"To-and-fro" waveform in the diagnosis of arterial pseudoaneurysms

Acupuncture gone awry: surgical management of a popliteal artery pseudoaneurysm with concurrent abdominal aortic aneurysm

Popliteal artery pseudoaneurysms are rare, especially from acupuncture-related trauma. We report a 67-year-old male with hypertension, diabetes, chronic kidney disease, and an abdominal aortic aneurysm (AAA), who developed a popliteal pseudoaneurysm after acupuncture. Imaging confirmed the pseudoaneurysm and a 55 mm AAA. Urgent surgical repair with a Gore-Tex graft led to a smooth recovery. This case emphasizes the vascular risks of acupuncture and the importance of early diagnosis, multidisciplinary care, and personalized follow-up in patients with complex comorbidities.

Pseudoaneurysm formation following core needle biopsy in a patient diagnosed with breast cancer: A case report

Core needle biopsy is a common diagnostic procedure in breast cancer patients, but it can occasionally lead to serious complications. We report a rare case of pseudoaneurysm formation following a core needle biopsy in a 54-year-old female patient diagnosed with breast cancer. Despite the routine nature of the procedure, the patient developed a palpable mass at the biopsy site, which prompted further diagnostic imaging and interventions. The pseudoaneurysm was effectively treated using a percutaneous approach with ultrasound-guided thrombin injection, demonstrating a minimally invasive solution that promptly addressed the complication without the need for surgical intervention. This case highlights the critical importance of detecting complications early in the biopsy process, as they have significant implications for disease staging and treatment initiation. It also underscores the importance of being prepared for immediate intervention in case of biopsy-related complications like pseudoaneurysms, to prevent severe consequences.

Double Trouble: Pseudoaneurysm on Pseudoaneurysm

•A pseudoaneurysm is an outpouching of a vessel involving partial layers of the wall. •A secondary pseudoaneurysm forms directly off the primary pseudoaneurysm. •Ultrasound-guided visualization is the reference standard for imaging. •Thrombin injection is used to treat primary and secondary pseudoaneurysms.

Thoracic aortic pseudoaneurysm: Inside its pathophysiology

OBJECTIVES

Our aim was to investigate pathophysiology of pseudoaneurysm of the thoracic aorta, an acute or chronic pathology, respectively, secondary to blunt thoracic trauma and aortitis, or complicating a deep penetrating aortic ulcer, intraparietal hematoma, aortic aneurysm, and even aortic graft, often with atherosclerosis as a common background.

METHODS

Given the relative rarity of this disease, an "inductive" retrospective method made it possible to retrieve clinical, radiological, and histopathological elements, which were mutually compared and validated through a "deductive" process of reinterpretation.

RESULTS

We have identified three main structural constituents of this disease: a cavity, a single blood entry port, communicating with the aortic lumen, and a pseudocapsule. It is often caused by a chronic degenerative pathology of the intima and medial layers of the aorta, typically involving elastic fibers and smooth muscle cells, with possible intermediate stages of deep aortic ulcer or intraparietal hematoma. Otherwise, the acute onset may be secondary to acute aortitis or aortic injury.

CONCLUSIONS

Today, thanks to the current angiographic tools represented by 3-D high resolution multidetector CT and MRI angiography, the diagnosis of thoracic aortic pseudoaneurysm is easier, as well as its surgical indications.

Health-care Professionals' Perspectives on Ultrasound Evaluation of Arteriovenous Hemodialysis Fistula: A Narrative Review

Arteriovenous hemodialysis fistulas play a critical role in maintaining life on hemodialysis. With the growing use of Doppler ultrasound in nephrology, its utility has expanded to improve the prognosis and quality of life of patients receiving hemodialysis. On a fistula care team, different health-care professionals, including nephrologists, dialysis technicians, and surgeons or vascular interventionalists, require different information. This review article comprehensively explains how Doppler ultrasound evaluation can be beneficial in the management of arteriovenous fistulas from different perspectives of health-care professionals. The article also introduces the pathophysiology of arteriovenous fistula disease and provides a thorough introduction to the use of Doppler ultrasound for the evaluation of arteriovenous fistulas and their associated diseases, addressing the need for a comprehensive understanding among ultrasound practitioners.

Delayed Presentation of a Post-traumatic Suprascapular Artery Pseudoaneurysm

Thyrocervical trunk pseudoaneurysms are a rare entity among pseudoaneurysms, mostly caused by trauma. We present the case of a 74-year-old male who suffered a traumatic pseudoaneurysm of the supra-scapular artery after a rib and scapular fracture. The patient was treated with various interventions along the treatment algorithm, including ultrasound-guided thrombin injection, coil embolization, and surgical excision. In our patient, the pseudoaneurysm was successfully treated with coil embolization, but a persistent thrombosed pseudoaneurysm caused the patient discomfort, prompting the eventual surgical removal. This case is unique as it enlightens the step-wise approach to managing thyrocervical trunk pseudoaneurysm.

