Lehigh Valley Health Network
LVHN Scholarly Works
Department of Surgery
Brachial Artery Aneursym with “Blue Finger
Syndrome” After Ligation of an Arterio-Venous
Fistula
Ramon Garza, III MD
Lehigh Valley Health Network, [email protected]
Dale A. Dangleben MD
Lehigh Valley Health Network, [email protected]
John F. Welkie MD
Lehigh Valley Health Network, [email protected]
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Published In/Presented At
Garza, R., Dangleben, D. A., Welkie, J. F. (2010, November). Brachial Artery Aneurysm with “Blue Finger Syndrome” After Ligation of an
Arterio-Venous Fistula. Poster presented at: Keystone ACS, Harrisburg, PA.
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Brachial Artery Aneursym with “Blue Finger Syndrome” After Ligation of an Arterio-Venous Fistula
Ramon Garza III, MD, Dale A. Dangleben, MD, John F. Welkie, MD • Lehigh Valley Health Network, Allentown, Pennsylvania
Introduction
As early as the 18th century, arterial dilation and large brachial
artery aneurysms have been described following arteriovenous (AV) fistula ligation.1,2 Studies from Rubanyi et al. have
shown that high blood flow triggers the release of relaxing
substances from endothelial cells which leads to dilatation
of the artery receiving high flow.3 According to Eugster et
al., arterial dilatation is locally mediated by these relaxing
substances.4 In addition, longstanding high flow leads to
transverse tears in the internal elastic membrane which can
cause proximal progression the dilatation from the site of
the fistula.5,6 Other studies suggest that immunosuppression
with corticosteroids may promote the development of arterial
aneurysms.4 The combination of these factors presents a
unique situation in renal transplant patients with AV fistulas.
We describe a corticosteroid, immunosuppressed, renal
transplant patient with pandilatation of his brachial artery
following ligation of a brachial cephalic AV fistula.
Case Report
A 47-year-old male was admitted to our hospital with a chief
complaint of pain and discoloration of the distal finger tips
on his right hand. The patient had a past medical history
significant for polycystic kidney disease resulting in renal
failure. He underwent a right upper extremity A-V fistula
creation and received hemodialysis for 15 months. The
patient later received a cadaveric kidney transplant and
began receiving immunosuppressive therapy with Prograf and
prednisone. Soon after, the patient noticed swelling in the area
of the fistula. He was evaluated by a surgeon at an outside
hospital who ligated and resected the dilated vein. The patient
remained asymptomatic postoperatively until 3 days prior to
presentation when he began having color changes of the skin
and paresthesia in the finger tips of his right hand. He denied
any loss of sensation or strength in the right hand. Over the
next several days the patient reported progression of the pain
to include the right forearm which he noted was intermittent
in nature. He denied any alleviating or aggravating factors. On
physical exam there was cyanosis of the right thumb, ring,
and little finger. Capillary refill was > 3 seconds in all the digits
and the palm of the right hand, with a palpable ulnar and radial
pulse. There was no motor or sensory loss in the right upper
extremity. The patient was admitted and began receiving
an intravenous heparin drip with the working diagnosis of
aneurysm with thrombosis of the right brachial artery. An
arterial duplex was obtained and showed the proximal brachial
artery to measure 14 mm in diameter and in the aneurismal
segment to measure 23 mm in diameter which also appeared
partially thrombosed. An arteriogram was then ordered to
better evaluate the brachial artery aneurysm. The result of this
study demonstrated an abnormal brachial artery from the origin
of the brachial artery to the elbow in addition to slow blood
flow throughout. All other branches of the brachial artery were
normal. After thorough discussion, the decision was made for
the patient to undergo operative management for prevention
of future thrombotic events. Intraoperatively, the aneurysmal
brachial artery was resected with ligation of its branches and
was sent to pathology. A harvested non-reversed greater
saphenous vein was used for bypass. Postoperatively the
patient recovered well, although he has not experienced
complete resolution of cyanosis in the right hand. Histologic
examination showed myxomatous degenerative changes and
an adherent partially dissecting thrombus.
Discussion
Aneurysm formation is defined as the dilatation of a blood
vessel >50% of the normal expected diameter and this
dilatation includes all three layers of the arterial wall. In men,
an aneurysm of the brachial artery will measure >6.15-7.2 mm;
for women 5.25-6.45 mm. Pan arterial dilatation following A-V
fistula ligation can lead to significant morbidity for the patient
including decreased arterial flow and embolization.7 In this
particular case, the patient suffered from digital ischemia from
microthromboembolic events as well as decreased flow from
the partially occluded artery. Previous reports in the literature
recommend routine arterial duplex studies for patients who
have undergone ligation of longstanding traumatic or iatrogenic
A-V fistulas to prevent these types of complications.7 After
reviewing the current literature and from what we have learned
from our patient, we agree that yearly ultrasound studies to
evaluate ligated A-V fistulas should be recommended.
Fig 1. Patient presenting with
blue finger syndrome.
Fig 2. Intraoperative images showing proximal and distal control and also ligation of branches.
Fig 3. From pathology: showing vessel lumen and total length of arterial aneurysm.
References
1. Nguyen DQA, et al. Late axillo-brachial arterial aneurysm following ligated Brescia-Cimino haemodialysis fistula. Eur J Vasc Endovasc Surg 2001;22:381-382.
2. Hunter W. The history of an aneurysm of the aorta with some remarks on aneurysms in general. Trans Obstet Soc London 1757;1:323.
3. Rubanyi GM, et al. Flow-induced release of endothelium-derived relaxing factor. Am J Physiol 1986;250:H1145-1149.
4. Eugster T, et al. Brachial artey dilatation after arteriovenous fistulae in patients after renal transplantation: A 10-year follow-up with ultrasound scan. J Vasc Surg 2003;37:564-567.
5. Greenhill NS, et al. Scanning electron microscopy investigation of the afferent arteries on experimental femoral arteriovenous fistulae in rabbits. Pathology 1987;19:22-28.
6. Martin BJ, et al. Scanning electron microscopic study of haemodynamically induced tears in the internal elastic lamina of rabbit arteries. Pathology 1989;21:207-212.
7. Battaglia L, et al. Late occurrence of a large brachial artery aneurysm following closure of a hemodialysis arteriovenous fistula. Ann Vasc Surg 2006;20:533-535.