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 Table of Contents  
INTERESTING CASE REPORT
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 155-157

Interarterial Pseudoaneurysm: A Potential Nightmare


1 Department of Cardiology, Bharati Vidyapeeth Medical College Hospital and Research Centre, Pune, Maharashtra, India
2 Faculty of Cardiology, Bharati Vidyapeeth Medical College, Hospital and Research Centre, Pune, Maharashtra, India

Date of Submission19-Jan-2022
Date of Decision24-Mar-2022
Date of Acceptance27-Mar-2022
Date of Web Publication29-Jul-2022

Correspondence Address:
Dr. Chandrakant Bhagwat Chavan
Faculty of Cardiology, Bharati Vidyapeeth Medical College,Hospital and Research Centre, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_7_22

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  Abstract 

Femoral artery pseudoaneurysm (FAP) is one of the most troublesome complications related to femoral artery access site after cardiovascular catheterization procedures and occurs in 0.8%–2.2% of the cases of cardiovascular interventional procedures. Management is by ultrasound-guided compression repair (UGCR). A 75-year-old male presented with anterior wall ST-elevation myocardial infarction and after percutaneous transluminal coronary angioplasty, developed FAP. This pseudoaneurysm had an interarterial communication between superficial femoral artery and deep femoral artery. It is unusual to have communication of pseudoaneurysm with two branches of femoral artery. Diagnosis was made using vascular sonography and Doppler study. Closure of this aneurysm was done by simple pressure with Doppler probe at both the narrow ends of the aneurysm. Arterial color Doppler is the mainstay for diagnosing FAPs. This case describes an interarterial pseudoaneurysm which is a rare entity to witness and the different modalities for its management, the most common one being UGCR.

Keywords: Femoral artery pseudoaneurysm, interarterial pseudoaneurysm, ultrasound-guided compression repair


How to cite this article:
Singhal S, Chavan CB, Kalra R. Interarterial Pseudoaneurysm: A Potential Nightmare. J Indian Acad Echocardiogr Cardiovasc Imaging 2022;6:155-7

How to cite this URL:
Singhal S, Chavan CB, Kalra R. Interarterial Pseudoaneurysm: A Potential Nightmare. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2022 [cited 2022 Oct 3];6:155-7. Available from: https://jiaecho.org/text.asp?2022/6/2/155/352990


  Introduction Top


One of the most troublesome complications related to femoral artery access site after cardiovascular catheterization procedures is femoral artery pseudoaneurysm (FAP) and it occurs in 0.8%–2.2% of the cases of cardiovascular interventional procedures. Differentials are hematoma, arteriovenous fistula, thrombosis, and infection. FAPs can also form due to intravenous drug use or penetrating trauma. When iatrogenic, the common factors leading to FAP formation are- anticoagulation therapy, coagulopathy, inadequate compression following femoral artery puncture, improper puncture technique or too low puncture site, and inadvertent femoral artery branch puncture.

Pseudoaneurysm is a false aneurysm that occurs after localized arterial injury related to incomplete hemostatic plug at the injury site. The blood flow from the puncture site erodes through the hemostatic plug and forms pseudoaneurysm. Extravasation of blood from aneurysm is prevented by pseudocapsule. We report a case of a 75-year-old male with anterior wall ST-elevation myocardial infarction and post-percutaneous transluminal coronary angioplasty (PTCA) developing FAP having an interarterial communication between superficial femoral artery (SFA) and deep femoral artery (DFA) and treated by simple pressure with Doppler probe at both the narrow ends of the aneurysm.