Delayed Life-Threatening Hemorrhage Caused by Cranial Tibial Artery Pseudoaneurysm in Two Dogs

Two adult dogs were presented at 25 and 30 days following tibial external skeletal fixator placement (case 1) and tibial plateau leveling osteotomy (case 2), respectively. Clinical signs at presentation for each of them included acute onset lethargy, non-weight-bearing lameness, and hemorrhage at the surgical site with large hematoma formation. On admission, emergency whole blood transfusion was required in case 2 with a preoperative packed cell volume of 13%. Both dogs were diagnosed with pseudoaneurysm of the cranial tibial artery based on color Doppler ultrasonography. Additionally, computed tomography angiography was performed in one dog. Surgical treatment of the dogs included ligation of the cranial tibial artery supplying the pseudoaneurysm and curettage of hematoma. The surgery was completed without complications in case 1, but case 2 experienced inadvertent rupture of pseudoaneurysm with significant blood loss, which required another whole blood transfusion during the procedure. Both dogs had excellent functional recovery with no recurrence of clinical signs. We hypothesized that pseudoaneurysms were primarily caused by trauma secondary to placement of surgical implants or osteotomy. For orthopedic surgeons, it is important to recognize clinical signs of a potential tibial arterial pseudoaneurysm, as early surgical intervention may prevent loss of limb or life.

Inflammatory Markers Involved in the Pathogenesis of Dupuytren's Contracture

Dupuytren's disease is a common fibroproliferative disease that can result in debilitating hand deformities. Partial correction and return of deformity are common with surgical or clinical treatments at present. While current treatments are limited to local procedures for relatively late effects of the disease, the pathophysiology of this connective tissue disorder is associated with both local and systemic processes (e.g., fibrosis, inflammation). Hence, a better understanding of the systemic circulation of Dupuytren related cytokines and growth factors may provide important insights into disease progression. In addition, systemic biomarker analysis could yield new concepts for treatments of Dupuytren that attenuate circulatory factors (e.g., anti-inflammatory agents, neutralizing antibodies). Progress in the development of any disease modifying biologic treatment for Dupuytren has been hampered by the lack of clinically useful biomarkers. The characterization of nonsurgical Dupuytren biomarkers will permit disease staging from diagnostic and prognostic perspectives, as well as allows evaluation of biologic responses to treatment. Identification of such markers may transcend their use in Dupuytren treatment, because fibrotic biological processes fundamental to Dupuytren are relevant to fibrosis in many other connective tissues and organs with collagen-based tissue compartments. There is a wide range of potential Dupuytren biomarker categories that could be informative, including disease determinants linked to genetics, collagen metabolism, as well as immunity and inflammation (e.g., cytokines, chemokines). This narrative review provides a broad overview of previous studies and emphasizes the importance of inflammatory mediators as candidate circulating biomarkers for monitoring Dupuytren's disease.

Traumatic Anterior Tibial Artery Pseudoaneurysm: A Case Report

Introduction

Traumatic pseudoaneurysms of the limbs are rare, with few cases described in vascular literature. Treatment is variable and dependent upon presentation and impact on local anatomy affected. Rapid assessment can be performed with ultrasound and assist in treatment decisions. We describe a case of traumatic anterior tibial artery pseudoaneurysm, which was rapidly identified with point-of-care ultrasound leading to definitive surgical management.

Case Report

A 37-year-old female presented to the emergency department for evaluation of right lower extremity pain and swelling following an exercise session with weighted squats and thigh abductor machines. She was found to have an anterior tibial artery pseudoaneurysm on point-of-care ultrasound, later confirmed with formal ultrasound as well as angiography, and was admitted for surgical management.

Conclusion

Traumatic pseudoaneurysms can rapidly be differentiated from other mass lesions and contributors to compartment syndrome using point-of-care ultrasound.

Evaluation of Soft-Tissue Hematomas With Real-Time, Contrast-Enhanced Ultrasound: A Pilot Study With Preliminary Findings

ABSTRACT

In this study, we investigated the feasibility of using contrast-enhanced ultrasound (CEUS) to detect active hemorrhage in patients presenting with soft-tissue hematomas. Adult patients with clinically suspected, actively bleeding hematomas were prospectively enrolled. Contrast-enhanced ultrasound was used to assess for contrast extravasation. Ultrasound results were compared with those of multidetector computed tomographic (MDCT) imaging, operative findings, and clinical course. Sixteen patients (9 women, 7 men; mean age, 69 [SD, 13] years) were enrolled. Thirteen patients underwent MDCT imaging during their initial visit, and for 11, CEUS and computed tomography (CT) findings were concordant. The remaining patients had a negative CEUS study that was consistent with their clinical course. In 8 patients, CT imaging showed active extravasation (6 arterial, 1 indeterminate, 1 slow venous). Contrast-enhanced ultrasound and CT findings were concordant for all cases of arterial bleeding. For 1 patient, CEUS provided superior diagnostic information by identifying a pseudoaneurysm. The 2 discrepant patient cases had a ≥3-hour delay between CT and CEUS, and in 1 patient, CEUS was limited by body habitus. The second patient had no active bleeding identified in the operating room. Compared with CT, CEUS had a sensitivity and specificity of 75% and 100%, respectively, and positive and negative predictive values were 100% and 71%, respectively. Diagnostic accuracy was 85% in this limited study. Contrast-enhanced ultrasound is a promising alternative to MDCT in select patients and may sometimes provide superior clinical information. Limiting factors are large hematoma size, unfavorable anatomic location, and body habitus.

