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Pseudoaneurysm of the Common Digital Artery with Magnetic Resonance Imaging and Surgical Findings
Pseudoaneurysm of the Common Digital Artery with Magnetic Resonance Imaging and Surgical Findings Emrah Sayit,1 Melih Bagir,1 and Asli Tanrivermis Sayit,2 Samsun, Turkey
Pseudoaneurysms are rare and are most commonly caused by blunt trauma. Taking a clinical history and doing an examination are very helpful to clinicians in making a diagnosis. In addition, imaging methods are very useful in distinguishing a pseudoaneurysm from soft-tissue tumors. Early diagnosis and treatment are crucial in preventing the development of possible complications. The treatment approach varies according to the localization and size of the lesion and presence of complications. We present a casedwith imaging and surgical findingsdof a pseudoaneurysm in a 27-year-old male in the second web interval after a penetrating trauma.
INTRODUCTION Partial or complete disruption of a blood vessel wall causes a pseudoaneurysm.1 The most common cause of a pseudoaneurysm is iatrogenic arterial trauma. Other causes include repetitive microtrauma, blunt trauma, index finger amputation, and iatrogenic injury during surgery.2 Pseudoaneurysm is very rare in hands, especially digital artery pseudoaneurysms.2 In the review of the literature, few reports describe a pseudoaneurysm of the digital artery. Early diagnosis and treatment are very important in preventing complications of the digital artery pseudoaneurysm, such as distal embolism, ischemia, gangrene of the fingers, ulnar and digital nerve dysfunction, rupture, bone erosion, and joint destruction.3 In
Conflict of Interest: The authors declare that they have no conflicts of interest. 1
Department of Orthopaedics and Traumatology, Samsun Education and Research Hospital, Samsun, Turkey. 2 Department of Radiology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey.
Correspondence to: Asli Tanrivermis Sayit, Department of Radiology, K€orfez Mahallesi, Ondokuz Mayis University Faculty of Medicine, Atakum/Samsun 55105, Turkey; E-mail: draslitanrivermissayit@ gmail.com Ann Vasc Surg 2017; 42: 304.e7–304.e10 http://dx.doi.org/10.1016/j.avsg.2017.03.165 Ó 2017 Elsevier Inc. All rights reserved. Manuscript received: December 17, 2016; manuscript accepted: March 7, 2017; published online: 4 April 2017
addition, a pseudoaneurysm should be distinguished from other soft-tissue tumors of the hand. Imaging findings and taking a clinical history are very useful in differential diagnosis.3 We present a casedwith imaging and surgical findingsdof a common digital artery pseudoaneurysm in a 27-year-old male in the second web interval after a penetrating trauma.
CASE PRESENTATION A 27-year-old male was admitted to a hospital as a result of progressive swelling in the palmar surface of his left hand. A palmar skin lesion in the same region, due to a penetrating trauma with a glass, had been sutured in the emergency department 1 month before. Physical examination revealed a 2 cm in diameter pulsatile tender mass on the palmar surface of the left hand, between the heads of the second and third metacarpal bone (Fig. 1). The overlying skin was thin. An Allen test of the second and third finger was negative. There was a hypoesthesia on the ulnar side of the second finger. We suspected the presence of a pseudoaneurysm in light of the medical history of the patient and the pulsation of the mass. Using B mode ultrasonography (US), a 2-cm well-defined hypoechoic lesion was seen on the palmar surface of the left hand. Then, contrast-enhanced magnetic resonance imaging (MRI) was performed to distinguish the lesion from other soft-tissue tumors. The MRI demonstrated a well-defined round lesion 304.e7
304.e8 Case reports
Annals of Vascular Surgery
measuring 2 cm in the second web interval. The lesion was isointense to the muscle on T1 weighted images (WIs) (Fig. 2) and hyperintense to the muscle on T2 WI (Fig. 3). Pathologic contrast enhancement was not detected. The lesion was not suppressed in the fat-suppressed sequences. A thrombosed pseudoaneurysm was suspected to the patient due to the disappearance of pulsation and the lack of contrast enhancement. A Z incision was performed at the level of the second metacarpal head after an axillary nerve block. A pseudoaneurysm originating from the superficial palmar arch was excised and a direct end-to-end microanastomosis of the digital artery was completed without complications (Figs. 4 and 5). In addition, a damaged digital nerve was repaired. Histological examination confirmed the diagnosis of a pseudoaneurysm. Fig. 1. Preoperative appearance of the lesion and the color change in the skin.
