Delayed Pseudoaneurysms of Vertebral Artery Post Penetrating Trauma: A Case Report

Objective: Vascular injuries usually present immediately after the penetration, but the delayed onset of vascular symptoms caused by vessel dissection or aneurysm after a traumatic event is extremely rare. Vertebral artery injury is a low-frequency but high-mortality injury. We aim to report evidence of delayed onset of vascular symptoms following penetrating trauma in the neck. Materials and Methods: A case report. Results: A 19-year-old boy was referred to our hospital and complained of a mass in the right part of his neck (right mandibular angle). He gave a history of penetrating trauma to his neck 2 months ago. The mass was expanding during these 2 months and doesn’t respond to antibiotic therapy. In the examination, 3 × 3 cm, firm, nonmobile, and without tenderness and pain mass was palpated in the second level of his neck. Doctors ordered a Doppler sonography in the hospital where a yin-yang pattern was reported. A 36 × 43 × 40 mm heterogeneous, solid, and hypodense area close to C1-C2-C3 with vascular flow was discovered in the right submandibular area after computed tomography (CT)-angiography. The patient was referred to an interventional neurologist for angiography and due to the lack of flow at the distal of the V3 segment, he decided to sacrifice this artery by two coils. Conclusion: Penetrating neck injuries are usually asymptomatic, but these injuries are often accompanied by hemorrhage, neurological symptoms, dysphagia, odynophagia, and windpipe. Penetrating lesions of the vertebral artery are rare and very difficult to diagnose. Also, these lesions are challenging for surgeons due to complex anatomy and difficult surgical exposure. So, endovascular treatment was used to treat the patient.

Follow-up strategy for early detection of delayed pseudoaneurysms in patients with blunt traumatic spleen injury: A single-center retrospective study

BACKGROUND The spleen is the most commonly injured solid organ in blunt abdominal trauma,and splenic pseudoaneurysm rupture is associated with a high risk of mortality.Nonoperative management has become the standard treatment for hemodynam-ically stable patients with splenic injuries.On the other hand,delayed splenic pseudoaneurysms can develop in any patient,and at present,there are no known risk factors that may reliably predict their occurrence.Furthermore,there is a lack of consensus regarding the most appropriate strategies for monitoring and mana-ging splenic injuries,especially lower-grade(I-III).AIM To determine the predictors of pseudo-aneurysm formation following splenic injury and develop follow-up strategies for early detection of pseudoaneurysms.METHODS We retrospectively analyzed patients who visited the Level I Trauma Center bet-ween January 2013 and December 2022 and were diagnosed with spleen injuries after blunt abdominal trauma.RESULTS Using the American Association for the Surgery of Trauma spleen injury scale,the splenic injuries were categorized into the following order based on severity:Grade I(n=57,17.6%),grade II(n=114,35.3%),grade III(n=89,27.6%),grade IV(n=50,15.5%),and grade V(n=13,4.0%).Of a total of 323 patients,35 underwent splenectomy and 126 underwent angioembolization.19 underwent delayed angioembolization,and 5 under-went both initial and delayed angioem-bolization.In 14 patients who had undergone delayed angioembolization,no extravasation or pseudoaneurysm was observed on the initial computed tomography scan.There are no particular patient-related risk factors for the formation of a delayed splenic pseudoaneurysm,which can occur even in a grade I spleen injury or even 21 days after the injury.The mean detection time for a delayed pseudoaneurysm was 6.26±5.4(1-21,median:6,inter-quartile range:2-9)days.CONCLUSION We recommend regular follow-up computed tomography scans,including an arterial and portal venous phase,at least 1 week and 1 month after injury in any grade of blunt traumatic spleen injury for the timely detection of delayed pseudoaneurysms.

