Case Report

1st Departmical School, Hi

CorrespondIraklion, Athe

Ann Vasc Surghttp://dx.doi.or� 2014 Elsevi

Manuscript r

December 29,

Synovial Cyst of the AntecubitalFossa Mimicking a Brachial ArteryPseudoaneurysm: Report of a Case

Konstantinos Filis, George Galyfos, Andreas Larentzakis, Evridiki Karanikola,

and Constantinos Zarmakoupis, Athens, Greece

Pseudoaneurysms of the brachial artery are common following a percutaneous cardiac catheter-ization. Synovial cysts are a commonly identified entity in patients with rheumatic diseases aswell. We present a rare case of a synovial cyst in the elbow masquerading as an iatrogenic pseu-doaneurysm of the brachial artery. A 51-year-old female patient presented with a pulsatile andpainful mass in the right antecubital fossa. The medical history revealed a recent diagnostic car-diac catheterization at the same site and rheumatoid arthritis under oral treatment. Imaginginvestigations were not fully diagnostic. Because of the clinical suspicion of a thrombosed pseu-doaneurysm, exploratory surgery was indicated. The pathologic examination of the specimenconfirmed the diagnosis of a synovial cyst. Ultrasonography and computed tomography imagingare valuable in the everyday clinical practice but they do not always exclude an iatrogenic pseu-doaneurysm, especially when the medical history is suspicious. Surgical removal is the propertreatment and pathologic examination sets the final diagnosis in such cases of diagnosticdifficulty.

Synovial cysts of the upper extremities and particu-

larly of the antecubital fossa are not uncommon in

patients with a history of rheumatoid arthritis.1,2

However, a pulsatile mass in the same anatomic

area with a former brachial artery catheterization

is commonly the result of an arterial pseudoaneur-

ysm formation.3e5 We present an unusual case of

a patient with a synovial cyst of the right elbow

masquerading as an iatrogenic pseudoaneurysm

and we discuss proper diagnostic and therapeutic

management.

ent of Propaedeutic Surgery, University of Athens Med-ppokration Hospital, Athens, Greece.

ence to: George Galyfos, 6 Melinas Merkouri Street, Neonns 14122, Greece; E-mail: georgegalyfos@hotmail.com

2014; -: 1–4g/10.1016/j.avsg.2013.12.033er Inc. All rights reserved.

eceived: December 17, 2013; manuscript accepted:

2013; published online: ---.

CASE REPORT

A 51-year-old female patient was referred to our depart-

ment for evaluation because of a growing and painful

mass in her right antecubital fossa. The patient com-

plained of a rapidly enlarging mass in her right elbow

during the last month, with accompanying discomfort

during the last 2 weeks. Her medical history revealed

rheumatoid arthritis under treatment with oral cortico-

steroids for the last 3 years. Additionally, she mentioned

a painful and ineffective arterial puncture during a diag-

nostic cardiac catheterization through the ipsilateral

brachial artery 2 months before. The rest of the medical

or surgical history was unremarkable. There was no his-

tory of trauma as well.

During the physical examination, a soft and pulsatile

mass, almost 3 cm in diameter, was palpated on the ante-

romedial aspect of the right upper extremity, at the level of

the antecubital fossa. No obvious hematoma or ecchy-

mosis was noted. There were no signs of ischemia or clau-

dication of the ipsilateral forearm or hand nor any

neurologic deficits. The ultrasonographic assessment of

the region revealed a cystic lesion of unknown origin in

the near of the brachial artery and no flow disturbance

1

Fig. 1. This is a duplex sonographic image that shows the

3.5 cm in maximum diameter mass at the level of the

brachial artery bifurcation. The black arrow points out to

the right brachial artery.

Fig. 2. Contrast CT scan shows the mass in proximity

with the origin of radial and ulnar arteries (A) as well

2 Case Report Annals of Vascular Surgery

in the radial and ulnar runoff arteries (Fig. 1). A computed

tomography (CT) imaging followed that could not differ-

entiate a mass from a thrombosed pseudoaneurysm as

well. The mass location, clinical presentation, history of

catheterization, and results of imaging studies set the sus-

picion of a thrombosed pseudoaneurysm. A magnetic

resonance evaluation study was indicated for further

investigation that revealed a cystic lesion with synovial

bursa cyst characteristics (Fig. 2A, B).

Given the possibility of a pseudoaneurysm, any kind of

biopsy was not indicated. Therefore, our patient under-

went surgical exploration under general anesthesia. Dur-

ing surgery, a cystic mass of soft consistency was removed

after proximal (brachial) and distal arterial (radial and ul-

nar) control of patency. The pathologic examination of the

surgical specimen confirmed the diagnosis of a degenera-

tive synovial bursa cyst with secondary evidence of

mechanical injury and additional lymphoplasmacytic

infiltration compatible with the patient’s history of rheu-

matoid arthritis. The postoperative course of the patient

was uneventful.

as the brachial artery (B).

DISCUSSION

Cystic masses at the level of the elbow generally

involve the posterior and lateral compartments;

anterior compartment masses at the level of the

antecubital fossa are less common.6 The antecubital

fossa is delimited mainly by musculotendinous and

aponeurotic structures: the supinator and brachial

muscles, which form the floor of the fossa; the round

pronator and brachioradial muscles, which repre-

sent the medial and lateral walls; and the bicipital

aponeurosis, which forms the roof.6,7 The antecubi-

tal fossa contains the distal tendon of the biceps bra-

chialis, the median nerve, and the brachial artery.