DISCUSSION Pseudoaneurysms often occur as a result of partial injury of the blood vessel wall due to penetrating trauma. As a result of an injury, the blood is extravasated from the vessel wall into the outside, and a hematoma develops. The hematoma is in the soft tissue, and a fibrosis develops. The pulsatile flow continues, leading to a recanalization of the hematoma to form a false lumen.4 A pseudoaneurysm, also known as a false aneurysm, is blood that collects between the 2 outer layers of an artery. In true aneurysms, all 3 layers of the arterial wall (intima, media, and adventitia) are present.3 Upper extremity pseudoaneurysms account for 27% of all pseudoaneurysms. However, the incidence of a pseudoaneurysm due to penetrating trauma is unknown.4 Pseudoaneurysms are more likely to be found on the palm area of the hand, involving the superficial palmar arch rather than the deep arch. True aneurysms often involve the dorsal aspect of the hand and wrist.3 Knowing the medical history of the patient is useful in a differential diagnosis of a pseudoaneurysm. An aneurysm or a pseudoaneurysm should be considered in the presence of a pulsatile mass in the hand when the aneurysm is not filled with thrombosis, especially after trauma.5 Imaging methods can be used in making a differential diagnosis of the pseudoaneurysm to the soft-tissue tumors. US and a color Doppler US are the first imaging modalities because they are noninvasive, low cost, easily accessible, and are not ionized. MRI, MRI angiography, and conventional angiography
are much more preferable than US in evaluating vascular structures.3 Angiography is the most accurate imaging modality for making a diagnosis because it shows the anatomical detail of a pseudoaneurysm and its collateral circulation. However, it is not a preferred method because of potential complications, such as distal embolization.6,7 In addition, an MRI is usually preferred in evaluating vascular lesions, such as a pseudoaneurysm.5 MRI findings of a pseudoaneurysm vary depending on the presence of a thrombus or turbulent flow in the lesion. The signal characteristics within the pseudoaneurysm on T1and T2 WIs can be decreased or increased or can be isointense.3 Intensive contrast enhancement is seen after an intravenous contrast injection, but contrast enhancement can not be seen in thrombotic lesions. In our case, the lesion was isointense with muscle in T1 WI and hyperintense in T2 WI. The lesion was not suppressed in the fatsuppressed sequences. No contrast enhancement was observed after a gadolinium injection. A thrombosed pseudoaneurysm was considered in the preliminary diagnosis due to US, color Doppler US, and MRI findings and in light of the medical history of the patient. In addition, benign soft-tissue tumors, such as a ganglion cyst, hemangioma, lipoma, and schwannoma, and malignant soft-tissue tumors, such as epithelioid or synovial sarcoma, and tendon sheath fibrosarcoma, should be considered in the differential diagnosis.3,7 Lipomas are the most common softtissue tumors and are isointense with subcutaneous fat in all sequences. They are suppressed in the fat-
Volume 42, July 2017
Fig. 2. (A) and (B): Coronal T1 WI (A) demonstrates a well-defined homogeneous mass isointense with muscle (arrow) at the palmar aspect of the hand. Coronal
Case reports 304.e9
postcontrast T1 WI (B) reveals no enhancement (arrow). In addition, there is a contrast enhancement in the soft tissue around the lesion compatible with edema.
Fig. 3. Axial fat-saturated T2 WI shows a well-defined hyperintense mass (arrow) in the second web.
saturated sequences in an MRI. Ganglion cysts are the most common tumor in the hand and wrist. These lesions should be isointense to fluid on all pulse sequences, except for the proteinous content. They show peripheral enhancement after contrast injection.8 Hemangiomas are typically hyperintense on T2 WI. They can be lobulated and contain thin septations and low-signal areas.3,7 Malignant soft-tissue tumors are usually irregular and show heterogeneous contrast enhancement due to cystic or hemorrhagic components.3 The medical and surgical treatment approach for true and false aneurysms in digital arteries differs according to the size of the lesion, its anatomical location, and the presence of complications.3 Treatment approaches include resection with ligation, end-toend repair, or grafting; the option used depends on collateral flow and vasomotor tone.4 Simple excision
Fig. 4. The appearance of the dissected thrombosed pseudoaneurysm. The yellow arrow shows the proximal arterial connection.
and ligation are sufficient in the presence of adequate collateral circulation.6 Microsurgical interposition vein graft is preferred when end-to-end anastomosis cannot be done. If there is insufficient collateral flow, microsurgical reconstruction should be performed.6 In our case, end-to-end anastomosis was performed following excising the pseudoaneurysm.
