|Patient: 69 year old male|
|History: A 69 year old male inpatient presents with left leg swelling. Patient was unable to communicate and has a history of dementia, obesity, hypoglycemia, hypertension, hyperlipidemia, peripheral vascular disease and left fem-pop bypass graft. Angiography was performed four weeks ago. Lower venous duplex exam was ordered to rule out deep vein thrombosis.|
|Findings: Lower venous duplex study was performed. The study was limited due to the patient’s clinical status. Normal compressibility and augmentation of the veins of the left leg were demonstrated with no evidence of venous thrombus. Incidentally, in the area of the left groin originating from the left femoral artery is a large unilocular pseudoaneurysm. There is a direct connection between the pseudoaneurysm and femoral artery. Spectral Doppler waveform demonstrates a classic pendulum waveform in the neck. The neck of the pseudoaneurysm measures 1.26cm in diameter. Longitudinally, the pseudoaneurysm measures 6.56 x 6.37cm and transversely it measures 8.05cm in diameter. In the transverse plain the classic “yin-yang” swirling pattern of blood flow is demonstrated within the lumen.|
Due to the size of the pseudoaneurysm the patient was taken into surgery. The artery appeared to have disrupted from the graft and dissected in the subintimal plane. The graft was somewhat mobile and there was a thin film of fluid around it. There was concern that the entire graft was infected. The left fem-pop bypass graft was removed. The pseudoaneurysm was repaired. An ilia profunda bypass with Artegraft was performed. Estimated blood loss was 3500mL.
Pseudoaneursym or “false” aneurysm is an encapsulated collection of blood that communicates with the adjacent artery. It occurs when there is an injury or disruption to one or more layers of the wall of the artery. The most common cause of pseudoaneurysms is the use of catheters required for endovascular interventions. Blunt or penetrating trauma, post-surgical bypass and graft infection may also cause pseudoaneurysms. The most common site for a pseudoaneurysm is the right common femoral artery. Symptoms are pain, bruising, pulsitlie mass, rapidly enlarging mass and swelling. Sonographic findings include: a hypoechoic collection outside the arterial lumen near puncture site. There may be mural thrombus, pulsitility and varying echogenicity. Color Doppler will show a swirling pattern of blood flow within lumen (yin-yang sign) and communication between the pseudoaneurysm and adjacent artery. Spectral Doppler will show a pendulum or “to and fro” waveform in neck. This is due to pressure pushing blood through the pseudoaneurysm and back out of the neck. Pseudoaneurysms may be unilocular or multilocular, may contain thrombus and vary in size. Small pseudoaneurysms may spontaneously thrombose while larger pseudoaneurysms greater them 3cm are at greater risk of rupture and fatal hemorrhage.
Pseudoaneurysms may be treated with Duplex ultrasound-guided compression in which pressure is applied at 10 minute intervals on the pseudoaneurysm and neck by the ultrasound probe. Four attempts are usually made and if successful ablation is achieved, the patient is kept flat on bed for 6-8 hours with sandbag on groin area. Patient must be evaluated after 24 hrs. Percutaneous thrombin injection is performed under real-time grey scale. It is cost effective relatively safe and an alternative method of treatment using bovine thrombin to occlude the pseudoaneurysm. Other treatments include endovascular stent and surgical intervention.
Textbook of Diagnostic Medical Sonography; Seventh Edition/Volume 2; Sandra L. Hagen-Ansert, MS, RDMS, RDCS, FASE, FSDMS
Diagnostic Medical Sonography: The Vascular System; First Edition; Ann Marie Kupinski, PhD, RVT, RDMS, FSVU
Clinical Guide To Ultrasonography;Charlotte Henningsen, MS, RT, RDMS, RVT
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Case Number: 64786834Last Updated: 2013-04-28 The reader is fully responsible for confirming the accuracy of this content.
The reader is fully responsible for confirming the accuracy of this content.