PSEUDO-ANI VRYSMES DE L'ARTI RE RADIALE int6r~t de la microchirurgie A propos d'un cas

M I C R O S U R G E R Y A N D P S E U D O A N E U R Y S M S OF T H E R A D I A L A R T E R Y

One case

R. MOUFARRI~GE, L. TI~OT, G.N. B E A U R E G A R D , J.P. BOSSI~, J. PAPILLON

MOUFFAREGE R., TEOT L., BEAUREGARD G.N., BOSSE J.P., PAPIL- LON J. - - Pseudo-anevrysmes de I'artere radiale. Int6r6t de la microchi- rurgie. Apropos d'un cas. Ann. Chit. Main, 1982, 1, 1, 40-44.

R#SUME : Apropos d'un cas de pseudo-anevrysme de I'artere radiale, les auteurs font une revue de la litterature de cinquante cas publies. Les etudes arteriographiques plethysmographiques et cliniques ainsi que les resultats anatomiques et physiologi- ques semblent en faveur d'un traitement qui retablit la permea- bilite vasculaire des principales arteres de I'avant-bras (radiale et cubitale). Un traitement conservateur expose le malade aux risques d'une impotence fonctionnelle a. plus ou moins long terme. Les auteurs proposent une technique micro-chirurgicale avec une greffe veineuse qui donne de meilleurs resultats b. court et long terme. Cette technique permet aussi de remplacer les pertes de substances secondaires a. la resection du pseudo- anevrysme.

MOTS-CLES : Arteres de la main. - - Anevrysmes arteriels. - - Microchi- rurgie.

MOUFARREGE R., TEOT L., BEAUREGARD G.N., BOSS¢: J.P., PAPIL- LON J. - - Microsurgery and pseudoaneurysms of the radial artery. (One case). Ann. Chir. Main, 1982, 1, 1, 40-44.

SUMMARY : Following a case of pseudoaneurysm of the radial artery, curiously a rare pathological entity, the authors reviewed the literature, which consists of a maximum of 50 publicized cases. The arteriographic, plethysmographic and clinical studies, as well as the anatomic and physiologic findings, all seem in favor of a treatment consisting of restoration of the vascular per- meability of the principal arterial axes of the forearm (radial and ulnar arterial axes). Conservative treatment may expose the af- fected limb to a latent or immediate functional impotency, which may be more or less serious. The authors propose a microsurgi- cal technique, with venous interposition grafting, for a better short or long term result, and also to replace the loss of substance se- condary to the resected pseudoaneurysm.

KEY-WORDS : Arteries (hand). - - Arterial aneuryms. - - Microsurgery.

Les pseudo-andvrysmes traumatiques de l 'artere radiale sont paradoxalement une raretd en patholo- gie du membre supdrieur.

Narsete [13] en 1964, au cours d 'une revue de la littdrature releve, apres le premier cas publid en 1914 par Morison, une vingtaine de cas. Lee [2] en 1977 dvalue /t cinquante le nombre de pseudo-and- vrysmes de l 'artere radiale rapportde.

Les 6tiologies sont essentiellement traumatiques, le point de p6n6tration passant souvent inaper~u ou 6tant oubli6 par le patient. Quelques cas apr6s ca- th6t6risme de l 'art6re radiale en milieu de r6anima- tion ou en milieu de chirurgie cardiaque ont dt6 rele- vds.

Clinique de Chirurgie Plastique St-Urbain Ltde 3875 St-Urbain, suite 602, M O N T R E A L H2 W 1 V1, Q UJ~,BEC (Canada).

VOL, 1, N ° 1 MA~ 1982 P 3 " E U D O - A N E V R Y S M E S

Sur le plan des manifestations cliniqucs, la symp- tomatologie reste univoque : aprb8 un traumafisme pOn(~trant survient dans les semaines qui suivent, I 'apparition d 'une masse souvent puLsatile sur le tra- jet de l 'artere radiale. L 'augmentat ion de volume est constante et s 'effectue progressivement, crdant une gene qui se majore, avec des signes de compression des dldments de voisinage, essentiellement du nerf mddian. Aucun signe d'ischdmie distale n 'a dtd rap- portd.

