Ruptured pseudoaneurysm of the thoracoacromial artery associated with habitual shoulder dislocation: a case report

Ruptured pseudoaneurysm of the thoracoacromial artery associated with habitual shoulder dislocation: a case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Ruptured pseudoaneurysm of the thoracoacromial artery associated with habitual shoulder dislocation: a case report Honoka Wada, Aya Hamasaki, Soichiro Okamoto, Shunki Yamamoto, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7423231/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Apr, 2026 Read the published version in International Journal of Emergency Medicine → Version 1 posted 12 You are reading this latest preprint version Abstract Background: Shoulder dislocation is one of the most common joint dislocations encountered in emergency departments, but vascular complications are rare and often underrecognized. Pseudoaneurysms of the thoracoacromial artery, a branch of the axillary artery, are extremely uncommon and may present with subtle symptoms, delaying diagnosis. Case Presentation: An 82-year-old woman with a history of habitual anterior shoulder dislocation presented with a 10-day history of progressive pain and swelling in the left shoulder. She was on edoxaban for atrial fibrillation. Examination revealed localized tenderness and swelling without neurological deficits. Contrast-enhanced computed tomography showed a 30 × 35 × 35 mm pseudoaneurysm arising from the acromial branch of the thoracoacromial artery. Angiography confirmed contrast extravasation. Endovascular embolization was performed using a proximal Celeskue sheet placement followed by injection of N-butyl cyanoacrylate and Lipiodol. The procedure achieved complete exclusion of the lesion. At three-month follow-up, the patient remained asymptomatic with preserved left upper limb function. Conclusion: Although rare, pseudoaneurysms of the thoracoacromial artery can occur after repeated shoulder dislocation and reduction, especially in elderly patients on anticoagulation therapy. Early recognition through imaging and prompt endovascular intervention can prevent serious vascular and neurological complications. Pseudoaneurysm shoulder dislocation thoracoacrominal artery anticoagulants Figures Figure 1 Figure 2 INTRODUCTION Although shoulder dislocation is one of the most frequently encountered conditions in the emergency department, late complications following its reduction are often underrecognized due to the generally low rate of adverse outcomes ( 1 ). A pseudoaneurysm occurs when the arterial wall loses its adventitia and peri-adventitial tissue. The causes of pseudoaneurysms near the shoulder joint can be broadly classified as iatrogenic or traumatic, with infection being a rare etiology ( 2 – 8 ). Iatrogenic pseudoaneurysms of peripheral arteries in the shoulder region are often associated with interventional procedures requiring arterial access or orthopedic interventions, particularly joint replacement surgeries. Traumatic pseudoaneurysms, on the other hand, may result from either penetrating or blunt trauma and typically form gradually in association with thrombus or hematoma formation ( 9 , 10 ). We report an extremely rare case of an 82-year-old female patient with a ruptured pseudoaneurysms of the thoracoacromial artery, a branch of the second part of the axillary artery, following repeated forceful reductions of an anterior glenohumeral dislocation, successfully managed with endovascular treatment. Emergency physicians should be aware that the frequency and severity of complications associated with shoulder dislocations may be greater than generally assumed. Early recognition and diagnosis of upper-limb pseudoaneurysms are essential to prevent vascular and neurological compromise, which can result in serious long-term sequelae ( 11 , 12 ). Our case may aid emergency physicians in recognizing and managing this potentially life-threatening complication related to shoulder dislocation. Case presentation An 82-year-old female patient with a history of habitual shoulder dislocation presented with a 10-day history of persistent left shoulder pain. Although the patient had been using a topical NSAID patch for pain relief, progressive shoulder swelling and worsening pain were noted. Past medical history included right femoral neck fracture, chronic heart failure, and atrial fibrillation, for