True Aneurysms of the Digital Artery: Case Report

Berish Strauch, MD, Bronx, NY, Charles Melone, MD, New York, NY, Steve A. McClain, MD, Bernard T. Lee, MD, Bronx, NY

True aneurysms of the digital arteries are extremely rare; a search of the literature in English yielded only 12 cases. An idiopathic true aneurysm of the radial digital artery of the small nger is described, with its clinical presentation and corresponding arteriogram. Microsurgical repair with an interposition vein graft was performed to re-establish the vascular anatomy. To our knowledge this is the rst such reconstruction reported. (J Hand Surg 2004;29A:54 58. Copyright 2004 by the American Society for Surgery of the Hand.) Key words: True aneurysm, digital artery, case report.

An aneurysm is dened as a permanent, localized dilation of an artery with a 50% increase in diameter over its expected normal diameter. Aneurysms are generally classied by location, cause, and appearance. Aneurysms can be classied by cause as traumatic and nontraumatic. Nontraumatic causes of peripheral artery aneurysms include mycotic, atherosclerotic, inammatory, and idiopathic.13 Traumatic aneurysms can be divided into true and false aneurysms. A true aneurysm is often associated with a history of blunt trauma. A contusion forms and damage to the arterial wall media causes weakness and dilation. Histologic examination shows arterial wall elements of muscle and elastin bers in the aneurysm wall1; all 3 layers of the arterial wall can be seen.
From the Department of Plastic and Reconstructive Surgery, Albert Einstein College of Medicine and Monteore Medical Center, Bronx, NY; Hand Surgery Center, Beth Israel Medical Center, New York, NY; and Division of Surgical Pathology, Albert Einstein College of Medicine and Monteore Medical Center, Bronx, NY. Received for publication April 1, 2003; accepted in revised form September 4, 2003. No benets in any form have been received or will be received by a commercial party related directly or indirectly to the subject of this article. Reprint requests: Berish Strauch, MD, 1625 Poplar St, Suite 200, Bronx, NY 10461. Copyright 2004 by the American Society for Surgery of the Hand 0363-5023/04/29A01-0010$30.00/0 doi:10.1016/j.jhsa.2003.09.012

A false aneurysm usually occurs after penetrating trauma to the arterial wall with hematoma formation. The hematoma is contained by the surrounding tissues and organizes. Histologic examination shows an organized thrombus with a brous wall that lacks arterial wall components.1 There is no evidence of muscle or elastic bers within the vessel wall, compared with a true aneurysm. True aneurysms of the digital arteries are extremely rare; a search of the literature in English yielded only 12 cases.1,4 11 An idiopathic true aneurysm of the radial digital artery of the small nger is described, with its clinical presentation and corresponding arteriogram. Microsurgical repair with an interposition vein graft was performed to re-establish the vascular anatomy. To our knowledge this is the rst reported case of a true aneurysm in which vascular reconstruction was performed with an interposition vein graft.

Case Report
A 32-year-old, right-hand dominant woman presented with a mass on the radial border of her right small nger. The mass had been present for several years and had increased in size over the previous year. The patient was experiencing increasing pain and discomfort over the involved area. No history of trauma was reported. The patient was otherwise

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results, revascularization with a reversed interposition vein graft was planned. The patient received general anesthesia and exploration was performed under tourniquet control. On exploration, a fusiform aneurysm was identied involving the radial digital artery (Fig. 3). The widest portion of the aneurysm was 0.5 cm and the total length was 4.0 cm. The digital nerve was identied and preserved. The mass was resected in its entirety with a resulting 4-cm gap. Microvascular reconstruction was performed with a reversed interposition vein graft taken from the ulnar aspect of the distal third of the palmar forearm. Blood ow was successfully re-established to the distal tip. The patient had an uneventful recovery with normal motion and sensibility. Doppler examination of the reconstruction showed good perfusion throughout the graft. Histologic examination of the specimen showed aneurysmal dilation, with elastin bers present in the arterial wall.

Figure 1. Preoperative view of right little nger shows a mass from a point distal to the distal interphalangeal joint crease to the midproximal phalanx. The mass was pulsatile.

healthy, had no other medical problems, and was not on any medications. On examination, there was a fusiform mass on the radial aspect of the small nger (Fig. 1). The mass had a blue discoloration and extended from the base of the proximal phalanx up to the proximal aspect of the distal phalanx. There was minimal pain on palpation; however, the mass was pulsatile and compressible. Sensibility was normal distal to the aneurysm according to the Strauch ten test.12 A digital Allens test was performed, and on release of the ulnar digital artery the nger remained blanched. Release of the aneurysmal side caused prompt lling of the nger. An arteriogram was obtained of the right hand (Fig. 2). The arteriogram conrmed the nding of an aneurysm on the radial aspect of the small nger extending from the proximal phalanx to the distal phalanx. The ulnar digital artery showed lling only to the middle phalanx. The patient was taken to the operating room for exploration of the nger. Given the preoperative ndings of the digital Allens test and the arteriogram

Figure 2. Preoperative arteriogram showing a 4-cmlong aneurysm in this subtraction study. Circulation to the ulnar aspect of the little nger is decreased.

