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EJVES Vascular Forum (2020) 49, 34e39

CASE REPORT

True Idiopathic Radial Artery Aneurysm: A Case Report and Review of


Current Literature
YM Madeline Chee *, Pei Shi Lew, MJ Darryl Lim
Department of Surgery, Changi General Hospital, Singapore

Introduction: True non-traumatic radial artery aneurysms (RAAs) are extremely rare, and few cases have been
described. The majority of RAAs are post-traumatic or iatrogenic pseudo-aneurysms following arterial
cannulation. However, RAAs due to other causes have also been described. Here a rare case of true idiopathic
distal RAA, which was managed by surgical resection and repair with interposition vein graft, is described.
Report: A 62 year old female with a known medical history of hypertension and hyperlipidaemia presented with
left wrist swelling of one year duration, associated with a pulsatile lump that was increasing in size. Duplex
ultrasound and computed tomography angiography revealed a distal RAA. She underwent open surgical resection
and repair with interposition vein graft using the distal left cephalic vein. Histopathology of the specimen
revealed an aneurysm with atherosclerosis. She recovered well post-operatively with no complications.
Discussion: True idiopathic RAAs are rare. Surgical treatment is almost always recommended in view of the risk of
complications. A case of true idiopathic distal RAA is presented here, which was managed successfully by surgical
resection and repair with interposition vein graft.
Ó 2020 Published by Elsevier Ltd on behalf of European Society for Vascular Surgery. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Article history: Received 10 July 2020, Revised 3 October 2020, Accepted 4 November 2020,
Keywords: Idiopathic, Interposition graft, Radial artery, True aneurysm

INTRODUCTION CASE REPORT


True non-traumatic radial artery aneurysms (RAAs) are rare A 62 year old female with a known medical history of hy-
and have only been described in a few case reports in the pertension and hyperlipidaemia presented with left wrist
current literature. As with other blood vessels, the radial swelling of one year duration, associated with a pulsatile
artery is defined as aneurysmal if there is focal dilatation of lump that was gradually increasing in size (Fig. 1). She was
the artery that has a diameter more than 1.5 times the right handed and a retired accountant. She denied any
normal diameter of the artery; the normal diameter of the previous trauma, injury, surgery, or instrumentation
radial artery is about 2e3 mm. A true RAA is defined as (including punctures or arterial cannulation) to the area and
dilatation of the artery containing all components of the did not have any personal or family history of aneurysmal or
arterial wall, usually occurring secondary to arterial wall connective tissue disease. On physical examination, there
weakening. The majority of RAAs are post-traumatic or was a pulsatile lump over the left wrist in the area of the
iatrogenic pseudo-aneurysms following arterial cannula- anatomical snuffbox proximal to the radial branch con-
tion.1 However, RAAs due to other causes have also been necting with the arch. Both ulnar and radial pulses were
described, such as connective tissue disorders2,3 and strong with a normal modified Allen’s test. There were no
vascular tumours.4 RAAs occurring in the anatomical signs of other arterial aneurysms on examination and no
snuffbox are extremely rare with very few cases reported. A pulsatile abdominal mass. Duplex ultrasound and computed
rare case of true idiopathic distal RAA is presented here, tomography angiography revealed a fusiform aneurysm of
which was managed by surgical resection and repair with the left distal radial artery measuring approximately 1.2 
interposition vein graft. 0.7 cm (Fig. 2). There was no evidence of aneurysm else-
Full written informed consent from the patient was ob- where in the upper extremity, trauma, previous fractures, or
tained for publishing this article and images. bone lesions on imaging.
Based on the size of the aneurysm, potential risk of
* Corresponding author. Department of Surgery, Changi General Hospital, embolisation and her symptoms, the patient decided to
2 Simei Street 3, 529889, Singapore. undergo definitive surgical treatment. Open surgical resec-
E-mail address: madeline.chee@gmail.com (YM Madeline Chee). tion and repair with interposition vein graft using the distal
2666-688X/Ó 2020 Published by Elsevier Ltd on behalf of European So- left cephalic vein was performed. The aneurysm was
ciety for Vascular Surgery. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
dissected, proximal and distal control were obtained, and
https://doi.org/10.1016/j.ejvsvf.2020.11.003 excision of the aneurysm was performed. In order to
True Idiopathic Radial Artery Aneurysm 35

Figure 1. Pre-operative photographs of the patient’s left hand showing a lump in the anatomical snuffbox (red arrows).