  Case Report Top


A 75-year-old male, known case of Type II diabetes mellitus and hypertension presented to emergency department with chest pain. Electrocardiogram was suggestive of acute anterior wall ST elevation myocardial infarction. He was thrombolysed with injection streptokinase. Elective coronary angiography performed after 24 h, using right femoral artery approach with Seldinger technique, showed significant lesion in the proximal and mid-left anterior descending coronary artery. PTCA with drug-eluting stent was performed at the same time. Post-PTCA day 2, the patient complained of pain and swelling in the right groin at the site of femoral artery puncture. On examination, there was a 4 cm × 2 cm hematoma in the right groin and redness over the area. Right femoral artery pulse showed pulsatile pseudoaneurysm [Figure 1]. All peripheral arterial pulses were well felt. A right groin arterial Doppler showed an anechoic collection measuring 2.7 cm × 0.55 cm anterior to right SFA and another similar collection of size 1.9 cm × 0.5 cm adjacent to it (which were interconnected). These two anechoic collections were connected to SFA through a tract measuring 9.5 mm in length and 2.6 mm in width and also to DFA through a tract measuring 9 mm in length and 3 mm in width [Figure 2]a, [Figure 2]b, [Figure 2]c and [Video 1] and [Video 2]. The color Doppler showed to-and-fro pulsatile flow through the collections (yin-yang pattern). Manual pressure with fingers was applied over the site of the neck of the pseudoaneurysm, pointing downward and forward toward the toe, at the bedside for initial management. However, it was not successful. Hence, ultrasound-guided compression was given over the pseudoaneurysm neck with the help of ultrasound probe for about 20 min, for 2 consecutive days, as the flow did not stop with the initial compression. Following the compression on the second day, not only the flow in the pseudoaneurysm connecting SFA got obliterated, but the connection with DFA was also obliterated. An ultrasound repeated on the following day showed a thrombosed pseudoaneurysm on the right groin region [Figure 3]. The patient's pain and swelling over the right groin region also decreased. All peripheral pulses were well preserved.
Figure 1: Diagrammatic representation of an interarterial pseudoaneurysm connecting SFA and DFA. DFA: Deep femoral artery, SFA: Superficial femoral artery

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Figure 2: (a) Tract connection between superficial femoral artery and pseudoaneurysm, (b) tract connection between deep femoral artery and pseudoaneurysm, (c) tract connecting pseudoaneurysm with superficial and deep femoral arteries. D: Deep femoral artery, Pa: Pseudoaneurysm, S: Superficial femoral artery

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Figure 3: Tract between superficial femoral artery, deep femoral artery, and pseudoaneurysm is closed and thrombosis observed. D: Deep femoral artery, S: Superficial femoral artery, Th: Thrombosis

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[Additional file 1]

Video 1: Color Doppler showing pseudoaneurysm connection with the superficial and deep femoral arteries.

[Additional file 2]

Video 2: Color Doppler showing two anechoic collections and the adjacent deep femoral artery.


  Discussion Top


Arterial color Doppler is the mainstay for diagnosing FAPs and the diagnostic criteria include the presence of color flow within a tract leading from the artery to the mass, consistent with the pseudoaneurysm neck, swirling color flow seen in a mass separate from the affected artery, and a “to-and-fro” Doppler waveform in the pseudoaneurysm neck.[1] Different strategies have been developed for this type of complication which include manual compression, ultrasound-guided compression repair (UGCR), surgical repair, and minimally invasive percutaneous treatments (thrombin injection, coil embolization, covered stent insertion).[2]

Manual compression over the site of pseudoaneurysm neck is a bedside technique for the management of this complication. After recognizing the neck of pseudoaneurysm, a manual pressure through fingers is applied in the direction pointing downward and forward toward the toe end of the same limb until the clinical signs of the communication decrease or disappear [Figure 4]. This method requires no equipment, is less painful, can be done at the bedside, and has good results. UGCR as a method for management was introduced by Fellmeth et al. in 1991.[3] For pseudoaneurysm thrombosis, it is a cost-effective and safe method.[1] It has significantly reduced the need for surgical repair. A pressure for about 20–25 min is applied using the ultrasound probe, under the direct ultrasound guidance, until the flow across the neck is obliterated, which might take more than one sitting. After successful thrombosis, the patient is kept in a supine position with legs outstretched for few hours. Overall procedural complication rate is 3.6%.[1] This method is contraindicated in cases of limb ischemia, infection, large hematomas, or compartment syndrome.[4] UGCR requires a skilled medical personnel and an ultrasound device. In a previous report by Schaub et al., a number of factors were associated with the failure of this method, most notably, the ongoing anticoagulation need and the length of the aneurysm tract (<10 mm).[5] Amount and the direction of the pressure over the neck of the pseudoaneurysm (just enough to obliterate the neck) are important determinants for the closure of the pseudoaneurysm.
Figure 4: Method to apply pressure in downward and obliquel direction toward the heel of the foot. A: Artery