Comparison of ultrasound-guided thrombin injection and compression repair in treatment of iatrogenic femoral arterial pseudoaneurysms

Objective ：To retrospectively compare the efficacy and safety of ultrasound-guided thrombin injection （UGTI） with ultrasound-guided compression repair （UGCR） in patients with postcatheterizational femoral arterial pseudoaneurysms （PSA）. Methods： Thirty patients of this iatrogenic PSA [8 males, 22 females, average age （66.5±5.2） years] in our institution from 1997 to 2004 were retrospectively analyzed. Among them, 11 patients were treated with UGCR, 2 under continuous uhrasonographic （US） guidance and 9 under the guidance of femoral arterial bruit auscultation and dorsalis pedis artery palpation. Because UGCR was failed in 5 patients, consecutively 24 patients were treated with UGTI. Swine thrombin solution at a concentration of 200 U/ml was injected percutaneously using 22-25 gauge needles under color Doppler US. Demographics, clinical variables, pseudoaneurysm characteristics, and results of the 2 groups were compared by using Fisher＇s exact test and Student＇s t test. Results： The initial success rate of UGCR was 36.4% （4/11） and the overall success rate was 45.5% （5/11）. Tenor 11 patients suffered from local pain during the compression, but there was no any complication in UGTI group. The av- erage dose of injected thrombin was （180±82） U for PSA of a single loculus and （315±150） U for multi- loculated PSA. The initial success rate of UGTI was 89.5% （17/19） and the overall success rate was 100% （24/24）. Conclusion：UGTI offers a safe, quick and effective means of definitively treating femoral pseudoaneurysms and seems superior to UGCR. The amount of thrombin applied on our people seems smaller compared with others＇ work.

Endovascular Embolization of Pseudoaneurysms Complicating Pancreatitis Using Microcoils: Case Series

Purpose: To determine whether endovascular embolization of pseudoaneurysms complicating pancreatitis with microcoils was associated with better therapeutic outcome. Materials and Method: The prospective clinical study was carried out in the Department of Interventional Radiology for a period of 2 years extending from May 2010 upto August 2012 on 16 male patients in the age group of about 30 - 55 years, with each one of them having vascular complications as a sequel to pancreatitis, after obtaining well informed written consent from each one of them. Results: The outcome of the procedure was judged by the following parameters—a) Restoration of the blood pressure of the patient;b) Cessation of the hemetemesis and malena;c) Reduction in abdominal pain and discomfort and d) Overall improvement in the general condition of the patient. Each of the patients had been on follow up for at least 6 months, except 2 of them, with no new complaints in any of them. The procedure related mortality was none. Conclusion: Vascular complications of pancreatitis need immediate and accurate diagnosis and prompt treatment. Micro coil embolisation, is a minimally invasive technique which helps to exclude the pseudoaneurysm from the circulation and thus reduces the scope for massive life threatening internal hemorrhage, and is a better alternative to surgery.

Efficacy of Willis covered stent of intracranial pseudoaneurysms in the internal carotid artery: A systematic review and meta-analysis

Objective:To evaluate the efficacy of a novel coated stent in the treatment of intracranial pseudoaneurysm.Methods:MEDLINE,EMBASE,and PubMed databases were searched for literature published between 1990 and April 2022 according to PRISMA guidelines.All studies with≥10 patients reporting successful implantation of Willis covered stent,therapeutic effect,complications,and postoperative follow-up were included.The combined incidence and corresponding 95%confidence intervals were assessed using a generalized linear mixed method and random effects model.Results:Five studies(116 patients with pseudoaneurysms)were included.The experimental groups in the selected studies showed a combined technical success rate of 81.03%(OR=18.31,95%CI=9.39-35.69,I^(2)=79%,P<0.001).Clinical follow-up showed that the complete cure rate was as high as 94.4%after the follow-up(OR=106.81,95%CI=39.08-291.88,I^(2)=0%,P=0.71).Conclusions:Willis covered stent is feasible,safe,and effective in the treatment of intracranial pseudoaneurysm.

l7 Pseudoaneurysms Treated by Padding and Compression

To introduce the method and curative effect of treating pseudoaneurysms by padding and compression.Method:retrospectively analyze the curative effect of treating 17 pseudoaneurysms bypadding hard things and compression.Result:15 of them was completely recovered by doing so,murmur disappeared and the local skin became even,there was no recurrences and complications after 0.5-3 year's following up,but the other two were the same as before the therapy.Conclusion:pseudoaneurysms can be treated effectively by padding and compression

Management of bleeding from pseudoaneurysms following pancreaticoduodenectomy

AIM:To review the clinical course and the management of pseudoaneurysms post-pancreaticoduodenectomy.METHODS: Medical records of 907 patients who underwent pancreaticoduodenectomies from January 1995 to May 2007 were evaluated retrospectively. The clinical course, management strategy, and outcome of ruptured pseudoaneurysms cases were analyzed.RESULTS: Twenty-seven (3.0%) of 907 cases had post-operative hemorrhage from ruptured pseudoan-eurysms. Pancreatic fistula was evident in 12 (44%) cases. Sentinel ble...