which the patient was taking edoxaban. On examination, the patient was alert and oriented, with a pulse rate of 65 bpm, blood pressure of 145/77 mmHg, respiratory rate of 15 breaths per minute, and body temperature of 36.5°C. There was no conjunctival pallor. Localized swelling and tenderness were observed over the anterior aspect of the left shoulder. No sensory disturbances or motor weakness were detected in the left upper extremity. Radial pulse was palpable and strong with capillary refill time less than 2 seconds. Plain radiographs showed no fracture and the shoulder remained in joint. Contrast-enhanced computed tomography demonstrated a pseudoaneurysm with 30 mm x 35 mm x 35 mm in diameter, which arose from the distal part of the branch of the axillary artery. An angiogram revealed a left shoulder pseudoaneurysm fed by the thoracoacromial artery and a subtle contrast extravasation originating in a pseudoaneurysm (Fig. 1 ). Due to suspected vascular spasm or stenosis, proximal embolization was performed first using a half sheet of Celeskue. Subsequently, 0.1 mL of a 1:2 mixture of N-butyl cyanoacrylate and Lipiodol was injected into the feeding artery, achieving complete exclusion (Fig. 2 ). After endovascular embolization, the patient was discharged and outpatient follow-up was arranged. Consequently, further studies on the vascular system are not carried out. Although only three months of follow-up have passed, the patient has no complaints and is leading a normal social life without any impairment in left hand movement. DISCUSSION This report presents a rare case of a ruptured pseudoaneurysm of the thoracoacromial artery, a branch of the axillary artery, following habitual shoulder dislocation. It is essential for emergency physicians to remain up-to-date on potential complications associated with shoulder dislocations. While complications such as bone fractures and concomitant brachial plexus injuries have been reported in 27–44% of cases ( 13 – 15 ), associated vascular injuries are rare, occurring in less than 1% of cases ( 12 , 16 – 18 ). Vascular injuries involving the axillary artery and its branches may present as pseudoaneurysms, true aneurysms, or complete transections. These injuries can be particularly challenging to diagnose when not promptly recognized, largely due to the robust collateral circulation of the upper extremities. Consequently, pseudoaneurysms of the axillary artery and its branches are considered delayed vascular complications of shoulder dislocation, often developing insidiously with minimal or no apparent symptoms, partially masked by collateral blood flow ( 6 , 10 ). Pseudoaneurysms of the axillary artery and its branches may become symptomatic due to compression of the brachial plexus, resulting in neurological deficits of the upper limb. Alternatively, symptoms may arise following rupture, presenting as absent or diminished distal pulses, a profuse axillary hematoma, a cold, pale, or cyanotic hand, delayed capillary refill, or in severe cases, hemorrhagic shock ( 19 ). In the present case, the pseudoaneurysm was located in a branch rather than the main trunk of the axillary artery, which likely accounts for the absence of severe or dramatic clinical manifestations. Lesions involving the main trunk of the axillary artery are more likely to produce overt symptoms. Vascular injury can occur either at the time of dislocation or directly during the reduction maneuver. A primary vascular injury may become apparent only after reduction, due to the loss of the tamponade effect provided by the dislocated humeral head. Shoulder dislocation predisposes to pseudoaneurysm formation because of the anatomical positioning of the axillary vessels between the humeral circumflex and scapular arteries. These vessels may be compressed against the pectoralis minor muscle during dislocation, particularly when the humeral head is forced into hyperabduction, causing mechanical distortion of the artery. Additionally, anatomical variations in the course of the axillary artery may contribute to susceptibility. Recurrent dislocations and forceful reductions further increase the risk of pseudoaneurysm development. A ruptured pseudoaneurysm of the axillary artery constitutes a medical emergency. However, recent clinical experience with shoulder dislocation has not firmly established the routine use of objective imaging to confirm or