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Figure 3. Intraoperative view of the dissected aneurysm.

Discussion
Aneurysms of the digital arteries are extremely rare. We found 12 cases in the English literature (listed in chronologic order in Table 1).1,4 11 Cases of false aneurysms reported in the literature are listed in Table 2.1,1321 A review of the literature conrms that the cause of true aneurysms of the digital artery, when known, is blunt trauma, whereas false aneurysms are predominantly caused by penetrating trauma. It is surprising, given the high incidence of hand trauma, that digital aneurysms are not seen more commonly. It has been postulated that the small caliber of a digital vessel would make a partial disruption more difcult.19 Blunt trauma would more likely produce a

thrombus rather than an aneurysm; penetrating injury would more likely sever the vessel. The pressure within a vessel is inversely proportional to its radius. A vessel with a small lumen, such as a digital artery, would require a much higher blood pressure for it to distend, compared with a vessel with a large lumen. Because the blood pressure in a digital vessel is relatively low, it follows that the incidence of aneurysmal dilation is also low.5 The most common symptom previously described is a tender, elastic mass. In approximately half of cases, the mass is pulsatile. Almost all the patients experienced pain at the site unrelated to lumenal patency. Other traditional symptoms of arterial insufciency, such as paresthesia, pallor, pulselessness, hypothermia, and cold intolerance, are rarely described. Complications of rupture and hemorrhage, which are observed in proximal aneurysms, have not been described in digital arteries.19 We found the digital Allens test to be particularly helpful in our case, predicting the arteriographic ndings. Diagnosis is traditionally conrmed by arteriogram. Delineation of lumen patency and perfusion of the contralateral digital artery are particularly helpful in determining treatment. In our case, we were able to determine inadequate perfusion through the contralateral digital artery and planned for revascularization with a vein graft. There have also been reports of diagnosis by magnetic resonance arteriogram.22 Other diagnostic modalities include bidirectional Doppler, digital plethysmography, and radionucleotide scanning.1 Early treatment of digital aneurysms is recommended for pain relief and avoidance of potential complications, such as rupture and thrombosis. Treatment of true aneurysms, is generally performed

Table 1. Review of Reports of True Aneurysms of the Digital Artery

Number 1 2 3 4 5 6 7 8 9 10 11 12 13 Author Layman et al Turner et al5 Dangles6 Ho et al1 Ho et al1 Ho et al1 Ho et al1 Trabulsy and Leftner7 Adant et al8 Yajima et al10 Yoshii et al9 Taniguchi et al11 Strauch et al
4

Year 1982 1984 1984 1987 1987 1987 1987 1992 1994 1995 2000 2002 2003

Digit Long Ring Thumb Index Small Ring Index Index Thumb Thumb Ring Thumb Small

Artery Ulnar Radial Ulnar Radial Ulnar Radial Radial Radial Radial Ulnar Ulnar Ulnar Radial

Histology True True True True True True True True True True True True True

Cause Blunt trauma Unknown Bowling Unknown Unknown Volleyball Unknown Unknown Hemophilia Baseball Golf Blunt trauma Unknown Excision Excision Excision Excision Excision Excision Excision Excision Excision Excision Excision Excision Excision

Treatment and and and and and and and and and and and and and ligation ligation ligation ligation ligation primary repair ligation ligation ligation ligation ligation ligation vein graft

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Table 2. Review of Reports of False Aneurysms of the Digital Artery

Number 1 2 3 4 5 6 7 8 9 10 11 12 Author Heuston Baruch14 Hentz et al15 Suzuki et al16 Hall and Watt17 Ho et al1 Ho et al1 Gracia and Ketchum18 Brunelli et al19 Brunelli et al19 Montoya et al20 Shidayama et al21
13

Year 1973 1977 1978 1980 1986 1987 1987 1987 1988 1988 1991 1992

Digit Small Thumb Long Thumb Small Thumb Small Long Ring Long Small Long

Artery Ulnar Ulnar Radial Ulnar Radial Radial Unknown Ulnar Ulnar Ulnar Radial Radial

