Aneurysm of Brachial Artery Following Axillary Crutch

Dear Editor, True aneurysm of brachial artery, just distal to axillary artery, is relatively rare. Moreover, this type of aneurysm following usage of axillary crutch has not reported in the literature. Furthermore, this entity presenting as Reynaud’s disease has not been described; though microemboli following subclavio-axillary artery aneurysm (arterial thoracic outlet syndrome) is well-defined. We report a case of large fusiform aneurysm of the brachial artery, following long time usage of unilateral axillary crutch, complicated by Reynaud’s phenomenon and complete outflow obstruction that presented as acute limb ischemia. A 64-year-old man was referred to the emergency unit, with symptoms and signs of acute limb ischemia of right upper extremity. The patient recounted that he had elective right cervical sympathectomy because of painful and non-healing ulcer of the tip of index finger. Following repeated coldness and painful events of his hand, all affected fingers of the hand became atrophic with decreased range of motion. On examination, the hand was cold and painful, without palpable pulses distal to the axillary artery. There was a palpable fusiform mass about 5x3 centimeter compatible with brachial artery, just distal to the axillary artery. The other peripheral pulses were normal. The right fingers showed signs of acute ischemia. His comorbidity included above-the-knee amputation of ipsilateral lower extremity in childhood following traffic accident. After that, he spent 50 years on unilateral crutch (Figure 1A). He was a cigarette smoker one pack/day for 45 years. A duplex scan demonstrated a normal triphasic flow in axillary artery, but biphasic pattern in distal brachial and forearm arteries. CT angiography revealed a cut-off in proximal part of the brachial artery and run-off the distal part (Figure 1B). The patient underwent emergency exploration of the right brachial artery. There was a fusiform aneurysm just distal to the axillary artery that obstructed it completely. The affected segment was removed and replaced by a saphenous vein graft. The affected hand became warm similar to contralateral hand, but digital pulses did not recover, though wrist pulses became palpable but diminished in comparison to the other side. Histology of the specimen confirmed a fibrous-walled saccular true aneurysm 2.5 centimeter diameter, containing organized and fresh thromboses. All three layers of the aneurysmal artery were intact, with atheromatous changes of intimo-medial layer.