Arterial Aneurysms

24 Arterial Aneurysms

Kevin D. Plancher

History and Clinical Presentation

A 38-year-old left hand dominant woman is seeking treatment for a tender mass in the palm of her hand. The patient had fallen with a glass bottle in her hand 2 weeks earlier and had sustained a puncture wound to the ulnar aspect of her right palm. At that time active arterial bleeding persisted despite direct pressure on the wound with a compressive dressing. She was originally treated in the emergency department with irrigation and exploration with cauterization of a “superficial” vessel and wound closure.

Physical Examination

Removal of her sutures of the skin resulted in pulsatile bleeding from the wound. The bleeding continued despite direct manual compression on the wound (Fig. 24–1). Manual compression of the ulnar and radial arteries individually at the wrist crease did not stop the bleeding. Bleeding only ceased with manual compression of both arteries. The Allen’s test was performed and found the ulnar artery not patent. The color of the hand when performing the Allen’s test, to the ulnar side of the wrist, showed lack of perfusion to the radial side of the wrist (Fig. 24–2).

PEARLS

Use of a tourniquet and appropriate anesthesia for adequate visualization and microscopic dissection of the artery
Meticulous microscopic dissection with tension-free anastomosis
Postoperative supervised therapy and appropriate incision care

PITFALLS

Vein graft selection too small
Inadequate graft length or anastomosis sewn under tension
Failure to maintain proper graft orientation

Diagnostic Studies

Radiographs of the patient’s hand were obtained. Doppler flow assessment, pulse volume recordings, and angiography were also obtained. Angiography provided definitive information regarding the location and extent of arterial injury (Fig. 24–3).

Figure 24–1. Manual compression of the wrist with a saturated dressing in the patient with persistent bleeding.

Figure 24–2. The Allen test. (A) Compression of both the ulnar and radial arteries. (B) Demonstrating no blood flow to the hand. (C) Release of only the radial artery in this example gives a negative test for the radial artery. (D) Release of only the ulnar artery in this example gives a positive Allen test for the ulnar artery.

Figure 24–3. (A) Arteriography of the forearm and digital subtraction angiography of the palm. (B) Close-up view of the palm.

Differential Diagnosis

Ganglions

Nerve tumors

Other soft tissue masses

Raynaud’s disease

Pseudoanerysm of the palm

Diagnosis

Pseudoaneurysm of the Palm

Aneurysms are classified into two groups: traumatic and nontraumatic. Traumatic aneurysms can be subgrouped into true and false aneurysms. True aneurysms occur after blunt trauma to the upper extremity. These arise from occupational hazards, thoracic outlet syndrome, or a malignancy. Damage occurs to the arterial wall media to cause vessel dilation.

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