A l'auscultation et h l 'examen Doppler , la masse est 8oufflante.

Sur le plan a r tdr iographique , elle se prdsente comme un lac sanguin appendu au trajet arteriel et relid "a lui par un mince pertuis (fig. 1).

L'att i tude chirurgicale suivie par de nombreux au- teur8 s'est rdsumde en une exdrbse de la masse avec ligature de l 'artere en amont et en aval (Buzza- chino, Sterling, Bok, Hegarty). Depuis quelques anndes les auteurs tendent ',5 rdtablir la continuitd artdrielle au moyen soit d 'une suture simple, soit de l ' interposition d'un greffon veineux.

CAS C L I N I Q U E

M. Y. 1 . . . . . ilgd dc 24 ans, t r ava i l t cur manue l s 'csl prdscntd ~'l la consul ta t ion cn n o v c m b r c 1980 aprC's l ' i n t roduc t ion acc idcntc l lc d 'un f ragment d ' ac ic r dc d i lncns ion minuscule au n ivcau ttu bord radial dc la lace an td r icurc ttu poignct droi t . A l ' cxan lcn , on no tail un ¢7cdCunc ct a n t conges t ion au tour dc ]a p l a i t d'cntrC'c pal lc- t i iormc ct unc artOre radia lc pulsat i lc d i s t a l cmcn t . 1.~ radiogra- phic s imple conf i rmai t In prdscncc d 'un corps d t rnngcr mdta l l iquc tic 1/2 Cm tie d imens ion .

DE I . ' A R T E R I i R A I ) I A I , E 41

Unc semainc aprbs, lots dc I ' cxamen dc cont ro le . IkcdOmc lai- salt place Ll une masse pulsa t i lc .

L'e .~amen art l )ol?pler pe rmc t t a i t de pc rccvo i r un soulf lc asscz imprcssionnant. Lc test d ' A l l c n , par compression dc I 'art0rc ra- dialc, p rovoqua i t uric ddvascular isat ion du c6td radial dc la main.

L'ar l ( ; r iowaphie a mis ol3 evidence un pscudo-andvrysmc saccu- hfirc (f ig. 2) appcndu ~l la paro i dc I 'ar terc radiale. Ur ic cure chirurgicale avcc grclTc vcincusc (f ig. 3) a dtd. ddciddc chcz cc pa- t ient, pour la rest i tu t ion ad in tegrum de la cont inui td de son ar- t~erc. L 'opdra t ion s 'cst ddrouldc de lag:on sat is fa isantc . Los sui tes pos t -opdra to i rcs s 'd tan t passdcs sans probK:mcs ct l ' a r td r iograph ic dc contr61c de j anv ic r 1981 rdvdlai t :

unc d ispar i t ion du p seudo andw'ysmc cn ques t ion :

uric res t i tu t ion de la pc rmdabi l i td par grc l fc ve incusc de 2 cm ainsi quc la p rddorn immcc dc I'artC'rc rad ia lc par compara i son avcc l ' a r tbrc cubi ta lc pour l ' i r r iga t ion de la main.

DIS( ;USSION

Deux questions se posent au chirurgien :

1. La ndcessitc d 'une restauration chirurgicale de I'axe arteriel ?

2. l. 'utilite des moyens microchirurgicaux ?

l.es justifications de ht restauration d'un axe arld- riel du tnenlbre supdrieur sont multiples.

Point de vue anatomique

La suppldance d 'une i n te r rup t i on d 'un axe ar tdr ic l du membre supcrieur se fait gl'{lCe ~'1 l'existcncc des arcades artdrielles de la main.

Traumat ic pseudoaneurysms of the radial a r te ry contrary to common belief, are rare.

In 1964, Narsete [13] drew up twenty (20) cases which had occurred since 1914, the year of the publication of the first reported case by Morison. In 1977 Lee evaluated at about fifty, the cases of reported pseudoaneurysms of the radial artery.

The etiologies are essentially traumatic. A penetration point may have been unnoticed or forgotten by the pa- tient. A few cases occuring after cannulation of the radial artery have been studied.

