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Axillary Pseudoaneurysm With Embolization Causing Arterial Occlusion And
Brachial Plexopathy
Sunter, H., MS III, Lancellotti, G., M.D.
Kent Hospital, Warwick, RI
Introduction: Most pseudoaneurysms are the result of iatrogenic or penetrating injuries
such as trauma resulting in an arterial puncture with subsequent formation of a
hematoma. When treatment is delayed, hemorrhage, venous edema, erosion of the skin
and neurologic compression due to mass effect are all emergent conditions that risk
permanent loss of function or potential life threatening complications. Common
presentation of this condition in an extremity includes pallor, decrease or loss of pulses,
poikilothermia, paresthesias, pain and potential paralysis. While these findings were all
present in our patient, an atypical precipitating event lead to an unforeseen diagnosis.
Case: A 62 year old male with a past medical history of hypertension presented to the
emergency room with a painful and weak left upper extremity. Patient stated his arm had
felt weak with a dull, non-radiating ache since an unwitnessed fall at his home one
month ago. Although vitals were within normal limits, on physical exam he had poor
capillary refill of the left distal upper extremity coupled with absent radial and ulnar
pulses. Also noted on physical was absent sensation distally from the cubital fossa along
with biceps strength 3/5, finger flexors 2/5, triceps and finger extensors and intrinsics
0/5. X-ray of the left shoulder revealed inferior and anterior humeral head subluxation,
which when coupled with history of traumatic injury raised suspicion of possible fracture.
Subsequent non-contrast CT revealed fracture of the superolateral portion of humeral
head with adjacent multiple bony fragments as well as a 12.6 X 9.0 cm hematoma. This
large hematoma not mentioned on the initial physical assessment, was palpable and the
size of a baseball, further explaining subsequent diminished brachial plexus function. CT
angiography discovered a large pseudoaneurysm of the left axillary-brachial junction
with complete disruption and distal embolization to the brachial trifrication and run off
branches. On further work up, arteriography showed thrombosis of the pseudoaneurysm
with distal constitution of the brachial artery. Interventional radiology then
performed endovascular stent and grafting after which embolectomy and thrombectomy
were done. Orthopedics attempted closed reduction of the anterior dislocation but were
unsuccessful. Following these interventions, patient regained pulses in ulnar and radial
arteries and experienced left upper extremity erythema and warmth. Median nerve
function was retained as well as the ability to flex his digits but he was unable to perform
digit or elbow extension or intrinsic motion. Despite the development of post perfusion
edema without evidence of compartment syndrome and residual symptoms such as
paresthesias in the distal extremity, the patient refused rehabilitation treatment but
agreed to discharge with home care services.
Discussion: While recognition of a pseudoaneurysm typically occurs in the history of a
penetrating injury, indicators such as pain, pallor, absent pulses, and paresthesias may
hasten diagnosis and decrease the likelihood of emergent vascular or neurologic
compromise. Despite the lack of penetrating injury or iatrogenic intervention, when
considering these symptoms in any patient, especially one with increased vascular risk
factors, it is essential to rule out pseudoaneurysm formation and perform a thorough
physical examination as potential mass effect can lead to a surgical emergency.