Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 286-289

Iatrogenic ulnar artery pseudoaneurysm: Emergency repair


Department of Cardiothoracic and Vascular Surgery, PSG IMSR and Super Speciality Hospital, Coimbatore, Tamil Nadu, India

Date of Submission07-Sep-2020
Date of Decision17-Sep-2020
Date of Acceptance28-Sep-2020
Date of Web Publication6-Jul-2021

Correspondence Address:
Murugesan Ramaiya Periyanarkunan
Department of Cardiothoracic and Vascular Surgery, PSG IMSR and Super Speciality Hospital, Coimbatore, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_125_20

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  Abstract 


We present a patient with a rare vascular emergency of iatrogenic right ulnar artery pseudoaneurysm presented as an expanding hematoma with right forearm compartment syndrome following a percutaneous coronary intervention done to place stent in the left anterior descending artery through right transulnar approach (radial nondominant). A 71-year-old female was referred with a mass on the flexor aspect of the right forearm associated with severe localized pain, tenderness, and weakness of distal forearm and hand. Investigations had revealed a right ulnar artery pseudoaneurysm. Ultrasonography of the right forearm demonstrated a pseudoaneurysm with thrombus formation arising from the right ulnar artery and using a hand Doppler, no blood flow detected distal to the swelling. Surgical repair by an open approach was done to remove the hematoma and the ulnar artery puncture site was repaired. The postoperative period was uneventful.

Keywords: Allen's test, compartment syndrome, hematoma, iatrogenic, pseudoaneurysm


How to cite this article:
Periyanarkunan MR, Chinnasamy G, Murugan MS, Elavarasan S. Iatrogenic ulnar artery pseudoaneurysm: Emergency repair. Indian J Vasc Endovasc Surg 2021;8:286-9

How to cite this URL:
Periyanarkunan MR, Chinnasamy G, Murugan MS, Elavarasan S. Iatrogenic ulnar artery pseudoaneurysm: Emergency repair. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jul 25];8:286-9. Available from: https://www.indjvascsurg.org/text.asp?2021/8/3/286/320619




  Introduction Top


Iatrogenic pseudoaneurysm is usually formed when an arterial puncture site following any medical intervention fails to seal, allowing arterial blood to jet into the surrounding tissues and form a hematoma.[1] These lesions lack a fibrous wall and are contained by a surrounding wall of hematoma and the overlying soft tissues and if left untreated they can cause compartment syndrome and later paralysis of limbs due to nerve compression; therefore, emergency surgical intervention is required.

Usually, medical intervention like percutaneous coronary intervention (PCI) is done through the dominant radial artery,[2] but in this case, the PCI procedure was done through a right ulnar artery because the right radial artery is nondominant and underdeveloped.


  Case Report Top


A moderately built 71-year-old female was referred to the cardiovascular surgeons with a well -defined mass on the flexor aspect of the right forearm[Figure 1] associated with severe localized pain, insidious in onset, and progressive in nature following a week after the PCI procedure done through right transulnar approach for stent placement in the left anterior descending (LAD). The mass was associated with tenderness and weakness of the right forearm and hand. Handheld Doppler-signal traceable. Hand shows signs of effort ischemia with evidence of finger drop, secondary to forearm compartment syndrome. SPO2 is 99%. There was no history of fever, trauma, and road traffic accident. On examination, she was normotensive with a blood pressure of 130/68 mmHg and a heart rate of 94/min. On Doppler examination of the right ulnar artery distal to the mass, no blood flow was detected. The right radial artery is patent, pulse traceable with a doppler scan. The general examination was unremarkable. Ultrasonography (USG) of the right forearm [Figure 2] revealed a pseudoaneurysm with thrombus formation noted arising from the right ulnar artery in the forearm about 5 cm from the wrist measuring about 5.5 cm × 3.6 cm × 3.2 cm [Figure 3].
Figure 1: Preoperative picture: Well-localized mass on the right forearm, flexor aspect, and 5 cm above the wrist

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Figure 2: Ultrasound of the right forearm

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Figure 3: Ultrasound reveals a pseudoaneurysm with thrombus formation noted arising from the right ulnar artery in the forearm about 5 cm from the wrist measuring about 5.5 cm × 3.6 cm × 3.2 cm

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The maximal diameter of lumen measures 10.1 mm with to and fro flow. Low monophasic flow noted in distal ulnar artery median nerve, muscles, and tendons appear normal.

She developed progressive worsening of the right forearm and hand movements with signs of expanding aneurysm and compartment syndrome. As this case required emergency intervention because she was referred after two months of initial intervention for PCI to LAD by rotablation, open surgical repair (OSR) was done.

