DOI: 10.1148/rg.25si055503
Pseudoaneurysms and the Role of Minimally Invasive Techniques in Their Management1
Nael E. A. Saad, MB, BCh,
Wael E. A. Saad, MB, BCh,
Mark G. Davies, MD, PhD,
David L. Waldman, MD, PhD,
Patrick J. Fultz, MD and
Deborah J. Rubens, MD
1 From the Departments of Radiology (N.E.A.S., W.E.A.S., D.L.W., P.J.F., D.J.R.) and Vascular Surgery (M.G.D.), University of Rochester Medical Center, 601 Elmwood Ave, Box 648, Rochester, NY 14642. Presented as an education exhibit at the 2004 RSNA Annual Meeting. Received February 1, 2005; revision requested March 22 and received April 28; accepted May 17. All authors have no financial relationships to disclose.
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Figure 1a. (a) Duplex Doppler US image depicts a pseudoaneurysm (PsA) with bidirectional flow within the neck (N). The donor artery supplying the pseudoaneurysm can also be seen (A). (b) Color Doppler US image of the pseudoaneurysm clearly depicts the pseudoaneurysmal neck (N) and the yin-yang (red-blue) Doppler US appearance of the pseudoaneurysmal sac (PsA).
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Figure 1b. (a) Duplex Doppler US image depicts a pseudoaneurysm (PsA) with bidirectional flow within the neck (N). The donor artery supplying the pseudoaneurysm can also be seen (A). (b) Color Doppler US image of the pseudoaneurysm clearly depicts the pseudoaneurysmal neck (N) and the yin-yang (red-blue) Doppler US appearance of the pseudoaneurysmal sac (PsA).
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Figure 2a. (a) Transvaginal gray-scale US image depicts a pseudoaneurysm of the left internal iliac artery (arrowhead) and concentric layers of mural thrombosis (arrow). (b) Transvaginal color Doppler US image of the pseudoaneurysm demonstrates characteristic yin-yang (red-blue) flow in the sac (arrowhead). (c) Trans-vaginal color Doppler flow US image demonstrates to-and-fro (bidirectional) flow.
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Figure 2b. (a) Transvaginal gray-scale US image depicts a pseudoaneurysm of the left internal iliac artery (arrowhead) and concentric layers of mural thrombosis (arrow). (b) Transvaginal color Doppler US image of the pseudoaneurysm demonstrates characteristic yin-yang (red-blue) flow in the sac (arrowhead). (c) Trans-vaginal color Doppler flow US image demonstrates to-and-fro (bidirectional) flow.
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Figure 2c. (a) Transvaginal gray-scale US image depicts a pseudoaneurysm of the left internal iliac artery (arrowhead) and concentric layers of mural thrombosis (arrow). (b) Transvaginal color Doppler US image of the pseudoaneurysm demonstrates characteristic yin-yang (red-blue) flow in the sac (arrowhead). (c) Trans-vaginal color Doppler flow US image demonstrates to-and-fro (bidirectional) flow.
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Figure 3a. Pseudoaneurysmal rupture in a 77-year-old woman who presented to the emergency department with acute onset of abdominal pain. (a) Axial contrast material–enhanced CT angiogram demonstrates a ruptured splenic artery pseudoaneurysm (PsA) with adjacent hemorrhage (arrowheads). The pseudoaneurysm is completely filled with contrast material, and the afferent (AA) and efferent (EA) splenic artery loops are clearly depicted. (b) Axial contrast-enhanced CT scan shows intrasac thrombosis of the pseudoaneurysm (arrow) and communication with the donor artery (arrowhead).
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Figure 3b. Pseudoaneurysmal rupture in a 77-year-old woman who presented to the emergency department with acute onset of abdominal pain. (a) Axial contrast material–enhanced CT angiogram demonstrates a ruptured splenic artery pseudoaneurysm (PsA) with adjacent hemorrhage (arrowheads). The pseudoaneurysm is completely filled with contrast material, and the afferent (AA) and efferent (EA) splenic artery loops are clearly depicted. (b) Axial contrast-enhanced CT scan shows intrasac thrombosis of the pseudoaneurysm (arrow) and communication with the donor artery (arrowhead).
