Treatment for femoral pseudoaneurysms

Axillary Artery Pseudoaneurysm After Revision Plate Osteosynthesis of a Midshaft Clavicle Fracture Nonunion: A Case Report

CASE

A patient with history of nonunion repair of traumatic midshaft clavicle fracture was referred to our orthopaedic trauma clinic for new-onset shoulder pain and paresthesias involving the ipsilateral arm. Computed tomography angiography revealed an axillary artery pseudoaneurysm adjacent to the instrumentation and recurrent nonunion of the fracture site. The patient underwent coil embolization of the pseudoaneurysm and nonunion repair.

CONCLUSION

This case demonstrates that iatrogenic neurovascular injury during clavicle fracture nonunion repairs can present in a delayed fashion requiring more thorough clinical and imaging evaluation to achieve successful treatment.

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.

Lateral Thoracic Artery Pseudoaneurysm as a Result of Penetrating Chest Trauma

Pseudoaneurysms are potentially fatal complications of vascular trauma; however, they are rarely seen as the sole complication of penetrating injury. We present a case of a pseudoaneurysm with an associated arteriovenous fistula of the left lateral thoracic artery as a result of direct trauma from a knife stab. The patient presented only with a painful, swollen left pectoralis muscle. Upon diagnosis, he was taken to the interventional radiology suite and treated successfully with fluoroscopic guided coil embolization. Cases such as these are infrequent and should encourage more aggressive use of contrast enhanced computed tomography imaging for soft tissue injury, as a missed traumatic pseudoaneurysm may result in life-threatening hemorrhage.

Man with a forehead mass: detection of a forehead pseudoaneurysm with bedside ultrasonography

A vascular pseudoaneurysm can present similarly to an abscess; yet incision and drainage of a pseudoaneurysm can lead to uncontrolled bleeding and expose the patient to further morbidity. This is a case of a patient with a forehead pseudoaneurysm who presented to our emergency room after blunt head trauma. Here we review different diagnostic modalities as well as some of the treatment options that are described in the literature.

Percutaneous cyanoacrylate glue embolization for peripheral pseudoaneurysms: an alternative treatment

Post-traumatic pseudoaneurysms are rare in the peripheral arteries and usually occur as a late sequel of trauma. Surgery has traditionally been considered as the gold standard of therapy for traumatic peripheral pseudoaneurysms. We report 2 cases of post traumatic pseudoaneurysms successfully treated by percutaneous cyanoacrylate glue (N-Butyl 2 cyanoacrylate) embolization. This method offers complete exclusion of the pseudoaneurysm, at the same time avoiding the morbidity of open surgery.

Treatment for femoral pseudoaneurysms

BACKGROUND

Femoral pseudoaneurysms may complicate up to 8% of vascular interventional procedures. Small pseudoaneurysms can spontaneously clot, but sometimes definitive treatment is needed. Surgery has traditionally been considered the 'gold standard' treatment, although it is not without risk in patients with severe cardiovascular disease. Less invasive treatment options such as Duplex ultrasound-guided compression and percutaneous thrombin injection are available, however, evidence of their efficacy is limited. This is an update of a Cochrane review first published in 2006.

OBJECTIVES

To assess the effects of different treatments for femoral pseudoaneurysms resulting from endovascular procedures, specifically assessing less invasive treatment options such as blind manual or mechanical compression, ultrasound-guided compression, or percutaneous thrombin injection.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched October 2013) and CENTRAL (2013, Issue 9).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing two treatments for femoral pseudoaneurysms following vascular interventional procedures were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Four studies were included in the analyses comparing: manual compression versus ultrasound-guided compression; ultrasound-guided application of a mechanical device (FemoStop) versus blind application; and ultrasound-guided compression versus percutaneous thrombin injection (two studies). There were no studies with a surgical intervention arm. Data were extracted independently by both authors.

MAIN RESULTS

Compression (manual or FemoStop) was effective in achieving pseudoaneurysm thrombosis although ultrasound-guided application failed to confer any benefit (risk ratio (RR) 0.96; 95% confidence interval (CI) 0.88 to 1.04).Percutaneous thrombin injection was more effective than a single session of ultrasound-guided compression in achieving primary pseudoaneurysm thrombosis within individual RCTs but merged data failed to show statistical significance (RR 2.81; 95% CI 0.44 to 18.13). There was no statistically significant difference in the length of hospital stay between the two groups and no complications were reported apart from one deep vein thrombosis in the compression group.

AUTHORS' CONCLUSIONS

The limited evidence base appears to support the use of thrombin injection as an effective treatment for femoral pseudoaneurysm. A pragmatic approach may be to use compression (blind or ultrasound-guided) as first-line treatment, reserving thrombin injection for those in whom the compression procedure fails.

Results of a New Human Recombinant Thrombin for the Treatment of Arterial Pseudoaneurysm

Objective: To evaluate the results of a new thrombin sealant (Recothrom) for the treatment of arterial pseudoaneurysms (PDAs). Methods: We reviewed 47 consecutive patients prospectively entered in a dedicated data set who underwent ultrasound-guided percutaneous thrombin injection to treat PDA. End points were PDA recurrence, need for reintervention, and related complications such as limb ischemia or allergic reactions. Results: Twenty-six patients were females (55%) and the median age of the entire group was 71 years (range, 45-87). The mean size of the PDA was 2.3 ± 0.9 cm. The mean injected volume was 2.4 ± 1.4 mL containing 500 ± 320 units. Recurrence of the PDA occurred in 4 (8.5%) patients and was not related to anticoagulation status, body habitus, platelets levels, or use of antiplatelets. All recurred PDAs were successfully sealed with a second (n = 3) and a third injection (n = 1). There was no distal embolization or allergic reactions and no surgical intervention was required. Conclusion: The new human recombinant thrombin (Recothrom) is a safer nonimmunogenic option with similar success rates of other fibrin glue sealants.

Percutaneous ultrasound-guided thrombin injection of a post-traumatic pancreatic pseudoaneurysm in a pediatric patient

Non-operative management for blunt injuries to the proximal pancreas has become increasingly common. A bleeding pseudoaneurysm in the setting of a traumatic pancreatic pseudocyst presents a morbid operation. We present the case of a 15-year old with a grade V pancreatic injury that developed a bleeding pseudoaneurysm successfully treated with percutaneous ultrasound-guided thrombin injection.

Pseudoaneurysm of the superior medial genicular artery following knee arthroscopy

We describe a case of a pseudoaneurysm of the superior medial genicular artery following arthroscopic knee surgery, which was diagnosed by means of computed tomography and arterial duplex ultrasound. The treatment consisted of surgical exploration with excision of the pseudoaneurysm, followed by ligation of the feeding artery.

Management of pseudoaneurysm of the leg: is Color Doppler US enough?

The authors describe two clinical cases showing that Color Doppler Ultrasonography (US) examination is effective and sufficient in the presence of a clinical suspicion of pseudoaneurysm. In cases of iatrogenic damage and post-traumatic lesions, US provides an easy and accurate diagnosis depicting the location and the morphology of the false aneurysm. The patient can thus be referred to appropriate treatment without undergoing further diagnostic examinations. Moreover, regardless of the performed treatment, Color Doppler US is an efficient non-invasive diagnostic tool in the follow-up.