Clinically in all cases the presentation is similar. A few weeks after the penetrating traumatism, there appears a pulsatile mass along the distribution of the radial artery at the wrist, growing progressively, it creates compression on neighbouring structures, such as the median nerve. No distal ischemia is observed. Auscultation and Doppler examinations reveal a thrill. On arteriograms, a blood-fil- led bag is seen continuous with the arterial passageway (fig. 1).

The surgical approach of many surgeons was a resec- tion of the tumor, with proximal and distal ligation of the artery (Buzzachino, Sterling, Bok, Hegarty). For a few years, authors tended to re-establish arterial continuity either with simple end to end suturing or by interposition of a vein graft.

CASE H I S T O R Y M Y. L , a 24 years old manual worker, was seen in consultation in

November of 1980, a few hours after an accidental penetration by a mi- nute steel fragment, of the radial side of the anterior surface of the right wrist. There was edema and congestion around the punctiform entry point. The distal radial artery was pulsafile A single X-ray confirmed the pre- sence of a 0.5 cm metallic foreign body

A week later, on re-examination, the edema had subsided, exposing a pulsatile tumor mass Doppler examination and ausculation revealed an impressive thrill. The Allen test, by compression of the radial artery, cau- sed a devascularization of the radial side of the hand The arteriogram showed a saccular pseudoaneurysm along the wall of the radial artery (fig 2).

Surgery repair with a vein graft and., restitutio ad integrum ,, of the ar- terial continuity was planned and executed (fig. 3) Post-operative results were excellent. The control arteriogram done in January of 1981 revealed : - - disappearance of the pseudoaneurysm ;

restitution of the permeability of the artery by an interposed vein graft, 2 cm in length ;

- - a significant predominance of the radial artery as compared to the ulnar artery in the irrigation of the hand.

DISCUSSION The surgeon is confronted with two questions : 1. Is surgical restoration of the arterial axis manda-

tory ? 2. Are microsurgical aids useful ? The surgical restoration of the arterial axis is manda-

tory for many reasons.

42 PSEUDO-ANJ2VR YSMES

Les etudes anatomiques classiques (Gray, Testut) et plus recemment les equipes de chirurgiens specia- lises (Michon) concluent/J la variabilitd de ces arca- des. Pour J .B. B r a u n , seule une a n a s t o m o s e comple t e pa r inocula t ion d e t e r m i n e l ' ex i s tence d 'une arcade palmaire fonctionnelle.

Au niveau de l'arcade pahnaire superficielle les etudes anatomiques retrouvent rarement un reseau n o r m a l : 2 cas sur 30 pour Braun et al. [2 bis] 15 cas sur 750 pour MacCormack et Ansorl [10].

Ces auteurs retrouvent plus f requemment : une artere mediane ; un rameau anastomotique de faible calibre ; une absence totale de communication (fig. 4).

Dans plus de 60 % des cas, ces anastomoses sont non fonctionnelles.

Au niveau de l'arcade palmaire pro/bnde, les au- teurs s 'accordent ~a re t rouver une arcade fonction- nelle dans environ 50 % des cas. Sur le plan anato- mique seul, les possibilites de souffrance distale par devascularisation de l 'artere radiale Mrs d'un geste de ligature sont reels et le test d 'Allen, mdme lors- qu'il est couple h l 'examen Doppler , peut 6tre trom- peur.

Point de vue physiologique

L'dtude de Hirai et al. en 1979 [7, 8], des pres- sions sanguines digitales sous compression selective

DE L 'ARTERE R A D I A L E ANNALES DE CHIRURGIE

DE LA MAIN

des arteres radiales et cubitales au moyen de metho- des pldthysmographiques couplde & des etudes artd- riographiques lui permet de conclure gt l 'existence dans 26 % des cas d 'une circulation il dominante ra- diale, dans laquelle la chute de pression du premier au cinquieme doigt est plus marquee sous compres- sion de l 'artere radiale.

Ces chutes de pression Iors de l 'oblitdration de l 'artere radiale sont rdalisdes << experimentalement ,, par l ' introduction de catheters intra-arteriels lots des mesures de pression sanguine, Crossland en 1977 [51 rapporte une sdrie de 600 catheterismes de l 'artbre radiale. 60 complications ischemiques sont relevees : 15 sont totalement reversibles "a la levee du cathe- ter ; 45 ont ndcessit6 56 interventions chirurgicales dont 5 amputat ions de la main, 8 amputations digita- les. 4 deces par complications gdndrales sont relevds dans cette derniere serie, bien qu'elles ne puissent 6tre ent ierement attribudes au seul arret du flux san- guin dans l 'artere radiale.

