Marco Lanzetta and Umberto Fox
ANEURYSMS OF THE PALMAR ARCH AND A PROPER DIGITAL ARTERY: CASE REPORT AND Downloaded by: University of British Columbia. Copyrighted material.
LITERATURE REVIEW ABSTRACT The first reported case of multiple aneurysms of both the palmar arch and a proper digital artery is described. A palmar arch aneurysm was excised, and two end-to-end anastomoses were necessary to restore the blood flow. Microsurgical repair was the only possible treatment in this case. The authors believe that the vascular anatomy should always be restored as naturally as possible. No treatment was necessary for the more distal aneurysms. Aneurysms of the common and proper digital arteries are rare, only 19 of them having been reported in the literature. Seven of them were traumatic and false aneurysms of proper digital arteries;1"7 seven were true aneurysms of proper digital arteries; 68 " 10 four were false aneurysms of common digital arteries;611"13 and one was a true aneurysm of a common digital artery.14 We believe that this is the first reported case of multiple (three) aneurysms of a proper digital artery together with a true aneurysm of the palmar arch, which itself involves two common digital arteries.
CASE REPORT The patient, a 28-year-old, right-handed, female, professional volleyball player, presented with a 1-month history of pulsatile tender mass in the palm of her right hand. She stated that the mass had been enlarging over the past month and was severely interfering with her daily activities, in addition to preventing her from playing volleyball. Physical examination of the patient's hand showed a full range of motion of all joints. Sensitivity and
motor (intrinsics and extrinsics) muscle function were normal. There was a 1- x 1.5-cm pulsatile mass present in the midpalm which was slightly tender to palpation and pressure, and easily compressible (Fig. 1). The fingers of the affected hand were found to be 3°F colder than the left. No other abnormalities were found. Radial and ulnar pulses were normal and the Allen's test was negative. Routine blood tests and blood pressure were normal. Intravenous digital subtraction angiography showed a 1.5-cm aneurysm of the palmar arch involving the proximal part of the common digital arteries to the III and IV interspaces. As an incidental finding, this investigation also revealed three aneurysms of the ulnar digital artery of the middle finger that were asymptomatic (Fig. 2). At operation, the palmar aneurysm was isolated and excised (Fig. 3). The anastomoses between the two digital arteries and the superficial arch had to be performed in the following crossover manner. The common digital artery to the III interspace was anastomosed to the medial stump of the palmar arch, while the common digital artery to the IV interspace was anastomosed to the lateral stump of the same arch (Figs. 4, 5). The reasons for doing this cross-over repair of the vessels were: 1) a better matching position
Microsurgery Center of the Microsearch Foundation of Australia, Sydney Hospital Hand Unit, Sydney, Australia, and Institute of General and Oncological Surgery, University of Milan, Italy Reprint requests-. Dr. Lanzetta, Microsurgery Centre, Microsearch Foundation of Australia, 1 Esther St., Surry Hills, P.O. Box 52, Surry Hills, Australia. NSW 2010 Accepted for publication February 25, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
371
SEPTEMBER 1992
Figure I. Mass over midpalmar aspect of the patient's right hand.
Figure 2. Angiogram of the right hand showing an aneurysm of the palmar arch involving the common digital arteries to the III and IV interspaces. Note three aneurysms of the ulnar digital artery of the middle finger (arrows).
372
between the ends of the vessels (A to A' and B to B'), compared to another possibility (A to B and A' to B'), which had been assessed intraoperatively; and 2) a safer procedure in order to assure blood perfusion to all fingers, in case of ulnar artery thrombosis or injury. The common digital arteries were long enough for this procedure, and vein grafts were therefore not necessary (Fig. 6). In this case, a microvascular repair was essential, as a resection of the aneurysm with ligations proximal and distal would have led to a complete cessation of the blood supply to the ring finger. The wound was closed primarily and satisfactory
Figure 3. Aneurysm exposed at operation.
healing was achieved. Microscopic examination of the excised tissue confirmed the diagnosis of true aneurysm. Three months postoperatively, the patient underwent an intravenous digital subtraction angiography, showing perfect patency of the anastomoses (Fig. 7). At follow-up after two years, hand function is nor-
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 5
Figure 4. Preoperative drawing of the aneurysms. Note that the palmar aneurysm involves two common digital arteries. A and B' are the ulnar and radial components of the superficial palmar arch; A' and B are the common digital arteries to the III and IV interspaces.
