|Year : 2019 | Volume
| Issue : 2 | Page : 102-106
Pseudoaneurysm of peripheral arteries: Our experience in a community-based hospital
Lokesh Shekher Jaiswal1, Narendra Pandit1, Jagat Narayan Prasad2, Shailesh Adhikary1
1 Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
2 Department of Anestheiology, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
|Date of Web Publication||6-Jun-2019|
Dr. Lokesh Shekher Jaiswal
Department of Surgery, B. P. Koirala Institute of Health Sciences, Dharan
Source of Support: None, Conflict of Interest: None
Introduction: Pseudoaneurysms are false aneurysm where disruption in the arterial wall forms a localized pulsatile hematoma connecting the artery. The common causes are intravenous drug abuse (IVDA), iatrogenic (vascular interventions and surgery), trauma, and infections. Aims: The aim of this study was to analyze the etiology, management, and outcome of patients with pseudoaneurysms of peripheral arteries. Materials and Methods: This is a retrospective analysis of prospectively maintained database of 32 patients with peripheral artery pseudoaneurysms over 45 months at a community-based hospital of Eastern Nepal. Results: The most common site involved was femoral artery (56.3%) followed by brachial (15.6%), radial (6.3%), anterior tibial (6.3%), and others (15.5%). The common etiologies were iatrogenic (46.9%), IVDA (31.3%), trauma (18.7%), and infection (3.1%). Operative intervention was performed in 29 (90.6%) patients as follows: ligation of artery and debridement (46.9%), primary repair (28.1%), and venous graft bypass (15.6%). Three patients (9.4%) with noninfected iatrogenic pseudoaneurysms of <3 cm were managed conservatively. Infected pseudoaneurysms were seen in 14 (43.7%) patients. Staphylococcus aureus was the most common isolate in the culture. There was no reoperation, amputation, or any in-hospital mortality. At follow-up, one patient developed leg claudication pain following a femoral artery ligation and one of the five patients developed a graft thrombosis after an autologous reversed saphenous vein bypass graft without any sequelae. Conclusion: Although repair with distal revascularization is an ideal approach, debridement and simple ligation of pseudoaneurysms is a safer alternative especially in IV drug abusers.
Keywords: Iatrogenic, intravenous drug abuse, peripheral artery, pseudoaneurysm, surgery
|How to cite this article:|
Jaiswal LS, Pandit N, Prasad JN, Adhikary S. Pseudoaneurysm of peripheral arteries: Our experience in a community-based hospital. Indian J Vasc Endovasc Surg 2019;6:102-6
|How to cite this URL:|
Jaiswal LS, Pandit N, Prasad JN, Adhikary S. Pseudoaneurysm of peripheral arteries: Our experience in a community-based hospital. Indian J Vasc Endovasc Surg [serial online] 2019 [cited 2019 Jun 25];6:102-6. Available from: http://www.indjvascsurg.org/text.asp?2019/6/2/102/259652
| Introduction|| |
Pseudoaneurysms are false aneurysm where there is a disruption in the arterial wall causing a localized pulsatile hematoma contained by a fibrous capsule with a persistent communication of blood flow between the vessel lumen. The common causes of pseudoaneurysm are intravenous drug abuse (IVDA), iatrogenic due to diagnostic and therapeutic vascular interventions or a vascular anastomotic disruption, trauma, and infection.
Drug abuse is an ever-increasing social as well as a global health problem. In our part, among the hard drug abusers, almost half of them use IV drug and 13% share injections, which are cleaned with water. There is an annual increase in the incidence of IVDA, thus increasing the number of individuals at risk for infected pseudoaneurysms.