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Figure 4a. Pseudoaneurysm in a 37-year-old woman who had undergone posterior lumbar fusion. (a) Axial gradient-echo T1-weighted MR angiogram demonstrates flow void in a pseudoaneurysm (arrowhead) due to turbulent flow. (b, c) Coronal spoiled gradient-echo (b) and conventional (c) T1-weighted MR images demonstrate a pseudoaneurysm of the right internal iliac artery (arrowhead). IVC = inferior vena cava.
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Figure 4b. Pseudoaneurysm in a 37-year-old woman who had undergone posterior lumbar fusion. (a) Axial gradient-echo T1-weighted MR angiogram demonstrates flow void in a pseudoaneurysm (arrowhead) due to turbulent flow. (b, c) Coronal spoiled gradient-echo (b) and conventional (c) T1-weighted MR images demonstrate a pseudoaneurysm of the right internal iliac artery (arrowhead). IVC = inferior vena cava.
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Figure 4c. Pseudoaneurysm in a 37-year-old woman who had undergone posterior lumbar fusion. (a) Axial gradient-echo T1-weighted MR angiogram demonstrates flow void in a pseudoaneurysm (arrowhead) due to turbulent flow. (b, c) Coronal spoiled gradient-echo (b) and conventional (c) T1-weighted MR images demonstrate a pseudoaneurysm of the right internal iliac artery (arrowhead). IVC = inferior vena cava.
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Figure 5a. Thrombotic pseudoaneurysm in a 58-year-old man who presented with abdominal pain. The patient had fallen 10 days earlier. (a) Selective digital subtraction angiogram of the phrenic artery shows contained contrast material extravasation (arrowhead). (b) Contrast-enhanced CT scan shows a large pseudoaneurysm of the phrenic artery (arrow) that is nearly completely thrombosed. A small area of contrast enhancement is seen (arrowhead), a finding that corresponds to the extravasation seen in a. Clearly, the full extent of the pseudoaneurysm was underestimated at angiography.
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Figure 5b. Thrombotic pseudoaneurysm in a 58-year-old man who presented with abdominal pain. The patient had fallen 10 days earlier. (a) Selective digital subtraction angiogram of the phrenic artery shows contained contrast material extravasation (arrowhead). (b) Contrast-enhanced CT scan shows a large pseudoaneurysm of the phrenic artery (arrow) that is nearly completely thrombosed. A small area of contrast enhancement is seen (arrowhead), a finding that corresponds to the extravasation seen in a. Clearly, the full extent of the pseudoaneurysm was underestimated at angiography.
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Figure 6a. Pseudoaneurysm in a patient who had undergone cardiac catheterization. (a) Color Doppler US image shows a pseudoaneurysm of the left common femoral artery (PsA). (b) On a color Doppler US image obtained after percutaneous injection of 1 mL of thrombin (concentration of 1000 IU/mL) through an 18-gauge needle, no flow is seen in the pseudoaneurysm (PsA).
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Figure 6b. Pseudoaneurysm in a patient who had undergone cardiac catheterization. (a) Color Doppler US image shows a pseudoaneurysm of the left common femoral artery (PsA). (b) On a color Doppler US image obtained after percutaneous injection of 1 mL of thrombin (concentration of 1000 IU/mL) through an 18-gauge needle, no flow is seen in the pseudoaneurysm (PsA).
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Figure 7. Chart illustrates the characteristic features of pseudoaneurysms used in determining their management.
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Figure 8. Schematic illustrates an algorithm for the management of all but superficial postcatheterization pseudoaneurysms, which should be treated with US-guided thrombin injection.
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Figure 9a. Occlusion of a pseudoaneurysm with coil embolization in a 67-year-old man who presented to the emergency department after sustaining a gunshot wound to the right arm. (a) Digital subtraction angiogram shows a pseudoaneurysm of the circumflex humeral artery (arrowhead). (b) Digital subtraction angiogram shows exclusion of the pseudoaneurysm from the donor artery by means of coil embolization (arrowhead).
