Description

A 53-year-old right hand dominant man with a significant medical history of intravenous heroin abuse for over 10 years. He admitted to last injecting heroin this morning into his right arm. Surgical history is significant for traumatic right-hand amputation 10 years ago and multiple right-arm debridements for chronic wound infections from active heroin use. Patient presented to the emergency department with a brisk pulsatile right upper arm bleed. On initial surgical consultation, the patient was found to be hypotensive and tachycardic. Manual pressure was held over a pseudoaneurysm that was noted to be bleeding (figure 1 and video 1). Blood pressure cuff was applied proximal to the bleeding site, and the patient was taken to the operating room for exploration.

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Figure 1

Note the chronic infected wounds and deformed upper extremity from multiple surgical procedures and pre-existing trauma.

In the operating room, a horizontal incision was made along the medial side of the upper arm traversing the bicep groove. Brachial artery and vein as well as median and ulnar nerves were identified and isolated accordingly. Brachial artery pseudoaneurysm was identified and suture ligated. Wound was packed and dressed. Multidisciplinary team and patient discussion decided to proceed with an amputation above the level of the elbow. Subsequent hospital course was uneventful. Patient was referred to a drug rehabilitation facility on discharge.