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

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.