Ultrasound Assessment of Postprocedural Arterial Pseudoaneurysms: Techniques, Clinical Implications, and Emergency Department Integration

This narrative aims to evaluate the efficacy of point-of-care ultrasound (POCUS) in the early diagnosis and management of postprocedural arterial pseudoaneurysms in the emergency department (ED). We hypothesize that POCUS can be used as the first line of imaging to distinguish vascular from non-vascular causes and diagnose a pseudoaneurysm if present. A comprehensive review of cases involving postprocedural pseudoaneurysms was conducted. We focus on patients who underwent endovascular procedures, including transfemoral and transradial arterial access for cardiac interventions, or received laceration repair after blunt head trauma. We analyzed each case's clinical symptoms, POCUS findings, and subsequent management. POCUS demonstrated high efficacy in early diagnosis by detecting pseudoaneurysm sacs with characteristic bi-directional flows (yin-yang sign) and, in some cases, partial thrombosis. The early identification of potential arterial complications allowed for efficient planning of further imaging and expedited surgical consultation, leading to timely and definitive management. Our study emphasizes the significance of using POCUS as the primary imaging modality for early detection and diagnosis of postprocedural arterial pseudoaneurysms. Incorporating POCUS into the initial assessment of patients presenting with pain and swelling at the site of arterial access or laceration repair can streamline consultation and potentially reduce the need for additional imaging, optimizing patient care in the ED setting.

Subclavian Artery Pseudoaneurysm in an Eight-Year-Old Boy: A Rare Case Report and Review of Literature

Pseudoaneurysms, also known as fake aneurysms, are balloon-like bulges that develop in the arteries and veins. This can happen due to injury, surgery, infection, or other conditions that damage blood vessels. Pseudoaneurysms are usually asymptomatic but can bleed and be painful. Left untreated, they can lead to severe complications such as thrombus formation and distant embolization. Subclavian pseudoaneurysms are rare, which can lead to potentially life-threatening complications of traumatic or iatrogenic injuries to the subclavian artery, such as catheterization. Prompt diagnosis and management are essential to avoid devastating outcomes. We report the case of a pediatric patient who developed a subclavian pseudoaneurysm after neck trauma and was successfully treated with endovascular embolization. This case highlights the importance of timely management and vigilant monitoring for this rare but potentially life-threatening condition.

Multimodality ultrasound assessment of the spleen: Normal appearances and emergency abnormalities

This paper summarizes the main splenic emergencies and their ultrasonographic findings to orient appropriate patient management. US requires minimal preparation time and allows to examine the parenchyma and to detect intraperitoneal fluid collections, which may be indirect evidence of solid organ injuries. In this paper, we analyze the role of B-mode, Doppler and Contrast-Enhanced Ultrasound in the diagnosis of splenic emergencies, with a particular focus on splenic infarction, infection, traumatic injuries and vascular splenic anomalies.

Transesophageal Echocardiography Guidance for Percutaneous Closure of Ascending Aortic Pseudoaneurysm

• Percutaneous closure of ascending aortic pseudoaneurysms is feasible in selected patients. • Procedural planning with multimodality imaging and multidisciplinary discussion is key. • TEE can be instrumental for intraprocedural guidance. • TEE guidance minimizes the amount of iodinated contrast and ionizing radiation used.

Left Gastric Artery Pseudoaneurysm Complicating Chronic Calcifying Pancreatitis in a Child

A left gastric artery pseudoaneurysm is a rare complication of pancreatitis and is associated with significant morbidity and mortality. We report a 14-year-old male with severe abdominal pain and a palpable upper abdominal mass, earlier diagnosed as chronic idiopathic calcifying pancreatitis, and awaiting surgical intervention. Computed tomography showed a pseudocyst and a pseudoaneurysm in the lesser sac near the left gastric artery. The patient underwent successful angiographic coiling of the left gastric artery and definitive pancreatic surgery weeks thereafter. The early detection and interventional radiologic management of the vascular complication averted a life-threatening hemorrhage without emergency surgery in a pediatric patient.

Imaging surveillance for complications after primary surgery for type A aortic dissection

Acute type A aortic dissection (ATAAD) is a life-threatening condition that requires emergency surgery to avert fatal outcome. Conventional surgical procedures comprise excision of the entry tear and replacement of the proximal aorta with a synthetic vascular graft. In patients with DeBakey type I dissection, this approach leaves a chronically dissected distal aorta, putting them at risk for progressive dilatation, dissection propagation and aortic rupture. Therefore, ATAAD survivors should undergo serial imaging for evaluation of the aortic valve, proximal and distal anastomoses, and the aortic segments beyond the distal anastomosis. The current narrative review aims to describe potential complications in the early and late phases after ATAAD surgery, with focus on their specific imaging findings.

Spontaneous resolution of superficial temporal artery pseudoaneurysm

Superficial temporal artery (STA) pseudoaneurysms are rare vascular lesions that typically present after traumatic head injury. Currently, surgery is the recommended treatment as spontaneous resolution has not been previously reported. Our study aims to present a review of the literature on STA pseudoaneurysms and report a case of spontaneous resolution of a traumatic STA pseudoaneurysm without the need for direct intervention.

Uterine Artery Pseudoaneurysm after an Uncomplicated Vaginal Delivery: A Case Report

Uterine artery pseudoaneurysm (UAP) is a rare and potentially life-threatening vascular anomaly caused by inadequate sealing of a ruptured wall of a uterine artery. It mainly occurs after a traumatic lesion and can lead to delayed postpartum hemorrhage. We report a rare case of UAP after an uncomplicated vaginal delivery in a patient with a history of deep-infiltrating endometriosis. Selective coil embolization was successfully performed. UAPs should always be considered in cases of unexplained abdominal pain after surgery or childbirth with or without vaginal bleeding.