Peripheral pseudoaneurysm is a common complication occurring in 0.2%–0.5% of patients undergoing a diagnostic intervention and may reach as high as 6% for therapeutic vascular interventions. Improper anatomic identification of the access site during femoral cannulation may lead to puncture of the external iliac or superficial femoral arteries. These vessels are difficult to compress after removal of sheath, leading to an increased risk of pseudoaneurysm. Although the diagnosis is usually confirmed by duplex ultrasonography, computed tomography (CT) angiogram with reconstruction is usually required to plan further management, especially in patients with infected pseudoaneurysm, which may have multiple pus pockets and deep extensions. Furthermore, the management of pseudoaneurysm depends on etiology, presence of infection, and availability of vascular intervention facilities (stent exclusion and ultrasound-guided therapy)., Surgical repair with debridement and vascular reconstruction is the most common modality of treatment (depending on the graft availability), where the advanced facilities are not available.,
Pseudoaneurysm of peripheral vascular system is a common and unaddressed emergent surgical problem in our setup. We aimed to study the clinical profile and management outcome of patients with peripheral artery pseudoaneurysm.
| Materials and Methods|| |
This is a retrospective review of a prospectively maintained database of all patients managed for peripheral vascular pseudoaneurysm from October 2014 to June 2018 at the Department of Surgery, B. P. Koirala Institute of Health Sciences. The hospital is a 700-bedded, community-based hospital in Eastern Nepal. The study protocol was approved by the Institutional Review Board. All patients with peripheral vascular pseudoaneurysms managed by surgical interventions or with conservative treatment were included in the study. The etiologies, clinical presentation, and surgery performed were recorded. The outcome measures were as follows: need for vascular reintervention, limb amputation/gangrene, in-hospital mortality, and claudication on follow-up visits.
All patients underwent duplex ultrasound to confirm the diagnosis. CT angiogram was done only in patients where the extent of involvement was not clear. Iatrogenic pseudoaneurysms <3 cm were observed routinely for 2 weeks for possible spontaneous resolution. Surgery was considered only in persistent or increase in the size of pseudoaneurysm. Similarly, infected and bleeding pseudoaneurysms were primarily managed by urgent surgery. The infected pseudoaneurysms were defined by the presence of cellulitis, pus pockets, foul-smelling hematoma, or positive bacterial culture of necrotic material. The surgical options included direct repair by oversewing the rent or ligation of the artery with or without revascularization. Routine revascularization was performed only in cases of uninfected pseudoaneurysms. In cases with infected pseudoaneurysms after dissection of proximal healthy artery, a clamp was applied temporarily, and saturation of affected limb was monitored with pulse oximetry. Ligation of the artery without revascularization was performed, only if the saturation was more than 90% with adequate collaterals. Revascularization with autologous vein graft was performed only when saturation was <90%.
The analysis of data was performed using the Microsoft Excel 2007. Descriptive analysis was performed, and data are presented as mean (standard deviation) for continuous variables or median and ranges as appropriate. Total counts and percentages are reported for categorical variables.
| Results|| |
Demographic and clinical profile
A total of 32 patients were managed for peripheral vascular pseudoaneurysms. There were 22 males (68.7%) and 10 (31.3%) females with a median age of 42 years (range: 4–84). The duration of symptoms varied from 7 days to 1 year. The most common presenting complaint was pulsatile swelling (93.7%) followed by pain (68.7%), fever (31.3%), and bleeding (18.7%). The most common etiologies were as follows: iatrogenic injury (46.9%), IV drug abuse (31.3%), and trauma (18.7%) [Figure 1], [Figure 2], and [Figure 3]a, [Figure 3]b. One patient (3.1%) presented with axillary artery pseudoaneurysm due to an infected lymph node eroding the artery [Figure 3]c. Among the iatrogenic group, it was most commonly due to vascular puncture for hemodialysis (n = 8, 25%), anastomotic site disruption of brachiocephalic fistula (n = 3, 9.4%), and diagnostic or a therapeutic angiogram (n = 3, 9.4%). One patient had pseudoaneurysm of brachial artery following blood donation. The details of the patient profile are summarized in [Table 1].
