Interventional radiology in the diagnosis, management, and follow-up of pseudoaneurysms. Cardiovasc Intervent Radiol. 2009;32:2-18. [PMID: 18923864 DOI: 10.1007/s00270-008-9440-3]

Safety and Efficacy of Ultrasound-Guided Thrombin Injection for Pseudoaneurysms Arising after Ultrasound-Guided Biopsy of Thyroid Nodules

Iatrogenic pseudoaneurysm is a rare but potentially fatal complication of a thyroid biopsy. However, a standard management strategy has not yet been established. We aimed to evaluate the efficacy and safety of ultrasound (US)-guided thrombin injection (TI) for thyroid pseudoaneurysms. This retrospective study included 7256 patients who underwent thyroid biopsy and TI from January 2020 to January 2024. The technical success, clinical efficacy, and complication rates were evaluated. A total of 0.1% (7/7256) of pseudoaneurysms developed after thyroid biopsy. Except for 1 case that showed obliteration with manual compression, the remaining 6 refractory aneurysms (0.08%) were managed with US-guided TI. All cases (100%) were successfully occluded with US-guided TI. No major complications were observed. One patient (16.7%) developed transient loss of consciousness, which spontaneously resolved within a few seconds. US-guided TI is an effective, relatively safe, and minimally invasive method for managing pseudoaneurysms after thyroid biopsy.

Developing a Carotid Pseudoaneurysm Model in Swine

BACKGROUND

Traumatic carotid artery pseudoaneurysms (PSAs) represent a vascular anomaly with potential for serious complications, including stroke. Traditional treatments involve endovascular stenting, which may not be ideally suited to otherwise healthy vessels that have the potential to remodel. Given the limitations of smaller animal models in replicating human vasculature and the need for improved treatment modalities, this study introduces a novel swine model for the creation and evaluation of carotid PSAs.

METHODS

The PSAs were created from bovine dura and anastomosed in an end-to-side fashion to bilateral carotid arteries. The PSAs were radiologically followed up post-operatively and were harvested at 3 and 10 days for histological analysis.

RESULTS

Pseudoaneurysms were successfully created in both animals without intra-operative or immediate post-operative complications. Radiological analysis showed well-perfused PSAs with intra-aneurysmal turbulence, hemodynamically mimicking human carotid artery PSAs. There was no evidence of thrombus or arterial stenosis. Histological examinations revealed thrombus maturation and tight anastomosis of the PSA sac with the native artery.

CONCLUSIONS

This PSA swine model offers a replicable, cost-effective, and easily implemented tool with the potential to advance carotid PSA management and educational efforts in vascular surgery.

CLINICAL IMPACT

The model presented in this methodology paper allows for a standardized PSA animal model allowing for the standardization of a clinical entity which is frequently heterogenenous in morphology. This can allow for the development of new therapies or provide a ground truth for computer modelling for further in silico study.

HIV-Associated Pseudoaneurysms: A Comprehensive Review

A pseudoaneurysm (PSA) is a contained vascular rupture that typically occurs following catheterization, at the anastomotic site between a native artery and a synthetic graft, post-trauma, or as a result of infection. It is characterized by a hematoma surrounded by tissue, often emerging as a complication of invasive arterial interventions. In patients with HIV/AIDS, PSAs can develop due to vessel wall disruption caused by chronic inflammation, opportunistic infections (such as cytomegalovirus or tuberculosis), or the direct effects of the virus, leading to abnormal blood flow into a chamber confined by adjacent tissue. The clinical presentation of PSAs varies based on their size and location. Diagnosis can be achieved through ultrasonography with color Doppler, contrast-enhanced computed tomography (CT), magnetic resonance angiography (MRA), or digital subtraction angiography (DSA). Treatment modalities include surgery, ultrasound-guided compression, thrombin injection, and endovascular techniques. This review discusses the pathophysiology, histology, diagnosis, and therapeutic options for HIV-related PSAs. Additionally, risk factors and rare complications associated with PSAs are explored in detail.

Ruptured carotid artery pseudoaneurysm following excision of a carotid body tumor: a rare complication managed successfully with surgery and literature review

A 47-year-old male presented with a right-sided Shamblin type 2 carotid body tumor measuring 5*5 cm. After preoperative embolization, a sub adventitial resection of the tumor was done. He was discharged after postoperative day 5 and presented again to emergency 10 days later with a bleeding pseudoaneurysm at the surgical site causing dysphagia and dyspnea. He was taken for emergency exploration of the surgical wound and, intraoperatively, it was observed that the proximal ends of the internal carotid artery and external carotid artery close to the bifurcation were forming a pseudoaneurysm, 1 cm distal to the common carotid artery. The external carotid artery was ligated and a common carotid to internal carotid artery bypass was done with a reversed saphenous vein graft. He recovered well in the postoperative period and was discharged on day 7. Pseudoaneurysm formation following carotid body tumor resection is extremely rare and has only been reported thrice in the literature.

Spontaneous brachial artery pseudoaneurysm secondary to vasculitis

BACKGROUND

Avoiding operative intervention during the active phase of vasculitis is a central tenant of management of this pathology. For unusual presentations of vascular disease, the early diagnosis of vasculitis is imperative to guide treatment.

METHODS

We present the case of a 68-year-old female who presented with a spontaneous brachial artery pseudoaneurysm and was found to have granulomatosis with polyangiitis.

RESULTS AND CONCLUSION

The management of arterial complications of vasculitis are particularly difficult in the active phase of disease. Our patient had successful resolution of her pseudoaneurysm with ultrasound compression, avoiding open or endovascular intervention during the active phase of disease.

Efficacy and Rationale of Endoscopic Ultrasound-Guided Thrombin Injection in Visceral Artery Pseudoaneurysm Not Amenable to Angioembolization

BACKGROUND

Pseudoaneurysm usually occurs after vascular injuries or erosions such as in trauma or inflammation like pancreatitis and is associated with high morbidity and mortality.

AIM

The aim of study is to assess efficacy and safety of EUS-guided thrombin injection in pseudoaneurysm.

MATERIALS AND METHODS

Prospective data collection was done at SMS Hospital, Jaipur, from January 2015 to March 2023. All patients with pseudoaneurysm were consecutively enrolled.