Spontaneous external jugular vein pseudoaneurysm: A rare cause of neck swelling

Pseudoaneurysm of the external jugular vein is a relatively unusual cause of a neck mass caused by the low pressure venous system. Regardless of etiology, spontaneous pseudoaneurysms are extremely rare, and only few cases have been described in literature. They require surgery; however, most patients can be safely discharged with close follow-up with a vascular surgeon. This case demonstrates a 30-year-old man who presented with a non-tender, compressible, left-sided neck mass that enlarged with Valsalva, and intermittent paresthesias. Ultrasound confirmed a cystic mass of unknown etiology containing doppler flow suggesting the diagnosis of an external jugular vein pseudoaneurysm, confirmed by a CT angiogrphy. The patient refused the surgery, and we agreed he was safe for discharge at that time and could follow up with vascular surgery as an outpatient.

Imaging Features of Soft Tissue Tumor Mimickers: A Pictorial Essay

Soft tissue lesions are commonly encountered and imaging is an important diagnostic step in the diagnosis and management of these lesions. While some of these lesions are true neoplasms, others are not. These soft tissue tumor mimickers can be due to a variety of conditions including traumatic, iatrogenic, inflammatory/reactive, infection, vascular, and variant anatomy. It is important for the radiologist and clinician to be aware of these common soft tissue tumor mimickers and their characteristic imaging features to avoid unnecessary workup and provide the best treatment outcome.

Single ultrasound-guided local high-dose thrombin injection in the treatment of giant brachial artery pseudoaneurysm: A case report

RATIONALE

Pseudoaneurysm (PSA) is a common complication related to vascular intervention, and surgical therapy is the primary method. However, a giant brachial artery PSA over 2 weeks is rarely observed. Due to the adhesion of surrounding tissue, thrombus organization, the extensive injury, and the high expense of transluminal stent-graft placement, a single ultrasound-guided local high-dose thrombin injection can be a therapy option. Such cases are rarely reported.

PATIENT CONCERNS

A 71-year-old man with a history of left elbow fossa interventional puncture presented to our hospital with a pulsatile mass in the left elbow fossa. He had a history of cerebral infarction 32 years prior without sequelae, emphysema for more than 2 years, hyperlipidemia for 3 months, and prostatic hyperplasia for 8 months. After conservative therapy, the lumbar compression fracture produced by trauma 24 years ago healed, and the intracranial hematoma induced by trauma ten years ago was absorbed.

DIAGNOSIS

Ultrasound examination showed giant mixed echoes on the posterior medial side of the left brachial artery.

INTERVENTIONS

The patient underwent a single ultrasound-guided local high-dose thrombin injection to treat giant brachial artery PSA.

OUTCOMES

Following therapy, the ultrasonography revealed that extensive thrombosis immediately formed in the cavity, and the internal blood flow signals had completely vanished. A week later, a physical examination showed that the PSA had shrunk with no apparent tenderness and that the texture had hardened. Pulsation and vascular murmurs disappeared. Ultrasound showed that the PSA was reduced, and no blood flow signals were found.

LESSONS

A single ultrasound-guided local high-dose thrombin injection had a considerable effect in curing large iatrogenic PSA. However, when deciding on the best therapy, specificity must be taken into account.

Spontaneous internal carotid artery pseudoaneurysm complicated with ischemic stroke in a young man: A case report and review of literature

BACKGROUND

Carotid artery pseudoaneurysm (PSA) is infrequently encountered in clinical settings. Internal carotid artery (ICA) PSA complicated with ischemic stroke is rare. PSAs are typically caused by iatrogenic injury, trauma, or infection. The underlying mechanisms of spontaneous PSA formation are not well characterized. We report a healthy young man who presented with stroke as a complication of spontaneous PSA of the left ICA.

CASE SUMMARY

A 30-year-old man working as a ceiling decoration worker was hospitalized due to sudden-onset speech disorder and right lower extremity weakness. Medical history was unremarkable. Brain computed tomography revealed ischemic stroke. Digital subtraction angiography showed a left ICA PSA with mild stenosis. The patient was conservatively managed with oral anticoagulation and antiplatelet therapy. He recovered well and was discharged. The patient was in good condition during follow-up.

CONCLUSION

The occupational history of patient should be taken into consideration while evaluating the etiology of spontaneous ICA PSA in young people with stroke.

A Pseudoaneurysm of the Inferior Lateral Geniculate Artery Following Total Knee Arthroplasty

Vascular complications after total knee arthroplasty are rare. We present a case of an inferior lateral geniculate artery pseudoaneurysm which became symptomatic 10 days after total knee arthroplasty in a patient with a cardiac comorbidity and using dabigatran. The pseudoaneurysm was most likely caused by iatrogenic injury during surgery. Fourteen days after the index surgery, the patient was seen with a painful but normal post-total knee arthroplasty effused knee, with a maximum flexion angle of 80 degrees. No signs of infection, hemarthrosis, or neurovascular deficit were present. Radiographic imaging included ultrasonography and computed tomography angiography. The pseudoaneurysm was successfully treated with coil embolization. The etiology, presentation, diagnosis, and treatment of a geniculate artery pseudoaneurysm are discussed in this case report.

Circumflex Scapular Artery Pseudoaneurysm as an Unusual Source of Emboli in Recurrent Posterior Circulation Stroke

OBJECTIVE

To present a rare cause of recurrent posterior embolic strokes originating from a partially thrombosed pseudoaneurysm of a shoulder artery after arthroscopy.

MATERIALS AND METHODS

The clinical history, complementary studies and follow-up were reviewed.