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Figure 9b. Occlusion of a pseudoaneurysm with coil embolization in a 67-year-old man who presented to the emergency department after sustaining a gunshot wound to the right arm. (a) Digital subtraction angiogram shows a pseudoaneurysm of the circumflex humeral artery (arrowhead). (b) Digital subtraction angiogram shows exclusion of the pseudoaneurysm from the donor artery by means of coil embolization (arrowhead).
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Figure 10a. Occlusion of a pseudoaneurysm with proximal and distal embolization in a 61-year-old woman with cholangiocarcinoma. The patient had undergone a Whipple procedure, percutaneous transhepatic cholangiography on several occasions, and biliary drainage catheter placement. (a) Digital subtraction angiogram demonstrates a pseudoaneurysm off a branch of the right hepatic artery (arrowhead). (b) Digital subtraction angiogram shows the pseudoaneurysm with its afferent (arrowhead) and efferent (arrow) hepatic arterial segments. (c) Digital subtraction angiogram demonstrates exclusion of the pseudoaneurysm by means of distal (arrow) and proximal (arrowhead) embolization.
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Figure 10b. Occlusion of a pseudoaneurysm with proximal and distal embolization in a 61-year-old woman with cholangiocarcinoma. The patient had undergone a Whipple procedure, percutaneous transhepatic cholangiography on several occasions, and biliary drainage catheter placement. (a) Digital subtraction angiogram demonstrates a pseudoaneurysm off a branch of the right hepatic artery (arrowhead). (b) Digital subtraction angiogram shows the pseudoaneurysm with its afferent (arrowhead) and efferent (arrow) hepatic arterial segments. (c) Digital subtraction angiogram demonstrates exclusion of the pseudoaneurysm by means of distal (arrow) and proximal (arrowhead) embolization.
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Figure 10c. Occlusion of a pseudoaneurysm with proximal and distal embolization in a 61-year-old woman with cholangiocarcinoma. The patient had undergone a Whipple procedure, percutaneous transhepatic cholangiography on several occasions, and biliary drainage catheter placement. (a) Digital subtraction angiogram demonstrates a pseudoaneurysm off a branch of the right hepatic artery (arrowhead). (b) Digital subtraction angiogram shows the pseudoaneurysm with its afferent (arrowhead) and efferent (arrow) hepatic arterial segments. (c) Digital subtraction angiogram demonstrates exclusion of the pseudoaneurysm by means of distal (arrow) and proximal (arrowhead) embolization.
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Figure 11a. (a) Digital subtraction angiogram shows a pseudoaneurysm of the suprageniculate popliteal artery. (b) Digital subtraction angiogram demonstrates successful embolization distal (arrowhead) and proximal (arrow) to the pseudoaneurysm. The patient subsequently underwent a surgical bypass procedure for occlusion of the popliteal artery.
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Figure 11b. (a) Digital subtraction angiogram shows a pseudoaneurysm of the suprageniculate popliteal artery. (b) Digital subtraction angiogram demonstrates successful embolization distal (arrowhead) and proximal (arrow) to the pseudoaneurysm. The patient subsequently underwent a surgical bypass procedure for occlusion of the popliteal artery.
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Figure 12a. (a) Digital subtraction angiogram shows a pseudoaneurysm of the proper hepatic artery (arrow). (b) Digital subtraction angiogram demonstrates embolization of the pseudoaneurysm (arrow) with preservation of flow in the distal hepatic artery (arrowhead).
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Figure 12b. (a) Digital subtraction angiogram shows a pseudoaneurysm of the proper hepatic artery (arrow). (b) Digital subtraction angiogram demonstrates embolization of the pseudoaneurysm (arrow) with preservation of flow in the distal hepatic artery (arrowhead).