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ANEURYSMS OF THE PALMAR ARCH/LANZETTA, FOX
Figure 5. Postoperative drawing. The common digital artery to the III interspace (A') has been anastomosed to the medial stump of the palmararch (A) and the common digital artery to the IV interspace (B) has been anastomosed to the lateral stump of the palmar arch (B'). Note that the crossover repair assures blood supply to the little finger, in the event of ulnar thrombosis.
mal; there has been no recurrence, and a Doppler study confirms patency of the anastomoses. The three aneurysms of the proper digital artery of the middle finger remain completely unchanged and asymptomatic, and we therefore believe that there is no indication for a further surgical procedure.
DISCUSSION The first case of true aneurysm was described by Guattani in 1772.15 The causes of true aneurysms include atherosclerosis, mycosis, and trauma, both acute or chronic.16 The latter type is usually correlated with the occupational activity of the patient, and can therefore be categorized as an occupational disease. Sporting activities which involve repetitive microtrauma to the hands deserve to be kept under consideration. Our patient was a professional volleyball player, and we consider that repetitive microtrauma was indeed the cause in this case. Two other cases of hand aneurysms related to sports have been previously reported, in basketball17 and volleyball6 players. With refinements in microvascular technique, the age-old treatment of resection with ligation proximal and distal to the aneurysm has been supplanted by
Figure 6. Intraoperative view of anastomoses described in Figure 5 (arrows).
373
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 5
SEPTEMBER 1992
aneurysms, apparently caused by the trauma of professional volleyball. These aneurysms disorganized the blood flow in the hand. A carefully worked-out reconstruction assured the patient of a competent blood supply, with restoration of the circulation to each finger from each of the major arteries. The patient's symptoms were alleviated, but she was advised not to resume her volleyball activities.
1. 2. 3. 4. 5.
6. 7.
8.
Figure 7. One month postoperative angiogram showing patency of the microvascular repairs (arrows). Note the three asymptomatic aneurysms of the ulnar digital artery of the middle finger.
9. 10. 11. 12.
vascular reconstruction. At present, after resection of the aneurysm, the defect in the vessel wall can be repaired by: 1) resecting the damaged area and performing an end-to-end anastomosis; 2) placing an interposition vein graft; or 3) excising the defect in the vessel and closing the vessel primarily or patching it with a piece of vein graft. Suitable synthetic grafts to bridge gaps in small arteries could be of further help in these cases. At present, only small-diameter polytetrafluoroethylene (PTFE; Gore-tex) grafts have shown encouraging results, but only in experimental models.18 We have presented a unique case of multiple hand
374
13. 14 15. 16.