RESULTS

The patient was successfully embolized and presented no new ischemic episodes at the 3-month follow-up visit.

CONCLUSIONS

Shoulder artery pseudoaneurysm should be considered as an unusual source of posterior embolic strokes.

Ultrasound-Guided Compression Method Effectively Counteracts Russell's Viper Bite-Induced Pseudoaneurysm

Russell's viper (Daboia russelii), one of the 'Big Four' venomous snakes in India, is responsible for the majority of snakebite-induced deaths and permanent disabilities. Russell's viper bites are known to induce bleeding/clotting abnormalities, as well as myotoxic, nephrotoxic, cytotoxic and neurotoxic envenomation effects. In addition, they have been reported to induce rare envenomation effects such as priapism, sialolithiasis and splenic rupture. However, Russell's viper bite-induced pseudoaneurysm (PA) has not been previously reported. PA or false aneurysm is a rare phenomenon that occurs in arteries following traumatic injuries including some animal bites, and it can become a life-threatening condition if not treated promptly. Here, we document two clinical cases of Russell's viper bites where PA has developed, despite antivenom treatment. Notably, a non-surgical procedure, ultrasound-guided compression (USGC), either alone, or in combination with thrombin was effectively used in both the cases to treat the PA. Following this procedure and additional measures, the patients made complete recoveries without the recurrence of PA which were confirmed by subsequent examination and ultrasound scans. These data demonstrate the development of PA as a rare complication following Russell's viper bites and the effective use of a simple, non-surgical procedure, USGC for the successful treatment of PA. These results will create awareness among healthcare professionals on the development of PA and the use of USGC in snakebite victims following bites from Russell's vipers, as well as other viper bites.

Ultrasound Imaging of Acquired Myometrial Pseudoaneurysm: The Role of Manipulators as an Unusual Cause during Laparoscopic Surgery

An acquired uterine artery myometrial pseudoaneurysm can occur due to inflammation, trauma, or iatrogenic causes, such as surgical procedures, and can lead to profuse bleeding. The efficacy of uterine manipulators in gynecological surgery, particularly as a cause of a pseudoaneurysm, has been poorly discussed in the literature. In this paper, we discuss a case of a 39-year-old woman with profuse uterine bleeding that occurred seven days after operative laparoscopic surgery for endometriosis. The color Doppler ultrasound better evoked the arterial-like turbulent blood flow inside this cavity. These sonographic features were highly suggestive of uterine artery pseudoaneurysm, presumably related to a secondary trauma caused by the manipulator. The diagnosis was subsequently re-confirmed by angiography, and the patient was treated conservatively with uterine artery embolization. Ultrasound has been shown to be a valuable and safe tool for imaging pseudoaneurysm and guiding subsequent interventional procedures. Accordingly, we briefly review the most suitable manipulators used in benign gynecological surgeries to verify if the different types in use can guide the surgeon towards the correct choice according to surgical needs and thus prevent potentially dangerous trauma.

Left Gastric Artery Pseudoaneurysm Due to Pancreatitis

Acute or chronic pancreatitis can cause pseudoaneurysms of visceral arteries. The left gastric artery (LGA) is the least common visceral artery being affected. Here, we report a case of chronic pancreatitis with a pseudoaneurysm of the LGA. A 42-year-old male, a chronic alcoholic, and smoker, presented with abdominal pain, haematemesis, and melena. Diagnosis of pseudoaneurysm of LGA aneurysm was confirmed by computed tomography abdomen. The endovascular coil embolization was done successfully, following which the patient had an uneventful recovery.

Iatrogenic vascular trauma and complications of vascular access in children

Vascular access is frequently a critical component of the diagnostic and therapeutic procedures required to manage childhood illnesses, including many emergent conditions and critical illnesses. Vascular access in the pediatric population presents unique challenges, and many clinical and technical factors must be considered to avoid complications that can occur with vascular access procedures. This article reviews various aspects of vascular access and associated iatrogenic trauma in children, including risk factors, management of complications, and preventive measures to avoid complications. It is only with a comprehensive understanding of the topic that vascular access in children can be performed safely, effectively, and efficiently.

Uterine artery pseudoaneurysm after treatment of cesarean scar pregnancy: a case report

BACKGROUND

Pseudoaneurysms are formed when a local arterial wall ruptures, leading to hemorrhage and hematoma adjacent to the artery. Continuous perfusion of the injured artery increases the pressure in the lumen of the pseudoaneurysm. It may rupture and lead to massive hemorrhage that could be life-threatening. Cesarean scar pregnancy (CSP) is an ectopic pregnancy where the gestational sac is implanted in the cesarean scar. Uterine artery pseudoaneurysm (UAP) after CSP treatment is rare.

CASE PRESENTATION

We report the case of a 36-year-old Chinese woman who presented with acute massive vaginal bleeding 53 days after transabdominal scar pregnancy excision. Doppler ultrasound confirmed UAP. Selective uterine artery embolization (UAE) failed because of the thin and curved blood vessels. The lesion decreased in size after transvaginal ultrasound-guided direct thrombin injection (UGTI); however, massive vaginal bleeding recurred and endangered the patient's life. The uterus was removed thereafter.

CONCLUSIONS

UAP is a rare complication after CSP treatment that can lead to fatal massive hemorrhage. Ultrasound should be reexamined regularly after treatment of CSP. In case of unexplained vaginal bleeding, we should be alert to the existence of UAP and the possibility of rupture and take effective diagnosis and treatment measures promptly.