Ces dernieres constatations tendent ~ prouver que les phdnombnes compensateurs d 'une interruption d'un axe du membre supdrieur (une dtude rdalisde en 1977 par Montgomery et Williams [11] ddmontre l 'existence de phenomenes vasomoteurs tres puis- sants au niveau de la main et des doigts) sont parfois mis en defaut. I1 semble donc necessaire de toujours rdtablir le flux sanguin d'une artere pdriphdrique du membre superieur.

Anatomical reasons

The suppleance of the interruption of an upper limb ar- terial axis is assured by the arterial arches of the hand.

The classical anatomical studies (Gray, Testut) and more recently those of specifialized surgical teams (Mi- chon) conclude in the variability of these arches. Accor- ding to J.B. Braun, only a complete anastomosis determi- nes the existence of a functional palmar arch.

At the level of the superficial palmar arch, the anatomi- cal studies rarely showed a normal typical network: in only two (2) cases out of thirty (30) in J.B. Braun studies [2 bis], and in fifteen (15) cases out of 750 in MacCor- mack and Anson's studies [10].

More frequently, these authors noted : a mediN artery ; an anastomosing arterial branch of small size or a complete absence of communication between the arches (fig. 4).

In more than 60 % of cases, anastomoses were non functional.

At the level of the deep palmar arch, the authors found a functional arch in only 50 % of cases. Therefore, anato- mically speaking, there are great possibilities of distal is- chemia after ligation of the radial artery, and the Allen test, even when coupled with the Doppler examination can be deceptive.

Physiological reasons

Hirai in 1979 studied digital blood pressure, during se- lective compression of radial and ulnar arteries. Plethys- mographical and arteriographical methods enabled him to conclude that there exists radial dominance in 26 % of cases. In these cases, during compression of the radial artery, there was a marked pressure gradient between the thumb and fifth finger.

These pressure failures occuring after radial artery obs- truction are experimentally reproduced by radial artery cannulation for blood pressure measurements. In 1977, Crossland presented a series of 600 radial artery cathete- rizations. Sixty (60) ischemic complications were noted. Fifteen (15) were completely reversible upon removal of the canula. Forty-five (45) necessitated 56 surgical inter- ventions including : 5 hand amputations, 8 digital amputa- tions, 4 deaths due to systemic complication are noted in this last series, even though they cannot be entirely attri- buted to the stopping of the blood flow in the radial artery.

These last observations prove that the compensatory phenomena after a vascular axis interruption in the upper ,limb are sometimes insufficient. (A study done by Montgo- mery and Williams [11] in 1977 showed the existence of very powerful compensatory vasoactive phenomena in the hand and fingers).

Vot . . 1, N" 1 MAI 1982 fLS'I~UI)O-A NI['VR YSME£" DE l. 'A R T/[RE RA DIA l.t,] 43

I t

Fig. 1. - - Decouve r tes hab i tue l les dans I ' a r te r iograph ie des p s e u d o - a n e v r y s m e s de I 'ar tere radiale.

Fig. 1. - - Usual findings on angiography of the radial artery pseudoai7eurysms

Fig. 3. - - A r te r i og raph ie {M.Y. L,..) apres la gref fe ve ineuse .

Fig. 3. M Y L Angiography after placement of a vein graf t

Fig. 2. - - A r te r i og raph ie (M .Y .L . . . ) rnont rant le p s e u d o - a n e v r y s m e le long de I 'ar tere radia le et I 'ob jet rad io -opaque qui a cause le t r auma t i sme .

Fig. 2. - - M . Y . L . Angiography : a radial artery pseudoaneurysm and a radio-opaque object responsable for the t rauma are visualised.

