Delayed Presentation of a Traumatic Radial Artery Pseudoaneurysm

Abstract

<h3>Introduction & Objective</h3> Radial artery pseudoaneurysms are rare and almost exclusively iatrogenic in origin. Post- traumatic radial artery pseudoaneurysms are even more uncommon, and relevant literature is limited to few case reports which mainly describe an acute presentation and management via external compression, thrombin injection, resection and bypass graft, or radial artery ligation. This case describes a rare diagnosis of traumatic radial artery pseudoaneurysm with a delayed presentation and successful resection with primary end-to-end anastomosis. <h3>Case Report</h3> A 29-year-old right-handed man sustained gunshot wounds to his bilateral forearms. He underwent surgical intervention on his left forearm at an outside institution; his right forearm was managed conservatively. His right forearm was asymptomatic until about one-week post-injury when he lifted groceries and experienced acute forearm pain and subsequent edema. He gradually developed a right forearm mass and increasing pain until 22 days post-injury when he noted decreased right-hand motor function, prompting presentation to our emergency department. A ∼1 cm pulsatile mass on the volar right forearm was noted, and his right proximal and distal interphalangeal joints were in flexion with limited weak extension (Figure 1Figure 1Preoperative Appearance of Right Forearm & HandFigure 1). Volar compartment pressure was normal. CT arteriogram revealed a right forearm hematoma and adjacent short segment of radial artery non-visualization. Ultrasound detailed a 1.4 cm pseudoaneurysm of the right radial artery (Figure 2Figure 2Ultrasound of Pseudoaneurysm with Pathognomonic "Yin-Yang" SignFigure 2) with distal reversal of flow and biphasic doppler signals. Ulnar and palmar arch doppler signals were triphasic with radial artery occlusion. We proceeded to the operating room for right forearm exploration and a large hematoma was evacuated. The radial artery pseudoaneurysm had active extravasation from an anterolateral 7mm segmental disruption of over 50% circumference (Figure 3Figure 3Radial Artery Segmental DisruptionFigure 3). The pseudoaneurysm was resected, and successful tension- free repair performed via primary end-to-end anastomosis (Figure 4Figure 4Radial Artery Following Pseudoaneurysm Resection & Primary AnastomosisFigure 4). At procedure completion triphasic distal radial artery and palmar arch doppler signals were identified. His right-hand motor function significantly improved immediately after surgery, with return to baseline over the following days. At one month follow-up his right radial pulse remained palpable and right hand had no residual deficit. <h3>Discussion</h3> Radial artery pseudoaneurysms are uncommon, but with progressive widespread adoption of trans-radial access for cardiac catheterization and recent literature on growing applications for noncoronary endovascular procedures the incidence is expected to rise. Radial artery pseudoaneurysms can carry significant morbidity including compartment syndrome, critical limb ischemia, and digital necrosis. Providers performing trans-radial procedures should maintain a high index of suspicion for this complication to avoid compromise of functional status and optimize patient outcomes.