Penetrating glass injury leading to brachial artery pseudoaneurysm: a rare case with early onset symptoms

Pseudoaneurysms of the brachial artery have been reported in the literature, with aetiologies including iatrogenic causes, trauma and intravenous drug use.¹ Among traumatic causes, blunt trauma is the most common and is often associated with humerus fractures.² The incidence of brachial artery pseudoaneurysms due to penetrating injuries is only around 0.04%.³ These cases typically present months or even years after the initial injury.³

We present a case of a penetrating injury to the right upper limb in a male patient in his mid-30s. The injury occurred when the patient sustained a laceration from a glass window while working. He presented to us 1 week later with pulsatile swelling and complaints of paresthesia in the affected limb.

Case report

A young male in his mid-30s presented to the Department of Trauma and Emergency, AIIMS Bathinda, with an alleged history of a glass-cut injury to the right antecubital fossa sustained 6 days prior. He complained of numbness in his right upper limb, associated with excruciating pain and a pulsatile swelling in the same region.

He reported receiving initial treatment from a local practitioner, where temporary bleeding control was achieved by an attempt of arterial ligation and suturing.

On examination, the patient appeared pale. A pulsatile swelling measuring approximately 4x3cm was noted in the right cubital fossa, with an overlying wound (Figure 1).

The limb was warm to touch; however, the hand and fingers were relatively cold. Capillary refill time (CRT) was delayed (>3 seconds), although oxygen saturation in all fingers remained between 97 and 98%.

Blood investigations revealed a haemoglobin level of 6g/dL, for which the patient received a blood transfusion. He was managed according to the advanced trauma life support (ATLS) protocol.

View Figure 1–5, Table 1.

Imaging

The patient underwent CT angiography of the right upper limb, which revealed a large pseudoaneurysm measuring 6.2x5.1x6cm arising from the distal part of the brachial artery proximal to its bifurcation in the cubital fossa. The periphery of the pseudoaneurysm sac showed signs of thrombosis (Figure 2).

Surgical management

The patient was planned for surgical exploration. Intraoperatively, the pseudoaneurysm was ligated, and a 5mm tear was identified in the brachial artery (Figure 3 and Figure 4).

Due to the fragile condition of the vessel wall, approximately 3cm of the artery was excised, and end-to-end anastomosis was performed (Figure 5).

Post-operative course

Post-operatively, the affected limb was warm, with a CRT of less than 3 seconds. Both radial and ulnar pulses were palpable. Follow-ups at 2 weeks, 2 months and 6 months demonstrated good recovery. The patient regained full range of motion at the elbow and wrist joints with no numbness after 6 months.

Discussion

Pseudoaneurysms of the brachial artery are a rare phenomenon, with few cases reported in the literature following penetrating injuries. The most extensive series to date was described by Yetkin et al., who reported nine cases—four resulting from gunshot wounds and five from stab injuries.⁴ In contrast, our case represents an occupational hazard, where the patient sustained a penetrating injury from a glass window while working.

The patient presented within 1 week of injury, whereas the reported cases of brachial artery pseudoaneurysms present months to years after the initial insult. To the best of our knowledge, we could not find any article where the patient presented with brachial artery pseudoaneurysms within a week of initial injury.^4–8 A few cases of traumatic femoral artery pseudoaneurysm have been reported at an early age, but these too did not present within a week.⁹

Several risk factors have been associated with developing pseudoaneurysms, including anticoagulant or antiplatelet therapy, arterial calcification, obesity, diabetes mellitus and haemodialysis. However, in our case, none of these risk factors were present. The patient also had no history of smoking or intravenous drug use.¹⁰

Pseudoaneurysms can pose serious threats to both limb and life. Common complications include haemorrhage, nerve injury and venous oedema of the distal extremity. Median nerve paraesthesia has been documented, notably by Esteban et al., and may result from either direct nerve injury or the mass effect of the pseudoaneurysm.⁷ Our patient’s paraesthesia was due to mass effect, as no nerve injury was observed intraoperatively. Additionally, thromboembolic events may lead to limb ischemia, amputation or, in rare cases, rupture—an event associated with high mortality.

CT angiography remains the gold standard for diagnosis, while Doppler ultrasonography is frequently used during follow-up. Management depends on the size, location and aetiology of the pseudoaneurysm. Endovascular techniques such as coil embolisation or stenting are increasingly employed. However, open surgical intervention is indicated in cases of rapidly expanding aneurysms, distal ischemia or compressive neuropathy.²

Surgical repair is generally recommended for lesions exceeding 2cm in diameter.¹¹ Options include ligation or revascularisation, with reported 50% and 6% amputation rates respectively. Among revascularisation techniques, both primary repair and interposition using saphenous vein grafts have been described. Yetkin et al. highlighted the superiority of venous grafts in lesions proximal to the brachial artery bifurcation.⁴ In our case, however, the lesion was amenable to primary repair, which was successfully performed.

We hereby in Table 1 present the articles of post-traumatic penetrating injury leading to brachial artery pseudoaneurysm with brief details of their time of presentation and the management.

Conclusion

Brachial artery pseudoaneurysm, though rare, is a well-recognised complication following penetrating injuries. Clinicians should maintain a high index of suspicion during both the initial management and follow-up periods. This is an individualised approach for the management of this particular case. More such cases in the future will guide us to develop a protocol for the management of such injuries. Furthermore, continued research and exploring alternative therapeutic approaches are warranted to enhance our understanding and improve management strategies for this uncommon but potentially serious complication.