Pseudoaneurysm within a desmoid tumor in an extremity: report of 2 cases

Desmoid tumor is considered a benign neoplasm, yet substantial morbidity can result from local invasion of structures adjacent to the tumor or from complications related to its treatment. We report two patients with extremity desmoid tumor who were each found at MRI to have an unsuspected pseudoaneurysm within their tumor after prior treatments (surgery and systemic therapy in one, surgery alone in the other). Such a pseudoaneurysm probably results from weakening of an arterial wall by adjacent desmoid tumor, as well as from local trauma. Due to the potential risk for life-threatening rupture of a pseudoaneurysm, one patient underwent surgical repair and the other, coil embolization. To our knowledge the presence of pseudoaneurysm has been reported within a few cases of abdominal desmoid tumor but not within an extremity desmoid tumor. This diagnosis has not been reported to have been made at MRI, either.

Endovascular management of a large renal artery aneurysm: a case report and review of the literature

Background

A renal artery aneurysm is a rare clinical presentation that can be found incidentally on imaging or during workup for refractory hypertension. Its presentation can be similar to that of a renal artery pseudoaneurysm, but the etiologies of the two vascular lesions differ. We present a patient who had an incidental finding of a large renal artery aneurysm that was managed with endovascular embolization. We also describe the literature surrounding the etiology, presentation and management of both renal artery aneurysms and renal artery pseudoaneurysms.

Case presentation

A 62-year-old man was referred to a urologic oncologist for workup of a newly found renal mass. Initial imaging with computed tomography showed a homogenous, well-circumscribed mass arising from the right kidney. Further evaluation with Doppler ultrasonography demonstrated pulsatile flow within the renal mass that was concerning for a renal artery pseudoaneurysm. The patient initially underwent a diagnostic angiogram by interventional radiology and was found to have a true renal artery aneurysm. Interventional radiology considered placement of a covered stent or angioembolization, but treatment was deferred due to concern for compromising the patient’s renal function. Patient was subsequently transferred to a neighboring hospital for management by vascular surgery. After considering both open surgical and endovascular approaches, the patient ultimately underwent angioembolization of the renal artery aneurysm. Short-term follow-up showed successful exclusion of the aneurysm with minimal adverse effects to the patient.

Conclusions

Our case report documents a unique case of an incidentally found large renal artery aneurysm that was successfully managed with endovascular embolization. Renal artery aneurysms and renal artery pseudoaneurysms, which can present similarly on imaging, are important diagnostic considerations in a patient presenting with a new renal mass. While open surgical approaches can be used to repair aneurysms, endovascular approaches using stenting or angioembolization are safe and effective options for treating renal aneurysms and renal pseudoaneurysms.

"Signs and Symptoms Tell All"-Pseudoaneurysm as a Cause of Postoperative Bleeding after Orthognathic Surgery-Report of a Case and a Systematic Review of Literature

PURPOSE

Pseudoaneurysms are one of the rare complications that can be encountered after the orthognathic surgery. We are presenting a new case of pseudoaneurysm of bilateral sphenopalatine artery after Bijaw Surgery in a young male and a systematic review of all the cases in the literature emphasizing on signs and symptoms, epistaxis or bleeding episodes and treatment outcomes.

METHODS

A systematic research strategy was planned according to the PRISMA guidelines, and articles were taken from 1986 to September, 2019. A total of 899 articles were selected for screening, out of which only 26 articles met our inclusion and exclusion criteria. These were included in the study for qualitative analysis.

RESULTS

Most PAs were associated with Lefort I osteotomy (69.7%), followed by sagittal split osteotomy (24.24%). Average intraoperative blood was 635 ml. Maximum number of episodes of epistaxis/swelling or bleeding occurred in second week. Mean bleeding episodes were 2.58 ± 0.996. The arteries commonly affected were internal maxillary artery (42%), sphenopalatine artery (27.27%), facial artery (15.15%), descending palatine artery (12.12%), internal carotid artery (9.09%) and infraorbital artery (3.03%). Embolization was treatment of choice in 81.81% cases.

CONCLUSION

If a patient has recurrent epistaxis or swelling after orthognathic surgery, it is advisable to go for diagnostic imaging like angiography without any delay. In recent times, advanced techniques and expertise are readily available for early diagnosis and management of pseudoaneurysm.

External carotid artery pseudoaneurysm with arteriovenous fistula: A rare complication of glass shrapnel injury

Posttraumatic external carotid artery pseudoaneurysm with arteriovenous fistula is a rare condition. An 8-year-old child presented with painful pulsatile swelling in the preauricular region following a penetrating glass shrapnel injury. Detailed evaluation showed distal external carotid artery pseudoaneurysm with fistula, which was draining into the retromandibular vein. Endovascular treatment was performed. This case highlights the role of endovascular intervention for such rare complicated vascular pathologies.

Endovascular management of episiotomy site hematoma: Two cases and a brief review

Episiotomy site hematoma, though uncommon, can be associated with serious maternal morbidity. It arises mostly due to tissue trauma or injury to blood vessels, leading to the formation of a pseudoaneurysm. Sometimes, when surgical management fails, embolization of the bleeding vessel is a lifesaving option. Here, we report two cases of episiotomy site hematoma that required selective arterial embolization for management, following the failure of surgical management. A 28-year-old G6A5 woman underwent forceps delivery following which she developed a 6*6-cm right-sided vulvovaginal hematoma at the episiotomy site. After failed surgical management, arterial embolization was performed and hemostasis was achieved. A 26-year-old P2L2 woman with a history of surgical exploration for episiotomy site hematoma, presented postdelivery on postpartum day seven with profuse vaginal bleeding. Her computed tomography angiogram revealed a pseudoaneurysm of around 2.1*1 cm in length with a vaginal hematoma of 4*5 cm. Selective artery embolization performed and complete hemostasis was achieved with no complications. Selective arterial embolization is a safe therapeutic option for episiotomy site hematoma, especially if surgical management fails.