Selective embolization for bleeding visceral artery pseudoaneurysms in patients with pancreatitis

BACKGROUND:Pancreatitis is associated with arterial complications in 4%-10%of patients,with untreated mortality approaching 90%.Timely intervention at a specialist center can reduce the mortality to 15%.We present a single institution experience of selective embolization as first line management of bleeding pseudoaneurysms in pancreatitis. METHODS:Sixteen patients with pancreatitis and visceral artery pseudoaneurysms were identified from searches of the records of interventional angiography from January 2000 to June 2007.True visceral artery aneurysms and pseudoaneurysms arising as a result of post-operative pancreatic or biliary leak were excluded from the study. RESULTS:In 50%of the patients,bleeding complicated the initial presentation of pancreatitis.Alcohol was the offending agent in 10 patients,gallstones in 3,trauma,drug-induced and idiopathic pancreatitis in one each.All 16 patients had a contrast CT scan and 15 underwent coeliac axis angiography. The pseudoaneurysms ranging from 0.9 to 9.0 cm affected the splenic artery in 7 patients:hepatic in 3,gastroduodenal and right gastric in 2 each,and left gastric and pancreatico-duodenal in 1 each.One patient developed spontaneous thrombosis of the pseudoaneurysm.Fourteen patients had effective coil embolization of the pseudoaneurysm.One patient needed surgical exclusion of the pseudoaneurysm following difficulty in accessing the coeliac axis radiologically.There were no episodes of re-bleeding and no in-hospital mortality. CONCLUSIONS:Pseudoaneurysms are unrelated to the severity of pancreatitis and major hemorrhage can occur irrespective of their size.Co-existent portal hypertension and sepsis increase the risk of surgery.Angiography and selective coil embolization is a safe and effective way to arrest the hemorrhage.

Endoscopic ultrasound guided thrombin injection of angiographically occult pancreatitis associated visceral artery pseudoaneurysms:Case series

Pseudoaneurysm is a known complication of pancreatitis associated with significant mortality and morbidity. Imaging plays an important role in the diagnosis and management. Computed tomography(CT) helps localize the lesion and the severity of the background pancreatitis but digital subtraction angiography with coil embolization is recommended to avoid bleeding and inadvertent surgery. However, in cases where angiographic coil embolization is not feasible due to technical reasons, thrombin injection via CT or ultrasound guidance remains a viable option and often described in literature. In this series, effort has been made to highlight the role of endoscopic ultrasound guided thrombin instillation especially in patients with poorly visualized pseudoaneurysm on ultrasound thereby avoiding surgery and the associated mortality and morbidity.

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

Medical ultrasound imaging with Doppler plays an essential role in the diagnosis of vascular disease. This study intended to review the clinical use of "to-and-fro" waveform at duplex Doppler ultrasonography(DDU) in the diagnosis of pseudoaneurysms in the arterial vessels of upper and lower extremities, abdominal aorta, carotid and vertebral arteries as well as to review our personal experiences of "to-and-fro" waveform at DDU also. After receiving institutional review board approval, an inclusive literature review was carried out in order to review the scientific foundation of "toand-fro" waveform at DDU and its clinical use in the diagnosis of pseudoaneurysms in various arterial vessels. Articles published in the English language between 2000 and 2013 were evaluated in this review study. Pseudoaneurysms in arterial vessels of the upper and lower extremities, abdominal aorta, carotid and vertebral arteries characterized by an extraluminal pattern of blood flow, which shows variable echogenicity, interval complexity, and "to-and-fro" flow pattern on color Doppler ultrasonography. In these arterial vessels, Duplex ultrasonography can demonstrate the degree of clotting, pseudoaneurysm communication, the blood flow patterns and velocities. Spectral Doppler applied to pseudoaneurysms lumen revealed systolic and diastolic turbulent blood flow with traditional "toand-fro" waveform in the communicating channel. Accurate diagnosis of pseudoaneurysm by spectral Doppler is based on the documentation of the "to-andfro" waveform. The size of pseudoaneurysm determines the appropriate treatment approach as surgical or conservative.

