Posttraumatic Pseudoaneurysm of the Axillary Artery Successfully Treated with a Stentgraft
Article Outline
We present the first case of a posttraumatic pseudoaneurysm of the axillary artery successfully treated with a stentgraft.
A 89-year-old woman with a conservatively treated subcapital humeral fracture developed a pseudoaneurysm of the left axillary artery which was percutaneously successfully treated with a stentgraft. Endovascular repair of a traumatic axillary artery pseudoaneurysm should be considered especially in unfit patients.
Keywords: Axillary artery, Stentgraft, Subcapital humeral fracture
Introduction
The incidence of subcapital humeral fractures is increasing because of an increasing number of osteoporosis related fractures in elderly patients.1 High age in patients and the presence of osteoporosis are not ideal factors for primary surgical repair of fractures.
Less than 1 per cent of all fractures are dislocated subcapital humeral fractures. With this type of fracture the neurovascular bundle is at risk for injury. This bundle contains the brachial plexus and the axillary artery.2
Only few cases have been published that describe endovascular repair of a post-traumatic pseudoaneurysm of a subclavian artery due to a fracture of the clavicula.1, 3 We herein present the first case of successful endovascular repair of a post-traumatic pseudoaneurysm of the axillary artery caused by a subcapital humeral fracture.
Case Report
A 89-year-old woman was admitted to our hospital because of serious dehydration. She had a history of osteoporosis and had been treated in another hospital eight weeks previously for a subcapital humeral fracture on the left side. Because of her advanced age and poor general condition her fracture had been treated conservatively.
During her admission in our hospital the pain in her left arm increased. Large ecchymosis was seen on the backside of the shoulder and the movements of her arm were limited. There were no signs of neurological deficit. The lab results showed a hemoglobine of 4.4
mmol/L, which had been 7.4mmol/L a week previously. A plain radiograph showed progressive dislocation of the humeral fragments compared with the one that had been made eight weeks previously (Fig. 1). On colour Doppler ultrasound there was a pseudoaneurysm probably originating from the left axillary artery. These findings were confirmed on CT Angiography (CTA) which showed a pseudoaneurysm, 5cm in diameter, with enough neck of the axillary artery to keep clear of the vertebral artery. The subclavian artery had a diameter of 7mm proximal of the pseudoaneurysm and the axillary artery distal of the pseudoaneurysm was 6mm. The pseudoaneurysm was considered suitable for endovascular stent-grafting (Fig. 2A, B). Angiography was performed by entering the right common femoral artery and an 80×8mm self expandable nitinol stentgraft (Fluency, Bard®, Karlsruhe, Germany) was placed in the left axillary artery. Control CTA after six days showed a good position of the stentgraft without any leakage (Fig. 2A, B). There was no more blood loss and three weeks later the patient was discharged from the hospital without signs and symptoms of bleeding. A few weeks later she died of old age in a nursing home.
Fig. 1
Left: subcapital humeral fracture eight weeks before admission. Right: Dislocated subcapital humeral fracture during admission.
Fig. 2
A. Angiography showing filling of false aneurysm (arrows) of left axillary artery. B. Control Angiography after stentgraft placement shows a good position of the stentgraft without filling of the pseudoaneurysm.
Discussion
Proximal humeral fractures are common and represent about 5 per cent of all fractures.4 Injuries of the subclavian or axillary artery are rare and most commonly caused by penetrating trauma.3 Many cases have been reported that describe operative reconstruction of a injured vessel of the upper extremity. However, it can be challenging to expose the injured vessel adequately. Recent development in endovascular techniques may enable minimal invasive treatment of injured bloodvessels and pseudoaneurysms. The remote access site is one of the greatest benefits of this technique. Stentgrafts may be composed of rigid or flexible material. One of the complications of a rigid stentgraft is a fracture of the stent, especially in areas that are exposed to bending and compressing forces. In this case a flexible stentgraft was used to avoid this complication. However, there are no long-term follow-up studies to evaluate endovascular repair of (post-traumatic) pseudoaneurysms treated with stentgrafts.
Conclusion
Endovascular repair of a traumatic axillary artery aneurysm should be considered especially in patients not suitable for open surgery.
References
- . Displaced proximal humeral fractures. I. Classification and evaluation. J Bone Joint Surg Am. 1970 Sep;52(6):1077–1089
- . Neurovascular injury complicating displaced proximal fractures of the humerus. Injury. 1987;18(6):423–425
- . Endovascular treatment of a pseudoaneurysm of the subclavian artery. J Trauma. 2003;55:969–971
- . Update in the epidemiology of proximal humerus fractures. Clin Orthop Relat Res. 2006;442:87–92
PII: S1533-3167(07)00032-5
doi:10.1016/j.ejvsextra.2007.09.002
© 2007 Published by Elsevier Inc.
