True aneurysm of the digital artery: a case report and systematic literature review.

Aneurysmal disease can occur in any vessel in the body and occur most commonly the aorta, cerebral and popliteal arteries; however, aneurysms of the digital artery remain a rare presentation. They form an important differential diagnosis in any patient presenting with a mass in the hand. This report presents the case of a 64-year-old man with a true aneurysm of the common palmar digital artery who underwent successful repair, following excision and end to end anastomosis. Only 21 cases of true digital artery aneurysm have been reported; we review the literature pertaining to the diagnosis and management of digital artery aneurysms since they were first described by Baruch et al in 1977. Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved.

INTRODUCTION

Aneurysms of the digital artery are exceedingly rare, and few cases have been reported. The majority of cases occur secondary to penetrating or iatrogenic injury causing a false aneurysm of the artery. True aneurysms have been described and can be the result of a congenital anomaly or repetitive blunt micro-trauma due to occupational or recreational predisposition. Patients present with a classic history of an enlarging, tender, pulsating mass. They may also experience cold intolerance, sensory compromise and ischaemic skin changes. A high degree of clinical suspicion is required, and diagnosis is usually confirmed through imaging. Surgical options consist of excision and ligation or restoration of the vasculature, either by primary anastomosis or reconstruction with an interposition graft. We discuss the case of a man presenting with a true digital artery aneurysm and a systematic review of the literature pertaining to the diagnosis and management of digital artery aneurysms.

CASE REPORT

A 64-year-old right-handed, retired man presented to vascular clinic with a 3-month history of an enlarging mass on the ulnar side of his right palm. He had no history of previous trauma but a clear occupational predisposition after spending 20 years working as an electrician.

On examination, there was a pulsatile, firm swelling on the ulnar aspect of the right palm with no tissue loss. There was a palpable radial pulse, but no ulnar pulse found on clinical examination. Doppler signals over the digital arteries, ulnar and radial artery were detected. The patient was asymptomatic, and capillary refill time was normal. An initial ultrasound scan demonstrated a 17 × 8 × 13 mm aneurysm of mixed echogenicity in the palmar arch. This was further characterized through angiography (Fig. 1) and was confirmed to be in fact an aneurysm of the common digital artery in the fourth web space.

Figure 1

Angiogram showing aneurysm of the common palmar digital artery in the fourth web space.

Following multidisciplinary team discussion, it was decided that the patient would be a candidate for excision and repair of the aneurysm either with interposition vein graft or primary anastomosis. The case was discussed with the plastic surgery team and undertaken as a joint procedure. After explaining the risks of leaving the aneurysm, specifically, digital ischaemia secondary to thrombosis or rupture, sensory compromise and cold intolerance, balanced against the risks of surgery, the patient decided to proceed with surgical intervention.

A true aneurysm arising from the third common digital artery was confirmed intraoperatively (Fig. 2), supplying the ring and little finger. This was dissected free and the proximal and distal segments clamped. The aneurysmal sac was excised (Fig. 3), and the artery repaired by primary anastomosis (Fig. 4) with good flow immediately after removal of both arterial clamps. The patient was followed up 1-year post surgery, with no evidence of recurrence.

Figure 2

Intraoperative view of the aneurysm.

Figure 3

Divided aneurysmal sac.

Figure 4

Repair of the common palmar digital artery.

DISCUSSION

Aneurysms of the digital artery are rare but an important differential diagnosis in patients presenting with a mass in the hand. They can be congenital, occur secondary to penetrating injury or recurrent blunt micro-trauma. Furthermore, iatrogenic causes have been described in patients following percutaneous trigger finger release and fasciectomy. The potential for thrombosis or rupture can cause digital ischaemia in cases of compromise to the collateral circulation.

A systematic search of the Medline and Embase databases was performed according to the PRISMA guidelines, using the terms ‘digital artery’ AND ‘aneurysm’ (Fig. 5). All titles and abstracts from the search were evaluated for relevance and full texts of papers meeting eligibility criteria were obtained. References within these articles were reviewed for suitability. This retrieved 42 case reports and 4 case series consisting of 21 true aneurysms, 26 false aneurysms and 2 mycotic aneurysms.

