Aneurysm of the Radial Artery in the Anatomical Snuff Box
Article Outline
Abstract
Aneurysms of the radial artery are uncommon; most of the recorded cases occurred after trauma. We report a case of true aneurysm of radial artery in the anatomical snuff box in a 63-year-old healthy non-smoking woman with no history of trauma. The Duplex scan and the MRA confirmed the presence of the aneurysm of the distal radial artery, approximately 1.1 by 1.0
cm. We checked the patency of the palmar collateral circle by a preoperative and intraoperative Allen's test with a hand held Doppler. We ligated the radial artery and excised the aneurysm. The histopathologic study showed a non-specific aneurysm without specific alterations, excluding atherosclerotic or micotic nature.
1. Introduction
Aneurysms of the radial artery are uncommon. Most of the recorded cases occurred after trauma at the level of the wrist or infection1, 2; atherosclerotic aneurysms are rare. We report a case of true aneurysm of radial artery in the anatomical snuff box and we discuss the operative and pathologic findings.
2. Case Report
A pulsating mass had been noticed 6 months ago in the anatomical snuff box of the right hand of a 63-year-old healthy nonsmoking woman. She was a housewife and there was no history of trauma or previous infections. The mass had since grown progressively.
Physical examination reveals a pulsating mass with no audible systolic bruit or thrill; the mass was compressible and it filled rapidly when the compressive force is released.
The duplex scan showed a fusiform aneurysm of radial artery located in the anatomical snuff box, approximately 1.1 by 1.0cm. A MRI scan confirmed the presence of the aneurysm of the distal radial artery in the segment included from the origin of carpus dorsalis to principal thumb's artery (Fig. 1).
Fig. 1.
RMA scan showing an isolated aneurysm of radial artery in the snuff box.
No similar mass or other aneurysms were noted elsewhere on physical examination and with duplex scan.
Considering the likelihood of rupture or thromboembolic complications, a surgical correction was performed under local anaesthesia.
We checked the patency of the palmar collateral circle by a preoperative and intraoperative Allen's test with a hand held Doppler. An incision was made in the anatomical snuff box and the thumb's long tendon was moved to permit the exposure of the aneurysm. The radial artery was ligated and the aneurysm was excised and kept for histopathologic study.
After surgery, the motility and sensibility of the thumb and all four digits remained normal.
The patient was discharged 2 days after surgery without complications and 3 weeks later she had resumed normal daily activities.
The histological specimen showed an arterial wall without endothelium and non recognizable intima-medial structure and lamina muscolaris in part replaced by collagen tissue. This suggested an aneurysm without specific alterations, excluding atherosclerotic or micotic causes (Fig. 2).
Fig. 2.
Wall artery with no recognizable intima-medial structure and lamina muscolaris in part replaced by collagen tissue.
3. Discussion
Aneurysms involving the distal artery of upper extremities are uncommon and are usually secondary to penetrating trauma or iatrogenic injury. Blunt trauma is an extremely rare cause. Radial artery aneurysms in the anatomical snuff box or in the hand are rare and can be adequately treated with prompt recognition and surgical excision.
Walton describes a case of idiopathic radial artery in the snuff box in a well 40-year-old left-handed male computer operator confirmed by MRI scan, but in view of his lack of symptoms the patient declined surgical intervention.3
De Broux describes a case of mycotic aneurysm of the palmar arch after endocarditis, and the superficial palmar arch was reconstructed with a end to end anastomosis.2
Clagett describes a traumatic aneurysmal degeneration of the ulnar artery as a result of repeated compression on the hamate bone. The treatment of the aneurysms, ligation or reconstruction, is dependent on the patency of collateral circle.4
Two cases of traumatic aneurysm of the radial artery at the wrist were presented by Turowski1 and a case of radial artery aneurysm in patient affected of neurofibromatosis was described by Singh;5 in both cases the artery was ligated and the aneurysm excised.
Dennis described two cases, with history of minor trauma, presenting a radial artery aneurysm in the anatomical snuff box: histological examination indicated that both aneurysms were traumatic false aneurysm.6 The radial artery was ligated and the aneurysm was excised. Three cases of post traumatic aneurysm of the radial artery in the anatomical snuff box were previously described by Poirier.7
The distal ischemia may be due to a chronic damage of the vascular supply, peripheral emboli from a laminar clot, distal propagation of a thrombus, or ischemic effects of the aneurysm compounding atherosclerotic arterial disease.
Possible, but rare, is traumatic rupture of the aneurysm.
A careful medical history excluded a traumatic or iatrogenic injury as an etiologic mechanism in our case. The patient did not report previous infections.
The Allen's test is important to establish the patency of both ulnar and radial arteries and the Doppler examination verified the patency of superficial arterial arch and of collateral circle in order to make a safe ligation of radial artery. If collateral circulation is unsatisfactory, reconstruction of the artery is recommended.
References
- . Aneurysm of the radial artery following blunt trauma to the wrist. Ann Plast Surg. 1997;38(5):527–530
- . Mycotic aneurysm of the palmar arch after endocarditis. J Vasc Surg. 1997;26(5):
- . Idiopathic radial artery aneurysm in the anatomical snuff box. Acta Orthop Belg. 2002;68(3):292–294
- Clagett GP. Upper extremity aneurysms. In: RUTHERFORD RB, ed. Vascular Surgery, 4th edition, 1995, vol.2, pp. 1119–1122.
- . Radial artery aneurysm in a case of neurofibromatosis. Br J Plastic Surg. 1998;51(7):564–565
- . Traumatic aneurysm of the radial artery in the anatomical snuff box—a report of two cases. The Hand. 1980;12(3):266–270
- . Arterial aneurysms of the hand. Am J Surg. 1972;124:72–74
PII: S1533-3167(06)00050-1
doi:10.1016/j.ejvsextra.2006.02.001
© 2006 Elsevier Ltd. All rights reserved.