Catastrophic vertebral artery and subclavian artery pseudoaneurysms caused by a fishbone:A case report

BACKGROUND Fishbone is the most common esophageal foreign body and tends to migrate after piercing the esophagus to nearby structures.Vascular injury around the esophagus is a serious complication and has a high mortality rate,especially in the case of multiple vascular injuries.CASE SUMMARY We report an extremely rare case of successive vertebral artery and subclavian artery pseudoaneurysms caused by swallowing a fishbone in a previously healthy 29-year-old female.She was transferred to the emergency department of our hospital because of hemorrhagic shock due to a vertebral artery pseudoaneurysm.We successfully managed the vertebral artery pseudoaneurysm with endovascular stent implantation and the patient's vital signs as well as hemodynamics once became stable.However,the patient died of the second subclavian artery pseudoaneurysm occurring within a short time,which was thought be related to the obvious displacement of the fishbone in the mediastinum.CONCLUSION Surgery and endovascular stent implantation may be the best choice for treating such complications.Early removal of the fishbone is of great significance in improving the survival of such patients.

Uncommon post-infarction pseudoaneurysms:A case report

BACKGROUND Mechanical complications are a rare presentation in chronic coronary syndromes,which have significantly decreased in the primary coronary intervention era.Incomplete rupture may occur,resulting in pseudoaneurysms(PANs).Early reperfusion decreases the risk of this complication.Echocardiography is the method of choice for diagnosis.CASE SUMMARY A 54-year-old female hypertensive patient,with a history of non-revascularized inferior and anterior ST-segment elevation myocardial infarction(MI)4 years prior,was admitted to the cardiac unit of the hospital with complaints of abdominal pain and dyspnea lasting 2 mo.The patient was hemodynamically stable,and 12-lead electrocardiogram showed persistent ST elevation and Q wave in the inferior and apical regions.Transthoracic echocardiogram in the twochamber view showed a narrow neck of a wide PAN in the distal apical left ventricular inferior wall.In addition,the apical four-chamber and subcostal views revealed a second bulky PAN of the apical wall separated from the first by a common organizing thrombus.Cardiac magnetic resonance imaging confirmed the coexistence of more than one PAN.The patient received conservative medical treatment,and surgery was scheduled for outside the country.The patient had worsening multiple organ failure and died 4 wk after presentation.CONCLUSION Multifocal PANs rarely occur in chronic MI.Attention should be paid to patients with pain and cardiovascular risk factors.

Repeated Surgery for Recurrent Pseudoaneurysms after Thoracoabdominal Aortic Replacement

Aneurysm or pseudoaneurysm formation in the aortic patch containing the intercostal or visceral arteries is an unusual late complication after thoracoabdominal aortic surgery. We report the case of a 58-year-old woman who had previously undergone thoracoabdominal aortic replacement (Crawford extent II) for dissecting aneurysm. About 12 months after the operation repeated pseudoaneurysmal degenerations occurred at the intercostal or visceral artery reattachment site. They were repaired with open surgery or endovascular stent-graft. The patient recovered without major complications, and computed tomographic scans showed no recurrence of aneurysm or pseudoaneurysm at the sites of repair 1 year after the procedure.

Endovascular and Percutaneous Management of the Pseudoaneurysms

Introduction: Pseudoaneurysm is a dilatation of an artery with actual disruption of one or more layers of its wall, rather than just expansion of wall layers. Pseudoaneurysms are common vascular abnormalities. Computed Tomography (CT), Magnetic Resonance Imaging (MRI), sonography, and angiography all are valuable modalities in the imaging workup of pseudoaneurysms. Conventional angiography remains the gold standard for diagnosis. Therapeutic options have evolved in recent years from the traditional surgical option toward a less invasive approach which includes procedures such as Ultrasound (US)-guided compression, US-guided percutaneous thrombin injection, and endovascular management (embolization, stent-graft placement and endovascular coiling). Objective: In this article, we discuss pseudoaneurysms of various arteries, and available percutaneous and endovascular treatment options. Materials and Methods: Sixteen patients diagnosed with pseudoaneurysm involving visceral and peripheral arteries were included in this study. The initial diagnosis was made with CDUS, CECT, and CTA followed by catheter angiogram for therapeutic procedures. Results: All the 16 patients with pseudoaneurysms were successfully treated with endovascular and percutaneous embolization to achieve stasis. Conclusion: CT, MRI, sonography, and angiography may all be valuable in the imaging workup of pseudoaneurysms. The use of minimally invasive treatment has led to a marked decrease in the morbidity and mortality rates for pseudoaneurysms.