rule out arterial injury, as such injuries may initially be well tolerated. Accurate diagnosis is often delayed because the surrounding bones and muscles of the shoulder region can obscure clinical signs of vascular injury. Misdiagnosis or delayed diagnosis can result in significant upper-limb morbidity—or even mortality. If vascular injury is suspected following an anterior glenohumeral dislocation or subsequent reduction maneuver, CT angiography is essential. In the present case, the diagnosis of a pseudoaneurysm was clearly established by contrast-enhanced CT. While MRI offers excellent soft tissue resolution, duplex ultrasonography and angiography provide more detailed assessments of vascular flow dynamics. Treatment options for pseudoaneurysms span a range from invasive to minimally invasive interventions. Historically, surgical repair was the standard approach for peripheral artery pseudoaneurysms. However, endovascular techniques—including coil embolization and covered stent placement—have gained increasing acceptance, particularly in emergency settings ( 16 , 17 , 20 ). The advantages of endovascular therapy include avoidance of extensive surgical dissection, reduced risk of damage to adjacent structures, decreased blood loss, and shorter hospital stays. These interventional radiological techniques have proven highly effective for hemorrhage control, especially in hemodynamically unstable patients. The present case underscores the utility of endovascular treatment in managing pseudoaneurysms. In conclusion, pseudoaneurysms of the thoracoacromial artery following recurrent shoulder dislocation are exceedingly rare but potentially life-threatening. When clinical suspicion is high, immediate CT angiography and vascular consultation are imperative to improve patient outcomes. This case is particularly notable due to the unusual mechanism of injury. Although predicting such arterial damage during shoulder reduction is difficult, emergency physicians and surgeons must remain vigilant for potential vascular injuries after dislocation or reduction. Declarations Acknowledgements: Not applicable. Authors’ contributions: HW and AN drafted the initial manuscript, while TN and TY provided critical revision. AH, SO and SY prepared patient data and figures. All authors reviewed and approved the final version prior to submission. Funding: Not applicable. Data availability: No datasets were generated or analysed during the current study. Ethics approval and consent to participate: Not applicable. Consent for publication: A written consent for publication is obtained from the patient for publication of this case report and accompanying images. Competing interests: The authors declare no competing interests. References Khiami F, Gerometta A, Loriaut P. Management of recent first-time anterior shoulder dislocations. Orthop Traumatol Surg Res. 2015;101(1 Suppl):S51-7. Carratola M, Parikh P, Tchorz K, Kauffman S. Traumatic axillary artery pseudoaneurysm treated with intravascular balloon occlusion and percutaneous thrombin injection. Radiol Case Rep. 2014;9(1):e00031. Stein E. Case report 374: Post-traumatic pseudoaneurysm of axillary artery. Skeletal Radiol. 1986;15(5):391-3. Pak M, Kagawa Y, Watanabe N, Imai K, Endo A, Tanabe K. Development of an iatrogenic aneurysm nine months after pacemaker implantation: Consideration of causes and treatment. J Cardiol Cases. 2017;16(3):89-92. Wright AE, Wall M, Slaney P, Downing R. An unusual presentation of thoracoacromial artery pseudoaneurysm following shoulder arthroplasty. BMJ Case Rep. 2014;2014. Sparks SR, DeLaRosa J, Bergan JJ, Hoyt DB, Owens EL. Arterial injury in uncomplicated upper extremity dislocations. Ann Vasc Surg. 2000;14(2):110-3. Huang TY, Feng PC, Wang YC, Su CY. Differential Diagnosis of Thoracoacromial Artery Pseudoaneurysm from Shoulder Inflammatory Pseudotumor: A Case Report. Diagnostics (Basel). 2022;13(1). Fitzgerald JF, Keates J. False aneurysm as a late complication of anterior dislocation of the shoulder. Ann Surg. 1975;181(6):785-6. Onyeka W. Anterior shoulder dislocation: an unusual complication. Emerg Med J. 2002;19(4):367-8. Gallen J, Wiss DA, Cantelmo N, Menzoin JO. Traumatic pseudoaneurysm of the axillary artery: report of three cases and literature review. J Trauma. 