynaud's phenomenon. N Engl J Med 2002;347:1001-8.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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