RESULTS

Twenty patients (M/F, 18:2) with median age of 41 years (25-58 years), were studied. Underlying etiology of pseudoaneurysm was chronic pancreatitis in 75% of the patients, blunt trauma abdomen in 15% of the patients, recurrent acute pancreatitis in 5%, and idiopathic in 5% of the patients. At the time of admission, mean hemoglobin was 6.7 g/dL (3.4-8.2), with median blood transfusion requirement was 2 units (0-6 units). Hemoglobin values after 4-6 weeks showed a significant improvement ( t = 9.21, P < 0.05).Mean dose of human thrombin required for complete obliteration of pseudoaneurysm was 520 ± 188.6 IU per patient (300-800 IU). Amount of thrombin (IU) dose needed to achieve complete obliteration correlated well significantly with the dimension of pseudoaneurysm, P value less than 0.05 ( R = 0.80). Median follow-up duration in this study was 44 months (3-84 months), which was the longest follow-up period by far.

CONCLUSIONS

Endoscopic ultrasound-guided thrombin injection in visceral artery pseudoaneurysm is a safe and effective alternative for patients not amenable for digital subtraction angiography-guided angioembolization.

Persistent pseudoaneurysm after non-operative management of a Grade 4 liver injury

A hepatic pseudoaneurysm (HPA) after blunt or penetrating liver injury is an unusual but potentially lethal complication that can develop from an injured hepatic artery branch [1-5]. Endovascular intervention with coil embolization to treat HPA is a safe and effective method and has become the standard first-line treatment, with a success rate achieving 70-100 % [13,14,15]. Infrequently the pseudoaneurysm is fed by collateral vessels and endovascular intervention may be unsuccessful. Other minimally invasive treatment options that can be considered include image guided percutaneous thrombin injection, endovascular placement of covered stents and injection of liquid agents such as fibrin glue [10,11]. We present a case of a young female who developed a post-traumatic persistent hepatic pseudoaneurysm requiring a total of nine interventions, including six endovascular interventions with angiography, three endoscopic procedures for bleeding, one percutaneous injection, and two re-admissions to the hospital. Although she avoided initial operative management, her three-month hospital course can be considered a failure of conservative management of blunt hepatic trauma due to the accrued health care costs and resources. The literature on the management of persistent pseudoaneurysm is limited. The decision to treat a persistent HPA that are found incidentally and stable in size needs further investigation.

Endovascular Treatment of Visceral Artery Pseudoaneurysms with Ethylene-Vinyl Alcohol (EVOH) Copolymer-Based Non-Adhesive Liquid Embolic Agents (NALEAs)

Background and Objectives: Treatment of visceral artery pseudoaneurysms (VAPs) is always indicated regardless of their diameters, as their risk of rupture is significantly higher than that of visceral artery aneurysms. The invasiveness of surgery and its associated complications have led to a shift in favor of radiological interventions as the initial treatment of choice. However, there are still some unanswered questions on endovascular treatment of VAPs regarding the optimal endovascular technique and the efficacy and safety outcomes. The purpose of this multicenter study was to retrospectively evaluate the effectiveness and safety of endovascular treatment of visceral pseudoaneurysms using Ethylene-Vinyl Alcohol (EVOH) Copolymer-Based Non-Adhesive Liquid Embolic Agents (NALEAs). Materials and Methods: Consecutive patients who underwent endovascular embolization with EVOH-based NALEAs for visceral artery pseudoaneurysms between January 2018 and June 2023 were retrospectively evaluated. Results: 38 embolizations were performed. Technical success was achieved in all patients. The clinical success rate was high (92.1% overall), with no significant differences between ruptured and unruptured VAPs (p = 0.679). Seven patients (18.4%) experienced procedure-related complications, related to one case of non-target embolization, four splenic abscesses due to end-organ infarction, and two femoral pseudoaneurysms. The rates of procedure-related complications, end-organ infarction, and vascular access-site complications did not significantly differ between ruptured and unruptured VAPs (p > 0.05). Conclusions: Both ruptured and unruptured visceral pseudoaneurysms can be effectively and safely treated with NALEA-based endovascular embolization. We suggest considering the use of NALEAs, particularly in specific clinical cases that highlight their advantages, including patients with coagulopathy, fragile vessels, and embolization targets that are located at a considerable distance from the microcatheter tip and are otherwise difficult to reach.

Asymptomatic hepatic pseudoaneurysm identified 25 days after knife injury: a case report

BACKGROUND

Hepatic pseudoaneurysm (HPA) is a rare complication that can occur after liver trauma and carries a high risk of rupture. HPA is usually asymptomatic until rupture, so performing routine surveillance of liver trauma patients is important. Most posttraumatic HPA occurs within the first week after injury, so surveillance imaging ~ 7 days postinjury is suggested.

CASE PRESENTATION

We herein report a 47-year-old man who was diagnosed with asymptomatic HPA 25 days after a knife injury. The patient was transferred to the emergency room after attempting suicide by stabbing himself in his abdomen with a knife. The knife was surgically removed, and the postoperative course was uneventful. Computed tomography (CT) on postoperative day (POD) 12 showed no HPA. However, follow-up CT on POD 25 revealed HPA. The HPA was treated with coil embolization. The patient was discharged with no complications. One year after the injury, the patient had no recurrence or medical problems.

CONCLUSION

When managing patients with penetrating liver trauma, it is important to note that HPA may not be identifiable on CT early after injury but may still develop later.

N-butyl-2-cyanoacrylate Packing of a Gastroduodenal Artery Pseudoaneurysm due to Distal Pancreatectomy After Subtotal Esophagectomy

We describe the successful n-butyl cyanoacrylate (NBCA) packing of a large gastroduodenal artery pseudoaneurysm after distal pancreatectomy in a patient with a history of subtotal esophagectomy and gastric tube reconstruction. The pseudoaneurysm was considered to be caused by direct injury to the gastroduodenal artery (GDA). However, embolization of the GDA was not possible in this case because due to prior esophageal surgery, the main blood vessel supplying the gastric tube was the right epigastric artery from the GDA. Packing a pseudoaneurysm with NBCA is a treatment option when preservation of the parent artery is required.