Echo-guided pin-point compression can effectively repair pseudoaneurysms associated with catheter procedure

Background: Catheter intervention is occasionally complicated by a pseudoaneurysm at the puncture site. Although the feasibility of echo-guided repair of a pseudoaneurysm has been reported, this method does not always repair the pseudoaneurysm. We hypothesized that if the communication to the artery could be effectively closed by pin-point compression, the clot that forms in the residual lumen would effectively cover the communication. We studied the safety and efficacy of the echo-guided pinpoint compression procedure for repairing a pseudoaneurysm. Methods: Ten consecutive patients with a pseudoaneurysm were enrolled. We determined the site of communication by echography with a high-frequency linear probe. We performed pin-point compression on the communication point with the right index finger, and we confirmed closure of the communication by color Doppler. During compression, we monitored echo images to confirm clot formation. Results: A pseudoaneurysm was located on the femoral artery in 6 patients and on the brachial artery in 4 patients. The sizes of the pseudoaneurysms ranged from 13 to 40 mm in diameter. We successfully closed the communication with one-finger compression in all patients. During the compression, we observed clot formation in the residual lumen of the pseudoaneurysm in all patients by echography. The duration of compression ranged from 5 to 40 minutes (mean, 18 minutes). We succeeded in repairing the pseudoaneurysm in all patients using this method. The success of the procedure was also confirmed 24 hours later in all patients. Conclusions: Echo-guided pin-point compression of the communication might be an effective technique for repairing a pseudoaneurysm at the puncture site, and echography is useful for confirming the success of the procedure.

Traumatic Middle Meningeal Artery Pseudoaneurysms Presenting with Intractable Epistaxis: A Rare Case Report and Review of Literature

Middle meningeal artery (MMA) pseudoaneurysms are very rare and are most often traumatic. They may present as an epidural or intraparenchymal hematoma. This study reports a rare case in which a patient suffered from intractable epistaxis because of a pseudoaneurysm in middle meningeal artery and skull base fracture after craniocerebra trauma. Pseudoaneurysm and the feeding artery were embolized by using Onyx-18 liquid embolic system. Complete cessation of bleeding was achieved in this case immediately after the endovascular therapies. In this study, clinical manifestation, diagnostic imaging and endovascular treatment are described. Formation mechanisms and the treatment of traumatic pseudoaneurysm of middle meningeal artery are discussed.

Treatment strategies and indications for interventional management of pseudoaneurysms

Background Pseudoaneurysms （PAs） are common vascular abnormalities predominantly arising from a disruption in the integrity of the arterial wall. The potential complications of PAs are usually unpredictable and carry high rates of morbidity and mortality. This paper presents our experience with various treatment strategies for PAs. Methods Fifty-four patients with 55 PAs were diagnosed by non-invasive imaging examination. The etiology of PAs included trauma （33/55）, infection （5/55）, iatrogenic （6/55）, and idiopathic （11/55）. Different procedures including ultrasound （US）-guided compression, endovascular treatment, and surgery were performed depending on the location of PAs, size of the sac and neck, and characteristics of the donor artery. The methods of endovascular treatment included embolization of parent artery, the PA sac, or implantation of a stent-graft. Follow-up was performed using US or CT and ranged from 1 day to 24 months （average 16.7 months）. Results In all 54 patients, 3 patients with superficial PAs were treated by US-guided compression, while 44 patients with 45 PAs located in the head and neck （n=20）, viscera （n=-10） or extremities （n=15） were treated by endovascular treatment. Nine patients with PAs located in the head and neck （n=2） or extremities （n=-7） were treated by surgery. Among them, one patient underwent endovascular treatment combined with surgery and 1 was treated by surgery after unsuccessful US-guided compression. In the 3 patients treated with US-guided compression, 2 were successfully treated while the remaining patient required additional surgery. Primary technical success of endovascular management was 97.7% （43/44） and the cure rate was 95.5% （42/44）. In the surgery group, 4 patients recovered well, 1 patient was cured by endovascular treatment combined with surgery, 2 cases underwent amputation, 1 patient died of multi-organ failure and 1 patient was paralysed. Conclusions Minimally invasive interventional techniques are established treatment methods for PA with favorable success rates and minimal morbidity. The therapeutic options should be tailored to the location, size and rupture risk of PA, condition of the donor artery and existing comorbidity.

