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Department of Surgery

Brachial Artery Aneursym with “Blue FingerSyndrome” After Ligation of an Arterio-VenousFistulaRamon Garza, III MDLehigh Valley Health Network, Ramon.Garzaiii@lvhn.org

Dale A. Dangleben MDLehigh Valley Health Network, Dale_A.Dangleben@lvhn.org

John F. Welkie MDLehigh Valley Health Network, John.Welkie@lvhn.org

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Published In/Presented AtGarza, R., Dangleben, D. A., Welkie, J. F. (2010, November). Brachial Artery Aneurysm with “Blue Finger Syndrome” After Ligation of anArterio-Venous Fistula. Poster presented at: Keystone ACS, Harrisburg, PA.

IntroductIon As early as the 18th century, arterial dilation and large brachial artery aneurysms have been described following arterio-venous (AV) fistula ligation.1,2 Studies from Rubanyi et al. have shown that high blood flow triggers the release of relaxing substances from endothelial cells which leads to dilatation of the artery receiving high flow.3 According to Eugster et al., arterial dilatation is locally mediated by these relaxing substances.4 In addition, longstanding high flow leads to transverse tears in the internal elastic membrane which can cause proximal progression the dilatation from the site of the fistula.5,6 Other studies suggest that immunosuppression with corticosteroids may promote the development of arterial aneurysms.4 The combination of these factors presents a unique situation in renal transplant patients with AV fistulas. We describe a corticosteroid, immunosuppressed, renal transplant patient with pandilatation of his brachial artery following ligation of a brachial cephalic AV fistula.

case report A 47-year-old male was admitted to our hospital with a chief complaint of pain and discoloration of the distal finger tips on his right hand. The patient had a past medical history significant for polycystic kidney disease resulting in renal failure. He underwent a right upper extremity A-V fistula creation and received hemodialysis for 15 months. The patient later received a cadaveric kidney transplant and began receiving immunosuppressive therapy with Prograf and prednisone. Soon after, the patient noticed swelling in the area of the fistula. He was evaluated by a surgeon at an outside hospital who ligated and resected the dilated vein. The patient remained asymptomatic postoperatively until 3 days prior to presentation when he began having color changes of the skin and paresthesia in the finger tips of his right hand. He denied any loss of sensation or strength in the right hand. Over the next several days the patient reported progression of the pain to include the right forearm which he noted was intermittent in nature. He denied any alleviating or aggravating factors. On physical exam there was cyanosis of the right thumb, ring, and little finger. Capillary refill was > 3 seconds in all the digits and the palm of the right hand, with a palpable ulnar and radial

pulse. There was no motor or sensory loss in the right upper extremity. The patient was admitted and began receiving an intravenous heparin drip with the working diagnosis of aneurysm with thrombosis of the right brachial artery. An arterial duplex was obtained and showed the proximal brachial artery to measure 14 mm in diameter and in the aneurismal segment to measure 23 mm in diameter which also appeared partially thrombosed. An arteriogram was then ordered to better evaluate the brachial artery aneurysm. The result of this study demonstrated an abnormal brachial artery from the origin of the brachial artery to the elbow in addition to slow blood flow throughout. All other branches of the brachial artery were normal. After thorough discussion, the decision was made for the patient to undergo operative management for prevention of future thrombotic events. Intraoperatively, the aneurysmal brachial artery was resected with ligation of its branches and was sent to pathology. A harvested non-reversed greater saphenous vein was used for bypass. Postoperatively the patient recovered well, although he has not experienced complete resolution of cyanosis in the right hand. Histologic examination showed myxomatous degenerative changes and an adherent partially dissecting thrombus.

dIscussIon Aneurysm formation is defined as the dilatation of a blood vessel >50% of the normal expected diameter and this dilatation includes all three layers of the arterial wall. In men, an aneurysm of the brachial artery will measure >6.15-7.2 mm; for women 5.25-6.45 mm. Pan arterial dilatation following A-V fistula ligation can lead to significant morbidity for the patient including decreased arterial flow and embolization.7 In this particular case, the patient suffered from digital ischemia from microthromboembolic events as well as decreased flow from the partially occluded artery. Previous reports in the literature recommend routine arterial duplex studies for patients who have undergone ligation of longstanding traumatic or iatrogenic A-V fistulas to prevent these types of complications.7 After reviewing the current literature and from what we have learned from our patient, we agree that yearly ultrasound studies to evaluate ligated A-V fistulas should be recommended.

Brachial artery aneursym with “Blue Finger syndrome” after Ligation of an arterio-Venous FistulaRamon Garza III, MD, Dale A. Dangleben, MD, John F. Welkie, MD • LehIgh VaLLey heaLth network, aLLentown, pennsyLVanIa

Fig 3. From pathology: showing vessel lumen and total length of arterial aneurysm.

References1. Nguyen DQA, et al. Late axillo-brachial arterial aneurysm following ligated Brescia-Cimino haemodialysis fistula. Eur J Vasc Endovasc Surg 2001;22:381-382.

2. Hunter W. The history of an aneurysm of the aorta with some remarks on aneurysms in general. Trans Obstet Soc London 1757;1:323.

3. Rubanyi GM, et al. Flow-induced release of endothelium-derived relaxing factor. Am J Physiol 1986;250:H1145-1149.

4. Eugster T, et al. Brachial artey dilatation after arteriovenous fistulae in patients after renal transplantation: A 10-year follow-up with ultrasound scan. J Vasc Surg 2003;37:564-567.

5. Greenhill NS, et al. Scanning electron microscopy investigation of the afferent arteries on experimental femoral arteriovenous fistulae in rabbits. Pathology 1987;19:22-28.

6. Martin BJ, et al. Scanning electron microscopic study of haemodynamically induced tears in the internal elastic lamina of rabbit arteries. Pathology 1989;21:207-212.

7. Battaglia L, et al. Late occurrence of a large brachial artery aneurysm following closure of a hemodialysis arteriovenous fistula. Ann Vasc Surg 2006;20:533-535.

Fig 1. Patient presenting with blue finger syndrome.

Fig 2. Intraoperative images showing proximal and distal control and also ligation of branches.