Detection of post-traumatic abdominal pseudoaneurysms by CEUS and CT: A prospective comparative global study (the PseAn study)-study protocol

The success of non-operative management in trauma increased with the availability of new-generation CT scan machines, endoscopy, and angiography, becoming the standard of care in hemodynamically stable trauma patients with abdominal solid organ injuries, with a success rate of 78% to 98%. Post-traumatic pseudoaneurysms (PAs) can develop at any region of an injured artery and they may cause delayed bleeding in splenic or hepatic trauma, with an incidence in patients treated with NOM of 2%-27% and 1.2%-6.1% respectively. Diagnosis is made by angiography, contrast-enhanced computer tomography (CT), or Doppler Ultrasound (US) while the use of contrast-enhanced ultrasound (CEUS), has increased in recent years although few data are available about CEUS feasibility in the follow-up setting. The PseaAn study has been designed to assess the role of CEUS in the follow-up of abdominal trauma by defining its sensitivity, specificity and predictive values compared with abdominal CT scan. The PseAn study is a multi-centric international diagnostic cross-sectional study initiated by the Level I Trauma Center of the Niguarda Ca' Granda Hospital in Milan, Italy. To study the role of CEUS in detecting post-traumatic splenic, hepatic, and renal PAs compared with the gold standard of CT with intravenous contrast at different follow-up time points, and whether it can replace CT scan in the follow-up of solid organ injuries, patients with OIS III and above will undergo a follow-up with both a CEUS and CT scan to detect post-traumatic parenchymal pseudoaneurysm within two to five days from injury. The use of CEUS in the follow-up of abdominal trauma follow-up (particularly blunt trauma) has increased, to minimise the use of ionizing radiation and contrast media and encouraging results have been published during the last decade showing that CEUS is an accurate technique for evaluating traumatic lesions of solid abdominal organs. Conclusions We think that CEUS, which is underused worldwide, is a useful and safe tool that may replace CT scan in follow-up with the major advantage of reduced radiation. Our current study may give stronger evidence to support this view.

Imaging of penetrating vascular trauma of the body and extremities secondary to ballistic and stab wounds

In the United States, gunshot wounds (GSWs) have become a critical public health concern with substantial annual morbidity, disability, and mortality. Vascular injuries associated with GSW may pose a clinical challenge to the physicians in the emergency department. Patients demonstrating hard signs require immediate intervention, whereas patients with soft signs can undergo further diagnostic testing for better injury delineation. Although digital subtraction angiography is the gold standard modality to assess vascular injuries, non-invasive techniques such as Doppler ultrasound, computed tomography angiography, and magnetic resonance angiography have evolved as appropriate alternatives. This article discusses penetrating bodily vascular injuries, specifically ballistic and stab wounds, and the corresponding radiological presentations.

Common and uncommon vascular injuries and endovascular treatment associated with pelvic blunt trauma: a real-world experience

Pelvic fractures are common in cases of blunt trauma, which is strongly associated with mortality. Transcatheter arterial embolization is a fundamental treatment strategy for fatal arterial injuries caused by blunt pelvic trauma. However, vascular injuries due to blunt pelvic trauma can show various imaging findings other than arterial hemorrhage. We present a pictorial review of common and uncommon vascular injuries, including active arterial bleeding, pseudoaneurysm, arteriovenous fistula, arterial occlusion, vasospasm, and active venous bleeding. Knowledge of these vascular injuries can help clinicians select the appropriate therapeutic strategy and thus save lives.

Delayed haemorrhage and pseudoaneurysms following liver trauma

BACKGROUND

Delayed Haemorrhage (DH) is a potential complication following liver trauma. Hepatic artery pseudoaneurysms (HAPAs) are also a frequently considered delayed complication of liver trauma, yet their incidence is rare. Furthermore, little is known about their natural history, with some observed to resolve spontaneously. Some authors postulate that DH following liver trauma may in fact originate from HAPAs.

AIM

To investigate the incidence of DH and HAPA following liver trauma, review subsequent management and explore a possible association between the two.

METHODS

A retrospective study of liver trauma over a 14 year period at a trauma centre, including a case-control analysis comparing patients with DH and HAPA to liver injury grade matched controls.

RESULTS

450 patients were admitted with liver trauma of which 10 patients had DH (2.2%) and 7 HAPA (1.6%). Both DH and HAPA patients had significantly greater blood transfusion requirements, lower haemoglobin (Hb) levels and a greater Hb decrease compared to controls. No patient with an HAPA had a large volume of haemoperitoneum on imaging, and there were no patients in the clinical DH group with previous or concurrent HAPA identified, and no deaths in either group.

CONCLUSION

DH and HAPA following liver trauma are rare. DH following liver trauma was not associated with HAPA on imaging. This study shows that HAPAs cause ongoing insidious bleeding and Hb decline, but we did not find evidence to support the commonly held perception of a risk of 'rupture' and catastrophic haemorrhage.

Unforeseen rupture of pseudoaneurysm of common carotid artery: An arduous anesthetic challenge

Pseudoaneurysm of the common carotid artery (CCA) is exceptionally unstable and unpredictable; it mandates quick medical attention in order to circumvent neurologic sequelae or hemorrhage. Unanticipated rupture is extremely lethal and a potential provocation for the anesthesia caregiver. It is an arduous challenge for an anesthetist to establish emergency airway when a huge bleeding pseudoaneurysm is compressing and deviating the trachea, securing invasive lines in collapsing vessels, volume and vasopressor resuscitation in deteriorating hemodynamics in order to maintain cerebral perfusion without compromising other vital organs, arranging huge amount of blood and blood products in a short span of time, and transferring an exsanguinating patient for the rapid institution of cardiopulmonary bypass. Not only preoperatively it also necessitates appropriate neuromonitoring and neuroprotection during and after surgery. The association of unforeseen rupture of common carotid artery pseudoaneurysm secondary to the tubercular spine and lifesaving management by the rapid institution of cardiopulmonary bypass (CPB) is a rare occasion. To the best of the authors' knowledge, there is not any similar case in the peer-reviewed literature. Therefore, the authors enumerate the clinical experience of an unexpected rupture of CCA pseudoaneurysm requiring lifesaving CPB and emphasize the “Timely Teamed Effort Approach” that can sustain a life in such an inevitable situation.