1984;24(4):350-4. Palcau L, Gouicem D, Dufranc J, Mackowiak E, Berger L. Delayed axillary artery pseudoaneurysm as an isolated consequence to anterior dislocation of the shoulder. Ann Vasc Surg. 2012;26(2):279 e9-12. Beeson MS. Complications of shoulder dislocation. Am J Emerg Med. 1999;17(3):288-95. Monem M, Iskandarani MK, Gokaraju K. Axillary artery pseudoaneurysm resulting in brachial plexus injury in a patient taking new oral anticoagulants. BMJ Case Rep. 2016;2016. Schumann DR, Superti MJ, Seyboth FC, Jacomel GE. Brachial plexus injury secondary to pseudoaneurysm of axillary artery after glenohumeral dislocation: case report. Rev Bras Ortop. 2017;52(4):491-5. Raju S, Carner DV. Brachial plexus compression: complication of delayed recognition of arterial injuries of the shoulder girdle. Arch Surg. 1981;116(2):175-8. Criado E, Marston WA, Ligush J, Mauro MA, Keagy BA. Endovascular repair of peripheral aneurysms, pseudoaneurysms, and arteriovenous fistulas. Ann Vasc Surg. 1997;11(3):256-63. Te Slaa A, Vos D, Geenen G, Dolmans D, van der Laan L. Endovascular Treatment of an Axillary Pseudoaneurysm Following a Traumatic Shoulder Dislocation. Eur J Trauma Emerg Surg. 2009;35(4):417. Mitsuzawa S, Yamashita S, Tsukamoto Y, Takeuchi H, Ota S, Onishi E, et al. Axillary Artery Injury Associated with Dislocated or Displaced Proximal Humeral Fracture: A Report of 3 Cases. JBJS Case Connect. 2024;14(3). Kelley SP, Hinsche AF, Hossain JF. Axillary artery transection following anterior shoulder dislocation: classical presentation and current concepts. Injury. 2004;35(11):1128-32. Stahnke M, Duddy MJ. Endovascular repair of a traumatic axillary pseudoaneurysm following anterior shoulder dislocation. Cardiovasc Intervent Radiol. 2006;29(2):298-301. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 09 Apr, 2026 Read the published version in International Journal of Emergency Medicine → Version 1 posted Editorial decision: Revision requested 02 Nov, 2025 Reviews received at journal 19 Oct, 2025 Reviews received at journal 18 Oct, 2025 Reviewers agreed at journal 16 Oct, 2025 Reviews received at journal 14 Oct, 2025 Reviewers agreed at journal 12 Oct, 2025 Reviewers agreed at journal 11 Oct, 2025 Reviewers agreed at journal 10 Oct, 2025 Reviewers invited by journal 10 Oct, 2025 Editor assigned by journal 23 Aug, 2025 Submission checks completed at journal 23 Aug, 2025 First submitted to journal 21 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":965085,"visible":true,"origin":"","legend":"\u003cp\u003eContrast-enhanced CT showing a pseudoaneurysm (white arrows) arising from the acromial branch of the thoracoacromial artery in axial (A) and coronal (B) planes. A subtle extravasation of contrast medium was detected,\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7423231/v1/1ff82548ae2232b680b743e0.png"},{"id":94225310,"identity":"1a44cee8-8d0e-4752-b165-4c69dfaf7b16","added_by":"auto","created_at":"2025-10-23 19:28:37","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":899392,"visible":true,"origin":"","legend":"\u003cp\u003eSelective angiography of the thoracoacromial artery showing direct inflow into the pseudoaneurysm (white arrow), confirming the vascular source prior to endovascular treatment.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7423231/v1/bb69d54a687fa1cd356eb64c.png"},{"id":106808746,"identity":"aa9f0c11-4df8-4509-8c48-920de316f662","added_by":"auto","created_at":"2026-04-13 16:00:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3053612,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7423231/v1/2ce4e9ae-9d04-4bcd-a34f-78a711cefc26.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ruptured pseudoaneurysm of the thoracoacromial artery associated with habitual shoulder dislocation: a case report","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eAlthough shoulder dislocation is one of the most frequently encountered conditions in the emergency department, late complications following its reduction are often underrecognized due to the generally low rate of adverse outcomes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). A pseudoaneurysm occurs when the arterial wall loses its adventitia and peri-adventitial tissue. The causes of pseudoaneurysms near the shoulder joint can be broadly classified as iatrogenic or traumatic, with infection being a rare etiology (\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIatrogenic pseudoaneurysms of peripheral arteries in the shoulder region are often associated with interventional procedures requiring arterial access or orthopedic interventions, particularly joint replacement surgeries. Traumatic pseudoaneurysms, on the other hand, may result from either penetrating or blunt trauma and typically form gradually in association with thrombus or hematoma formation (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWe report an extremely rare case of an 82-year-old female patient with a ruptured pseudoaneurysms of the thoracoacromial artery, a branch of the second part of the axillary artery, following repeated forceful reductions of an anterior glenohumeral dislocation, successfully managed with endovascular treatment.