|Figure 1: Different cutaneous manifestations of pseudoaneurysms seen in intravenous drug abusers. (a) large pulsatile swelling. (b,c) large swelling with skin necrosis. (d) pseudoaneurysm with minimal skin change|
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|Figure 2: Iatrogenic pseudoaneurysms. (a) Femoral artery pseudoaneurysm following dialysis. (b) Pseudoaneurysm of brachial artery following anastomotic dehiscence. (c) Pseudoaneurysm of brachial artery following brachial artery puncture|
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|Figure 3: Traumatic and infective pseudoaneurysms. (a) Traumatic pseudoaneurysm of subclavian artery following blunt trauma chest. (b) Infected traumatic pseudoaneurysm of anterior tibial artery. (c) Infected pseudoaneurysm of axillary artery|
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The most common artery involved was femoral artery (n = 18, 56.3%). The common femoral was involved in 11 (34.4%), superficial femoral in 5 (6.4%), and bifurcation of common femoral artery in 2 (6.3%) patients. The remaining involved arterial segments were brachial (15.6%), radial (6.3%), and the anterior tibial artery (6.3%) [Table 2]. One patient presented with pseudoaneurysm of subclavian artery following the blunt trauma of the chest with first rib and clavicle fracture. Two patients (6.3%) presented with large pseudoaneurysm of arterialized cephalic vein following puncture for hemodialysis requiring ligation.
Surgical interventions and outcome
Surgical intervention was done in 29 (90.6%) patients. Three patients (9.4%) were diagnosed with pseudoaneurysm of <3 cm within 1 week of vascular punctures and were managed conservatively with observation. The follow-up ultrasound after 2 weeks showed spontaneous resolution and did not require further intervention [Table 3].
Debridement and ligation of pseudoaneurysm without distal revascularization was done in 15 (46.9%) patients. Seven out of ten patients (75%) with pseudoaneurysm due to IV drug abuse had ligation of the femoral artery. The most common artery ligated was femoral artery (n = 7), followed by radial (n = 2), anterior tibial (n = 2), brachial (n = 1), and axillary artery (n = 1). Two patients had large painful pseudoaneurysm of arterialized cephalic vein in the arm requiring ligation [Table 2]. Primary repair was done in 9 (28.1%) patients, which included oversewing of rent in the injured artery (n = 8) and repair of the anastomotic disruption of the brachiocephalic fistula (n = 1). Similarly, repair with autologous reverse saphenous vein graft was done in 5 (15.6%) patients; three in the IV drug abuser and two in patients with iatrogenic pseudoaneurysm [Table 3].
The predominant bacterial isolate in infected pseudoaneurysm was Staphylococcus aureus (n = 4). Seroma was seen in 3 (9.4%) patients following surgery, which was managed conservatively. There was no reexploration for hemorrhage or any in-hospital mortality. None of the patients, who underwent ligation without distal revascularization, developed limb ischemia or needed amputation. One patient developed reverse saphenous vein graft thrombosis following wound infection without any sequelae. Another patient developed leg claudication on brisk walking, following ligation of the femoral artery at follow-up and is on medical management.
| Discussion|| |
Diagnostic and therapeutic vascular intervention, IVDA, and trauma are the leading causes of pseudoaneurysm. The risk factors during vascular intervention include inadequate compression, simultaneous artery and vein puncture, hypertension, obesity, hemodialysis, heavily calcified arteries, and low femoral puncture. The risk further increases with the use of large-bore sheaths and postprocedural anticoagulation/antiplatelet therapy, In this study, 34.4% of the patients (11 out of 32) had end-stage renal disease. Six (54.5%) were due to direct arterial puncture for hemodialysis, and 3 (25%) due to the anastomotic disruption of arteriovenous fistula at brachial artery. They are mostly attributed due to the inherent risk factors such as calcified arteries, poorly controlled hypertension, and unsupervised insertion of the dialysis catheter. The development of pseudoaneurysm of an arterialized cephalic vein in two cases (6.3%) perhaps points toward the need for a proper training of concerned healthcare providers.
