Pseudoaneurysm and arteriovenous fistula of the brachial artery presenting 25 years after elbow fracture: a case report

Abstract

Introduction:

Post-traumatic pseudoaneurysms (PSAs) are uncommon vascular complications resulting from partial disruption of the arterial wall, leading to a contained hematoma that maintains communication with the arterial lumen. Although most PSAs develop shortly after trauma or vascular intervention, markedly delayed presentations are exceedingly rare and may pose significant diagnostic and therapeutic challenges. When associated with arteriovenous fistula (AVF) formation, these lesions carry an increased risk of progressive enlargement and sudden hemorrhage.

Case presentation:

We report a 37-year-old male who presented with intermittent bleeding, pain, and swelling in the left upper extremity, 25 years after sustaining a simple elbow fracture treated conservatively during childhood. Physical examination revealed a firm, tender, expansile pulsatile mass over the posterior aspect of the left elbow, with a palpable thrill and continuous bruit. Color duplex ultrasonography demonstrated a saccular PSA arising from the brachial artery, with an associated AVF draining into the adjacent vein. Given the risk of recurrent bleeding and the superficial location of the lesion, open surgical repair was performed, including excision of the PSA sac, ligation of the fistulous tract, and primary arterial repair. Histopathological examination confirmed features of a chronic PSA. The postoperative course was uneventful, and the patient remained symptom-free with no recurrence at the 6-month follow-up.

Discussion:

Delayed PSA and AVF formation following upper extremity fractures are rare but potentially life-threatening complications. These lesions likely originate from occult arterial injury sustained at the time of trauma and may remain clinically silent for decades before presenting with acute hemorrhage. In the absence of validated predictive scoring systems for rupture risk in peripheral traumatic PSAs, management should be guided by clinical presentation and lesion morphology. While endovascular techniques are increasingly utilized, open surgical repair remains a durable and definitive option in cases involving active bleeding or anatomically complex regions such as the elbow.

Conclusion:

This case underscores the importance of considering PSA formation as a late vascular complication of previous extremity trauma, even decades after the initial injury. Early recognition and timely intervention are essential to prevent catastrophic hemorrhage, with open surgical repair providing an effective and definitive treatment in selected cases.

Introduction

A pseudoaneurysm (PSA), characterized by a contained rupture in the vessel wall leading to blood accumulation outside the artery, can develop from vascular injuries incurred during trauma or surgical procedures^[1,2^]. While often asymptomatic initially, these vascular anomalies pose serious risks, including life-threatening hemorrhage if left undiagnosed and untreated, thereby necessitating ongoing surveillance of affected patients, particularly those with a history of trauma^[2,3^].

HIGHLIGHTS

• Pseudoaneurysms (PSAs) developing decades after trauma are exceptionally rare vascular complications.

• The patient presented with active hemorrhage 25 years after a conservatively treated elbow fracture.

• Doppler ultrasonography revealed a PSA with arteriovenous fistula formation between the brachial artery branches and the basilic vein.

• Open surgical repair successfully controlled bleeding and preserved limb function.

• This case emphasizes the importance of considering delayed vascular complications in patients with a history of trauma, even many years later.

The phenomenon of PSA formation as a long-term complication of upper extremity fractures highlights the importance of understanding the intricate anatomy of the region, including the proximity of arterial structures to commonly fractured bones. Injuries to the humerus, radius, and ulna can compromise the integrity of surrounding vascular systems, leading to complications that may not present until many years after the injury^[1,4^]. Such chronic complications can result in significant morbidity, requiring timely and effective medical intervention to mitigate the risks associated with rupture and active bleeding^[2,5^]. Most AVFs occur secondary to penetrating injuries, and surgical interventions are the most common mode of management, followed by endovascular surgical techniques^[6^].

This case report describes a 37-year-old male who presented with a PSA 25 years after a simple humeral fracture – a rare and delayed complication that resulted in active bleeding. This case report has been written in line with the SCARE 2025 criteria^[7^].

Case presentation

A 37-year-old male with no significant past medical history except for a previous fracture of the left elbow at the age of 12 was treated conservatively with casting. The patient presented with swelling, pain, and active hemorrhage from the site of a healed fracture on the left upper extremity. The bleeding was intermittent and occurred without any recent trauma. The timeline of key events is as follows:

• Year 0 (25 years prior to presentation [PTA]): Sustained left elbow fracture → treated with closed reduction and casting for 6 weeks.