\u003c/p\u003e\u003cp\u003eEmergency physicians should be aware that the frequency and severity of complications associated with shoulder dislocations may be greater than generally assumed. Early recognition and diagnosis of upper-limb pseudoaneurysms are essential to prevent vascular and neurological compromise, which can result in serious long-term sequelae (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Our case may aid emergency physicians in recognizing and managing this potentially life-threatening complication related to shoulder dislocation.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eAn 82-year-old female patient with a history of habitual shoulder dislocation presented with a 10-day history of persistent left shoulder pain. Although the patient had been using a topical NSAID patch for pain relief, progressive shoulder swelling and worsening pain were noted. Past medical history included right femoral neck fracture, chronic heart failure, and atrial fibrillation, for which the patient was taking edoxaban.\u003c/p\u003e\u003cp\u003eOn examination, the patient was alert and oriented, with a pulse rate of 65 bpm, blood pressure of 145/77 mmHg, respiratory rate of 15 breaths per minute, and body temperature of 36.5\u0026deg;C. There was no conjunctival pallor. Localized swelling and tenderness were observed over the anterior aspect of the left shoulder. No sensory disturbances or motor weakness were detected in the left upper extremity. Radial pulse was palpable and strong with capillary refill time less than 2 seconds.\u003c/p\u003e\u003cp\u003ePlain radiographs showed no fracture and the shoulder remained in joint. Contrast-enhanced computed tomography demonstrated a pseudoaneurysm with 30 mm x 35 mm x 35 mm in diameter, which arose from the distal part of the branch of the axillary artery. An angiogram revealed a left shoulder pseudoaneurysm fed by the thoracoacromial artery and a subtle contrast extravasation originating in a pseudoaneurysm (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Due to suspected vascular spasm or stenosis, proximal embolization was performed first using a half sheet of Celeskue. Subsequently, 0.1 mL of a 1:2 mixture of N-butyl cyanoacrylate and Lipiodol was injected into the feeding artery, achieving complete exclusion (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). After endovascular embolization, the patient was discharged and outpatient follow-up was arranged. Consequently, further studies on the vascular system are not carried out. Although only three months of follow-up have passed, the patient has no complaints and is leading a normal social life without any impairment in left hand movement.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis report presents a rare case of a ruptured pseudoaneurysm of the thoracoacromial artery, a branch of the axillary artery, following habitual shoulder dislocation. It is essential for emergency physicians to remain up-to-date on potential complications associated with shoulder dislocations. While complications such as bone fractures and concomitant brachial plexus injuries have been reported in 27\u0026ndash;44% of cases (\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), associated vascular injuries are rare, occurring in less than 1% of cases (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eVascular injuries involving the axillary artery and its branches may present as pseudoaneurysms, true aneurysms, or complete transections. These injuries can be particularly challenging to diagnose when not promptly recognized, largely due to the robust collateral circulation of the upper extremities. Consequently, pseudoaneurysms of the axillary artery and its branches are considered