The surgery was done under the supraclavicular block with axillary supplementation. A vertical incision [Figure 4] made at the right midforearm near the ulnar side and the clot was evacuated [Figure 5]. After the clot evacuation, the ulnar artery puncture site was sutured [Figure 6] with > one stitch with 7-c proline as required horizontally. After hemostasis secured, the incision site was closed with subcuticular suturing [Figure 7] and [Figure 8]. Postoperative recovery was good, hand movements perceived, finger grip present, ulnar artery palpable, and radial artery nontraceable.
Figure 4: Step 1: A vertical incision made

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Figure 5: Step 2: Evacuation of clot

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Figure 6: Step 3: Ulnar artery exposed

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Figure 7: Step 4: Ulnar artery puncture site sutured

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Figure 8: Step 5: Hemostasis achieved

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  Discussion Top


Pseudoaneurysm is a term used to describe the outpouching of a blood vessel that involves the innermost layers of a blood vessel (intima and media) with an intact outer layer (adventitia) or damage to all three layers with bleeding being contained by a surrounding clot or structures.[3] Iatrogenic pseudoaneurysms typically occur following percutaneous arterial interventions, as in this case PCI was done to the LAD artery. Before doing any arterial intervention in the upper arm, clinical tests such as Allen's and reverse Allen's can be done. In Allen's test, the radial artery occlusion is maintained with digital pressure to assess the palmar inflow through the ulnar artery.[4] In reverse Allen's test, the ulnar artery occlusion is maintained with digital pressure to assess the palmar inflow through the radial artery. Upper arm PCI is usually done through the radial artery. If radial artery access is unsuccessful, PCI is done through the ulnar artery. In this patient, PCI was done through the ulnar artery due to an underdeveloped radial artery. Access to the ulnar artery is generally difficult compared to the radial artery because it is less pulsatile because of its deeper location. In case PCI is done through the radial artery and is unsuccessful, ipsilateral ulnar artery access is not recommended on the same day because of potential spasm incited in the radial artery that could result in hand ischemia if the ulnar artery becomes occluded or goes into spasm,[4] whereas in this patient PCI was not tried on the radial artery as the radial artery being underdeveloped, identified (method of identification not known) by the doctors who did the PCI directly went for transulnar approach. Factors which increases the risk of iatrogenic pseudoaneurysm after ulnar artery catheterization is due to procedural and patient factors. Procedural factors are inadvertent catheterization, interventional rather than diagnostic procedures, inadequate compression following removal of sheath.[5] Patient factors are obesity and patients on anti-coagulant medications postprocedure. The risk factors associated with this patient were PCI done through non-dominant hand, was on anti-coagulant medication post PCI procedure. Iatrogenic pseudoaneurysm usually presents with pain, swelling in the affected region along with palpable mass (hematoma) which may be pulsatile with a thrill or bruit. If a pseudoaneurysm is small, it can resolve spontaneously but if it is large and there is associated expanding hematoma, it can cause compression neuropathy, skin necrosis, compartment syndrome, paralysis, limb loss. Sometimes iatrogenic pseudoaneurysm can thrombose spontaneously. Angiography remains the gold standard in detecting vascular injury, several articles outline that the use of ultrasonography, multidetector computer tomography angiography, and magnetic resonance angiography specifically are all effective tool for establishing the diagnosis. The treatment options available for iatrogenic pseudoaneurysms are OSR, USG-guided compression (UGC), percutaneous ultrasound-guided thrombin injection (UGTI).[6] OSR is considered to be the gold standard treatment for iatrogenic pseudoaneurysm as the arterial defect is repaired definitively. This patient particularly underwent OSR as she already developed symptoms and signs of vascular compromise, UGC cannot be done for well-formed large hematoma, UGTI cannot be done as it is not an emergency intervention. The main steps of OSR are evacuating the aneurysmal sac and repairing the defect in the arterial wall either by primary or patch closure. The main complications of OSR include blood loss and surgical site infection.


  Conclusion Top


Ulnar artery pseudoaneurysm secondary to PCI procedure in the presence of hematoma, with symptoms of vascular compromise, was treated by OSR. Postoperative recovery was good with intact hand movements.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lenartova M, Tak T. Iatrogenic pseudoaneurysm of femoral artery: Case report and literature review. Clin Med Res 2003;1:243-7.  Back to cited text no. 1
    
2.
Bachar BJ, Manna B. Coronary Artery Bypass Graft. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507836/. [Last accessed on 2020 Aug 11].  Back to cited text no. 2
    
3.
Woodley-Cook J, Konieczny M, Simons M. The ulnar artery pseudoaneurysm case reports 2015;2015:bcr2015212791.  Back to cited text no. 3
    
4.
Layton KF, Kallmes DF, Kaufmann TJ. Use of the ulnar artery as an alternative access site for cerebral angiography. Am J Neuroradiol 2006;27:2073-4.  Back to cited text no. 4
    
5.
Petrou E, Malakos I, Kampanarou S, Doulas N, Voudris V. Life-threatening rupture of a femoral pseudoaneurysm after cardiac catheterization. Open Cardiovasc Med J 2016;10:201-4.  Back to cited text no. 5
    
6.
Shah KJ, Halaharvi DR, Franz RW, Jenkins II J. Treatment of iatrogenic pseudoaneurysms using ultrasound-guided thrombin injection over a 5-year period. Int J Angiol 2011;20:235-42.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]



 

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