• Intermittent Period: Occasional, mild local discomfort attributed to “arthritis”; no vascular symptoms.

• 2 months PTA: Noticed a small, painless lump in the posterior aspect of the left elbow, which progressively enlarged and became pulsatile and painful.

• Day of Presentation: Clinical evaluation and duplex ultrasound.

• Day 1: Admission.

• Day 2: Open surgical repair.

• 1-week and 1-month post-op: Follow-up visits with duplex surveillance, showing patent repair.

On presentation, the patient was afebrile and hemodynamically stable. Blood pressure: 128/82 mmHg in the left arm, heart rate: 76 bpm, respiratory rate: 16 bpm, oxygen saturation: 98% on room air. Local examination of the left upper extremity revealed a 4 × 3 cm firm, tender, and expansile pulsatile mass in the posterior aspect of the left elbow (Fig. 1). A palpable thrill and a continuous machinery-like bruit were auscultated over the mass. Distal pulses (radial and ulnar) were present but slightly diminished compared to the contralateral side. Capillary refill was <2 s, and no neurological deficit or signs of distal ischemia were noted.

Figure 1.

Clinical photograph showing a pulsatile mass over the posterior aspect of the left elbow, corresponding to the site of previous fracture, with overlying skin changes caused by repeated bleeding episodes.

Routine labs were within normal limits. Complete blood count: Hb 14.2 g/dL, WBC: 7.1 × 10⁹/L, Platelets 245 × 10⁹/L. Coagulation profile: prothrombin time 12.5 s, international normalized ratio 1.0, activated partial thromboplastin time 28 s. Basic metabolic panel unremarkable.

Initial color duplex ultrasound demonstrated a saccular, hypoechoic lesion arising from the mid-brachial artery with classic “yin-yang” swirling color flow, diagnostic of a PSA (Fig. 2). Adjacent to it, high-velocity, turbulent flow was noted from the artery into the brachial vein, confirming an AVF. Given the clear duplex findings, the superficial location of the lesion, and the need for urgent surgical control due to active bleeding, further cross-sectional imaging such as CTA was deemed unnecessary and would not have altered management.

Figure 2.

Color duplex ultrasonography demonstrating a saccular pseudoaneurysm with characteristic “yin-yang” flow pattern and adjacent high-velocity turbulent flow consistent with an arteriovenous fistula.

After informed consent, the patient was taken to the operating room for open surgical repair. The procedure was performed under general anesthesia. A transverse incision was made over the posterior aspect of the elbow. The PSA and associated veins were carefully dissected, with proximal and distal vascular control achieved using vessel loops. Intraoperative findings confirmed a thin-walled, saccular PSA adherent to the surrounding scar tissue and nerve. The fistulous connection to the brachial vein was identified and controlled.

The surgical principle involved complete excision of the PSA sac (Fig. 3). The fistulous tract was ligated and divided. The primary repair of artery was performed using 6-0 polypropylene sutures. Intraoperative Doppler confirmed patent flow.

Figure 3.

Intraoperative view showing complete excision of the pseudoaneurysm sac and surgical repair of the brachial artery following ligation of the arteriovenous fistula.

The excised PSA wall was sent for histopathological examination, which revealed fibrotic tissue with chronic inflammatory infiltrates and hemosiderin-laden macrophages, consistent with a chronic PSA, with no evidence of vasculitis or neoplasm.

Postoperative instructions included arm elevation, monitoring for compartment syndrome, and daily low-dose aspirin (100 mg) for 4 weeks.

The patient had an uncomplicated postoperative recovery and was discharged on postoperative day 3. At 6-month follow-up, the wound was well-healed, distal pulses were strong and equal bilaterally, and follow-up duplex ultrasound confirmed a patent brachial artery with no residual PSA or AVF. The patient resumed normal activities.

The patient provided explicit written consent for publication. He expressed significant anxiety upon noticing the pulsatile mass and relief following the definitive diagnosis and successful surgery. He was pleased with the functional and cosmetic outcome and understood the rarity of his condition’s delayed presentation.

Discussion

Delayed vascular complications after extremity trauma, such as PSAs and arteriovenous fistulas (AVFs), are rare but clinically significant conditions that may remain unrecognized for prolonged periods. These lesions typically originate from occult arterial injury sustained at the time of trauma and may remain asymptomatic until progressive enlargement or sudden destabilization occurs^[8,9^]. The present case demonstrates an exceptionally delayed presentation of a combined brachial artery PSA and AVF, manifesting 25 years after a conservatively treated supracondylar humeral fracture, emphasizing that even seemingly minor orthopedic injuries can have long-term vascular consequences^[10,11^].