delayed vascular complications of shoulder dislocation, often developing insidiously with minimal or no apparent symptoms, partially masked by collateral blood flow (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Pseudoaneurysms of the axillary artery and its branches may become symptomatic due to compression of the brachial plexus, resulting in neurological deficits of the upper limb. Alternatively, symptoms may arise following rupture, presenting as absent or diminished distal pulses, a profuse axillary hematoma, a cold, pale, or cyanotic hand, delayed capillary refill, or in severe cases, hemorrhagic shock (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In the present case, the pseudoaneurysm was located in a branch rather than the main trunk of the axillary artery, which likely accounts for the absence of severe or dramatic clinical manifestations. Lesions involving the main trunk of the axillary artery are more likely to produce overt symptoms.\u003c/p\u003e\u003cp\u003eVascular injury can occur either at the time of dislocation or directly during the reduction maneuver. A primary vascular injury may become apparent only after reduction, due to the loss of the tamponade effect provided by the dislocated humeral head. Shoulder dislocation predisposes to pseudoaneurysm formation because of the anatomical positioning of the axillary vessels between the humeral circumflex and scapular arteries. These vessels may be compressed against the pectoralis minor muscle during dislocation, particularly when the humeral head is forced into hyperabduction, causing mechanical distortion of the artery. Additionally, anatomical variations in the course of the axillary artery may contribute to susceptibility. Recurrent dislocations and forceful reductions further increase the risk of pseudoaneurysm development.\u003c/p\u003e\u003cp\u003eA ruptured pseudoaneurysm of the axillary artery constitutes a medical emergency. However, recent clinical experience with shoulder dislocation has not firmly established the routine use of objective imaging to confirm or rule out arterial injury, as such injuries may initially be well tolerated. Accurate diagnosis is often delayed because the surrounding bones and muscles of the shoulder region can obscure clinical signs of vascular injury. Misdiagnosis or delayed diagnosis can result in significant upper-limb morbidity\u0026mdash;or even mortality. If vascular injury is suspected following an anterior glenohumeral dislocation or subsequent reduction maneuver, CT angiography is essential. In the present case, the diagnosis of a pseudoaneurysm was clearly established by contrast-enhanced CT. While MRI offers excellent soft tissue resolution, duplex ultrasonography and angiography provide more detailed assessments of vascular flow dynamics.\u003c/p\u003e\u003cp\u003eTreatment options for pseudoaneurysms span a range from invasive to minimally invasive interventions. Historically, surgical repair was the standard approach for peripheral artery pseudoaneurysms. However, endovascular techniques\u0026mdash;including coil embolization and covered stent placement\u0026mdash;have gained increasing acceptance, particularly in emergency settings (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The advantages of endovascular therapy include avoidance of extensive surgical dissection, reduced risk of damage to adjacent structures, decreased blood loss, and shorter hospital stays. These interventional radiological techniques have proven highly effective for hemorrhage control, especially in hemodynamically unstable patients. The present case underscores the utility of endovascular treatment in managing pseudoaneurysms.\u003c/p\u003e\u003cp\u003eIn conclusion, pseudoaneurysms of the thoracoacromial artery following recurrent shoulder dislocation are exceedingly rare but potentially life-threatening. When clinical suspicion is high, immediate CT angiography and vascular consultation are imperative to improve patient outcomes. This case is particularly notable due to the unusual mechanism of injury. Although predicting such arterial damage during shoulder reduction is difficult, emergency physicians and surgeons must remain vigilant for potential vascular injuries after dislocation or reduction.