Hueston (T: Traumatic aneurysm of the digital artery: A complication of fasciectomy. Hand 5:232, 1973 Baruch A: False aneurysm of the digital artery. Hand 9:195,1977 Hentz V, Jackson 1, Fogarty D: Case report: False aneurysm of the hand secondary to digital amputation. I Hand Surg 3A: 199, 1978 Suzuki K, Takahashi S, Nakagawa T: False aneurysm in a digital artery. I Hand Surg 5A:402, 1980 Hall RF, Watt DH: Osseous changes due to a false aneurysm of the properdigital artery: Acase report. I Hand Surg 11A:44O, 1986 Ho PK, Weiland A|, McClinton MA, Wilgis EFS: Aneurysms of the upper extremity. ) Hand Surg 12A:39, 1987 Brunelli G.VigasioA, Battiston B, eta!.: Traumatic aneurysms of two proper digital arteries in the same patient: A case report. I Hand Surg 13B:345, 1988 Layman CD, Ogden LL, Lister GD: True aneurysms of the digital artery. I Hand Surg 7A:617, 1982 Dangles CJ: True aneurysm of a thumb digital artery. ] Hand Surg 9A:444, 1984 Berrettoni BA, Seitz WH: Mycotic aneurysm in a digital artery: Case report and literature review. 1 Hand Surg 15A:305,1990 Sanchez A, Archer S, Levine N, Buchanan R: Traumatic aneurysm of a common digital artery. A case report. I Hand Surg 7A:619, 1982 Walsh Ml, Conolly WB: False aneurysm due to trauma to the hand. Hand 14:177, 1982 Tyler G, Stein A: Aneurysm of a common digital artery: Resection and vein graft. ) Hand Surg 13B:348, 1988 Freiberg A, Fish |: Aneurysm of a common digital artery: Case report and literature review. Can ) Surg 31:254, 1988 Guattani C: De Externis Aneurysmatibus Manu Chirurgica Methodice Pertractandis. Rome, 1772. Erichsen |E (translator): Observation on Aneurysm. London, Sydenham Society, 1844 Mays ET: Traumatic aneurysm of the hand. Am Surg 36:552, 1970
17. 18.
Aulicino PL, Hutton PM, Du Puy TE: True palmar aneurysms. A case report and literature review. I Hand Surg 7A:613, 1982 Lanzetta M, Owen ER: Achieving better patency rates and neoendothelialization in 1-millimeter polytetrafluoroethylene grafts by varying fibril length and wall thickness. Microsurgery 13:76, 1992
Downloaded by: University of British Columbia. Copyrighted material.
REFERENCES
ANEURYSMS OF THE PALMAR ARCH AND A PROPER DIGITAL ARTERY: CASE REPORT AND Downloaded by: University of British Columbia. Copyrighted material.
LITERATURE REVIEW ABSTRACT The first reported case of multiple aneurysms of both the palmar arch and a proper digital artery is described. A palmar arch aneurysm was excised, and two end-to-end anastomoses were necessary to restore the blood flow. Microsurgical repair was the only possible treatment in this case. The authors believe that the vascular anatomy should always be restored as naturally as possible. No treatment was necessary for the more distal aneurysms. Aneurysms of the common and proper digital arteries are rare, only 19 of them having been reported in the literature. Seven of them were traumatic and false aneurysms of proper digital arteries;1"7 seven were true aneurysms of proper digital arteries; 68 " 10 four were false aneurysms of common digital arteries;611"13 and one was a true aneurysm of a common digital artery.14 We believe that this is the first reported case of multiple (three) aneurysms of a proper digital artery together with a true aneurysm of the palmar arch, which itself involves two common digital arteries.