304.e10 Case reports
Annals of Vascular Surgery
to vascular structures. In addition, MRI is very useful in distinguishing a pseudoaneurysm from other softtissue tumors. We presented a thrombosed pseudoaneurysm that occurred in the common digital artery in the second web after a penetrating trauma, with radiologic findings. REFERENCES
Fig. 5. The appearance of the dissected thrombosed pseudoaneurysm. The yellow arrow shows the distal arterial connection, and the red arrow shows the injured digital nerve.
CONCLUSION Pseudoaneurysms of the hand are rare. They usually occur due to penetrating trauma. Early diagnosis and treatment are very important in preventing possible complications. The most useful imaging modality is the MRI for evaluating the lesion and its relationship
1. Sakamoto A, Arai K. False aneurysm of the superficial palmar arch in a child: a case report. Cases J 2009;2:7985. 2. Taylor SA, Osei DA, Jain S, et al. Digital artery pseudoaneurysm following percutaneous trigger thumb release: a case report. J Bone Joint Surg Am 2012;94:e6. 3. Anderson SE, De Monaco D, Buechler U, et al. Imaging features of pseudoaneurysms of the hand in children and adults. AJR Am J Roentgenol 2003;180:659e64. 4. Lucchina S, Nistor A, Stricker H, et al. False aneurysm of the common digital artery. Is reconstruction with an arterial graft worth the efforts? A case report. Microsurgery 2011;31: 246e50. 5. Gull S, Spence RA, Loan W. Superficial palmar arch aneurysm after carpal tunnel decompression, a rare complication: a case report. Case Rep Med 2011;2011:595120. 6. Plant MA, Panchapakesan V. Digital artery pseudoaneurysm in a patient with previous radial artery harvest. Can J Plast Surg 2011;19:148e50. 7. Lee CH, Tandon A. Focal hand lesions: review and radiological approach. Insights Imaging 2014;5:301e19. 8. Agarwal A, Prakash M, Gupta P, et al. Soft tissue masses of hand: a radio-pathological correlation. Radiol Res Pract 2015;2015:752054. http://dx.doi.org/10.1155/2015/ 752054.
Pseudoaneurysms are rare and are most commonly caused by blunt trauma. Taking a clinical history and doing an examination are very helpful to clinicians in making a diagnosis. In addition, imaging methods are very useful in distinguishing a pseudoaneurysm from soft-tissue tumors. Early diagnosis and treatment are crucial in preventing the development of possible complications. The treatment approach varies according to the localization and size of the lesion and presence of complications. We present a casedwith imaging and surgical findingsdof a pseudoaneurysm in a 27-year-old male in the second web interval after a penetrating trauma.
INTRODUCTION Partial or complete disruption of a blood vessel wall causes a pseudoaneurysm.1 The most common cause of a pseudoaneurysm is iatrogenic arterial trauma. Other causes include repetitive microtrauma, blunt trauma, index finger amputation, and iatrogenic injury during surgery.2 Pseudoaneurysm is very rare in hands, especially digital artery pseudoaneurysms.2 In the review of the literature, few reports describe a pseudoaneurysm of the digital artery. Early diagnosis and treatment are very important in preventing complications of the digital artery pseudoaneurysm, such as distal embolism, ischemia, gangrene of the fingers, ulnar and digital nerve dysfunction, rupture, bone erosion, and joint destruction.3 In
Conflict of Interest: The authors declare that they have no conflicts of interest. 1
Department of Orthopaedics and Traumatology, Samsun Education and Research Hospital, Samsun, Turkey. 2 Department of Radiology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey.
Correspondence to: Asli Tanrivermis Sayit, Department of Radiology, K€orfez Mahallesi, Ondokuz Mayis University Faculty of Medicine, Atakum/Samsun 55105, Turkey; E-mail: draslitanrivermissayit@ gmail.com Ann Vasc Surg 2017; 42: 304.e7–304.e10 http://dx.doi.org/10.1016/j.avsg.2017.03.165 Ó 2017 Elsevier Inc. All rights reserved. Manuscript received: December 17, 2016; manuscript accepted: March 7, 2017; published online: 4 April 2017
addition, a pseudoaneurysm should be distinguished from other soft-tissue tumors of the hand. Imaging findings and taking a clinical history are very useful in differential diagnosis.3 We present a casedwith imaging and surgical findingsdof a common digital artery pseudoaneurysm in a 27-year-old male in the second web interval after a penetrating trauma.