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Not applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/strong\u003eHW and AN drafted the initial manuscript, while TN and TY provided critical revision. AH, SO and SY prepared patient data and figures. All authors reviewed and approved the final version prior to submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003eNo datasets were generated or analysed during the current study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eA written consent for publication is obtained from the patient for publication of this case report and accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare no competing interests.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKhiami F, Gerometta A, Loriaut P. Management of recent first-time anterior shoulder dislocations. Orthop Traumatol Surg Res. 2015;101(1 Suppl):S51-7.\u003c/li\u003e\n\u003cli\u003eCarratola M, Parikh P, Tchorz K, Kauffman S. Traumatic axillary artery pseudoaneurysm treated with intravascular balloon occlusion and percutaneous thrombin injection. Radiol Case Rep. 2014;9(1):e00031.\u003c/li\u003e\n\u003cli\u003eStein E. Case report 374: Post-traumatic pseudoaneurysm of axillary artery. Skeletal Radiol. 1986;15(5):391-3.\u003c/li\u003e\n\u003cli\u003ePak M, Kagawa Y, Watanabe N, Imai K, Endo A, Tanabe K. Development of an iatrogenic aneurysm nine months after pacemaker implantation: Consideration of causes and treatment. J Cardiol Cases. 2017;16(3):89-92.\u003c/li\u003e\n\u003cli\u003eWright AE, Wall M, Slaney P, Downing R. An unusual presentation of thoracoacromial artery pseudoaneurysm following shoulder arthroplasty. BMJ Case Rep. 2014;2014.\u003c/li\u003e\n\u003cli\u003eSparks SR, DeLaRosa J, Bergan JJ, Hoyt DB, Owens EL. Arterial injury in uncomplicated upper extremity dislocations. Ann Vasc Surg. 2000;14(2):110-3.\u003c/li\u003e\n\u003cli\u003eHuang TY, Feng PC, Wang YC, Su CY. Differential Diagnosis of Thoracoacromial Artery Pseudoaneurysm from Shoulder Inflammatory Pseudotumor: A Case Report. Diagnostics (Basel). 2022;13(1).\u003c/li\u003e\n\u003cli\u003eFitzgerald JF, Keates J. False aneurysm as a late complication of anterior dislocation of the shoulder. Ann Surg. 1975;181(6):785-6.\u003c/li\u003e\n\u003cli\u003eOnyeka W. Anterior shoulder dislocation: an unusual complication. Emerg Med J. 2002;19(4):367-8.\u003c/li\u003e\n\u003cli\u003eGallen J, Wiss DA, Cantelmo N, Menzoin JO. Traumatic pseudoaneurysm of the axillary artery: report of three cases and literature review. J Trauma. 1984;24(4):350-4.\u003c/li\u003e\n\u003cli\u003ePalcau L, Gouicem D, Dufranc J, Mackowiak E, Berger L. Delayed axillary artery pseudoaneurysm as an isolated consequence to anterior dislocation of the shoulder. Ann Vasc Surg. 2012;26(2):279 e9-12.\u003c/li\u003e\n\u003cli\u003eBeeson MS. Complications of shoulder dislocation. Am J Emerg Med. 1999;17(3):288-95.\u003c/li\u003e\n\u003cli\u003eMonem M, Iskandarani MK, Gokaraju K. Axillary artery pseudoaneurysm resulting in brachial plexus injury in a patient taking new oral anticoagulants. BMJ Case Rep. 2016;2016.\u003c/li\u003e\n\u003cli\u003eSchumann DR, Superti MJ, Seyboth FC, Jacomel GE. Brachial plexus injury secondary to pseudoaneurysm of axillary artery after glenohumeral dislocation: case report. Rev Bras Ortop. 2017;52(4):491-5.\u003c/li\u003e\n\u003cli\u003eRaju S, Carner DV. Brachial plexus compression: complication of delayed recognition of arterial injuries of the shoulder girdle. Arch Surg. 1981;116(2):175-8.\u003c/li\u003e\n\u003cli\u003eCriado E, Marston WA, Ligush J, Mauro MA, Keagy BA. Endovascular repair of peripheral aneurysms, pseudoaneurysms, and arteriovenous fistulas. Ann Vasc Surg. 1997;11(3):256-63.\u003c/li\u003e\n\u003cli\u003eTe Slaa A, Vos D, Geenen G, Dolmans D, van der Laan L. Endovascular Treatment of an Axillary Pseudoaneurysm Following a Traumatic Shoulder Dislocation. Eur J Trauma Emerg Surg. 2009;35(4):417.\u003c/li\u003e\n\u003cli\u003eMitsuzawa S, Yamashita S, Tsukamoto Y, Takeuchi H, Ota S, Onishi E, et al. Axillary Artery Injury Associated with Dislocated or Displaced Proximal Humeral Fracture: A Report of 3 Cases. JBJS Case Connect. 2024;14(3).\u003c/li\u003e\n\u003cli\u003eKelley SP, Hinsche AF, Hossain JF. Axillary artery transection following anterior shoulder dislocation: classical presentation and current concepts. Injury. 2004;35(11):1128-32.\u003c/li\u003e\n\u003cli\u003eStahnke M, Duddy MJ. Endovascular repair of a traumatic axillary pseudoaneurysm following anterior shoulder dislocation. Cardiovasc Intervent Radiol. 