Most post-traumatic PSAs and AVFs are diagnosed within weeks or months of injury, particularly following penetrating trauma or orthopedic instrumentation^[12^]. Presentations occurring decades later are exceedingly uncommon and suggest a chronic, slowly progressive pathological process rather than an acute vascular disruption^[13,14^]. It is plausible that a small, initially contained arterial wall defect developed at the time of the initial trauma and remained hemodynamically insignificant for many years^[15^]. Progressive enlargement of the PSA may have been promoted by repetitive mechanical stress at the elbow joint, altered local hemodynamics, and chronic inflammatory changes, ultimately leading to erosion into the adjacent brachial vein and secondary AVF formation. The intraoperative finding of a well-defined saccular PSA with a discrete fistulous tract supports this proposed sequence. Based on the clinical timeline and intraoperative findings, it is most likely that the PSA formed first as a result of an occult arterial wall injury, with subsequent erosion into the adjacent vein leading to secondary AVF formation.

The acute presentation with active pulsatile hemorrhage highlights the unpredictable natural history of chronic traumatic PSAs, which may remain silent for long periods before sudden rupture^[14^]. Although several scoring systems exist for assessing hemorrhage risk in cerebral arteriovenous malformations and femoral PSA formation, no validated predictive scoring model is currently available for rupture risk stratification in peripheral traumatic PSAs^[16^]. Consequently, management decisions are guided by clinical presentation and morphological characteristics rather than formal risk scores. In such settings, prompt intervention is mandatory. Although endovascular techniques are increasingly used in the management of peripheral vascular lesions, their application across highly mobile joints such as the elbow is limited by concerns regarding long-term durability, including stent fracture, migration, and occlusion^[17,18^]. These limitations are particularly relevant in young and active patients^[18^].

In the present case, open surgical repair was favored due to active bleeding, superficial lesion location, and the need for immediate and definitive hemorrhage control. Surgical exploration enabled complete excision of the PSA sac, ligation of the fistulous communication, and primary arterial repair, providing a durable anatomical solution without the long-term risks associated with endovascular devices. This case underscores the importance of maintaining long-term clinical vigilance after extremity trauma and confirms that open surgery remains a reliable treatment for traumatic PSAs associated with AVFs, particularly in anatomically challenging regions.

Strengths and limitations

The major strength of this case report lies in the exceptionally long latency period of 25 years between the initial blunt trauma and clinical presentation, which is rarely reported in the literature. Detailed clinical, imaging, intraoperative, and histopathological findings provide a comprehensive insight into the natural history and management of delayed traumatic vascular lesions.

However, this report has limitations. It describes a single patient, which limits generalizability. In addition, computed tomography angiography was not performed; although this did not affect management due to the clear duplex findings and the urgent clinical scenario, it may limit anatomical characterization compared to cross-sectional imaging.

Conclusion

In conclusion, this case highlights that life-threatening vascular complications can manifest decades after initial trauma, necessitating a high index of suspicion even in patients with remote orthopedic injuries. A focused diagnostic workup, primarily with Doppler ultrasound, can be sufficient for planning definitive management in clear-cut cases. Open surgical repair remains the gold-standard, definitive treatment option for traumatic PSAs with AVFs, particularly in acute settings and anatomically challenging locations like the elbow, where it offers superior durability and a cure. This report reinforces the principle of lifelong clinical vigilance following significant extremity trauma.

Ethical approval

This study was conducted in accordance with the ethical guidelines of Shiraz University of Medical Sciences, and all necessary approvals were obtained.

Consent

Written and verbal informed consent were obtained from the patient, with all necessary explanations provided. The informed consent was obtained in Persian, and an English translation is available for the journal upon request.

Sources of funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contributions

M.G.G., A.H.J., and M.R. contributed equally to the study concept, data collection, analysis, manuscript drafting, and final approval of the version to be published.

Conflicts of interest disclosure

The authors declare no conflicts of interest related to this manuscript. No funding was received for the preparation of this work. All authors have reviewed and approved the final manuscript, and there are no financial or personal relationships that could have influenced the work presented.

Guarantor

Meghdad Ghasemi Gorji.

Research registration unique identifying number (UIN)

Not applicable.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Data availability statement

All data relevant to the study are included in the article. Additional information is available from the corresponding author upon reasonable request.

Acknowledgements

Not applicable.