Presentation, treatment, and outcomes of brachial artery aneurysms

Objective

Brachial artery aneurysms are rare entities that have typically been associated with trauma, infection, arteriovenous fistula creation, or connective tissue disorders. These aneurysms are often asymptomatic, but they can also cause local tenderness or thrombo-embolic events. Due to the very low incidence of true brachial artery aneurysms, there are no standardized guidelines on their optimal management.

Methods

From August 2000 to July 2022, all patients with a diagnosis of true brachial artery aneurysm were managed within our health care system. Demographic information, imaging findings, and operative details for these patients were collected.

Results

Twenty-three patients with a diagnosis of true brachial artery aneurysm were identified. The median age was 50.4 years (range, 1-75 years). Eighteen patients (78%) were male, and the mean body mass index was 25.8 ± 6.5 kg/m². Concomitant risk factors included hypertension in 18 (79%), a smoking history in 12 (52%), hyperlipidemia in nine (39%), and coronary artery disease in five (22%). Fifteen patients (65%) had a prior arterio-venous fistula created in the affected arm, 12 (52%) had a history of kidney transplant, and 10 (44%) were taking immunosuppressive medication. Four patients (18%) had a history of arterial aneurysm at other locations, and three (13%) had been diagnosed with a connective tissue disorder. Thirteen patients (57%) presented with symptoms of local or exertional pain, whereas 10 (44%) were asymptomatic. Ultrasound or computed tomography imaging was performed in all patients, with an average aneurysm size of 2.9 ± 2.0 cm. Eighteen patients (78%) underwent surgical repair (13 symptomatic and 5 asymptomatic). Surgical repair included resection of the aneurysm and brachio-brachial interposition/bypass graft placement with a reversed (n = 8; 61.5%) or non-reversed (n = 3; 23.1%) saphenous vein, ringed PTFE graft (n = 1; 7.7%), or cryopreserved graft (n = 1; 7.7%). Of the 18 patients who underwent surgical repair, two (11%) experienced a postoperative complication. One patient had a superficial wound infection managed with antibiotics, and the other patient underwent hematoma evacuation. There were no nerve injuries or distal embolization. At a median follow-up of 2.4 years (range, 0.1-18.9 years), five surgical patients were lost, and the remaining 10 of 13 grafts (77%) remained patent. Three patients developed asymptomatic graft occlusion, which were managed nonoperatively. Among the five asymptomatic patients who did not undergo aneurysm repair, two died awaiting transplant and another two were lost to follow-up. One patient’s aneurysm thrombosed at 1-year follow-up without causing symptoms.

Conclusions

Brachial artery aneurysm is diagnosed more commonly in male patients and in those who have a history of arteriovenous fistula creation or connective tissue disorder. Surgical repair of true brachial artery aneurysms should be recommended in all symptomatic patients. In asymptomatic patients, surgery was offered in the presence of aneurysms with intraluminal thrombus and diameter larger than 2.5 cm, with low morbidity. The type of repair is dictated by length of the aneurysm and presence of brachial artery redundancy, with patency of 81% at 2.4 years median follow-up.