2006;29(2):298-301.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Pseudoaneurysm, shoulder dislocation, thoracoacrominal artery, anticoagulants","lastPublishedDoi":"10.21203/rs.3.rs-7423231/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7423231/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eShoulder dislocation is one of the most common joint dislocations encountered in emergency departments, but vascular complications are rare and often underrecognized. Pseudoaneurysms of the thoracoacromial artery, a branch of the axillary artery, are extremely uncommon and may present with subtle symptoms, delaying diagnosis.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e\u003cp\u003eAn 82-year-old woman with a history of habitual anterior shoulder dislocation presented with a 10-day history of progressive pain and swelling in the left shoulder. She was on edoxaban for atrial fibrillation. Examination revealed localized tenderness and swelling without neurological deficits. Contrast-enhanced computed tomography showed a 30 \u0026times; 35 \u0026times; 35 mm pseudoaneurysm arising from the acromial branch of the thoracoacromial artery. Angiography confirmed contrast extravasation. Endovascular embolization was performed using a proximal Celeskue sheet placement followed by injection of N-butyl cyanoacrylate and Lipiodol. The procedure achieved complete exclusion of the lesion. At three-month follow-up, the patient remained asymptomatic with preserved left upper limb function.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e\u003cp\u003eAlthough rare, pseudoaneurysms of the thoracoacromial artery can occur after repeated shoulder dislocation and reduction, especially in elderly patients on anticoagulation therapy. Early recognition through imaging and prompt endovascular intervention can prevent serious vascular and neurological complications.\u003c/p\u003e","manuscriptTitle":"Ruptured pseudoaneurysm of the thoracoacromial artery associated with habitual shoulder dislocation: a case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-23 19:28:33","doi":"10.21203/rs.3.rs-7423231/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-02T22:37:03+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-20T01:37:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-18T20:26:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"329034236291048206916696203037525417337","date":"2025-10-16T18:48:26+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-14T23:14:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"93564090648801397254906303854260333089","date":"2025-10-12T07:27:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"2064943498322005974227393759608043756","date":"2025-10-11T18:14:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"275392132700274466421019254904025673869","date":"2025-10-10T07:11:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-10T06:51:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-23T13:11:59+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-23T13:11:43+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Emergency Medicine","date":"2025-08-21T07:06:54+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijem","sideBox":"Learn more about [International Journal of Emergency Medicine](https://intjem.biomedcentral.com/)","snPcode":"12245","submissionUrl":"https://submission.nature.com/new-submission/12245/3","title":"International Journal of Emergency Medicine","twitterHandle":"@IntJEmergMed","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e0816563-b7ec-40b8-a192-aa72e1441bdf","owner":[],"postedDate":"October 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T15:59:43+00:00","versionOfRecord":{"articleIdentity":"rs-7423231","link":"https://doi.org/10.1186/s12245-026-01202-4","journal":{"identity":"international-journal-of-emergency-medicine","isVorOnly":false,"title":"International Journal of Emergency Medicine"},"publishedOn":"2026-04-09 15:57:03","publishedOnDateReadable":"April 9th, 2026"},"versionCreatedAt":"2025-10-23 19:28:33","video":"","vorDoi":"10.1186/s12245-026-01202-4","vorDoiUrl":"https://doi.org/10.1186/s12245-026-01202-4","workflowStages":[]},"version":"v1","identity":"rs-7423231","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7423231","identity":"rs-7423231","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}