Pseudoaneurysms

Dissection of the internal carotid and vertebral arteries is a common cause of stroke, particularly in young patients. Although many occur due to trauma, it is estimated that over half occur spontaneously. The mechanism of stroke following arterial dissection is either by artery-to-artery embolism, by thrombosis in situ, or by dissection-induced lumenal stenosis with secondary cerebral hypoperfusion and low-flow watershed infarction. Occasionally, dissection may lead to the formation of a pseudoaneurysm as a source of thrombus formation. Vertebrobasilar dissections that extend intracranially have a higher risk of rupture leading to subarachnoid hemorrhage (SAH). ° ... 

Thrombosis of a splenic artery pseudoaneurysm has been reported in a patient receiving octreotide (24). 

A 55-year-old woman with a history of chronic pancreatitis developed epigastric pain and melena and was found to have a splenic artery pseudoaneurysm expanding a pseudocyst. She was given an intravenous bolus of octreotide followed by an infusion of 50 micrograms/ hour. A CT scan subsequently suggested thrombosis of the pseudoaneurysm, with segmental splenic infarction. Nine months later the pseudoaneurysm had recanalized. 

The octreotide may have contributed by causing vasoconstriction. A case of thrombosis in a splenic artery pseudoaneurysm in a patient receiving somatostatin has previously been reported (25). 

Tang LJ, Zipser S, Kang YS. Temporary spontaneous thrombosis of a splenic artery pseudoaneurysm in chronic pancreatitis during intravenous octreotide administration. J Vase Interv Radiol 2005 16(6) 863-6. 

De Rone T, VanBeers B, de Canniere L, Trigaux JP, Melange M. Thrombosis of splenic artery pseudoaneurysm complicating pancreatitis Gut 1993 34 1271-3. 

Vascular access Hemodynamic/arrhythmic Groin hematoma Femoral artey pseudoaneurysm Hypotension Transient bradycardia Retroperitoneal hemorrhage... 

Fifteen years ago, the only option for patients with large abdominal aortic aneurysms (AAA) that required either elective or emergent repair was an open surgical approach using a transperitoneal or retroperitoneal incision. Now with the advent of endovascular approaches to aortic diseases, many patients, especially those in the high-risk groups, have a minimally invasive option to permit repair of aortic aneurysms, dissections, pseudoaneurysms, and ruptures. 

Patients with atherosclerosis present with stenoses and irregularities of vessel walls and elongated and ectatic arteries. Extreme dilative atherosclerotic pseudoaneurysms can typically occur with wall adherent thrombus. The differentiation of flow and thrombus signal can be difficult, although its age... 

Graver LM, Mulcare RJ (1986). Pseudoaneurysm after carotid endarterectomy. Journal of Cardiovascular Surgery 27 294-297... 

Satoh, H., Takeda, T., Takashima, M., Sumlyoshl, K., Imaizninl, N. Gas-forming liver abscess following transcatheter hepatic arterial embolization for an iatrogenic intrahepatic pseudoaneurysm report of a case. Jpn. J. Surg. 1995 25 361 -364... 

Congenital anomalies and aneurysms in the hepatic arteries are very rare. (129) Acquired aneurysms are the result of vessel wall damage, injuries or inflammatory processes. (I3l, 133, 136) Pseudoaneurysms may occur after acute pancreatitis and the formation of pseudocysts. (135) (s. tab. 39.5)... 

Pinsky, M.A., May, E.S., Taxier, M.S., Blackford, J. Late manifestation of hepatic artery pseudoaneurysm case presentation and review. Amer. J. Gastroenterol. 1987 82 467-469... 

A 71-year-old man with bladder carcinoma in situ received six instillations of BCG at weekly intervals followed 3 months later by three booster instillations at weekly intervals. Four months later an inflammatory aortic aneurysm, which had ruptured into a pseudoaneurysm, was diagnosed and excised. Mycobacterium bovis was found. After treatment with isoniazid and rifampicin he recovered. There was no sign of tumor in the bladder at cystocopy 8 months after the last BCG instillation. 

Back pain Rupture of a pseudoaneurysm Local Likely (53)... 

Matsuyama H, Nagao K, Yamakawa GI, Akahoshi K, Naito K. Retroperitoneal hematoma due to rupture of a pseudoaneurysm caused by acupuncture therapy. J Urol 1998 159(6) 2087-8. 