Histology False False False False False False False False False False False False

Cause After fasciotomy Penetrating trauma Amputation stump Penetrating trauma Penetrating trauma Penetrating trauma Penetrating trauma Penetrating trauma Blunt trauma Blunt trauma Penetrating trauma Penetrating trauma

Treatment Excision Excision Excision Excision Excision Excision Excision Excision Excision Excision Excision Excision and and and and and and and and and and and and ligation ligation ligation ligation ligation ligation ligation ligation ligation vein graft ligation ligation

by excision of the lesion and ligation of the digital vessel. Given our physical ndings and radiographic results, we thought that microvascular reconstruction was necessary to avoid compromise of distal circulation. Our case was repaired with an interposition vein graft; cases of false aneurysms have been reported that were repaired also with a vein graft.19 Four cases have been reported of thrombosed thumb aneurysms repaired with a vein graft; however, no mention is made as to whether these lesions were true or false aneurysms.23 It has been suggested that, for patent lesions diagnosed by arteriography, lesions located in the proximal part of the nger, and lesions in manual workers and young patients, reconstruction of the artery to restore blood ow should be considered19 to provide for a more physiologic condition. It may prevent cold intolerance and tissue loss. Depending on the size of the lesion and defect in the artery, reconstruction can be performed by resection and primary end-to-end anastomosis, excision of the defect in the artery and placement of a vein patch, or placement of a reversed interposition vein graft. Great care must be taken to nd a vein graft of comparable size and caliber. In our case, we were left with a 4-cm gap; to traverse this distance a vein graft was necessary. It was taken from the forearm and provided a perfect size match for the involved artery.

References
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3. Leitner DW, Ross JS, Neary JR. Granulomatous radial arteritis with bilateral nontraumatic, true arterial aneurysms within the anatomic snuffbox. J Hand Surg 1985;10A:131 135. 4. Layman CD, Ogden LL, Lister GD. True aneurysm of digital artery. J Hand Surg 1982;7:617 618. 5. Turner S, Howard CB, Dallimore NS. A case report of a true aneurysm of a digital artery. J Hand Surg 1984;2B:205206. 6. Dangles CJ. True aneurysm of a thumb digital artery. J Hand Surg 1984;9A:444 445. 7. Trabulsy P, Leitner DW. A true aneurysm of a collateral branch of a proper digital artery. Ann Plast Surg 1992;29: 161163. 8. Adnat JP, Grattagliano B, Fissette J. True aneurysm of digital artery in hemophilia: a case report. Ann Chir Main 1994;13:278 281. 9. Yoshii S, Ikeda K, Murakami H. True aneurysm of the digital artery: case report and review. Scand J Plast Reconstr Hand Surg 2000;34:279 281. 10. Yajima H, Tamai S, Ono H. Aneurysms of the digital artery: a review and report of three cases. Microsurgery 1995;16: 566 570. 11. Taniguchi Y, Enyo Y, Tamaki T, Yoshida M. True aneurysm of a thumb digital artery in a radiographer: a case report. Hong Kong J Orthop Surg 2002;10:89 91. 12. Strauch B, Lang A, Ferder M, Keyes-Ford M, Freeman K, Newstein D: The ten test. Plast Reconstr Surg 1997; 924 930. 13. Hueston JT. Traumatic aneurysm of the digital artery: a complication of fasciectomy. Hand 1973;5:232234. 14. Baruch A. False aneurysm of the digital artery. Hand 1977; 9:195197. 15. Hentz V, Jackson I, Fogarty D. Case report: false aneurysm of the hand secondary to digital amputation. J Hand Surg 1978;3:199 200. 16. Suzuki K, Takahashi S, Nagakawa T. False aneurysm in a digital artery. J Hand Surg 1980;5:402 403. 17. Hall RF, Watt DH. Osseous changes due to a false aneurysm of the proper digital artery: a case report. J Hand Surg 1986;11A:440 443. 18. Hoidal CR, Hall AH. Pseudoaneurysm of a digital artery (letter). Ann Emerg Med 1987;16:830 831.

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The Journal of Hand Surgery / Vol. 29A No. 1 January 2004 matic false aneurysm of nger tip. Scand J Plast Reconstr Hand Surg 1992;26:113114. 22. Abouzahr MK, Coppa LM, Boxt LM. Aneurysms of the digital arteries: a case report and literature review. J Hand Surg 1997;33A:311315. 23. Adham MN, Seradge H. Treatment of thrombosed thumb artery aneurysm: a report of four cases. J Hand Surg 1997; 22A:750 752.

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