Fig. 4. - - Les d i f fe ren tes va r i an tes de la d i s t r i bu t ion ar ter ie l le dans le m e m b r e super ieu r de gauche ~1 d ro i te : une ar te re med iane add i t ionne i le , une a b s e n c e comp le te d ' a n a s t o m o s e , une a n a s t o m o s e t res f ine. Fig. 4, - - Variable arterial distribution of the upper limb from left to right ; an addit io nal medial ar tery ; a complete absence of anas tomos is : an anastomosing arterial branch of small s i ze

ANNALES DE CHIRURGIE 44 PSEUDO-ANEVRYSMES DE L ' A R T E R E R A D I A L E DE LA MAIN

C O N C L U S I O N REFERENCES

L ' u t i l i t 6 d e m o y e n s m i c r o c h i r u r g i c a u x e s t l a c o n s 6 q u e n c e d e s p r e u v e s i r r e f u t a b l e s d e f i a b i l i t 6 a p - p o r t d e s p a r t o u t e s l e s 6 q u i p e s d e c h i r u r g i e n s d ' u r - g e n c e d e la m a i n e n m a t i e r e d e p e t i t s v a i s s e a u x . L a r 6 p a r a t i o n d ' u n e a r t e r e d e 2 m m d e d i a m e t r e s e f a i t m l e u x p a r u n c h i r u r g i e n e n t r a i n 6 ~ s u t u r e r d e s v a i s - s e a u x d e 1 m m d e d i a m ~ : t r e .

Q u e l q u e s a u t e u r s ( K l e i n e r t [9] , D e C o n i n c k [4]) p r e c o n i s e n t l ' u t i l i s a t i o n d u m i c r o s c o p e p o u r s u t u r e r l e s v a i s s e a u x d e l ' a v a n t b r a s e t d e la m a i n .

I1 s e m b l e n e c e s s a i r e , d e p l u s , d ' a p p o r t e r u n t i s s u d e r e m p l a c e m e n t b, la p e r t e d e s u b s t a n c e c r 6 6 e p a r l ' e x e r e s e d u p s e u d o - a n 6 v r y s m e e t d e s a b a s e . L e g r e f f o n v e i n e u x e s t l a r g e m e n t u t i l i s 6 e n m i c r o c h i r u r - g i e d i s t a l e e t t r o u v e ici u n e p a r f a i t e i n d i c a t i o n . U n e d o u b l e s u t u r e d e ce c a l i b r e p e u t s e r e v e l e r d i f f i c i l e e t h a s a r d e u s e s a n s m o y e n s g r o s s i s s a n t s . L a n 6 c e s s i t 6 d ' u n g r e f f o n v e i n e u x r 6 a l i s 6 e n m i l i e u m i c r o c h i r u r g i - ca l s ' i m p o s e .

N o u s p e n s o n s q u e la t e c h n i q u e c h i r u r g i c a l e i d e a l e d e s p s e u d o - a n e v r y s m e s d e l ' a r t e r e r a d i a l e e s t le g r e f f o n v e i n e u x m i c r o c h i r u r g i c a l .

1. ALLEN E.V. - - Thromboangiitisobliterans, Methods of diagnosis'of chronic occlusive arterial lesions distal to the wrist with illustrative cases. Amer. J. Med. Sci., 1929, 178, 237-244.

2. BOK Y,, LEE, KANGKIELKIM J.L., MADDEN. - - True aneurysm of the radial artery : report of a case with long term follow up. J. Amer. Geriat. Soc.. 1977, 25, 8,376-378.

2 his. BRAUN J.B.. WERNER J.E., BORRELLY J., FOUCHER G., MERLE M., MICHON J. - - Quelques notions d'anatomie arterielle de la main et leurs applications chirurgicales. Ann. Chir.. 1979, 33, 9, 701-71/6.

3. BUZZACHINO A., BARILE C., BOLTRI F.~ PEGORARO M. - - Gli ancvrismi delle arterie periferiche. Minerva Cardio. AngoIogica, 1979, 27. 79. 693.

4. DE CONINCK A., BILTERYS L., GRANT R., LOKIETEK W. - - Faux anevrysme cubito-palmairc. Acta Orthop. Belg., 1979, 45. 4, 395- 402.

5, GROSSLAND S.G., NEVIASER R.F. - - Complication of radial ar- tery catherization. The hand. 1977, 9, 3,287-290.