Late development of giant hepatic artery pseudoaneurysm following abdominal trauma due to tire blast: case report and literature review

Giant hepatic artery pseudoaneurysm is rare but could have a significant implication. A 35-year-old male was severely injured by a truck tire explosion and presented with hypotension and positive focused assessment with sonography in trauma scan. After resuscitation, abdomen computed tomography (CT) scan showed a Grade 4 liver injury. The patient was admitted to the intensive care unit, and the liver injury was treated conservatively. Seventeen days later, he developed abdominal pain with deep epigastric tenderness. Repeated abdomen CT scan detected a giant hepatic artery pseudoaneurysm. Embolization was achieved using gel foam with the placement of six microcoils. The patient had an uneventful recovery. Late development of giant hepatic artery pseudoaneurysm is a rare complication of hepatic trauma and could be life-threatening. Timely identification and treatment with endovascular intervention are crucial. We recommend, especially when dealing with trauma related to blast injury, follow-up images for patients who develop symptoms suggestive of hepatic injury.

Cervical to Petrous Carotid Artery High-Flow Bypass for Carotid Artery Pseudoaneurysm Through Zygomatic Approach: 2-Dimensional Operative Video

Pseudoaneurysms of the cervical internal carotid artery may generate grave risk from catastrophic rupture, thromboembolic stroke, or mass effect. They have many causes, including malignancy, infection, and iatrogenic and most commonly blunt or penetrating trauma.1 These aneurysms require treatment to eliminate their risk. Treatment options include trapping, with or without revascularization, or endovascular stenting. Trapping without revascularization requires evaluation of the cerebral collateral under a physiological challenge, which is usually done with a balloon occlusion test, which is not applicable in this lesion.2 Occluding the carotid without revascularization carries the risk of delayed ischemia and aneurysm formation.3,4 Carotid stenting has been applied in the treatment of these lesions5,6; however, the extent of the lesion in our patient from the carotid bifurcation to the petrous carotid makes endovascular treatment challenging. We present a patient with a delayed post-traumatic pseudoaneurysm of the carotid artery that extended from the bifurcation to the petrous carotid who was treated with trapping and high-flow saphenous vein bypass from the proximal cervical internal carotid to the petrous carotid. Adequate exposure of the petrous carotid to perform anastomosis requires a thorough knowledge of the anatomy and surgical nuances, which we demonstrate here through a zygomatic approach.7 The patient consented to the procedure and publication of imaging. Image at 2:28 from Al-Mefty O, Operative Atlas of Meningiomas, © LWW, 1997, with permission.

The Minimally Invasive Treatment of Visceral Artery Pseudoaneurysms: A Retrospective Observational Single Centre Cohort Study on Glue Embolization

OBJECTIVE

The objective is to report a single centre experience in the embolization of visceral artery pseudoaneurysms with N-butyl-cyanoacrylate-methacryloxy sulfolane (NBCA-MS).

METHODS

A retrospective observational cohort study was conducted on data about all consecutive patients treated for visceral artery pseudoaneurysms in the Interventional Radiology Unit of SS Annunziata Hospital, in Taranto (Italy) between January 2016 and July 2020. Only patients treated with NBCA-MS embolization were included. Clinical and technical outcomes were evaluated during in-hospital stay and at 3-month follow-up by computed angiotomography (CTA).

RESULTS

Among 89 patients undergoing treatment for visceral artery pseudoaneurysm, a total of 58 (65.2%) patients (n = 32, 55.2% men; median age 45.8 years, range: 35-81) treated with NBCA-MS only were enrolled. Pseudoaneurysms were located in the renal artery (n = 18 cases, 31%), in the splenic artery (n = 27, 46.6%), in the intra-parenchymal hepatic artery (n = 3, 5.2%), in the common hepatic artery (n = 4, 6.9%) or in the pancreatic artery (n = 6, 10.3%). N-butyl-cyanoacrylate was diluted 1:1 with Lipiodol ultra-fluid, and mean volume injected was 0.6 ± 0.3 mL (range: 0.2-2.8 mL). Embolization was technically and clinically successful in all patients (n = 58, 100%) with an immediate total thrombosis of the pseudoaneurysm at the completion angiography. No systemic complications were noted in all cases. Five cases (8.6%) of non-target vessel embolization occurred without any clinical complication. No pseudoaneurysm recurrence was detected at the CTA control 1 day postoperatively. In one case (1.7%), a recurrence was detected 4 days after the initial treatment and successfully managed by a repeated NBCA-MS embolization. During the hospital stay, 56 patients recovered well but 2 (3.4%) died from multi-organ failure not related to the embolization. No recurrences were detected at the 3-month postoperative CTA in the remaining patients.

CONCLUSIONS

In properly selected patients affected with visceral artery pseudoaneurysms, NBCA-MS represents a definitive and safe embolization agent.

Safety of Transcatheter Arterial Embolization for Visceral Artery Pseudoaneurysms: Incidence of Intraprocedural Rupture

INTRODUCTION

Transcatheter arterial embolization is the first-line treatment for visceral artery pseudoaneurysms (VAPAs); however, the intraprocedural rupture of pseudoaneurysms is an important complication. The present study was performed to evaluate the safety of embolization for VAPAs, including the incidence of intraprocedural rupture.

METHODS

Among 56 consecutive patients with 57 VAPAs who underwent treatment between April 2009 and October 2020, 46 patients with 47 VAPAs underwent embolization. Complications related to embolization including intraprocedural rupture, the technical success rate, and clinical outcomes were evaluated. Complications that required extended hospitalization, an advanced level of care, or resulted in permanent adverse sequelae or death were classified as major complications, while the remainder were considered to be minor. Technical success was defined as the completion of embolization.

RESULTS

The intraprocedural rupture of pseudoaneurysms occurred in 3 out of 47 VAPAs treated with embolization (6%) and resulted in minor complications. One liver abscess requiring drainage was regarded as a major complication (2%). Focal infarction after embolization was observed as a minor complication in 20 cases. Complications occurred in 24 out of 47 cases (51%), comprising one major complication (2%) and 23 minor complications (48%). The technical success rate was 100% (47/47). Fifty-three out of 56 patients (95%) were alive in a median follow-up period of 18 months (range: 2 days-137 months).

CONCLUSIONS

Embolization is safe and useful for the treatment of VAPAs; however, the intraprocedural rupture of pseudoaneurysms may occur, and, thus, care is needed during this procedure.

