A surgical case of excision of infected aneurysm
arising from anterior interosseal artery following
Shigetoshi Mieno, MD,aHideki Ozawa, MD,aJun Tanigawa, MD,bYoshitaka Kurisu, MD,cand
Takahiro Katsumata, MD,aOsaka, Japan
Infected aneurysm (IA) of the anterior interosseal artery (AIA), the first branch of the ulnar artery, is an infrequent but
serious complication of infectious endocarditis (IE). We report a successful case of excision of IA arising from AIA. In this
case, the IA expanded and adhered to the ulnar artery, resulting in occlusion of the ulnar artery. Reconstruction of the
ulnar artery was not needed by the preoperative evaluation and the intraoperative occlusion testing. We discuss surgical
treatment of IA following IE in upper extremities. (J Vasc Surg 2011;53:1104-6.)
A 76-year-old man complained of swelling and redness with
ongoing pain and fever at the right forearm, and came to our
hospital for evaluation of the symptoms on November 5, 2009.
The patient also had a continuous low-grade fever (37.0 to
37.5°C) for 3 weeks. He had undergone cholecystectomy for
cholelithiasis in 2000 and prostatectomy for prostate cancer in
2008. Upon admission, the patient had a Levine II/VI systolic
heart murmur at apex. The heart murmur was not previously
pointed out in his past history. Janeway lesions were found at his
bilateral foot bottom. A transthoracic echocardiogram revealed
moderate mitral regurgitation due to prolapse of the postero-
medial site of the anterior leaflet (A3 prolapse) but no vegetation.
Other abnormal findings were not evident. White blood cell
counts and C-reactive protein were 4000/?L and 5 mg/dL,
respectively. Blood culture yielded Enterococcus durans for a con-
secutive 2 days after admission. Enhanced computed tomography
(CT) presented an aneurysm possibly arising from the right ulnar
artery. The maximum diameter of the aneurysm was 24 ? 22 mm
(Fig 1, A). New valvar regurgitation and positive blood culture for
2 consecutive days after admission were involved in the major
criteria of the diagnostic criteria for infectious endocarditis (IE)
from Duke University. Evidence of Janeway lesions and the aneu-
rysm in the right forearm were also involved in the minor criteria.
Following the treatment guideline of IE, the patient received
intravenous injection of 12 g/day of ampicillin sodium and 120
mg of Gemtamaicin sulfate for 3 weeks. As the antibiotic treat-
ments continued, the patient did not have a fever, and C-reactive
protein decreased to 0.07 mg/dL. Subsequent blood cultures
were sterile. However, a follow-up enhanced CT 3 weeks after the
treatment presented a slight increase in the size of the aneurysm of
27 mm ? 23 mm. The aneurysm was palpable at the middle part of
the ulnar side and upper third of his right forearm but not at the
the ulnar rather than the radial direction. Palpitation was clearly
observed on the radial artery of his right forearm, but not on the
ulnar artery. We did not perform an Allen test in this case, but the
intact circulation of the radial artery was observed in an enhanced
CT (Fig 1, A) as well as on an ultrasound echogram. In addition,
retrograde blood flow was also recognized by ultrasound echogra-
phy in the ulnar artery distally from the aneurysm.
After median skin incision of the upper third of his forearm,
the brachial, radial, and ulnar arteries were exposed. We carefully
artery (AIA). We performed taping to the ulnar artery and AIA,
hard to dissect the outer surface of the aneurysm because of its
tight adhesion. After snaring the tourniquets, we recognized 100%
wave of the pulse oximeter setting on the ring finger as well as the
index finger. Then we opened the aneurysm. A relatively fresh
thrombus existed into the aneurysm. There was no backward flow
into the aneurysm. After recognizing inflow from the ulnar artery
by releasing the tourniquets, we ligated the AIA. As we dissected
the aneurysm distally, we found that the distal ulnar artery was
occluded, possibly due to adhesion and compression by the ex-
panded aneurysm. There was no communication between the
distal ulnar artery and the aneurysm. Finally, we excised the aneu-
rysm. No organism was observed from a culture of a piece of the
excised aneurismal tissue. The postoperative enhanced CT is
shown in Fig 1, B. Pathologic findings from the resected aneurys-
mal tissue show pseudoaneurysmal formation (Fig 2, A) and the
subacute phase of inflammatory response (Fig 2, B). The antibiotic
therapy was continued for 3 weeks after the surgery. His postop-
erative course was uneventful. A cardiologist is following up on the
patient at clinic. Similar to the preoperative status, pulsation of the
radial artery in his right forearm was clearly palpable, but not that
of the ulnar artery. There is neither limitation of movement nor
From the Department of Thoracic and Cardiovascular Surgery,aCardiology,b
and Pathology,cOsaka Medical College Hospital, Takatsuki, Osaka,
Competition of interest: none.
Reprint requests: Takahiro Katsumata, MD, Department of Thoracic and
Cardiovascular Surgery, Osaka Medical College Hospital, 2-7 Daigaku-
machi, Takatsuki-city, Osaka, Japan (e-mail: firstname.lastname@example.org.