CASE PRESENTATION A 27-year-old male was admitted to a hospital as a result of progressive swelling in the palmar surface of his left hand. A palmar skin lesion in the same region, due to a penetrating trauma with a glass, had been sutured in the emergency department 1 month before. Physical examination revealed a 2 cm in diameter pulsatile tender mass on the palmar surface of the left hand, between the heads of the second and third metacarpal bone (Fig. 1). The overlying skin was thin. An Allen test of the second and third finger was negative. There was a hypoesthesia on the ulnar side of the second finger. We suspected the presence of a pseudoaneurysm in light of the medical history of the patient and the pulsation of the mass. Using B mode ultrasonography (US), a 2-cm well-defined hypoechoic lesion was seen on the palmar surface of the left hand. Then, contrast-enhanced magnetic resonance imaging (MRI) was performed to distinguish the lesion from other soft-tissue tumors. The MRI demonstrated a well-defined round lesion 304.e7
304.e8 Case reports
Annals of Vascular Surgery
measuring 2 cm in the second web interval. The lesion was isointense to the muscle on T1 weighted images (WIs) (Fig. 2) and hyperintense to the muscle on T2 WI (Fig. 3). Pathologic contrast enhancement was not detected. The lesion was not suppressed in the fat-suppressed sequences. A thrombosed pseudoaneurysm was suspected to the patient due to the disappearance of pulsation and the lack of contrast enhancement. A Z incision was performed at the level of the second metacarpal head after an axillary nerve block. A pseudoaneurysm originating from the superficial palmar arch was excised and a direct end-to-end microanastomosis of the digital artery was completed without complications (Figs. 4 and 5). In addition, a damaged digital nerve was repaired. Histological examination confirmed the diagnosis of a pseudoaneurysm. Fig. 1. Preoperative appearance of the lesion and the color change in the skin.
DISCUSSION Pseudoaneurysms often occur as a result of partial injury of the blood vessel wall due to penetrating trauma. As a result of an injury, the blood is extravasated from the vessel wall into the outside, and a hematoma develops. The hematoma is in the soft tissue, and a fibrosis develops. The pulsatile flow continues, leading to a recanalization of the hematoma to form a false lumen.4 A pseudoaneurysm, also known as a false aneurysm, is blood that collects between the 2 outer layers of an artery. In true aneurysms, all 3 layers of the arterial wall (intima, media, and adventitia) are present.3 Upper extremity pseudoaneurysms account for 27% of all pseudoaneurysms. However, the incidence of a pseudoaneurysm due to penetrating trauma is unknown.4 Pseudoaneurysms are more likely to be found on the palm area of the hand, involving the superficial palmar arch rather than the deep arch. True aneurysms often involve the dorsal aspect of the hand and wrist.3 Knowing the medical history of the patient is useful in a differential diagnosis of a pseudoaneurysm. An aneurysm or a pseudoaneurysm should be considered in the presence of a pulsatile mass in the hand when the aneurysm is not filled with thrombosis, especially after trauma.5 Imaging methods can be used in making a differential diagnosis of the pseudoaneurysm to the soft-tissue tumors. US and a color Doppler US are the first imaging modalities because they are noninvasive, low cost, easily accessible, and are not ionized. MRI, MRI angiography, and conventional angiography
are much more preferable than US in evaluating vascular structures.3 Angiography is the most accurate imaging modality for making a diagnosis because it shows the anatomical detail of a pseudoaneurysm and its collateral circulation. However, it is not a preferred method because of potential complications, such as distal embolization.6,7 In addition, an MRI is usually preferred in evaluating vascular lesions, such as a pseudoaneurysm.5 MRI findings of a pseudoaneurysm vary depending on the presence of a thrombus or turbulent flow in the lesion. The signal characteristics within the pseudoaneurysm on T1and T2 WIs can be decreased or increased or can be isointense.3 Intensive contrast enhancement is seen after an intravenous contrast injection, but contrast enhancement can not be seen in thrombotic lesions. In our case, the lesion was isointense with muscle in T1 WI and hyperintense in T2 WI. The lesion was not suppressed in the fatsuppressed sequences. No contrast enhancement was observed after a gadolinium injection. A thrombosed pseudoaneurysm was considered in the preliminary diagnosis due to US, color Doppler US, and MRI findings and in light of the medical history of the patient. In addition, benign soft-tissue tumors, such as a ganglion cyst, hemangioma, lipoma, and schwannoma, and malignant soft-tissue tumors, such as epithelioid or synovial sarcoma, and tendon sheath fibrosarcoma, should be considered in the differential diagnosis.3,7 Lipomas are the most common softtissue tumors and are isointense with subcutaneous fat in all sequences. They are suppressed in the fat-
Volume 42, July 2017
Fig. 2. (A) and (B): Coronal T1 WI (A) demonstrates a well-defined homogeneous mass isointense with muscle (arrow) at the palmar aspect of the hand. Coronal
Case reports 304.e9
postcontrast T1 WI (B) reveals no enhancement (arrow). In addition, there is a contrast enhancement in the soft tissue around the lesion compatible with edema.
