CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 9, October 2012
e6
AFRICA
compared to blunt vascular trauma where the clinical presentation
can be misleading.
Manifestations
The natural history of AA pseudoaneurysms is poorly understood.
Most aneurysms are likely to be asymptomatic despite there
being no reports supporting such an assessment. Among the
patients described in the surgical literature, a pulsatile mass of
the arm axilla with a bruit is a common presentation.
1-6
As is the
case for any aneurysm, rupture may occur. Spontaneous rupture
of an AA pseudoaneurysm has not been described, probably due
to the surrounding muscular protection.
Neurological symptoms may be the presenting symptoms
in some patients with large pseudoaneurysms due to primary
lesions or secondary compression of the brachial plexus. Mild
primary lesion and severe compression of the brachial plexus
was found in our patient. The question of initial brachial plexus
injury, which is described in up to 44% of these patients,
7-9
can
be answered by the delay in onset of the neurological symptoms.
Some patients, unlike this case, may suffer upper extremity
oedema resulting from venous and/or lymphatic compression.
A lymph node, pulsatile haematoma or axillary tumour may
be the differential diagnosis. Ultrasonography, arteriography,
CTA or MRI angiography are particularly useful to establish the
diagnosis and proceed to operative therapy.
1-6,9
Treatment
Operative intervention is recommended for all symptomatic
axillary artery aneurysms or pseudoaneurysms with
manifestations related to arm ischaemia, local discomfort or
brachial plexus compression. A diameter greater than 2 cm may
be considered the threshold in asymptomatic cases. Because of
its rarity, the natural history of asymptomatic pseudoaneurysms
is not known, therefore a threshold is difficult to define.
1-6
Due to
the high risk of embolisation, surgical management at a smaller
diameter is perhaps the best choice.
Several types of AA reconstructions have been proposed
according to the size, location and aetiology of the
pseudoaneurysm. The most common is resection or exclusion
of the aneurysm, with reconstruction using interposition with
a saphenous vein graft. Other options include a resection and
primary anastomosis, aneurysmorrhaphy and reconstruction
using a venous or prosthetic patch.
4-6,10
Surgery is the traditional definitive treatment even though
endovascular therapy is also now well established. Endovascular
therapy using stent grafts can be considered for patients with
extensive medical co-morbidities, making open operative repair
too risky. Patients with small non-compressive aneurysms and
no concomitant lesions may also be good candidates for the
endovascular approach.
1-3
In our patient, although endovascular treatment of this
lesion could seem attractive, we preferred to use an open
surgical technique. This allowed us to perform decompression
of the axillary fossa since the pseudoaneurysm was large, and to
explore the brachial plexus.
Conclusion
Despite its clinical magnitude, axillary artery pseudoaneurysms
are uncommon and the published experience of this condition is
limited. Surgical repair may control the aneurysm but morbidity
from brachial plexus injuries could leave the patient with poor
recovery of the upper extremity function.
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