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A 60-year-old male presented with a huge mass on right arm just above the elbow joint. He had presented with these complaints with gradual progress in size over a period of 1 year. He denied any significant pain or warmth in the swelling. He also had no difficulty in elbow movements. He was seen by a general practitioner and abscess was suspected and incision and drainage was planned. Patient was examined by the author (Dr. ANK) as a second opinion. He noticed the swelling to be soft and pulsatile with no warmth or tenderness. Suspecting a vascular origin of the swelling, a vascular surgeon (Dr. VS) Consult and a CT angiogram was advised. CT Angiogram revealed a 6.1 x 5.4 x 8.1 cm sacular aneurysm of the right brachial artery with eccentric thrombus. The CT angiogram also picked up a persistent ductus arteriosus with features of pulmonary hypertension. A cardiology (Dr. PM) consult and a 2 D echo was advised. The PDA measuring 4.6 mm with left to right shunt with moderate pulmonary hypertension (PASP=46 mmHg) with mild LV Dysfunction.
Hence, a surgical excision was planned. In view of the asymptomatic cardiac status, the cardiologist (Dr. PM) advised to proceed with aneurysm excision with a moderate risk of CV events in perioperative period. He underwent successful aneurysm excision with bypass grafting and made an uneventful recovery. The case highlights the unusual location of the aneurysm hitherto unreported to literature. It also highlights the late presentation at 60 years of an asymptomatic yet hemodynamically significant PDA with such significant pulmonary hypertension.
The cardinal teaching of being beware of a pulsatile swelling is again reemphasized.