Fig. 3. Axial fat-saturated T2 WI shows a well-defined hyperintense mass (arrow) in the second web.
saturated sequences in an MRI. Ganglion cysts are the most common tumor in the hand and wrist. These lesions should be isointense to fluid on all pulse sequences, except for the proteinous content. They show peripheral enhancement after contrast injection.8 Hemangiomas are typically hyperintense on T2 WI. They can be lobulated and contain thin septations and low-signal areas.3,7 Malignant soft-tissue tumors are usually irregular and show heterogeneous contrast enhancement due to cystic or hemorrhagic components.3 The medical and surgical treatment approach for true and false aneurysms in digital arteries differs according to the size of the lesion, its anatomical location, and the presence of complications.3 Treatment approaches include resection with ligation, end-toend repair, or grafting; the option used depends on collateral flow and vasomotor tone.4 Simple excision
Fig. 4. The appearance of the dissected thrombosed pseudoaneurysm. The yellow arrow shows the proximal arterial connection.
and ligation are sufficient in the presence of adequate collateral circulation.6 Microsurgical interposition vein graft is preferred when end-to-end anastomosis cannot be done. If there is insufficient collateral flow, microsurgical reconstruction should be performed.6 In our case, end-to-end anastomosis was performed following excising the pseudoaneurysm.
304.e10 Case reports
Annals of Vascular Surgery
to vascular structures. In addition, MRI is very useful in distinguishing a pseudoaneurysm from other softtissue tumors. We presented a thrombosed pseudoaneurysm that occurred in the common digital artery in the second web after a penetrating trauma, with radiologic findings. REFERENCES
Fig. 5. The appearance of the dissected thrombosed pseudoaneurysm. The yellow arrow shows the distal arterial connection, and the red arrow shows the injured digital nerve.
CONCLUSION Pseudoaneurysms of the hand are rare. They usually occur due to penetrating trauma. Early diagnosis and treatment are very important in preventing possible complications. The most useful imaging modality is the MRI for evaluating the lesion and its relationship
1. Sakamoto A, Arai K. False aneurysm of the superficial palmar arch in a child: a case report. Cases J 2009;2:7985. 2. Taylor SA, Osei DA, Jain S, et al. Digital artery pseudoaneurysm following percutaneous trigger thumb release: a case report. J Bone Joint Surg Am 2012;94:e6. 3. Anderson SE, De Monaco D, Buechler U, et al. Imaging features of pseudoaneurysms of the hand in children and adults. AJR Am J Roentgenol 2003;180:659e64. 4. Lucchina S, Nistor A, Stricker H, et al. False aneurysm of the common digital artery. Is reconstruction with an arterial graft worth the efforts? A case report. Microsurgery 2011;31: 246e50. 5. Gull S, Spence RA, Loan W. Superficial palmar arch aneurysm after carpal tunnel decompression, a rare complication: a case report. Case Rep Med 2011;2011:595120. 6. Plant MA, Panchapakesan V. Digital artery pseudoaneurysm in a patient with previous radial artery harvest. Can J Plast Surg 2011;19:148e50. 7. Lee CH, Tandon A. Focal hand lesions: review and radiological approach. Insights Imaging 2014;5:301e19. 8. Agarwal A, Prakash M, Gupta P, et al. Soft tissue masses of hand: a radio-pathological correlation. Radiol Res Pract 2015;2015:752054. http://dx.doi.org/10.1155/2015/ 752054.