6. HEGARTY M.M., ANGORN I.B., GOLLOWGHY J., BAKER L.W. - - Traumatic arteriovenous fistulae. Injury, 1975, 7, 1,20-28.

7. HIRAI M. - - Arterial insufficiency of the hand evaluated by digital blood pressure and arteriographic findings. Circulation, 1978.58, (S), 9/12-9/18.

8. HIRAI M., NIELSEN S.L., LASSEN N.A. - - Blood pressure measu- rement of all five fingers by strain gauge plethysmography. Scand. J. Clin. Lab. Invest.. 1976, 36, 627.

9. KLEINERT H.E., VOLIANITIS G.J. - - Thrombosis of the palmar arterial arch and its tributaries. Etiology and newer concepts in treat- ment. Trauma, 1965, 4, 447,

10. McCORMACK L., CAULDWELL E.W., ANSON B.J. Brachial and antebrachial patterns. Study of 750 extremities. SGO, 1953, 96. 43-54.

11 MONTGOMERY L.D., WILLIAMS B.A, Variation of forearm, hand and finger blood flow indices with ambient temperature. Aviation 8pace Environmental Medecine. 1977, 231-235.

12 NARSETE E. - - Traumatic anevrvsm of the radial artery. A report of three cases. Amer. J. Surg., 1964, 108. 424.

13. STERLING A.P., HABERMANN E.T. - - Traumatic anevrysm of , the radial a rteLy ~ The hand., 1975, 7, 3,294-296.

C O N C L U S I O N

Thus it seems necessary to always re-establish the blood flow of a major peripheral artery of the upper limb.

The usefulness of microsurgical aids is due largely to the perfection of such methods developped by various teams dealing with surgery of the hand. The anastomosis of a 2 mm diameter artery is better executed by a surgeon

whose training has enabled him to suture 1 mm diameter arteries. Kleinert and De Coninck propose always using microsurgery for the suturing of forearm and hand ves- sels.

It seems necessary, furthermore, to replace lost vascu- lar tissue secondary to pseudoaneurysm resection. The venous interposition graft finds here an ideal indication.

Informations

BELGIAN HAND GROUP

CONGRES DU X e ANNIVERSAIRE Bruxelles, 4 et 5 juin 1982

Presidente : D' M. Lejour (Bruxelles) Vendred i 4 ju in 1982

• Pathologie rare de la main.

• P a t h o l o g i e vasculairc de la main.

Samed i 5 ju in 1982

• Traumat i smes nerveux de la main.

Avec la participation de : J.Y. Alnot (Paris), R .A. Dickson (Leeds, Angleterre) , D.M. Evans (Bucks, Angleterre) , G. Fou- cher (Strasbourg), J. Glicenstein (Paris), B. Gr ibomont (Bruxel- les), P. Jaumain (Bruxelles), M. Jesel (Strasbourg), R. Malek (Par is ) , G. M a t t o n ( G e n t ) , M. M a t t o n ( G e n t ) , M. Mer le (Nancy), J. Michon (Nancy), A. Narakas (Lausanne) , J. Struyven (Bruxelles), N. Te le rman-Toppe t (Bruxelles), R. Vilain (Paris), G. Willems (Bruxelles).

Secretariat scientifique : D r J.J. Rombouts , Cliniques Universi- taires Saint-Luc, avenue Hippocrate 10, B-1200 Bruxelles.

Secretariat administratif : Mme H. van Leemput ten, rue Jo- seph Stalleart 28, B-1180 Bruxelles. Tel. (02) 344.06.30.

REEDUCATION DE LA MAIN COURS DE PERFECTIONNEMENT

Vendredi 18 et le samedi 19 juin 1982 Service de Chirurgie de la Maison de Nanterre.

(Chef de Service : Docteur Ph. Detrie)

Ce cours est reserve aux reeducateurs : medecins, kindsithera- peutes, ergotherapeutes diplemes.

Pour tout renseignement ~erire & I'adresse suivante : Mile M. Ad- jouri , Secretariat du Cours de Reeducat ion de la Main, Service de Chirurgie, 403, avenue de la Republ ique, 92014 N A N T E R R E CEDEX.