achieve a tension free repair, a segment of the left cephalic palpated radial pulse was strong with no neurovascular
vein at the incision site was harvested, and the radial artery deficits, and Duplex ultrasound showed that the repair was
defect was repaired with interposition vein graft by an end patent. Histopathology of the specimen revealed an aneu-
to end anastomosis (Fig. 3). The radial pulse was strong. rysm with atherosclerosis (Fig. 4).
Post-operatively, she recovered well with no complications.
She was discharged with analgesia, a short course of anti- DISCUSSION
biotics and her usual medications for hypertension (los- True RAAs are rare with a prevalence of 2.9% among all
artan) and hyperlipidaemia (atorvastatin). Aspirin was not aneurysms affecting the upper extremities and have only
prescribed due to allergy. During the latest follow up visit been described in few case reports in the current literature
(one month post-operatively) there were no complaints, the (Table 1). The majority of RAAs are post-traumatic or

Figure 2. (A) Duplex ultrasound and (B) computed tomography angiogram showing the distal radial artery aneurysm in the area of the
anatomical snuffbox.
36 YM Madeline Chee et al.

A B

C D
Figure 3. Intra-operative photographs showing (A,B) the radial artery aneurysm identified with proximal and distal control achieved, (C)
completed repair with cephalic vein interposition graft with end to end anastomosis, and (D) the resected radial artery aneurysm.

Figure 4. Histopathology images of the excised radial artery aneurysm with H&E (left) and EVG (right) stains. Sections of the vessel show
fibrotic and focally thinned out wall with loss of internal elastic lamina. There is also intimal thickening and atherosclerotic changes.
Table 1. Cases of true radial artery aneurysms published in English language to date.

True Idiopathic Radial Artery Aneurysm


No. Authors Age Sex Size of aneurysm (largest Aneurysm location Aetiology Diagnostic modality Treatment Outcome
diameter, mm)
1. Thorrens et al. 60 M 30 Anatomical snuffbox Idiopathic Angiography Surgical excision and Post-operative
(1966) primary end to side arteriogram confirmed
anastomosis patency of anastomosis
2. Malt et al. 56 M 20 Anatomical snuffbox Idiopathic Angiography Surgical excision and Small Post-operative
(1978) primary anastomosis haematoma; lost to follow
up
3. Turner et al. 55 M 20 Cubital fossa e proximal Idiopathic Angiography Surgical excision and Post-operative uneventful
(1988) radial artery just distal to primary end to end
posterior interosseous anastomosis
branch
4. Singh et al. 45 M Not stated Proximal radial artery over Neurofibromatosis I US duplex, CT Surgical excision and Post-op uneventful, no
(1998) proximal radial aspect of angiography radial artery ligation complications at six
forearm months follow up
5. Walton et al. 40 M 15 Anatomical snuffbox Idiopathic MR angiography Observation alone Not reported
(2002)
6. Luzzani et al. 63 F 11 Anatomical snuffbox Idiopathic US duplex, MR Surgical excision and Discharged two days post-
(2006) angiography radial artery ligation op without complications
7. Yaghoubian 77 M 15 Just distal to anatomical Idiopathic Angiography Observation alone No change in aneurysm
et al. (2006) snuffbox at base of thumb size, no symptoms at 14
months follow up
8. Behar et al. 62 M 19 Anatomical snuffbox at Repetitive US duplex Surgical excision and Post-op uneventful
(2007) base of thumb occupational injury radial artery ligation
(tailor)
9. Filis et al. 45 M 30 Wrist Idiopathic Angiography Surgical excision and Discharged two days post-
(2007) primary anastomosis of op, no complications at 12
radial artery to 2nd digital months follow up
artery, 1st digital artery
ligated
10. Yukios et al. 74 F 9 (right), five (left) Anatomical snuffbox Marfan’s syndrome US duplex Surgical excision and Discharged same day, no
(2009) radial artery ligation post-op complications
(right), observation (left)
11. Meira et al. 3 M 11 Proximal radial artery Idiopathic CT angiography Surgical excision and No complications 30 days
(2011) (2cm from radial artery radial artery ligation post-op
origin)
12. Jedynak et al. 60 M Not stated Anatomical snuffbox Idiopathic US duplex, CT Surgical excision and No complications three
(2012) angiography radial artery ligation months post-op
13. Gabriel et al. 49 M 18.8 Wrist Idiopathic US duplex Surgical excision and Post-op uneventful
(2013) radial artery ligation
14. Igari et al. 72 F 15 Anatomical snuffbox Idiopathic Not stated Surgical excision and No recurrence, ischaemia
(2013) radial artery ligation symptoms or post-op
complications at 42
months post-op