Figure 5

Systematic search strategy and selection process.

Demographic data, aetiology, imaging modality, surgical procedure and outcomes were recorded for each case (Table 1). Several early publications did not include diagnostic imaging or report the type of aneurysm, and missing data were recorded in these cases. We found that of 26 patients presenting with false aneurysms of the digital artery, 20 had a clear history of penetrating trauma. Of the two mycotic aneurysms identified, one was secondary to infective endocarditis and one was due to an infected collection surrounding the digital artery. The majority of true aneurysms were due to repetitive micro-trauma from occupational injury, for example metal work, radiography and professional golf. The remainder of true aneurysms were either congenital or of unknown cause. No case of Marfan syndrome, Ehlers-Danlos or other collagen disorder was identified.

Table 1

Digital artery aneurysms: literature review [1–10]

Author	Year	Age + gender	Mechanism of injury	Imaging	Location	True/false	Presentation	Repair	Outcome
Lee	2006	44 F	Poor fitting wedding ring	No imaging	Ring finger	True	Firm, tender, non-pulsatile mass	E + L	No sequelae
Baruch	1977	21 M	Glass laceration	X-ray	Thumb	False	Hard, painful mass	E + L	NR
Taniguchi	2002	47 M	Radiographer	No imaging	Thumb	True	Tender mass, no sensory compromise	E + L	No sequelae
Adant	1994	55 M	Metal worker + Haemophilia	No imaging	Thumb	True	Severe pain and numbness when trying to grasp objects, present for 1.5 years	E + L	No sequelae
Ballas	2006	40 M	Textile factory worker—hammer injury + partial factor 8 deficiency	MRA	Index finger	False	Fixed, painless, pulseless lesion	E + L	No sequelae
Montoya	1991	23 M	Manual worker—penetrating injury	No imaging	Little finger	False	Painful, pulsatile, cyanotic mass, hypoaesthesia, 18 days post injury	E + L	No sequelae
Trabulsy	1992	21 F	Telephone operator	No imaging	Index finger	True	Painful, non-pulsatile mass, loss of sensation, reduced two-point discrimination	E + L	No sequelae + regained two-point discrimination
Lucchina	2011	43 M	Scissor injury	CTA	1st CPDA	False	Throbbing, painful, violaceous mass, 6 weeks post injury	Excision + reconstruction with SBRA	No sequelae
Yoshii	2000	29 M	Golfer	MRI	Ring finger	True	Non pulsatile, tenderness mass + numbness on ulnar side of finger	E + L	Complete resolution of symptoms
Yasuda	1996	NR M	Softball catcher	USS	Thumb	False	NR	NR	NR
Dangles	1984	46 M	US navy officer + bowler	No imaging	Thumb	True	Painful mass	E + L	NR
Cromheecke	1997	69 M	Screwdriver injury	Angiography	Second CPDA	False	Pulsatile, tender, compressible mass, no sensory compromise	Conservative	No sequelae
Tyler	1988	57 F	Opened tins by banging palm of her hand on opener for several years	DSA	first CPDA	False	Median nerve compression, tingling and pain + intermittent cyanosis, pulsatile mass	Excision + vein graft	No sequelae
Chaudhry	2011	54 F	Dog bite	USS	Index finger	False	Firm, cystic, pulsatile, tender mass	E + L	No sequelae
Turner	1984	52 F	Canteen assistant	No imaging	Ring finger	True	Tender mass, + hypoaesthesia	E + L	Complete pain relief, residual hypoaesthesia
Layman	1982	38 M	Crush injury	No imaging	Middle finger	True	Tender mass + hypoaesthesia, 2 years following injury	E + L	NR
Hentz	1978	19 M	Digital amputation	No imaging	Middle finger	False	2 cm pulsatile mass, 11 days postoperatively—following partial amputation of right index finger	E + L + complete amputation of digital stump	No sequelae
Suzuki	1980	69 M	Machinist—penetrating injury	Angiography	Thumb	False	Mass, ischaemic skin changes, hypoaesthesia	E + L
Hueston	1973	62 F	Post-fasciectomy for Dupuytren’s contracture	No imaging	Little finger	NR	Enlarging, painful, non-pulsatile mass 10 days post fasciectomy	E + L	NR
Sanchez	1982	26 M	Penetrating injury	Angiography	Ring finger	False	Tender pulsatile mass	Excision + PA	No sequelae
Simeonov	1998	4 M	Penetrating injury	No imaging	Second CPDA	False	Enlarging, bleeding mass	E + L	NR
Hall	1986	24 M	Penetrating injury	Angiography	Little finger	False	Throbbing, painful mass, 5 days post-injury	Repair	No sequelae