Application of interventional embolization in the treatment of iatrogenic pseudoaneurysms

The present study aimed to investigate the clinical effectiveness and safety of endovascular embolization for the treatment of pseudoaneurysm secondary to previous abdominal and pelvic surgery or radiological percutaneous abdominal procedure. A retrospective review was performed on all patients with abdominal and pelvic pseudoaneurysm confirmed by CT angiography or digital subtraction angiography and treated with endovascular embolization. Different techniques of embolization with coils were applied and the outcomes, including clinical effectiveness and safety, were assessed. A total of 31 patients with a total of 32 pseudoaneurysms were included in the present study. Of these pseudoaneurysms, 23 were from the main trunks and branches of the gastroduodenal artery, 5 were from the splenic artery, 2 were from the common hepatic artery, 1 was from the right hepatic artery and 1 was from the right internal iliac artery. There were no serious complications observed and there was no occurrence of re-bleeding following embolization. The embolization of the pseudoaneurysms was successful in all patients. In conclusion, endovascular embolization is a safe and effective method for the treatment of secondary iatrogenic pseudoaneurysm in the abdomen and pelvis.

Endovascular management of traumatic pseudoaneurysms

Background

Pseudoaneurysms (PAs) caused by traumatic injury to the arterial vasculature have a high risk of rupture, leading to life-threatening hemorrhage and mortality, requiring urgent treatment. The purpose of this study was to determine the technical and clinical outcomes of endovascular treatment of visceral and extremity traumatic pseudoaneurysms.

Methods

Clinical data were retrospectively collected from all patients presenting for endovascular treatment of PAs between September 2012 and September 2018 at a single academic level one trauma center. Technical success was defined as successful treatment of the PA with no residual filling on post-embolization angiogram. Clinical success was defined as technical successful treatment with no rebleeding throughout the follow-up period and no reintervention for the PA.

Results

Thirty-five patients (10F/25M), average age (± stdev) 41.7 ± 20.1 years, presented with PAs secondary to blunt (n = 31) or penetrating (n = 4) trauma. Time from trauma to intervention ranged from 2 h - 75 days (median: 4.4 h, IQR: 3.5–17.1 h) with 27 (77%) of PAs identified and treated within 24 h of trauma. Average hospitalization was 13.78 ± 13.4 days. Ten patients underwent surgery prior to intervention. PA number per patient ranged from 1 to 5 (multiple diffuse). PAs were located on the splenic (n = 12, 34.3%), pelvic (n = 11, 31.4%), hepatic (n = 9, 25.7%), upper extremity/axilla (n = 2, 5.7%), and renal arteries (n = 1, 2.9%). Technical success was 85.7%. Clinical success was 71.4%, for technical failure (n = 5), repeat embolization (n = 1) or post-IR surgical intervention (n = 4). There was no PA rebleeding or reintervention for any patient after discharge over the reported follow-up periods. Three patients died during the trauma hospitalization for reasons unrelated to the PAs.

Conclusions

Endovascular treatment of traumatic visceral and extremity PAs is efficacious with minimal complication rates and low reintervention requirements.

Management of Post-Traumatic Maxillofacial Pseudoaneurysms: Review of the Literature and Suggested Algorithm

A pseudoaneurysm (PA) is a collection of blood caused by an incomplete tear in the vessel wall. PA can be arterial or venous in origin. In the maxillofacial region, arterial PA can result from surgical interventions. Venous PAs in the maxillofacial region have never been described. A standardized protocol for management of post-traumatic PAs in the maxillofacial region would help clinicians make treatment decisions. On the basis of the available literature and our institutional experience, we present an algorithm for management of post-traumatic maxillofacial PAs. We also present patients from our institution who illustrate some of the management options in the algorithm.

Percutaneous treatment of vascular access-site complications: a ten years' experience in two centres

Background

The spread of percutaneous arterial catheterization in diagnostic and therapeutic procedures has led to a parallel increase of vascular access site complications. The incidence of these events is between 0.2–1%. A detailed analysis of injuries by type of procedure shows a higher incidence of injuries after therapeutic procedures (3%) than those observed for diagnostic ones (1%), due to the greater size of the vascular devices used and the necessity to frequently administer anticoagulant and antiplatelet therapy during procedures. The iatrogenic arterial injuries requiring treatment are the pseudoaneurysm, arteriovenous fistula, arterial rupture and dissection. Less frequent complications include distal embolization of the limbs, nerve damage, abscess and lymphocele.

Moreover, the use of percutaneous vascular closure devices (VCD) has further expanded the types of complications, with an increased risk of stenosis, thrombosis, distal embolism and infection. Our work aims to bring the personal 10 years’ experience in the percutaneous treatment of vascular access-site complications.

Results

Ninety-two pseudoaneurysms (PSA), 12 arteriovenous fistulas (AVF), 15 retrograde dissections (RD) and 11 retroperitoneal bleedings (RB) have been selected and treated. In 120/130 cases there were no periprocedural complications with immediate technical success (92.3%). Nine femoral PSA, treated with percutaneous ultrasound-guided thrombin injection, showed a failure to close the sac and therefore they were treated by PTA balloon inflation with a contralateral approach and cross-over technique. Only one case of brachial dissection, in which the prolonged inflation of the balloon has not led to a full reimbursement of the dissection flap, was then surgically repaired. At the 7 days follow-up, complications were two abscesses in retroperitoneal bleedings, treated by percutaneous drainage. At 3 months, acute occlusion of 3 covered femoral stents occurred, then treated by loco-regional thrombolysis and PTA. A total of 18 major complications was recorded at 2 years, with a complication rate at 2 years of 13.8%.

Conclusions

The percutaneous treatment of vascular access-site complications is the first-choice treatment. It represents a safe and effective option, validated by a high technical success rate and a low long-term complication rate, that allows avoiding the surgical approach in most cases.

Intrahepatic pseudoaneurysm following penetrating abdominal injury: Surgical and endovascular management of 2 complicated cases

INTRODUCTION

Post-traumatic pseudoaneurysm of the hepatic artery is a rare complication of abdominal injury. Prompt intervention is essential to avoid a life-threatening hemorrhage. We report two complicated cases of intrahepatic pseudoaneurysm (IHPA).