CASE REPORT The patient, a 28-year-old, right-handed, female, professional volleyball player, presented with a 1-month history of pulsatile tender mass in the palm of her right hand. She stated that the mass had been enlarging over the past month and was severely interfering with her daily activities, in addition to preventing her from playing volleyball. Physical examination of the patient's hand showed a full range of motion of all joints. Sensitivity and
motor (intrinsics and extrinsics) muscle function were normal. There was a 1- x 1.5-cm pulsatile mass present in the midpalm which was slightly tender to palpation and pressure, and easily compressible (Fig. 1). The fingers of the affected hand were found to be 3°F colder than the left. No other abnormalities were found. Radial and ulnar pulses were normal and the Allen's test was negative. Routine blood tests and blood pressure were normal. Intravenous digital subtraction angiography showed a 1.5-cm aneurysm of the palmar arch involving the proximal part of the common digital arteries to the III and IV interspaces. As an incidental finding, this investigation also revealed three aneurysms of the ulnar digital artery of the middle finger that were asymptomatic (Fig. 2). At operation, the palmar aneurysm was isolated and excised (Fig. 3). The anastomoses between the two digital arteries and the superficial arch had to be performed in the following crossover manner. The common digital artery to the III interspace was anastomosed to the medial stump of the palmar arch, while the common digital artery to the IV interspace was anastomosed to the lateral stump of the same arch (Figs. 4, 5). The reasons for doing this cross-over repair of the vessels were: 1) a better matching position
Microsurgery Center of the Microsearch Foundation of Australia, Sydney Hospital Hand Unit, Sydney, Australia, and Institute of General and Oncological Surgery, University of Milan, Italy Reprint requests-. Dr. Lanzetta, Microsurgery Centre, Microsearch Foundation of Australia, 1 Esther St., Surry Hills, P.O. Box 52, Surry Hills, Australia. NSW 2010 Accepted for publication February 25, 1992 Copyright © 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
371
SEPTEMBER 1992
Figure I. Mass over midpalmar aspect of the patient's right hand.
Figure 2. Angiogram of the right hand showing an aneurysm of the palmar arch involving the common digital arteries to the III and IV interspaces. Note three aneurysms of the ulnar digital artery of the middle finger (arrows).
372
between the ends of the vessels (A to A' and B to B'), compared to another possibility (A to B and A' to B'), which had been assessed intraoperatively; and 2) a safer procedure in order to assure blood perfusion to all fingers, in case of ulnar artery thrombosis or injury. The common digital arteries were long enough for this procedure, and vein grafts were therefore not necessary (Fig. 6). In this case, a microvascular repair was essential, as a resection of the aneurysm with ligations proximal and distal would have led to a complete cessation of the blood supply to the ring finger. The wound was closed primarily and satisfactory
Figure 3. Aneurysm exposed at operation.
healing was achieved. Microscopic examination of the excised tissue confirmed the diagnosis of true aneurysm. Three months postoperatively, the patient underwent an intravenous digital subtraction angiography, showing perfect patency of the anastomoses (Fig. 7). At follow-up after two years, hand function is nor-
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JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 5
Figure 4. Preoperative drawing of the aneurysms. Note that the palmar aneurysm involves two common digital arteries. A and B' are the ulnar and radial components of the superficial palmar arch; A' and B are the common digital arteries to the III and IV interspaces.
Downloaded by: University of British Columbia. Copyrighted material.
ANEURYSMS OF THE PALMAR ARCH/LANZETTA, FOX
Figure 5. Postoperative drawing. The common digital artery to the III interspace (A') has been anastomosed to the medial stump of the palmararch (A) and the common digital artery to the IV interspace (B) has been anastomosed to the lateral stump of the palmar arch (B'). Note that the crossover repair assures blood supply to the little finger, in the event of ulnar thrombosis.
mal; there has been no recurrence, and a Doppler study confirms patency of the anastomoses. The three aneurysms of the proper digital artery of the middle finger remain completely unchanged and asymptomatic, and we therefore believe that there is no indication for a further surgical procedure.
DISCUSSION The first case of true aneurysm was described by Guattani in 1772.15 The causes of true aneurysms include atherosclerosis, mycosis, and trauma, both acute or chronic.16 The latter type is usually correlated with the occupational activity of the patient, and can therefore be categorized as an occupational disease. Sporting activities which involve repetitive microtrauma to the hands deserve to be kept under consideration. Our patient was a professional volleyball player, and we consider that repetitive microtrauma was indeed the cause in this case. Two other cases of hand aneurysms related to sports have been previously reported, in basketball17 and volleyball6 players. With refinements in microvascular technique, the age-old treatment of resection with ligation proximal and distal to the aneurysm has been supplanted by
Figure 6. Intraoperative view of anastomoses described in Figure 5 (arrows).