The editors and reviewers of this article have no relevant financial relationships
to disclose per the JVS policy that requires reviewers to decline review of any
manuscript for which they may have a competition of interest.
Copyright © 2011 by the Society for Vascular Surgery.
change in palmar and digital circulation even after the excision in
the right hand as compared with the left hand. As with the
preoperative status, the echocardiogram shows no vegetation but
mild-to-moderate mitral regurgitation due to A3 prolapse.
The preoperative evaluation for distal circulation from
the aneurysm, including digital circulation, as well as judg-
ments for the need of reconstruction of the ulnar artery, are
important factors in this case. The radial artery was intact,
and retrograde flow in the ulnar artery distally from the
aneurysm was observed by ultrasound echogram. In addi-
tion, we confirmed maintenance of the digital circulation
using a pulse oximeter on both ring and index fingers after
the occlusion testing of the AIA during the operation. The
aneurysm expanded and adhered to the ulnar artery, result-
ing in ulnar artery occlusion. Based on the pre- and intra-
operative evaluation, we ligated the AIA as an inflow tract
and excised the aneurysm without reconstruction of the
The existence of an infected aneurysm (IA) following
IE in the upper extremity should be surgically treated. An
IA forms when an infected embolus lodges in either an
arterial lumen or in a vasa vasorum.1-3The infection weak-
ens the arterial wall, and the natural history of an IA in an
upper extremity is to enlarge and rupture, regardless of
Fig 1. Preoperative and postoperative 3D computed tomography (CT) pictures. A, The preoperative 3D CT picture
on admission. The size of the arterial aneurysm was 24 mm x 22 mm, as the large arrow indicates. The radial artery was
enhanced clearly, as the four small arrows indicate. The ulnar artery distally from the aneurysm was not clearly
enhanced. B, The postoperative 3D CT picture. The aneurysm was not enhanced after the surgery. The first branch of
the ulnar artery, the anterior interosseal artery, was ligated, and the aneurysm was excised.
Fig 2. Pathologic findings of the aneurysm. A, Elastica van Gieson staining. Arrows indicate the disruption of elastic
fiber, which is stained by black. B, Hematoxylin-eosin staining. Infiltration of neutrophil and existence of hemosiderin
is shown in the aneurysmal wall. The findings indicate the subacute phase of inflammatory response.
JOURNAL OF VASCULAR SURGERY
Volume 53, Number 4
Mieno et al 1105
whether the infection is cleared.3Rupture, uncontrollable Download full-text
bleeding, and interruption of the peripheral circulation
require emergent surgery for an IA following IE. Consid-
ering the pathogenesis, an IA should be surgically treated,
even if clinically silent. In this context, an earlier operation
would be recommended in this case, although we waited
for 3 weeks to do the surgery until antibiotics sterilized the
blood. A recommended surgical procedure for an IA is to
ligate the inflow artery and excise the aneurysm.4Arterial
repair or vein graft should be avoided because of a high
incidence of persistent infection and of late rupture.1,5In
addition, endovascular repair as well as coil embolization
should be avoided. In this case, we ligated the AIA as the
inflow artery and excised the aneurysm.
When we perform surgery of an IA in an upper extrem-
ity, the judgment of the need for arterial reconstruction
should be critical. In this case, as we evaluated the circula-
tion in the forearm using ultrasound echography and en-
hanced CT, as well as physical examination, retrograde
blood flow was confirmed in the ulnar artery distally from
the aneurysm. In addition, we performed intraoperative
occlusion testing using a pulse oximeter before ligating the
AIA. Based on the pre- and intraoperative evaluation, re-
construction of the ulnar artery was not necessary in this
case. If reconstruction is needed, an interposition graft
should be recommended. The saphenous, cephalic, and
basilica veins are considered as graft options. However,
these veins are often too large. Therefore, a small-caliber
vein harvested from the forearm may be suitable for inter-
position.6In addition, interrupted sutures are often used
for the anastomosis, which is performed with microsurgical
Median and lateral approaches are generally considered
for the open surgery of the ulnar artery and its branches.8
Anatomically, the aneurysm arising from the ulnar artery
and/or the AIA tends to expand toward the lateral side
because of lack of muscle component at its location be-
tween the superficial and deep flexor muscles of the fin-
gers.9Therefore, the aneurysm was easily recognized as a
pulsatile mass at the lateral middle and upper third of his
right forearm. In this case, it was easier to use the lateral
approach to reach the aneurysm than the median approach.
However, we considered that ligation of inflow artery, as
well as occlusion testing for evaluation in reconstruction of
peripheral circulation, was easily performed by the median
approach rather than the lateral approach in the preopera-
tive planning. That is the reason why we chose the median
approach in this case. If graft surgery is needed, the lateral
aneurysm and to achieve distal anastomosis.
In conclusion, we report a successful surgical case of
ligation of the AIA and excision of an IA in a right forearm
without reconstruction of the ulnar artery. Long-term
follow-up will be required for revival of infection and
exacerbation of mitral regurgitation.
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Submitted Jun 30, 2010; accepted Oct 21, 2010.
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