PRESENTATION OF CASES

Case 1: A victim of a bomb blast with thoracoabdominal injury presented in hypovolemic shock. Emergency laparotomy revealed actively bleeding liver lacerations, which had been successfully controlled with perihepatic packing. After 72 h, computed tomography (CT) of the abdomen showed a 3 cm × 1.8 cm IHPA of the left hepatic artery, which was treated with endovascular microcoils embolization. Postoperatively, the patient developed bile leakage and biliopleural fistula, which were managed conservatively. Case 2: A patient suffered a shotgun injury to the abdomen. In laparotomy, a grade III liver laceration was noted. The bleeding was controlled with perihepatic packing. The packs were removed 48 h later. Ten days postoperatively, the patient developed severe abdominal pain with shock, CT of the abdomen showed; 24 cm × 13 cm × 8 cm subcapsular liver hematoma. Superselective hepatic angiography showed a 1-cm IHPA of the right hepatic artery. The entry and exit points of the aneurysm were successfully embolized with two microcoils. No complications related to angioembolizaion were encountered.

DISCUSSION

IHPA following bomb blast and shotgun injury is rarely reported. Timely diagnosis is crucial.

CONCLUSION

We advise to keep in mind the possibility of IHPA, when dealing with high-grade liver injury. CT is recommended before removal of perihepatic packs, as it may pick up a life-threatening pseudoaneurysm.

Iatrogenic thyroid pseudoaneurysm following thyroid nodule radiofrequency ablation

A 54-year-old Chinese woman presented for radiofrequency ablation (RFA) of benign thyroid nodules. A few hours after the procedure, the patient developed neck swelling and tenderness. Doppler ultrasound (US) images of the neck revealed haematoma with a vascular hypoechoic mass at the RFA site, suspicious for pseudoaneurysm. These findings were confirmed on subsequent on-table fluoroscopy following direct US-guided needle puncture and injection of contrast, demonstrating opacification of the mass and extravasation. Successful occlusion of the pseudoaneurysm was performed using US-guided thrombin injection. The patient made a good recovery with follow-up US 1 month later showing no recurrence of haematoma or pseudoaneurysm.

Ultrasound-Guided Thrombin Injection for Iliopsoas Pseudoaneurysm

Bilateral iliopsoas hematoma is an uncommon phenomenon, which has been described in individuals receiving anticoagulation therapy. The hematoma is caused by bleeding of arteries to the muscle. In rare cases, pseudoaneurysms can also be formed. We present a case of an adolescent, with partial factor XI deficiency, who experienced a mild fall. Imaging studies revealed large bilateral iliopsoas hematomas and bilateral iliopsoas pseudoaneurysms. One pseudoaneurysm was demonstrated by angiography and was embolized with micro coils. The second, more persistent one, was sealed via ultrasound-guided thrombin injection, with excellent morphological and clinical results.

Stent-Assisted Coiling of Pseudoaneurysm After Vertebro-Carotid Transposition: Harmonious Combination of Open and Endovascular Neurosurgical Techniques

BACKGROUND

Most cases of vertebral artery stenosis are treated either conservatively or surgically. When non-conservative treatment is chosen, whether to treat it with open surgery or endovascular intervention remains a topic of divergence. In the setting of endovascular therapy failure, the vertebral to common carotid artery transposition certainly is an appropriate choice to recover the posterior circulation. Like any other open surgery, it is not devoid of soft-tissue-related complications. A pseudoaneurysm following this procedure and at this particular location is a rare but lethal complication and, to the best of our knowledge, has not yet been reported.

CASE DESCRIPTION

We present the case of an 80-year-old man with previous ischemic stroke who presented to the emergency department with aphasia, right-sided weakness, and dysarthria. Invasive imaging revealed right vertebral stenosis and hypoplastic left vertebral artery that failed endovascular therapy. The patient was then treated with a right vertebral to common carotid artery transposition. During follow-up, a pseudoaneurysm was found and treated with a stent-assisted coiling.

CONCLUSIONS

Pseudoaneurysms at the extracranial carotid and vertebral circulation are rare and have potential for deadly outcomes. Despite several treatments available, this anatomical location requires endovascular therapy due to efficacy and promptitude of this treatment. This is an interesting case where the patient's management required open and endovascular procedures. The pseudoaneurysm was a rare complication that, to the best of our knowledge, has not previously been reported. This case is an illustration of complementary work between open surgery and endovascular intervention.

Endovascular glue embolization for control of massive hemoptysis caused by peripheral pulmonary artery pseudoaneurysms: Report of 7 cases

Purpose:

Pulmonary artery pseudoaneurysms are a rare cause of massive hemoptysis and need to be considered as a differential with prompt recognition preventing mortality from life-threatening hemorrhage. We report the clinical details and imaging findings for a series of patients presenting with massive haemoptysis due to peripheral pulmonary artery pseudoaneurysm, managed by endovascular glue embolization.

Methods:

Hospital based retrospective study wherein records and image database of patients presenting with massive hemoptysis between January 2014 and March 2016 were studied. The immediate technical success, reintervention rate, and recurrence of massive hemoptysis were recorded.

Results:

Among patients with massive hemoptysis who underwent endovascular management in our department, seven patients fulfilled the inclusion criteria. The mean age was 54.3 years; mean lesion diameter was 10.8 mm (range 6–14 mm); underlying pathology being infective (tuberculosis) in all cases (n = 7). All lesions were treated with endovascular glue embolization. The technical success was 100%. Mean follow-up was 11.7 months. There was no case of recurrence of massive hemoptysis. There were no major complications with a single case of minor complication (in the form of chest pain and discomfort) which resolved with medical management.

Conclusion:

The endovascular approach using glue (N-butyl cyanoacrylate) is a minimally invasive and technically feasible, effective technique for emergent management of pulmonary artery pseudoaneurysms presenting as massive hemoptysis.

Hepatic artery pseudoaneurysm, bronchobiliary fistula in a patient with liver trauma

BACKGROUND

Bronchobiliary fistula and hepatic artery pseudoaneurysm are rare complications of hepatic trauma. There are isolated case reports for both pseudoaneurysm and bronchobiliary fistula following hepatic trauma but there aren't reports of both conditions developing in a single patient.

CASE PRESENTATION

This case describes an 18 year old hindu male who developed right hepatic artery pseudoaneurysm and bronchobiliary fistula following blunt abdominal trauma. Patient was managed with exploratory laparotomy followed by coil embolization and Endoscopic retrograde cholangiopancreatography stenting respectively.

CONCLUSION

Rare complications of liver trauma include pseudoaneurysm and bronchobiliary fistula. These complications can rarely co- exist in a single patient.

