Pseudo-pseudo aneurysm of (R) axillary artery
This 67 yr old male was seen at the request of the  orthopedic service.  He had surgery just  8 weeks prior for a rotator cuff injury involving the (R) shoulder.The patient was immobilized in a  shoulder spica and after it was removed  a pulsating mass was detected in the deltopectoral groove.This was associated with limitation of movement of the shoulder joint(A & B ).The mass  was  extremely tender and warm , did not have an associated thrill but did demonstrate  a bruit .The man's arm was swollen with congestion and cyanosis of his right hand.An ultrasound of this pulsating mass  revealed a large hypoechogenic mass(8x6cm) compressing the axillary vein with arterialized flow, not to the axillary artery but in the area of the thoraco-acromial artery (see diagram C ).A standard   angiogram was confusing.On the scout film a lytic lesion was seen  .The findings were consistent with some form of vascular "tumor" fed by branches off the axillary artery  (subscapular or thoraco-acromial) .Although the angio was of poor quality there  was some suspicion  of neovascularity (D) . A  bone scan  prior to the orthopedic surgerywas negative  and the previous arthrogram did not support any pathology. The rotator cuff  repair had been done with the use of  sharp, pointed self-retaining retractors.The diagnosis of a false aneurysm of a branch of the axillary artery (likely thoraco-acromial ) was made and to this end the man was brought to the operating room.

Proximal and distal control was obtained  both above and below the clavicle as well as distally in the axillary artery(open book approach)The anatomy was grossly distorted  with severe angulation of the vessels due to displacent of the pulsating mass.( E)When the mass was opened after control was obtained approximately 1500cc of blood was lost in a few minutes.The mass had almost tripled in size from the original asssessment.Bleeding was posterior and from several different  locations mostly over the brachial plexus beneath,.With sequential pressure these were controlled.The bleeding   was  then controlled with several Surgicel packs and imbrication of the sac of the pulsating mass. Although no specific feeder vessel was identified the above manoeuvers  rid the mass of its pulsation.


    Thrombus fom the sac and a portion of the sac wall were sent for assessment. The pathology report was that of clear malignant cells surrounding thin- walled blood vessels  compatible with a  renal cell carcinoma .Post operatively , a  CT scan did confirm the diagnosis  of bilateral renal cell carcinoma with nodal involvement ( F ) .CT of the shoulder showed a large destructive and expansile   soft tissue mass in the (R) scapula destroying the glenoid and coracoid process ( G ) . This mass extended to the spine of the scapula and extended to the fossa below the (R) acromial joint.The humerus was also likely involved.  Recall that  bone scan initially was reported as normal

     The patient was given aggressive radiation therapy to the area as well as chemotherapy.Despite the advanced presentation he survived five years and died of diffuse metastatic disease

         Renal cell carcinoma can be a very aggressive and vascular tumor  with  metastatic  spread  particulary to skin and subcutaneous areas.  Metastatic  disease can be the intial  presentation particularly with subcutaneous  deposits which are quite vascular. Duplex scan ,here , favored a false aneurysm based on an arterialized flow in a pulsating mass. Is this a" pulsating lymph node"  from  metastatic disease or  a subcutaneous metastatic deposit  with uncontrolled  neoangiogenesis  ? The latter is most likely the case since there was never any adenopathy demonstrated.In the context of modern therapy  would early embolization made a difference in outcome?What about the use of thalidomide?

  The reference below is from a prolific author on the subject of  tumor angiogenesis and deals with the concept of VEGF  (Vascular Endothelial Growth Factor)