Giant Celiac Artery Pseudoaneurysm in a Case of Chronic Pancreatitis: A Rare Case Report With Literature Review

Pancreatic pseudoaneurysms though uncommon can result in life-threatening spontaneous acute gastrointestinal or intraperitoneal hemorrhage. Celiac artery pseudoaneurysm in a background of chronic pancreatitis is a very rare event. Digital Subtraction Angiography is an important adjunct in the diagnosis and follow-up with the advantage of providing therapeutic options along with giving other details regarding the site, size, and flow characteristics. It has replaced emergency surgical procedures with the added advantage of fewer postoperative complications and lower morbidity and mortality. An urgent surgical intervention remains the only option when such endovascular management fails, not feasible, or is unavailable. Surgical options include proximal arterial ligation or a pancreatic resection, depending on the location of the pseudoaneurysm. We report a case of a 35-year-old gentleman, a known patient of chronic pancreatitis, who presented to our emergency with clinical features of hypovolemic shock and was diagnosed to have celiac artery pseudoaneurysm. Following a failed endovascular coiling, he was successfully managed with operative celiac artery ligation.

Pseudo aneurysm of the uterine artery with arteriovenous fistula after cesarean section: A rare but sinister cause of delayed postpartum hemorrhage

Pseudoaneurysm of the uterine artery is a rare complication of cesarean section. Delayed diagnosis and management may result in rapid and catastrophic postpartum hemorrhage and may necessitate hysterectomy or can even be fatal. A 28-year-old woman (gravida I, para I) presented with delayed postpartum hemorrhage 10 days after emergency cesarean section. Using transabdominal and transvaginal Color Doppler sonography, we detected a pseudoaneurysm in the posterior uterine wall, which was successfully treated with selective embolization distal and proximal to the lesion with platinum coils. In patients with delayed postpartum hemorrhage-especially after cesarean section-the rare possibility of uterine artery pseudoaneurysm must be kept in mind.

Delayed Refractory Urethrorrhagia Secondary to Traumatic Pseudoaneurysm of Bulbourethral Artery Managed by Superselective Coil Embolization

Background: Delayed persistent urethral hemorrhage caused by pseudoaneurysm of bulbourethral artery after straddle injury is a rare event. In this case report, we underline the cause, diagnostic methods, and image-guided treatment modality of straddle injury-induced symptomatic pseudoaneurysm of bulbourethral artery. Case Presentation: A 44-year-old Indian man, with history of straddle injury, was managed conservatively with per urethral Foley catheter placement. He had an uneventful initial period. One week after the injury, he complained of recurrent episodes of gross urethrorrhagia, which failed to resolve with conservative management. On further evaluation, he was found to have a pseudoaneurysm of bulbourethral artery, which was effectively managed by superselective intra-arterial coiling. Prompt diagnosis and timely management by superselective coiling helped in achieving desirable outcome without any undue complication of the injury and procedure. Conclusion: We report the largest pseudoaneurysm poststraddle injury reported till date. Considering its rarity, the desired diagnostic and treatment protocol has been highlighted. Using novel superselective angioembolization technique, adequate and permanent relief from symptoms and complications was achieved.

Traumatic Pseudoaneurysm of Anterior Tibial Artery Treated by Thrombin Injection

Traumatic pseudoaneurysm of limb arteries are relatively rare. A 70-year-old gentleman, with history of mechanical aortic valve implantation on warfarin, presented to the emergency department with pain and swelling in the right leg. He had sustained blunt injury to the leg, a week prior to presentation. On examination, the lateral compartment of the leg was swollen, ecchymotic, and tense. Distal pulses were well palpable. An ultrasound Doppler evaluation revealed a large intramuscular hematoma in the lateral compartment with a pseudoaneurysm of a muscular branch of the anterior tibial artery. An ultrasound-guided compression of the pseudoaneurysm was initially attempted for 24 hours, which failed in closing off the pseudoaneurysm. He was subsequently taken up for thrombin injection into the pseudoaneurysm, which resulted in instant thrombosis of the pseudoaneurysm, with an uneventful clinical course thereafter. Thrombin injection is an effective and safe modality to treat pseudoaneurysms of limb arteries.

Management of Brachial Artery Pseudoaneurysms in Intravenous Drug Abusers

Objective To determine the outcomes of the ligation and excision of brachial artery pseudoaneurysm in IV drug abusers without revascularization.  Methodology This retrospective observational study was conducted at the vascular surgery department Shaheed Muhtarma Benazir Bhutto trauma center Karachi from January 2019 to June 2020. All the patients with a history of intravenous drug abuse presented with pulsatile mass at or near cubital fossa, diagnosed as pseudoaneurysm, age ranging from 18-70 years, and of either gender were included in the study. Patients with pseudo-aneurysm secondary to trauma, hemodialysis, arteriovenous fistula, location other than cubital fossa, and whom primary revascularization was performed were excluded. The recorded data entered and analyzed using SPSS 20.0 (IBM Corp., Armonk, NY). Results A total of 20 intravenous drug addicts were included in the study. The mean age was of 31.10 ± 7.80 years, and the mean duration of addiction was 2.24 ± 1.16 years. The right arm is affected in almost two-thirds of patients. The most common presentation in the emergency department was ruptured pseudo-aneurysm with bleeding (65%), followed by oozing with pulsatile mass (30%), and infected pulsatile mass (5%). The outcome was Limb salvage (100%), and none of the patients had developed threatened ischemia of the arm or required amputation. Conclusion The ligation and excision of the pseudo-aneurysm, without revascularization, is a safe and effective treatment option for the management of pseudoaneurysm of the brachial artery secondary to intravenous drug addiction.