Abouzahr	1997	6 M	Penetrating injury	MRA	Index finger	False	Violaceous, tender, pulsatile mass 10 days post-injury	E + L	No sequelae
Strauch	2004	32 F	No cause identified	Angiography	Little finger	True	Fusiform, pulsatile, blue swelling	Excision + reconstruction with IVG	No sequelae
Shidayama	1992	13 F	Penetrating injury	No imaging	Middle finger	False	Tender, pulsatile mass, 1-week post-injury	E + L	No sequelae
Lanzetta	1992	28 F	Volleyball player	DSA	Middle finger (x3) + Superficial palmar arch	True	Tender, pulsatile mass + digit 3 degrees cooler than opposite hand	Conservative	No sequelae
Khan	1998	70 M	Penetrating injury	No imaging	Middle finger	False	Tender swelling	E + L	No sequelae
Sayit	2017	27 M	Penetrating injury	MRI	1ST CPDA	False	Tender, pulsatile mass, skin atrophy + hypoaesthesia, 1-month post injury	Excision + PA	NR
Brunelli	1988	27 M	Crush injury	X-ray	Middle and Ring finger	False	Tender, non-pulsatile mass	Excision + reconstruction with IVG	No sequelae
Quintella	2019	60 M	No cause identified	MRA	Middle finger	True	Tender, pulsatile mass	E + L	No sequelae
Dean	2019	13 months M	Congenital	Angiography	Second CPDA	True	Enlarging, pulsatile mass	E + L	No sequelae
Taylor	2012	60 M	Percutaneous trigger finger release	MRA	Thumb	False	Enlarging mass, pulsating + painful, reduced sensation in radial nerve distribution of thumb	E + L	No sequelae
Berrettoni	1990	67 M	Infective endocarditis	USS	Index	Mycotic	1-week history of painful swelling in the palm	Excision + reconstruction with arterial graft	No sequelae
Gracia	1987	70 M	Penetrating injury	NR	Middle	False	Pulsatile mass three weeks following knife injury	E + L	No sequelae
Miyamoto	2009	16 M	Baseball player	MRA	Thumb	False	1-year history of enlarging mass + hypoaesthesia	Excision + PA	No sequelae
Bianchi	1993	70 M	Penetrating injury	Angiography	Middle	False	Non-tender, non-pulsatile mass—gradually enlarging for 15 years following penetrating trauma	E + L	NR
Tanaka	2005	2 F	Congenital	Angiography	Middle finger	True	Pulsatile swelling	Excision + reconstruction with IVG	No sequelae
Bouvet	2018	39 M	Previous penetrating trauma and infected collection	MRI	Thumb	Mycotic	Painful mass	Excision + PA	No sequelae
Vinnivombe	2019	44 M	Musician + Golfer	MRA	Second CPDA	True	Swelling	E + L	No sequelae
Videodo	2017	71 F	No cause identified	USS	Little finger	NR	Pulsatile mass	E + L	No sequelae
Itoh	1992	8 month M	Congenital	USS	Third CPDA	True	1-month history of enlarging, pulsating mass	E + L	No sequelae
Plant	2011	65 F	Penetrating injury	USS + Angiogram	Thumb	False	Tender, pulsating mass, 2 weeks post injury	Excision + PA	No sequelae
Case series
Ho	1987	NR	Unknown	NR	Index finger	True	NR	E + L	No sequelae
		NR	Puncture wound	NR	Thumb	False	NR	E + L	No sequelae
		NR	Unknown	NR	Little finger	True	NR	E + L	No sequelae
		NR	Unknown	NR	Index finger	True	NR	E + L	No sequelae
		NR	Penetrating injury	NR	Little finger	False	NR	E + L	No sequelae
		NR	Volleyball player	NR	Ring finger	True	NR	Excision + PA	No sequelae
Adham	1997	48 M	Baseball bat injury	Angiography	Thumb	NR	Ulceration, pain and cold intolerance 1 week post injury	Excision + reconstruction with IVG	Ulceration healed, cold intolerance improved, asymptomatic at 2.5 years of follow-up
		49 M	Computer repair technician	X-ray	Thumb	NR	Mobile mass	Excision + reconstruction with IVG	Patent graft, slightly reduced flow compared to index finger
		32 M	Police academy firearms instructor	NR	Thumb	NR	Bruising and localized swelling, pain and cold intolerance 2 weeks following a long session of shooting practice	Excision + reconstruction with IVG	Patent graft, asymptomatic 5 years post procedure
		43 M	Bowler	NR	Thumb	NR	Painful mass for 2 weeks	Excision + reconstruction with IVG	Diminished flow 2 years post procedure but patent graft
Yajima	1995	58 F	Cut	No imaging	CPDA	False	`Mass	Excision + PA	No sequelae
		69 F	Farming	No imaging	CPDA	True	Mass + sensory disturbance	E + L	No sequelae
		16 M	Baseball	No imaging	Thumb	True	Mass + sensory disturbance	E + L	No sequelae
Gray	1998	NR	NR	NR	NR	NR	NR	E + L	No sequelae
		NR	NR	NR	NR	NR	NR	No intervention	No sequelae
		NR	NR	NR	NR	NR	NR	E + L	No sequelae