373
JOURNAL OF RECONSTRUCTIVE MICROSURGERY/VOLUME 8, NUMBER 5
SEPTEMBER 1992
aneurysms, apparently caused by the trauma of professional volleyball. These aneurysms disorganized the blood flow in the hand. A carefully worked-out reconstruction assured the patient of a competent blood supply, with restoration of the circulation to each finger from each of the major arteries. The patient's symptoms were alleviated, but she was advised not to resume her volleyball activities.
1. 2. 3. 4. 5.
6. 7.
8.
Figure 7. One month postoperative angiogram showing patency of the microvascular repairs (arrows). Note the three asymptomatic aneurysms of the ulnar digital artery of the middle finger.
9. 10. 11. 12.
vascular reconstruction. At present, after resection of the aneurysm, the defect in the vessel wall can be repaired by: 1) resecting the damaged area and performing an end-to-end anastomosis; 2) placing an interposition vein graft; or 3) excising the defect in the vessel and closing the vessel primarily or patching it with a piece of vein graft. Suitable synthetic grafts to bridge gaps in small arteries could be of further help in these cases. At present, only small-diameter polytetrafluoroethylene (PTFE; Gore-tex) grafts have shown encouraging results, but only in experimental models.18 We have presented a unique case of multiple hand
374
13. 14 15. 16.
Hueston (T: Traumatic aneurysm of the digital artery: A complication of fasciectomy. Hand 5:232, 1973 Baruch A: False aneurysm of the digital artery. Hand 9:195,1977 Hentz V, Jackson 1, Fogarty D: Case report: False aneurysm of the hand secondary to digital amputation. I Hand Surg 3A: 199, 1978 Suzuki K, Takahashi S, Nakagawa T: False aneurysm in a digital artery. I Hand Surg 5A:402, 1980 Hall RF, Watt DH: Osseous changes due to a false aneurysm of the properdigital artery: Acase report. I Hand Surg 11A:44O, 1986 Ho PK, Weiland A|, McClinton MA, Wilgis EFS: Aneurysms of the upper extremity. ) Hand Surg 12A:39, 1987 Brunelli G.VigasioA, Battiston B, eta!.: Traumatic aneurysms of two proper digital arteries in the same patient: A case report. I Hand Surg 13B:345, 1988 Layman CD, Ogden LL, Lister GD: True aneurysms of the digital artery. I Hand Surg 7A:617, 1982 Dangles CJ: True aneurysm of a thumb digital artery. ] Hand Surg 9A:444, 1984 Berrettoni BA, Seitz WH: Mycotic aneurysm in a digital artery: Case report and literature review. 1 Hand Surg 15A:305,1990 Sanchez A, Archer S, Levine N, Buchanan R: Traumatic aneurysm of a common digital artery. A case report. I Hand Surg 7A:619, 1982 Walsh Ml, Conolly WB: False aneurysm due to trauma to the hand. Hand 14:177, 1982 Tyler G, Stein A: Aneurysm of a common digital artery: Resection and vein graft. ) Hand Surg 13B:348, 1988 Freiberg A, Fish |: Aneurysm of a common digital artery: Case report and literature review. Can ) Surg 31:254, 1988 Guattani C: De Externis Aneurysmatibus Manu Chirurgica Methodice Pertractandis. Rome, 1772. Erichsen |E (translator): Observation on Aneurysm. London, Sydenham Society, 1844 Mays ET: Traumatic aneurysm of the hand. Am Surg 36:552, 1970
17. 18.
Aulicino PL, Hutton PM, Du Puy TE: True palmar aneurysms. A case report and literature review. I Hand Surg 7A:613, 1982 Lanzetta M, Owen ER: Achieving better patency rates and neoendothelialization in 1-millimeter polytetrafluoroethylene grafts by varying fibril length and wall thickness. Microsurgery 13:76, 1992
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REFERENCES