Traumatic Radial Artery Pseudoaneurysm: Vein Graft Repair through a Single Incision

Radial artery pseudoaneurysms are rare clinical entities usually occurring after penetrating trauma or iatrogenic injury. The radial artery is the least common location for peripheral artery pseudoaneurysms, and no clear standard of treatment exists. We present a case of an adolescent male who developed a radial artery pseudoaneurysm after slitting his wrists. Using a single incision, the radial artery pseudoaneurysm was excised and repaired using a reversed venae comitantes interposition graft. This single incision technique for radial artery pseudoaneurysm repair preserves the dual arterial supply to the hand, which is of particular importance in young patients.

Emergency Point-of-Care Ultrasound Diagnosis of a Femoral Artery Pseudoaneurysm

BACKGROUND

Iatrogenic femoral artery pseudoaneurysm formation after intervention of the femoral artery may present weeks after intervention. We report a case of a patient with delayed pseudoaneurysm diagnosis that was ultimately diagnosed with bedside ultrasound. Importantly, our case demonstrates a patient who had a left-sided atherectomy and angioplasty with microcatheter access of the right femoral artery.

CASE REPORT

A 68-year-old man with multiple comorbidities presented to the Emergency Department (ED) with right inguinal pain, swelling, and overlying skin changes 17 days after an interventional radiology-guided left-sided femoral artery atherectomy and angioplasty. His first postoperative ED visit at an outside hospital led to the diagnosis of a hematoma vs. abscess, with attempted bedside drainage. On presentation to our ED, a bedside ultrasound confirmed arterial pseudoaneurysm formation of the right femoral artery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In patients presenting with the constellation of symptoms after arterial site intervention of either side, iatrogenic pseudoaneurysm should be in the differential. Although the patient had atherectomy and angioplasty of the left femoral artery, it is important to highlight that both femoral arteries were accessed during intervention, and thus, both sites are at risk for pseudoaneurysm formation. Emergency sonography can be a useful tool to diagnose, expedite treatment, and avoid potentially harmful invasive procedures in patients presenting with pain and swelling after arterial site intervention.

An Unusual Volar Wrist Mass: Radial Artery Pseudoaneurysm Following Transradial Catheterization

Arterial pseudoaneurysms can develop secondary to a vessel injury, for example, an arterial line installation. We present a case of an 18-year-old female with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes syndrome who developed left radial artery and right brachial artery pseudoaneurysms secondary to arterial line placement and repeated blood draws, respectively. The ultrasonographic features of pulsating mass in connection with an artery and the yin-yang sign, combined with the patient's history, allowed accurate diagnosis. She was referred to vascular surgery for definitive treatment.

Multimodality imaging of pancreas-kidney transplants

Simultaneous pancreas-kidney transplant remains a treatment option for patients with insulin-dependent diabetes mellitus type 1, aimed at restoring normoglycemia, alleviating insulin dependency, avoiding diabetic nephropathy, and thereby improving the quality of life. Imaging remains critical in the assessment of these transplant grafts. Ultrasound with Doppler remains the primary imaging modality for establishing baseline assessment of the graft as well as for evaluating vascular, parenchymal, and perigraft complications. Noncontrast MR imaging is preferred over non-contrast CT for evaluation of parenchymal or perigraft complications in patients with decreased renal function, although contrast-enhanced CT/MR imaging may be obtained following multidisciplinary consultation in cases with high clinical and laboratory suspicion for graft dysfunction. Catheter angiography is reserved primarily for therapeutic intervention in suspected or confirmed vascular complications. An understanding of the surgical techniques and imaging appearance of a normal graft is crucial to identify potential complications and direct timely management. This article provides an overview of surgical techniques, normal imaging appearance, as well as the spectrum of imaging findings and potential complications in pancreas-kidney transplants.

Sonographer’s Role in the Screening, Diagnosis, and Treatment of Dialysis Fistula Pseudoaneurysms

Pseudoaneurysm (PSA) formation, in an arteriovenous fistula (AVF) undergoing hemodialysis, can occur as a result of frequent venipunctures and can lead to a weakened vessel wall. Since many dialysis patients’ lives depend on their weekly hemodialysis sessions, complications that result from dialysis require treatment. A PSA can be a life-threatening complication, especially for these patients. Sonography has been demonstrated to be a useful modality of choice in the screening, diagnosis, and treatment of a PSA. The sonographic appearance of a PSA using gray-scale, color, and spectral Doppler can play a significant role in ruling out other diagnoses. A case study is presented of a dialysis-dependent patient who developed a PSA in his dialysis access site. Sonography played a key role in the diagnosis and follow-up for this specific case. Due to the risks involved with these patients, there is an essential need for sonographers to be competent in performing these examinations. Evaluation of the AVF to check for patency and a thorough assessment of the PSA are required.