MRA, magnetic resonance angiography; CTA, CT angiography; MRI, magnetic resonance imaging; USS, Ultrasound scan; DSA, digital subtraction angiography; NR, not recorded; CPDA, common palmar digital artery; SPBRA, superficial palmar branch of the radial artery; E + L, excision + ligation; E + L + PA, excision + ligation + primary anastomosis; IVG, interposition vein graft.

Excision of the aneurysmal sac and ligation of the proximal and distal segment of the digital artery was the most commonly undertaken procedure. Some authors chose to repair the artery, usually through primary anastomosis. Few undertook an interposition vein graft and only two authors describe repair with an arterial graft, using the superficial palmar branch of the radial artery or a digital artery graft from the adjacent finger. Outcomes were favourable, and the majority of patients experienced resolution of symptoms with no recurrence reported.

Imaging modalities varied across the reviewed literature with the use of MR angiography, ultrasound scan, angiography and CT angiogram all being reported. Angiography was most commonly performed; however, in several cases, diagnosis was made at exploration. Patency of the corresponding digital artery should be confirmed through preoperative imaging or a digital Allen’s test. One case describes the absence of the ulnar digital artery on ultrasound, and the authors therefore opted for repair using an arterial graft.

The optimal management of these cases is still unclear with various approaches described. All patients identified through the systematic literature review made an uneventful recovery following excision and ligation. We felt that if the corresponding digital artery were to become compromised in the future, there would be a high risk of digital ischaemia and therefore chose to repair the artery.

In conclusion, digital artery aneurysms remain a rare presentation and management varies across the literature. Whilst outcomes are favourable following excision and ligation, restoring the normal anatomy and physiological condition could prevent symptoms of cold intolerance and tissue loss in the future. Furthermore, patients with a predisposition to hand injuries may sustain future penetrating trauma which could compromise the collateral vasculature. Repairing the artery mitigates the risk of future ischaemia.

Funding

There was no funding approved for this project.

Conflict of interest

There was no conflict of interest to declare.