- anticoagulation therapy
- inadequate compression following endovascular intervention
- improper arterial puncture technique: ideally the common femoral artery should be punctured
- inadvertent femoral artery branch puncture
- post surgical
- intravenous drug use
- penetrating trauma
Pseudoaneurysms generally appear as rounded sacs in close proximity to, and often with, a connecting "neck" from the parent vessel. The internal appearance of the sac is variable, depending on the degree of thrombosis. Partial rupture of the pseudoaneurysm may lead to a complex (multilobed) configuration, with multiple interconnected sacs (see Case 6). Complete rupture may lead to more diffusely infiltrative hematoma.
Ultrasound is the quickest and best modality for assessment. Due to the turbulent forward and backwards flow, a characteristic yin-yang sign may be seen on color flow while a "to-and-fro" pattern may be seen with pulsed Doppler. Ultrasound can also be used for therapeutic probe compression (ultrasound-guided compression), providing real time feedback of the thrombosing pseudoaneurysm.
Unenhanced CT scans may demonstrate a low-attenuation rounded structure arising from the donor artery. Intermediate or high attenuation (hemorrhage) adjacent to the pseudoaneurysm may been seen and indicates pseudoaneurysmal rupture, which may vary in attenuation dependent on being chronic or acute. The pseudoaneurysmal wall is usually smooth and well-defined except in a mycotic pseudoaneurysm, where the wall can be thickened, irregular, or ill-defined.
CT angiography may demonstrate a contrast-filled sac. Non-enhancing low-attenuation area within the pseudoaneurysm sac, indicates partial thrombosis 2. A communication with a donor artery adjacent to the pseudoaneurysm can usually be seen.
Treatment and prognosis
Treatment options include 2
- surgical repair
- ultrasound-guided compression
- ultrasound-guided thrombin injection
- endovascular therapy: stent-graft placement
At the time of writing, the success rate of thrombin injection (89-96%) is considered to be much higher than with compression (74-78%) 1-4.
- 1. Paulson EK, Sheafor DH, Kliewer MA et-al. Treatment of iatrogenic femoral arterial pseudoaneurysms: comparison of US-guided thrombin injection with compression repair. Radiology. 2000;215 (2): 403-8. Radiology (citation) - Pubmed citation
- 2. Saad NE, Saad WE, Davies MG et-al. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics. 2005;25 Suppl 1 : S173-89. doi:10.1148/rg.25si055503 - Pubmed citation
- 3. Heis HA, Bani-hani KE, Elheis MA et-al. Postcatheterization femoral artery pseudoaneurysms: therapeutic options. A case-controlled study. Int J Surg. 2008;6 (3): 214-9. doi:10.1016/j.ijsu.2008.03.006 - Pubmed citation
- 4. Krueger K, Zaehringer M, Strohe D et-al. Postcatheterization pseudoaneurysm: results of US-guided percutaneous thrombin injection in 240 patients. Radiology. 2005;236 (3): 1104-10. doi:10.1148/radiol.2363040736 - Pubmed citation