Diagnosis and treatment of epistaxis caused by non-traumatic pseudoaneurysms of carotid artery

Epistaxis remains one of the most common otolaryngology emergencies. Severe epistaxis may be caused by internal carotid artery （ICA） pseudoaneurysm or cavernous fistula, which is clinically rare but life threatening if it is not diagnosed and treated timely. Most ICA pseudoaneurysms are mainly caused by trauma with few other causes. From January 1998 to December 2005, a total of 8 cases with non-traumatic carotid artery pseudoaneurysm were correctly diagnosed through digital subtraction angiography （DSA） in Ganzhou People＇s Hospital. The patients had suffered from serious nose bleeding repeatedly and had been resistant to routine treatments.

Traumatic pseudoaneurysms of external carotid artery branch:Case series and treatment considerations

Purpose:To explore the diagnosis and treatment of traumatic external carotid branch pseudoaneurysms.Methods:Eleven cases of traumatic external carotid artery branch pseudoaneurysms were admitted in our hospital.Digital subtraction angiography was performed in all patients.It revealed that the pseudoaneurysms originated from the internal maxillary artery in 5 cases,superficial temporal artery in 5 cases and occipital artery in 1 case.Five cases of internal maxillary artery pseudoaneurysms and 2 cases of superficial temporal artery pseudoaneurysms were treated by embolization;the other 3 cases were surgically resected.Results:Complete cessation of nasal bleeding was achieved in all the 5 pseudoaneurysms of internal maxillary artery after the endovascular therapies.Scalp bleeding stopped and scalp defect healed up in 2 patients with superficial temporal artery pseudoaneurysms treated by interventional therapy.All patients were followed up for 0.5-2.0 years without recurrence of nosebleed and scalp lump.Conclusion:For patients with repeated severe epistaxis after craniocerebral injury,digital subtraction angiography should be performed as soon as possible to confirm traumatic pseudoaneurysm.Endovascular therapy is an effective method for traumatic internal maxillary artery pseudoaneurysms.For patients with scalp injuries and pulsatile lumps,further examinations including digital subtraction angiography should be performed to confirm the diagnosis.Surgical treatment or endovascular therapy for scalp traumatic pseudoaneurysm is effective.

Surgical treatment of post-traumatic pseudoaneurysms and arteriovenous fistulas

Objective: To report the experience in the diagnosis and treatment of post traumatic pseudoaneurysms and arteriovenous fistulas. Methods: A series of 30 patients (11 women and 19 men) with posttraumatic pseudoaneurysms were reviewed retrospectively. Among them 7 patients (5 women and 2 men) were associated with arteriovenous fistula. Results: The causes included sharp penetrating trauma (18 cases), blunt trauma (6 cases) and iatrogenic arterial injury (6 cases). The main clinical manifestations consisted of local pulsatile mass (26 cases), vascular bruits (19 cases), thrill (13 cases), ischemia of distal limb (9 cases), neuropathy (5 cases) and pseudoaneurysm rupture (2 cases). All patients underwent surgery. The operations included: ligation of the vessels (12 cases), surgical resection and primary suture repair of the vascular defect or anastomosis (11 cases), vascular reconstruction with autogenous saphenous vein (3 cases) and synthetic vascular graft (4 cases). Conclusions: Because of the imminent clinical course, early operation is usually indicated. The operative treatment is effective and safe for most of the patients with post traumatic pseudoaneurysms and arteriovenous fistulas.