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Low-dose thrombin injection for the treatment of pseudoaneurysm was a method introduced by Reeder et al.[6] The effectiveness of thrombin injections in treating pseudoaneurysms has been demonstrated.[6],[7],[8],[9] A study by Vlachou et al. had a high success rate of 95% in which 81 patients were treated with 425 U/ml of thrombin.[7] Another study by Illescas et al. demonstrated a 100% success rate in 36 patients in which various concentrations of thrombin injection were used (50–1000 IU/ml).[10] In addition to distal limb ischemia caused by in situ thrombosis from thrombin, a hypothetical risk of type I IgE-mediated allergic reaction to bovine thrombin can also be present. Due to the simplicity of the procedure, ultrasound-guided thrombin injection is an appealing treatment but is costly. The current research efforts are directed at sponge-like application form of collagen. Placement of covered stents/endoluminal prosthesis is another modality for treating pseudoaneurysms but majority are used for atherosclerotic aneurysm exclusion. Percutaneous coil placement to occlude FAPs has also been reported. In few cases, coil was placed inside the pseudoaneurysm while in some, it was placed only in the neck to achieve closure and local thrombosis.[11] Surgery is definitive and usually effective. However, it is also relatively expensive means of pseudoaneurysm repair. Surgical repair is needed when there is rapid expansion of the pseudoaneurysm, concomitant distal ischemia or neurological deficit due to local pressure from the pseudoaneurysm, or distal embolization from within it, mycotic infection of pseudoaneurysm, failure of percutaneous intervention or compromised soft tissue viability.


  Conclusion Top


It is unusual to get pseudoaneurysm over femoral artery with communication with both SFA and DFA. It can be a potential nightmare if not addressed promptly, leading to rupture, distal embolization, or neuropathy. UGCR can be an effective method to treat it, but requires skill.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eisenberg L, Paulson EK, Kliewer MA, Hudson MP, DeLong DM, Carroll BA. Sonographically guided compression repair of pseudoaneurysms: Further experience from a single institution. AJR Am J Roentgenol 1999;173:1567-73.  Back to cited text no. 1
    
2.
Hamraoui K, Ernst SM, van Dessel PF, Kelder JC, Ten Berg JM, Suttorp MJ, et al. Efficacy and safety of percutaneous treatment of iatrogenic femoral artery pseudoaneurysm by biodegradable collagen injection. J Am Coll Cardiol 2002;39:1297-304.  Back to cited text no. 2
    
3.
Fellmeth BD, Roberts AC, Bookstein JJ, Freischlag JA, Forsythe JR, Buckner NK, et al. Postangiographic femoral artery injuries: Nonsurgical repair with US-guided compression. Radiology 1991;178:671-5.  Back to cited text no. 3
    
4.
O'Sullivan GJ, Ray SA, Lewis JS, Lopez AJ, Powell BW, Moss AH, et al. A review of alternative approaches in the management of iatrogenic femoral pseudoaneurysms. Ann R Coll Surg Engl 1999;81:226-34.  Back to cited text no. 4
    
5.
Schaub F, Theiss W, Busch R, Heinz M, Paschalidis M, Schomig A. Management of 219 consecutive cases of postcatheterization pseudianeurysm. J Am Coll Cardiol 1997;30:670-5.  Back to cited text no. 5
    
6.
Reeder SB, Widlus DM, Lazinger M. Low-dose thrombin injection to treat iatrogenic femoral artery pseudoaneurysms. AJR Am J Roentgenol 2001;177:595-8.  Back to cited text no. 6
    
7.
Vlachou PA, Karkos CD, Bains S, McCarthy MJ, Fishwick G, Bolia A. Percutaneous ultrasound-guided thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms. Eur J Radiol 2011;77:172-4.  Back to cited text no. 7
    
8.
Stone PA, Campbell JE, AbuRahma AF. Femoral pseudoaneurysms after percutaneous access. J Vasc Surg 2014;60:1359-66.  Back to cited text no. 8
    
9.
Yoo T, Starr JE, Go MR, Vaccaro PS, Satiani B, Haurani MJ. Ultrasound-guided thrombin injection is a safe and effective treatment for femoral artery pseudoaneurysm in the morbidly obese. Vasc Endovascular Surg 2017;51:368-72.  Back to cited text no. 9
    
10.
Illescas MEB, Ruiz AP, Rodríguez MLR, Pardo LC, de la Cruz RQ. Femoral artery pseudoaneurysms. Treatment with thrombin, but ¿always? ECR 2015 Scientific Exhibit; 2015.  Back to cited text no. 10
    
11.
Pan M, Medina A, Suárez de Lezo J, Romero M, Hernández E, Segura J, et al. Obliteration of femoral pseudoaneurysm complicating coronary intervention by direct puncture and permanent or removable coil insertion. Am J Cardiol 1997;80:786-8.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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