Cranial nerve palsies are rare, occurring in less than 7% of cervical artery dissection cases in hospital-based series. The outwardly distended vessel wall may compress nearby structures. In carotid dissection at the base of the skull, compression palsies of cranial nerves IX, X, XI, and XII are sometimes seen due to the dissection or to the formation of a pseudoaneurysm at the site. Carotid dissection can also intermpt the sympathetic... 

Infrequently, cervical artery dissection can lead to subarachnoid hemorrhage, usually when the dissection extends to the intracranial part of the vessel, with pseudoaneurysm formation and rupture (1% of cervical artery dissection cases in the large hospital-based series) [36, 37], Rupture of dissected vertebral arteries into the subarachnoid space is more common in children. Rupture of dissected carotid artery pseudoaneurysms into the neck or nasal sinuses is generally rare. Dissection can occur intracraiually and, on rare occasions, can spread intracraniaUy from a primary extracranial origin. 

Antegrade obliteration of the superior duodenal branches via the gastroduodenal artery is often insufficient alone, as the bleeding points can be quickly pressurized via the rich anastomotic connections from the inferior pancreaticoduodenal arcade. In such cases, a coil-sandwich technique or alternatively direct obliteration of the bleeding segment or pseudoaneurysm by nested coils or a casting agent may be needed to prevent recurrence. 

Golzarian J, Nicaise N, Deviere J, et al. (1997) Transcatheter embolization of pseudoaneurysms complicating pancreatitis. Cardiovasc Intervent Radiol 20 435-440... 

Reber PU, Baer HU, Patel AG, Wildi S, Triller J, Buchler MW (1998) Superselective microcoil embolization treatment of choice in high-risk patients with extrahepatic pseudoaneurysms of the hepatic arteries. J Am Coll Surg 186 325-330... 

Phatouros CC, Sasaki TY, Higashida RT,et al. (2000) Stent-supported coil embolization the treatment of fusiform and wide-neck aneurysms and pseudoaneurysms. Neurosurgery 47 107-113... 

Matson MB, Morgan RA, Belli AM (2001) Percutaneous treatment of pseudoaneurysms using fibrin adhesive. Br J Radiol 74 690-694... 

Gale SS, Scissons RP, Jones L, Salles-Cunha SX (2001) Femoral pseudoaneurysm thrombinjection [see comment]. Am J Surg 181 379-383... 

If there is an acute indication for embolization therapy, but if the patient is hemodynamic stable, a spiral CT can be very beneficial to help planning the intervention. A pseudoaneurysm of a visceral vessel certainly will target the intervention. A retroperitoneal hematoma will suggest potential bleeding sites. Active extravasation can also sometimes be visual-... 

After each series, the images are examined on the display to look for extravasation of contrast medium or a pseudoaneurysm. When bowel movement is disturbing, images should also be examined in the non-subtraction mode. Since Nusbaum and Baum investigated gastrointestinal bleeding in a canine model, it has been generally accepted that extravasation of contrast medium becomes visible when the blood loss exceeds 0.5 ml/min [54-56]. 

Any aneurysm detected on the arterial tributaries located in the bleeding area should be considered as a pseudoaneurysm and therefore treated as a contrast medium extravasation. 

Yamakado K, Nakatsuka A, Tanaka N, et al. (2000) Transcatheter arterial embolization of ruptured pseudoaneurysms with coils and n-butyl cyanoacrylate. J Vase Interv Radiol 11 66-72... 

Fig. 7.1a,b. Coeliac angiography in a patient with life threatening haemobilia 24 h post cholecystectomy revealed a large hepatic pseudoaneurysm (a) treated successfully by proximal and distal coil embolization (b)... 

Haemobilia requires treatment as spontaneous resolution is exceedingly rare and the mortality from ruptured pseudoaneurysms is in excess of 90%. Technically endovascular management is relatively simple and involves the proximal and distal embolization, with tightly packed steel coils, of the hepatic... 

Fig. 7.3a,b. Hepatic arteriogram in a 26-year-old man with a small inoperable neuroendocrine tumour in the head of his pancreas. The papilla of Vater could not be accessed at ERCP and he underwent a percutaneous stenting procedure at which two self-expanding stents were inserted (lower arrowheads) apparently side by side (a). 12 hours later repeat ERCP revealed a significant haemorrhage from the papilla. The angiogram revealed a segment 4 arterial pseudoaneurysm (upper arrowheads) which was embolized successfully with coils (b)... 

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