There are also 3 locoregional bursae: the cubital

interosseous, the bicipitoradial, and the supinator

bursae. The presence of an elastic mass in this fossa

can thus be caused by inflammation of one of these

bursae (the brachioradial bursa in particular), a

vascular alteration (brachial artery aneurysm), a

periarticular lesion (ganglion), as well as benign

and malignant tumors (hemangioma, synovial

sarcoma).7

In our case, the patient had a soft mass in her

right elbow without any ischemic or neurologic

symptoms or signs. Indeed, synovial cysts are rare

at the elbow joint where they cause as an exception

Vol. -, No. -, - 2014 Case Report 3

a compression of the ulnar nerve or the brachial

artery.8 A history of osteoarthritis or inflammatory

joint diseases increases the possibility of the diag-

nosis of a synovial cyst, as it was in our case.9 On

the other hand, the palpitation of a pulsatile mass

in the antecubital fossa, given a history of brachial

artery puncture, raises the suspicion of an iatrogenic

pseudoaneurysm, as it was also the case with our

patient. Brachial artery puncture and catheteriza-

tion are thought to be a viable, safe, and efficient

alternative to the transfemoral approach in a center

that is experienced with the arm approach, when

radial or femoral access is not possible.3,10 However,

the formation of an iatrogenic hematoma or a pseu-

doaneurysm is common in the literature.11e14

Regarding the imaging work-up of masses in this

region, ultrasound is considered the first-level study

of choice for ‘‘cystic’’ lesions of the elbow because it

is easy to perform, rapid, relatively low in cost, and

widely available.15 The combination of sonographic

and color Doppler imaging techniques can be used

to distinguish solid and fluid-filled masses, but it

also represents a simple and safe method for identi-

fying vascular lesions.16 Thanks to its high spatial

resolution; ultrasound is also useful for identifying

the lesion’s relations with the joint capsule. Ultra-

sound has been shown to be better than physical ex-

amination and even better than arteriography.16

This is because many aneurysms cannot be detected

through arteriography, as they are occupied by

thrombus. An ultrasound lets not only the aneu-

rysm walls but also the internal clots be seen. It

has also been shown that aneurysm size and ultra-

sound extension correlate well with surgical find-

ings. However, sonographic assessment in our case

revealed the patency of the blood vessels, but could

not clearly differentiate a pseudoaneurysm from

another type of cystic mass.

A history of iatrogenic arterial trauma raises the

possibility of an arterial pseudoaneurysm.17 The arte-

rial flow inside an aneurysmal sac can be detected by

vascular ultrasound, CTwith intravenous contrast, or

digital angiography. However, there are reports of a

solidmass in the thighmimicking a femoral pseudoa-

neurysm.18,19 CT may not always be able to differen-

tiate a thrombosed pseudoaneurysm from a solid or

cystic mass of other origin, as it was in our case. In

addition, thrombosed pseudoaneurysms do not

show either arterial flow or a communication be-

tween the aneurysm and the feeding artery.16 Thus,

in these cases, magnetic resonance imaging (MRI)

could add further information regarding themorpho-

logic features of a mass, because the majority of the

aforementioned lesions have characteristic MRI ap-

pearances that allow a confident diagnosis, obviating

the need for additional imaging or interventional

procedures.20,21 However, our patient underwent a

surgical procedure for final diagnosis despite the

valuable information acquired by the MRI study.

Most of the times, patients have to be operated

in an exploratory manner under extremely

different surgical treatment plans that include

arterial reconstruction or a mass exclusion. Surgi-

cal access to the antecubital fossa may be required

in the presence of tumors or nerve compression.22

The latter is caused usually by fractures, ganglia,

or neoplasms. However, our patient did not pre-

sent with any neurologic symptoms. Surgery can

be associated with early and late complications.

The former is frequently vascular in nature and

include hematomas caused by injury to the basilic,

cephalic, or median cubital vein.23 Late complica-

tions are generally functional and may include

limitation of flexion/extension of the elbow

caused by the formation of adhesions.24 Delayed

vascular complications are less common, but

they are reported from time to time. These phe-

nomena are frequently caused by trauma; as post-

operative complications, they are relatively rare.

They generally consist of pseudoaneurysms of

the brachial artery.17 Fortunately, there were no

complications in our patient after surgical removal

of the synovial cyst.

In conclusion, definite diagnosis in similar situa-

tions may not always be possible preoperatively.

The case illustrates the value of ultrasound and CT

in the diagnosis of fluid-filled lesions of the elbow,

including those that are rare and unexpected,

although these investigations do not always set the

definite diagnosis. Thus, surgeons and clinicians

must be very suspicious and cautious concerning

their treatment plans. A fast decision toward a

biopsy may be lethal in case of an aneurysm,

whereas a prolonged delay in a case of a tender

aneurysm can be dangerous because of the risk of

rupture. Thus, surgical removal is the proper treat-

ment and pathologic examination sets the final

diagnosis in such cases of diagnostic difficulty.

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