IV drug abuse was the second leading cause of pseudoaneurysm. It was also the most important cause of infected pseudoaneurysm. Repeated puncture of artery with an unsterile needle is the main reason behind the infection in IVDA. In this study, all patients had infected pseudoaneurysm, 7 (70%) had large-sized deep pus pockets at presentation. All of them had pseudoaneurysm involving common and superficial femoral artery, and majority (70%) was managed with debridement and bipolar ligation. Postsurgery, none of them developed limb ischemia or gangrene. Only 3 (30%) patients needed reverse saphenous vein graft due to low oxygen saturation of the limb during intraoperative test ligation. This observation supports the findings that debridement and ligation of the artery is a safer procedure especially in IVDA.
Peripheral pseudoaneurysms can be managed with either open surgical repair or other less invasive procedures such as ultrasound-guided compression, thrombin injection, and covered-stent graft., Historically, surgical repair was the mainstay of treatment for pseudoaneurysms. However, with the development of these minimally invasive interventions, surgical repair of pseudoaneurysms is limited to cases with rapid expansion (especially in an unstable patient), distal ischemia, infection, neuropathy, overlying soft-tissue or skin ischemia, impending compartment syndrome, and the failure of percutaneous treatment. The type of surgery and vascular reconstruction vary with the etiology and the mode of presentation. Surgical principle includes evacuation of hematoma and perianeurysmal necrotic tissue, followed by the maintenance of vascular continuity (revascularization) either by primary repair or interposition/bypass graft. Primary repair can be simple repair of the rent in the arterial wall or resection and end-to-end anastomosis. In long-segment loss of artery or involvement of bifurcation, distal revascularization can be done with autologous venous graft or synthetic conduit. These options are suitable especially for noninfected pseudoaneurysm.
The use of conduit in infected pseudoaneurysm can be troublesome due to the risk of graft thrombosis, hemorrhage, and progression to sepsis. Recent studies have shown that ligation of artery and evacuation of infected hematoma are a safer option, especially in IVDA, provided there is an adequate Doppler signal in the distal pedal artery during intraoperative test occlusion., The development of severe lower extremity ischemia and limb loss has always been the issue especially if it involves bifurcation necessitating triple ligation and has prevented the widespread use of this modality. However, demonstration of adequate collateral by intraoperative Doppler signal in pedal artery, adequate capillary refill time, and saturation on pulse oximetry can avoid this complication., The limb claudication is reported late complications of ligation and excision of pseudoaneurysm. The option for these situations can be extra-anatomic bypass or delayed revascularization with autologous vein graft or synthetic conduit. Another potential disadvantage of using superficial conduit in IVDA is continued use of IV drug by some, thus leading to the risk of recurrence and bleeding.
In a study by Toursarkissian et al., small pseudoaneurysms of <3 cm in diameter got spontaneously thrombosed at an average of 23 days in 87% of patients. In our series, three out of 32 (9.4%) patients with a noninfected small (<3 cm) pseudoaneurysm involving femoral artery were managed conservatively with observation.
Ultrasound-guided compression and thrombin injection have become the procedure of choice and are relatively safe and effective with a success rate ranging from 75% to 89%., Recently, covered-stent graft has also been used for selected cases of pseudoaneurysm, thus avoiding the morbidity of surgery. However, stent migration and fracture are of concern necessitating regular follow-up., This procedure is of limited value in IVDA and traumatic cases, where the incidence of infection is very high. We were unable to use these minimally invasive techniques due to the limited resource, expertise, and the lack of thrombin injection in our setup. Surgery still remains the mainstay of treatment at our center.
The main limitations of our study are the relatively small sample size, heterogeneous group of patients, and its retrospective design.
| Conclusion|| |
Iatrogenic injury (46.9%) (diagnostic and therapeutic vascular intervention) and IVDA (31.3%) are the two most common causes of pseudoaneurysm in our setting. Abusers usually present with infected pseudoaneurysm which can be safely managed by ligation of artery and debridement and avoids sepsis or associated complications of revascularization.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]