This is a presentation about a Bilateral brachial artery pseudoaneurysm acute rupture and repair with reverse saphenous vein graft.

1. Bilateral Brachial Artery Pseudoaneurysm W. Thomas McClellan, M.D. Duke Hand Club Kauai HI 2010

2. Title CM is a 42 year-old female who presented to the ED complaining of pulsatile bleeding from a small wound in her left antecubital fossa. Patient described a raised, tender “scab” in her left antecubitalfossa which had been present for 3 months. The lesion bled intermittently, but was controllable by application of pressure. On the day of presentation, the patient had picked the scab, and blood began “squirting from the area”

4. Raynaud’s Disease

5. Chronic Pain Syndrome

6. Depression

7. Bilateral sympathectomy and carpal tunnel release 10 years prior

8. Former smoker (20 pack-years)

10. Left PSA

11. Left PSA Bleeding

12. Left PSA Initial Dissection

13. Left PSA Disection

15. Video Left PSA Repair

16. Left PSA Arteriogram Post-op

17. Post-op Left PSA H/H fell to 8.1/23.3 – patient transfused 2 units PRBCs Intraoperative cultures demonstrated methicillin-sensitive Staphylococcus aureus, and antibiotics were adjusted accordingly Patient met with psychiatrist and drug counselor prior to discharge on POD #3

18. Developed pain on r Approximately 2 months after her left pseudoaneurysm repair, CM developed worsening pain, increased finger cyanosis and episodic bleeding from the right side

19. Right hand Pre-op

20. Right PSA Arteriogram

21. Pre-op Right PSA

22. Right PSA Dissected

23. Right PSA Repair

25. What is a pseudoaneurysm? Disruption of the vessel wall leading to extravasation of blood which is contained by surrounding tissues Etiology Penetrating injury most commonly Stab wounds, iatrogenic arterial injury, IVDA Other causes include infection, connective tissue disease, bacterial endocarditis Mechanisms at work in the IV drug user Direct trauma, peri-vascular abscess, chemical arteritis

26. Epidemiology A study by Tsao et al. estimates the annual prevalence of arterial pseudoaneurysm in IV drug users presenting to the ED to be 0.03% Pseudoaneurysm secondary to drug abuse has been reported in the subclavian, axillary, brachial, radial, external iliac, femoral, popliteal, and carotid arteries The femoral artery is the most common location, as the groin is a preferred injection site One report of Bilateral PSA

27. Sign and Syptoms Painful, expanding mass Overlying erythema and induration Pulsatility, a palpable thrill, or audible bruit Paresthesias Loss of pulses and evidence of ischemia in the distal extremity – decreased temperature, pallor, cyanosis The triad of infected pseudoaneurysm – pus, blood, and a pulsatile mass – Staph A. most common Arterial thrombi may develop in the pseudoaneurysm cavity, giving rise to embolic events distally

28. Diagnosis Duplex Ultrasound Least invasive method for confirming diagnosis Flow within the cavity produces the characteristic “yin-yang” sign “to-and-fro” signal at the neck as flow enters and exits during systole and diastole

29. Diagnosis CT Angiography More invasive, but better for demonstrating arterial anatomy and defining surrounding structures Invasive angiography Gold standard, particularly for surgical planning Most reliable for defining arterial anatomy, anatomic variants, and involvement of other vessels

30. Non-surgical options: Simple compression Ultrasound-guided compression Ultrasound-guided thrombin injection Percutaneous coil embolization Given the extensive damage and presence of infection often seen in IV drug users, resection of the pseudoaneurysm and removal of infected and necrotic tissue is often required

31. Debate exists over treatment by excision and primary grafting or simple excision and ligation of the brachial artery Simple exision and ligation avoids the risks of graft sepsis and hemorrhage, as well as the risk of the patient using the graft for continued drug injection 75% experience forearm claudication during exericse following brachial artery occlusion IV drug users may not have the collateral blood flow necessary to prevent ischemia and gangrene of the extremity Patient was showing signs of distal ischemia preoperatively, immediate revascularization was warranted

32. References 1. Gow KW, Mykytenko J, Patrick EL, Dodoson TF. Brachial artery pseudoaneurysm in a 6-week-old infant. Am Surg. 2004; 70(6): 518-521. 2. Forde JC, Conneely JB, Aly S. Delayed presentation of a traumatic brachial artery pseudoaneurysm. Turkish Journal of Trauma & Emergency Surgery. 2009; 15(5): 515-517. 3. Tsau JW, Marder SR, Goldstone J, Bloom AI. Presentation, diagnosis, and management of arterial mycoticpseudoaneurysms in injection drug users. Ann Vasc Surg. 2002; 16(5): 652-662. 4. Yetkin U, Gurbuz A. Post-traumatic pseudoaneurysm of the brachial artery and its surgical treatment. Tex Heart Inst J. 2003; 30(4): 293-297. 5. Panagiotopoulos E, Athanaselis E, Matzaroglou C, Kasimatis G, Gliatis J, Tsolakis I. Compound and acutely ruptured false aneurysm of the brachial artery: A case report. J Med Case Reports. 2009; 3: 6627-6630. 6. Siu WT, Yau KK, Cheung YS, et al. Management of brachial artery pseudoaneurysms secondary to drug abuse. Ann Vasc Surg. 2005; 19(5): 657-661. 7. Tan K-K, Chen K, Chia K-H, Lee C-W, Nalachandran S. Surgical management of infected pseduoaneurysms in intravenous drug abusers: Single institution experience and a proposed algorithm. World J Surg. 2009; 33(9): 1830-1835. 8. Georgiadis GS, Bessias NC, Pavlidis PM, Pomoni M, Batakis N, Lazarides MK. Infected false aneurysms of the limbs secondary to chronic intravenous drug abuse: Analysis of perioperative considerations and operative outcomes. Surg Today. 2007; 37(10): 837-844. 9. Leon LR, Psalms SB, Labropoulos N, Mills JL. Infected upper extremity aneurysms: A review. Eur J VascEndovasc Surg. 2008; 35(3):320-331. 10. Wahlgren C-M, Lohman R, Pearce BJ, Spiguel LRP, Dorafshar A, Skelly CL. Metachronous giant brachial artery pseudoaneurysms: A case report and review of the literature. VascEndovasc Surg. 2007; 41(5): 467-472.

33. Mahalonuiloa!