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CASE REPORT
Year : 2022 | Volume
: 9
| Issue : 5 | Page : 404-406
Surgical management of a true aneurysm of the digital artery
Devender Singh, Madavan Praveena, Shalini Aryala
Department of Vascular and Endovascular Surgery, Yashoda Hospitals, Hyderabad, Telangana, India
Correspondence Address:
Dr. Devender Singh
Department of Vascular and Endovascular Surgery, Yashoda Hospitals, Hyderabad, Telangana
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijves.ijves_56_22
True aneurysms of the digital artery are exceedingly rare, and a few cases have been reported. They form an important differential diagnosis in any patient presenting with a lump in the hand. We present a case of a 44-year-old man with a true aneurysm of the left common palmar digital artery, who underwent successful repair, following excision and end-to-end anastomosis.
Keywords: Aneurysm, digital aneurysm, end-to-end repair, microvascular surgery
An aneurysm is defined as a permanent dilation of an artery with a 50% increase in its normal diameter. Aneurysms of the digital artery are rare, and the majority of cases occur secondary to penetrating or iatrogenic injury causing a false aneurysm of the artery.[1] True aneurysms have been described and can be the result of a congenital anomaly or repetitive blunt microtrauma due to occupational or recreational predisposition.[2] Usually, the patients present with an enlarging, tender, and pulsating lump in the hand. They may also experience cold intolerance, sensory compromise, and ischemic skin changes. An angiography confirms the diagnosis and helps in the management. In this case report, we discuss the case of a true digital artery aneurysm and the surgical management.
Case ReportA 44-year-old gentleman presented with a painful lump in the left hand for the past 6 months. The size seems to be increasing gradually (from a size of a peanut to a groundnut). He did not recall any significant or repetitive trauma. He has no other comorbidities and no family history of aneurysms.
On examination, there was a pulsatile, firm, and tender swelling of 2 cm × 2 cm on the palmer aspect of the left hand between 3rd and 4th metacarpals [Figure 1]. Radial and ulnar arteries were well palpable. An initial ultrasound scan showed a pulsatile, anechoic sac without any thrombus measuring 2 × 2 cm in size, consistent with an aneurysm.
A subsequent computed tomography (CT) angiogram confirmed a saccular aneurysm of the common digital artery between the middle and ring fingers with intact distal circulation of the left hand [Figure 2]. His hematological and biochemical reports were normal; vasculitis workup and two-dimensional ECHO did not show any abnormality. After explaining the risks of leaving the aneurysm, specifically digital ischemia secondary to thrombosis or rupture, balanced against the risks of surgery, the patient decided to proceed with surgical intervention under brachial block. A true aneurysm arising from the third common digital artery was confirmed intraoperatively, supplying the middle and ring fingers [Figure 3]. This was dissected free with the release from the digital nerve, which was badly adherent to the aneurysmal wall [Figure 4]. The proximal and distal segments were clamped, and aneurysmal sac was excised. The artery was repaired by primary end-to-end anastomosis with a good flow immediately after the removal of both arterial clamps [Figure 5]. His specimen was sent for histopathological examination [Figure 6], which confirmed the true aneurysm of the digital artery. He recovered well in the postoperative period [Figure 7] and given his consent for the publication of his case in the journal.
Figure 2: CT angiography confirming the left digital artery aneurysm. CT: Computed tomography Discussion Aneurysms of the digital artery are rare, but an important differential diagnosis in patients presenting with a lump in the hand. Due to the paucity of literature on digital artery aneurysms, etiological evidence is lacking. They can be congenital, occur secondary to penetrating injury or recurrent blunt microtrauma.[2] The majority of true aneurysms are due to repetitive microtrauma from occupational injury, for example metal work, radiography, and professional golf. The remainder of true aneurysms is either congenital or of unknown cause.[2]
Previous case reports have suggested that mechanisms of chronic trauma causing digital artery aneurysm include bowling, volleyball, baseball, golf, and repetitive trauma from a wedding ring.[3] We did not find any of the causes mentioned in the literature for our case.
Imaging modalities varied across the reviewed literature with the use of magnetic resonance angiography, ultrasound scan, angiography, and CT angiogram all being reported. Bouvet et al. have recently suggested an imaging algorithm for diagnosis of aneurysms of the hand.[4] Ultrasound scanning is the primary modality for diagnosis of palpable masses in the hand, which can then be supplemented by CT angiography if there is no evidence of acute ischemia. This was the approach used for diagnosis in our case and serves to further strengthen the evidence for CT angiography as a diagnostic adjunct in similar presentations.
There are several documented surgical techniques for treatment of aneurysms of the hand. These include excision and ligation, end-to end microsurgical anastomosis, vein grafting, and arterial grafting.
Excision and ligation is the most commonly used technique.[5] However, on-table testing suggestive of insufficient collateral supply necessitates grafting or direct anastomosis. In our case, after clamping the artery proximally and distally of aneurysm, the finger turned pale with no capillary filling. There were no appreciable Doppler signals in the digital arteries. Hence, we decided for the revascularization of the digital artery after excision of the aneurysm.
In conclusion, digital artery aneurysms remain a rare presentation, and the management varies across the literature. While outcomes are favorable following excision and ligation, restoration of blood supply is mandatory in patients with insufficient collateral supply. We report such a case of excision of the digital artery and restoration of vascular supply with microvascular anastomosis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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