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Figure 13a. (a) Digital subtraction angiogram shows a posttraumatic pseudoaneurysm of the common carotid artery (arrow). (b) Digital subtraction angiogram demonstrates exclusion of the pseudoaneurysm with use of a bare (uncovered) stent and coil embolization through the interstices of the stent (arrow). The stent acts as a barrier, confining the coils to the pseudoaneurysm and keeping them out of the patent vital carotid artery.
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Figure 13b. (a) Digital subtraction angiogram shows a posttraumatic pseudoaneurysm of the common carotid artery (arrow). (b) Digital subtraction angiogram demonstrates exclusion of the pseudoaneurysm with use of a bare (uncovered) stent and coil embolization through the interstices of the stent (arrow). The stent acts as a barrier, confining the coils to the pseudoaneurysm and keeping them out of the patent vital carotid artery.
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Figure 14a. Exclusion of a pseudoaneurysm by means of stent-graft placement in a 61-year-old man who had undergone prostatectomy and cystectomy with Indiana pouch creation for bladder carcinoma. A Jackson-Pratt drain placed in the surgical bed at the time of surgery had subsequently eroded into the left external iliac artery. (a) Contrast-enhanced CT scan reveals a pseudoaneurysm of the left external iliac artery (arrowhead). (b) Digital subtraction angiogram shows the pseudoaneurysm (arrowhead) prior to stent-graft (covered stent) placement. (c) Digital subtraction angiogram shows successful exclusion of the pseudoaneurysm with the stent-graft.
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Figure 14b. Exclusion of a pseudoaneurysm by means of stent-graft placement in a 61-year-old man who had undergone prostatectomy and cystectomy with Indiana pouch creation for bladder carcinoma. A Jackson-Pratt drain placed in the surgical bed at the time of surgery had subsequently eroded into the left external iliac artery. (a) Contrast-enhanced CT scan reveals a pseudoaneurysm of the left external iliac artery (arrowhead). (b) Digital subtraction angiogram shows the pseudoaneurysm (arrowhead) prior to stent-graft (covered stent) placement. (c) Digital subtraction angiogram shows successful exclusion of the pseudoaneurysm with the stent-graft.
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Figure 14c. Exclusion of a pseudoaneurysm by means of stent-graft placement in a 61-year-old man who had undergone prostatectomy and cystectomy with Indiana pouch creation for bladder carcinoma. A Jackson-Pratt drain placed in the surgical bed at the time of surgery had subsequently eroded into the left external iliac artery. (a) Contrast-enhanced CT scan reveals a pseudoaneurysm of the left external iliac artery (arrowhead). (b) Digital subtraction angiogram shows the pseudoaneurysm (arrowhead) prior to stent-graft (covered stent) placement. (c) Digital subtraction angiogram shows successful exclusion of the pseudoaneurysm with the stent-graft.
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Figure 15a. Exclusion of a pseudoaneurysm by means of stent-graft placement in a patient who had sustained traumatic injury in a motor vehicle accident. (a) Digital subtraction angiogram demonstrates a pseudoaneurysm of the aorta (arrowhead). (b) Digital subtraction angiogram shows a deployed stent-graft. (c) Digital subtraction angiogram obtained after stent-graft deployment demonstrates minimal residual filling of the pseudoaneurysm.
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Figure 15b. Exclusion of a pseudoaneurysm by means of stent-graft placement in a patient who had sustained traumatic injury in a motor vehicle accident. (a) Digital subtraction angiogram demonstrates a pseudoaneurysm of the aorta (arrowhead). (b) Digital subtraction angiogram shows a deployed stent-graft. (c) Digital subtraction angiogram obtained after stent-graft deployment demonstrates minimal residual filling of the pseudoaneurysm.
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Figure 15c. Exclusion of a pseudoaneurysm by means of stent-graft placement in a patient who had sustained traumatic injury in a motor vehicle accident. (a) Digital subtraction angiogram demonstrates a pseudoaneurysm of the aorta (arrowhead). (b) Digital subtraction angiogram shows a deployed stent-graft. (c) Digital subtraction angiogram obtained after stent-graft deployment demonstrates minimal residual filling of the pseudoaneurysm.
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Copyright © 2005 by the Radiological Society of North America.