37
Continued
Table 1-continued

38
No. Authors Age Sex Size of aneurysm (largest Aneurysm location Aetiology Diagnostic modality Treatment Outcome
diameter, mm)
15. Santis et al. 48 F Multiple small fusiform Multiple e most proximal Neurofibromatosis I CT angiography Surgical excision and Discharged 10 days post-
(2013) aneurysms located 3cm below radial artery ligation op, no complications at
brachial artery bifurcation six months follow up
16. Shaabi et al. 65 F 20 Anatomical snuffbox Idiopathic CT angiography Surgical excision and Post-op uneventful
(2014) radial artery ligation
17. DeŞer et al. 25 M 20 Wrist Behçet’s disease US duplex Surgical excision and Post-op uneventful
(2017) radial artery ligation
18. Al-Zoubi et al. 61 M 30 Wrist Idiopathic US Doppler, CT Surgical excision and Discharged same day, no
(2018) angiography primary end to end post-op complications
anastomosis
19. Erdogan et al. 52 M 14 Anatomical snuffbox Idiopathic CT angiography Surgical excision with Discharged three days
(2018) primary end to end post-op, no lesion at three
anastomosis months on CT
reconstruction
20. Ghaffarian 25 M 6.3 Anatomical snuffbox Idiopathic US duplex, angiography Surgical excision and No complications at 10
et al. (2018) repair with interposition months post-op, duplex
great saphenous vein US shows patent vein
graft graft with normal hand
perfusion
21. Maalouly et al. 73 F 15 Anatomical snuffbox Idiopathic CT angiography Surgical excision and Discharged two days post-
(2019) radial artery ligation op, uneventful
22. Umana et al. 83 M 20 Proximal radial artery just Idiopathic US duplex, CT Surgical excision and Discharged 24h post-op,
(2019) distal to elbow crease, angiography primary end to end US duplex at six months
8cm distal to brachial anastomosis post-op shows patent
artery bifurcation radial artery
23. Wu et al. 65 M Not stated Wrist Snake bite Not done e diagnosed Surgical excision and Right forearm amputated
(2020) intra-op during radial artery ligation
emergency surgery
24. Chee et al. 62 F 12 Anatomical snuffbox Idiopathic US duplex, CT Surgical excision and Discharged one day post-
(2020) angiography repair with interposition op, no post-op
cephalic vein graft complications
CT ¼ computed tomography; US ¼ ultrasound.

YM Madeline Chee et al.


True Idiopathic Radial Artery Aneurysm 39

iatrogenic pseudo-aneurysms.1 Previous reports of true RAA CONCLUSION


aetiologies include mycotic, arteriosclerotic, idiopathic, and True idiopathic RAAs are rare. There are currently no
underlying vasculopathy. Patients may present with local- guidelines with regards to the risk of embolisation and
ised swelling, a pulsatile lump, pain due to nerve rupture, as well as management and indications for surgical
compression or rupture, or ischaemic symptoms secondary repair, but surgical treatment is almost always recom-
to thrombosis or distal embolisation. The most common mended in view of the risk of complications and can be
location for a distal RAA is at the level of the anatomical carried out with minimal morbidity. A rare case of true
snuffbox. The diagnosis is often confirmed with duplex ul- idiopathic distal RAA is presented, which was managed
trasound and/or computed tomography angiography. The successfully by surgical resection and repair with interpo-
risk of embolisation or rupture is unknown, but risk of sition vein graft.
rupture is presumed to be higher the more proximal the
location of the aneurysm,5 the larger the aneurysm, or in
the presence of thrombus within the aneurysm sac. FUNDING
A MEDLINE search using the terms “radial artery” and None.
“aneurysm” revealed 23 cases of true RAAs previously
published in English language since the first case described CONFLICT OF INTEREST
by Thorrens in 1966, presented in Table 1.
There are currently no guidelines for the management None.
and indications for surgical repair of RAAs; the existing
literature has reported management with observation APPENDIX A. SUPPLEMENTARY DATA
alone6 vs. surgical excision. Surgical treatment is almost
Supplementary data related to this article can be found at
always recommended in view of the risks of rupture, em-
https://doi.org/10.1016/j.ejvsvf.2020.11.003.
bolisation, distal ischaemia as well as the low morbidity of
repair, and in symptomatic RAAs.7 The choice of surgical
treatment depends on whether there is adequate perfusion REFERENCES
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