Management Of Pseudoaneurysm In A Single Surgeon Vascular Unit in East Coast Malaysia

Introduction Pseudoaneurysm, also known as false aneurysm, occurs when there is a localised extravasation of blood from the arterial wall and is confined by a pseudocapsule. There is an increasing trend in cases of iatrogenic pseudoaneurysms due to the increase rates of endovascular procedures. Open surgical repair used to be the mainstay of treatment, however it has since been replaced by less invasive approaches such as ultrasound-guided compression and endovascular techniques such as stenting and embolization. Materials and methods We conducted a retrospective review from 2019 until 2021 on cases of iatrogenic pseudoaneurysms that were referred to our Vascular Unit for our expert management. Medical records of patients who presented with iatrogenic pseudoaneurysms were reviewed. Results We managed a total of 7 cases of iatrogenic pseudoaneurysms. Majority of our patients were male (85%) whereby the eldest patient was 55 years old and the youngest patient being only 14 years old. The commonest site of pseudoaneurysms was femoral artery (42%) followed by brachial artery (28%), inferior thyroid artery (15%) and carotid artery (15%). Treatment given ranged from non-invasive methods such as observation and ultrasound guided compression, to less invasive approaches such as endovascular embolization and stent deployment, and finally, via open surgical repair. Successful treatment was confirmed by radiological imaging and patients were observed closely for post-procedural complications until discharge. Five patients (70%) were discharged well while another two patients (30%) succumbed to non-vascular disease related death. Discussion Pseudoaneurysms (PSA) can occur due to various causes, which can be categorised into acquired, iatrogenic and spontaneous. Acquired causes include blunt or penetrating injuries from trauma, repeated drug abuse via intravenous route, and bacterial seedling. Patients with vasculitis could present with spontaneous aneurysm. The most common site of iatrogenic pseudoaneurysm is the femoral artery. It is the most common complication of femoral access following diagnostic or therapeutic cardiac and peripheral angiographic procedures. 1 Incidence of pseudoaneurysm at 0.2% to 0.5% following diagnostic procedures and up to 8% following procedures with an intervention. 2 Patients would normally present with pain or swelling in the affected region after catheterization. The pain would be severe, out of proportion as compared to a normal post-procedure discomfort. In severe cases, pseudoaneurysms can be large to cause compression to nearby structures causing neuropathy, others can present with profuse active bleeding, due to rupture, or localised forming a hematoma that can be infected. Rarely, a patient may come with an acute limb, secondary to distal embolization from the pseudoaneurysm. A duplex ultrasound offers confirmation of the pseudoaneurysm and the size including the neck. Most patients will benefit from a CTA which will allow accurate assessment of the vascular anatomy in relation to the pseudoaneurysm in preparation for any intervention. For pseudoaneurysms less than 2 cm, we can offer observation. In a study by Toursarkissian et. al, spontaneous thrombosis occurred in 72 of 82 patients with PSA