Pseudoaneurysm

Pseudoaneurysms (PSAs) are commonly known as complications associated with invasive interventions. Because of the pulsatile in- and outflow of blood through the neck of PSAs, they tend to grow and, in the worse cases, can rupture. Therapeutic options are compression therapy, using a compression bandage and ultrasound-guided compression, and thrombin injection. Manual ultrasound-guided compression is widely performed and is successful in most cases. In general, it is combined with a subsequently applied compression bandage. Thrombin injection is a more difficult technique, but it has a higher success rate. This article gives an overview of the characteristics of PSAs, their diagnostic characteristics and the therapeutic methods used to treat them. Complications associated with compression or thrombin injection are also explained in detail.

Treatment strategies for bleeding from gastroduodenal artery pseudoaneurysms complicating the course of chronic pancreatitis-A case series of 10 patients

We analyzed our experience with management of gastroduodenal artery (GDA) pseudoaneurysms associated with chronic pancreatitis using a multidisciplinary approach. We treated 10 patients with GDA pseudoaneurysms (all men, aged 24-62 year) who underwent treatment during April 1998 to December 2016. All had presented with recent hematemesis and/or melena. Hemodynamically, stable patients were initially subjected to transcatheter embolization or radiologically guided thrombin injection. Recurrence of bleeding within 48 h was taken as failure. Emergency surgery was done for hemodynamic instability and recurrent bleeding, and elective surgery was carried out as per specific indications. Ten interventional procedures were performed in nine patients, while one was directly subjected to surgery. Angioembolization was done in five patients (with success in four) and thrombin injection in five patients (including one with embolization failure; with success in three). Six patients underwent surgery, two on emergency basis, for hemodynamic instability and recurrent bleeding in one each, and four for definitive treatment of pancreatitis/associated complication. One patient died while the other nine survived and well with no recurrence of bleeding during follow up (6 months to 10 years). Management of GDA pseudoaneurysms requires a multidisciplinary approach. Pseudoaneurysms with narrow neck are suitable for thrombin injection while those with wide neck should be subjected to angioembolization. Emergency surgical treatment is reserved for non-surgical failures, and choice between trans-ductal or trans-cystic approach is based on the location of the aneurysm.

Endovascular treatment of acute gastrointestinal bleeding from a large splenic artery pseudoaneurysm: case report and literature review

Pseudoaneurysm of the splenic artery is a rare entity, with little more than 150 cases described in the literature. Pancreatitis is the most common etiology, followed by trauma. In contrast with true aneurysms, pseudoaneurysms are frequently symptomatic, with a 47% risk of rupture and 90% mortality if left untreated. We describe the case of a 48-year-old female patient who suffered a gastrointestinal hemorrhage associated with acute-on-chronic pancreatitis. During workup, endoscopy revealed signs of recent bleeding and magnetic resonance angiography of the abdomen showed a large pseudoaneurysm of the splenic artery. The patient underwent endovascular treatment with microcoil embolization and no further bleeding episodes occurred. Endovascular treatment is now an effective option with low morbidity and mortality and success rates in the range of 79-100%, making it a viable technique for patients with active abdominal inflammation. We conducted a review of endovascular techniques and embolization agents used to treat this pathology.

Non-invasive repair of an iatrogenic tibial artery branch pseudoaneurysm after intramedullary nailing

Tibial fractures are a commonly seen injury in orthopedic surgery. Intramedullary nailing is considered the standard of care, as complications are rare. Those of a vascular nature, including iatrogenically induced pseudoaneurysms of the tibial artery have been previously described in the literature, however each reported case has required surgical repair. In the current case, we describe a repair of a tibial artery branch pseudoaneurysm, after direct contact with an interlocking screw from tibial intramedullary nailing, via ultrasound-guided thrombin injection. To the authors' knowledge, this is the first reported case of a tibial artery pseudoaneurysm repaired non-surgically. This adds support to the promising literature on non-invasive repair of orthopedically related pseudoaneurysms.

Ultrasound-guided thrombin injection for treatment of superficial traumatic pseudoaneurysms and associated expanding hematomas: experience in five patients

Background

Angiography allows for excellent characterization and treatment of traumatic pseudoaneurysms. However, ultrasound-guided thrombin injection for pseudoaneurysm thrombosis allows for radiation-free treatment of superficial pseudoaneurysms and superficial expanding hematomas.

Methods

A retrospective review of 5 patient cases treated under this paradigm was performed following institutional review board approval. Outcomes following intervention were recorded and compared amongst the patient cohort.

Results

Ultrasound-guided closure of traumatic pseudoaneurysms allowed for reduced procedural times and procedural invasiveness.

Conclusions

As demonstrated by the following cases, ultrasound guided thrombin injection is a good method of primary treatment for superficial pseudoaneurysms, or as an alternative treatment in cases where transcatheter embolization fails.

Brachial pseudoaneurysm of the neonate with partial response to thrombin injections and late spontaneous thrombosis and regression during expectant management

We illustrate the case of a brachial pseudoaneurysm in a 32-week preterm baby male who presented with a large pulsatile mass in the right antecubital fossa, with no clear aetiologic factor. The management of this type of lesion has been controversial and based mainly on case reports. In this case, after obtaining partial response with two thrombin injections, it spontaneously regressed during expectant management. This combination of therapeutic options may be an alternative for the management of complex lesions and, to the best of our knowledge, has not been previously reported.

Interventional Radiology in the Management of Visceral Artery Pseudoaneurysms: A Review of Techniques and Embolic Materials

Visceral artery pseudoaneurysms occur mostly as a result of inflammation and trauma. Owing to high risk of rupture, they require early treatment to prevent lethal complications. Knowledge of the various approaches of embolization of pseudoaneurysms and different embolic materials used in the management of visceral artery pseudoaneurysms is essential for successful and safe embolization. We review and illustrate the endovascular, percutaneous and endoscopic ultrasound techniques used in the treatment of visceral artery pseudoaneurysm and briefly discuss the embolic materials and their benefits and risks.

Post-traumatic liver and splenic pseudoaneurysms in children: Diagnosis, management, and follow-up screening using contrast enhanced ultrasound (CEUS)

BACKGROUND

Pseudoaneurysm (PA) formation following blunt and penetrating abdominal trauma is a recognized complication in solid organ injury, usually diagnosed by contrast-enhanced CT (CECT) imaging. Delayed rupture is a potentially life-threatening event, although its frequency is not known in pediatric trauma. Contrast enhanced ultrasound (CEUS) is a novel radiation-free alternative to CECT with the potential to identify PA.

METHODS

A retrospective review of consecutive cases of significant liver and splenic injuries admitted to single institution (tertiary and quaternary referrals) over more than a 12year period was performed. From 2011, CEUS was performed routinely postinjury (5-10days) using SonoVue™ as contrast. Initially, CECT and CEUS were performed in tandem to ensure accurate correlation.

RESULTS

From January 2002-December 2014, 101 (73M) children [median age was 14.2 (1.3-18)years] with liver and splenic injuries were admitted. Injuries included: liver [n=57, grade 3 (1-5)], splenic [n=35, grade 3 (1-5)], and combined liver/spleen [n=8, (1-4)]. Median Injury Severity Score (ISS) was 13 (2-72). The predominant mechanisms of injury were blunt trauma n=73 (72%) and penetrating trauma n=28 (28%). Seventeen children (17%) developed PA. Six children became symptomatic (35%), and five went on to have embolization [at 7 (3-11)days]. These were detected by CECT (n=4) and CEUS (n=2). Eleven children remained asymptomatic [detected by CECT (n=8) and CEUS (n=3) at median 5 (4-8)days]. One underwent embolization owing to evidence of interval bleeding. Sensitivity of CEUS at detection of PA was 83%, with specificity of 92% (PPV=71%, NPV=96%). There was no association between grade of injury and presence of PA in either liver or splenic trauma (P=0.4), nor was there an association between size of PA and symptoms (P=0.68). Children sustaining splenic PA were significantly younger than those with hepatic PA (P=0.03). Follow-up imaging confirmed resolution of PA in 16 cases. One child was lost to follow-up.

CONCLUSIONS

The incidence of PA is higher than previously reported in the pediatric literature (<5%). Postinjury imaging appears mandatory, and CEUS appears to be highly sensitive and specific for diagnosis and follow-up.

Traumatic axillary artery pseudoaneurysm treated with intravascular balloon occlusion and percutaneous thrombin injection

Axillary artery pseudoaneurysms are relatively rare, with few reported cases found in the literature. Furthermore, treatment with percutaneous thrombin injection has not yet been reported. We report the case of a 59-year-old man with a large (10 cm) post-traumatic pseudoaneurysm of the left axillary artery found five weeks after a motorcycle crash. The patient sustained multiple injuries, including fractures of the left scapula and clavicle. Edema was observed at the time of diagnosis. Arteriography with successful ultrasound-guided percutaneous thrombin injection was undertaken. The patient experienced no complications after the procedure.

Pulmonary artery pseudoaneurysm arising secondary to cavitary pneumonia

Pulmonary artery pseudoaneurysms have classically been associated with the cavitary lesions of reactivation tuberculosis and termed Rasmussen’s aneurysm. There have been relatively few case reports of pulmonary artery pseudoaneuryms arising secondary to cavitary pneumonia. We present a case of pulmonary artery pseudoaneurysm occurring secondary to cavitating aspiration pneumonia that was treated successfully with coil embolization.

Post-partum hemoperitoneum: Do not miss false aneurysm as a cause of bleeding

A 27-year-old woman underwent a first vaginal delivery at our institution. She returned four days after delivery, presenting with abdominal pain and an unexplained drop in her hemoglobin value, without external bleeding. The initial computed tomography abdominal scan revealed an isolated diffuse hemoperitoneum. A laparoscopy did not find the cause of bleeding. A second computed tomography scan, performed 15 days later, revealed hemoperitoneum associated with a false aneurysm of the right uterine artery. Treatment consisted of embolization of the uterine arteries, with clinical success. False aneurysms are a rare cause of intra-abdominal non-exteriorized bleeding in late post-partum hemorrhage.

Endovascular treatment of visceral artery pseudoaneurysms: Analysis of 42 cases

AIM: To determine the clinical features and endovascular treatment of visceral artery pseudoaneurysms (VAPA).

METHODS: Clinical data and our experience with interventional treatment of 42 patients with VAPA were retrospectively analyzed. Follow-up was carried out via assessment of contrast-enhanced computed tomography or computed tomography angiography images.

RESULTS: Endovascular treatment was technically successful in 38 (90.4%) patients, of whom one died of multisystem organ failure 28 d after intervention. The 30 d mortality rate was 2.4% (1/42). Four patients required secondary interventions because of rebleeding and were successfully treated by reintervention. In the follow-up period, 17 patients suffering from cancer died from 1 to 12 mo after embolization because of disease progression (n = 8), multisystem organ failure (n = 7), myocardial infarction (n = 1), and septic shock (n = 1). Four patients suffered partial splenic infarction and post-embolization syndrome. During follow-up, no patient had hepatic insufficiency or bowel ischemia; no VAPA occurred in all patients.

CONCLUSION: Endovascular management is minimally invasive and highly successful in treating VAPA and particularly useful in poor surgical candidates.

Hepatic pseudoaneurysm after traumatic liver injury; is CT follow-up warranted?

Introduction

Hepatic pseudoaneurysm (HPA) is a rare complication after liver trauma, yet it is potentially fatal, as it can lead to sudden severe haemorrhage. The risk of developing posttraumatic HPA is one of the arguments for performing follow-up CT of patients with liver injuries. The aim of this study was to investigate the occurrence of HPA post liver trauma.

Methods

A retrospective study from 2000-2010 of conservatively treated patients with blunt liver trauma was performed to investigate the incidence and nature of HPA. After the initial CT scan patients were admitted to the department and if not clinically indicated prior a follow-up CT was performed on day 4-5.

Results

A total of 259 non-operatively managed patients with liver injury were reviewed. 188 had a follow-up CT or US and in 7 patients a HPA was diagnosed. All aneurysms were treated with angiographic embolization and there were no treatment failures. There was no correlation between the severity of the liver injury and development of HPA. 5 out of 7 patients were asymptomatic and would have been discharged without treatment if the protocol did not include a default follow-up CT.

Conclusions

In conclusion, this study shows that HPA is not correlated to the severity of liver injury and it develops in 4% of patients after traumatic liver injury. In order to avoid potentially life-threatening haemorrhage from a post trauma hepatic pseudoaneurysm, it seems appropriate to do follow-up CT as part of the conservative management of blunt and penetrating liver injuries.