This case report describes a late pseudoaneurysm that developed at the puncture site in a 30-year old male with systemic lupus erythematosus (SLE) and antiphospholipid antibody syndrome (APLA) who underwent coronary angiography. Two weeks after the procedure, an enlarging pulsatile bulge was detected at the puncture site. Ultrasound-guided thrombin injection resolved the pseudoaneurysm. The authors speculate that patients with chronic inflammatory diseases treated with anticoagulation and steroids may be predisposed to late pseudoaneurysm formation due to vessel wall weakness. Close follow-up is recommended for high-risk patients.

1. Sa’ar
Minha
M.D,
Chen
David
M.D,
Alex
Blatt
M.D,
Ricardo
Krakover
M.D
and
Alberto
Hendler
M.D
FESC
Dept.
of
Cardiology
&
Dept.
of
Vascular
Surgery
,
Assaf
Harofeh
Medical
Center.
Zerifin

2. Background
— Patient
characteristics:
— 30-­‐year-­‐old
male
— Hx
of
systemic
lupus
erythematosus
(SLE)
since
the
age
of
15.
— Diagnosed
as
APLA
syndrome
at
the
age
of
19
after
an
embolic
event
involving
the
spleen.
— On
chronic
warfarin
therapy,
corticoesteroids
and
anti-­‐
inflammatory
drugs
(plaquanil).
— Positive
family
history
of
CAD.

3. Clinical
Characteris3cs
— Effort
dyspnea
and
non-­‐specific
chest
pain
— Echo-­‐Doppler
demonstrated
LVEF
of
50%
&
regional
wall
motion
abnormalities
(apico-­‐inferior
hypokinesis)
— Referred
to
an
elective
coronary
angiography.

4. Procedural
Characteris3cs
— 5
days
prior
to
the
procedure
the
oral
anticoagulation
therapy
was
replaced
by
LMWH
(60
mg
bid),
while
continuing
the
steroids
and
the
anti-­‐inflammatory
medication.
— The
last
dose
of
LMWH
was
given
the
morning
of
the
procedure,
about
8
hours
before.
— ASA
100
mg
was
added
at
admission.

5. Procedural
Characteris3cs
cont’
— Coronary
Angiography
— Right
radial
approach
— 6F
radial
vascular
sheath.
— Prior
to
angiography
we
routinely
inject
through
the
vascular
sheath:
UFH
2500
units
and
2
cc
of
5
mg
of
Verapamil
diluted
to
10
cc
with
NS
0.9%.
— Coronary
angiography
was
performed
utilizing
a
Judkin’s
technique
and
demonstrated
normal
coronary
arteries.
— No
additional
UFH
or
Verapamil
was
administered.
— The
vascular
sheath
was
immediately
removed
and
local
hemostasis
performed
manually.
— The
patient
was
discharged
4
hrs.
after
the
procedure.

6. Procedural
Outcome
— 3
days
after
parallel
therapy
with
warfarin
and
LMWH,
when
a
therapeutic
INR
was
achieved,
the
LMWH
was
interrupted.
— Two
weeks
after
the
procedure,
a
2x2
cm
pulsatile
bulge
appeared
at
the
puncture
site
and
the
patient
was
referred
to
a
Dupplex-­‐US
of
the
puncture
site.

8. at
the
puncture
site US-­‐Doppler

9. at
the
puncture
site US-­‐Doppler

10. Treatment
— After
local
thrombin
injection
under
ultrasound
guidance,
the
pseudoaneurysm
was
resolved

11. US-­‐Doppler-­‐
post
injec3on

12. Discussion
— Late
appearance
of
pseudoaneurysm
is
rare
with
few
reported
cases
in
the
literature.
— pseudoaneurysms
are
caused
by
trauma,
vasculitis,
infections
and
iatrogenic
causes-­‐all
promoting
weakness
of
the
vessel
wall
supporting
structures.
— Pseudoaneurysm
rupture
and
bleeding
to
the
forearm
can
have
devastating
outcome.
— We
speculate
that
patients
presenting
with
chronic
inflammatory
diseases
(SLE,
APLA,
vasculitis),
treated
by
both
anticoagulation
and
steroids
all
may
predispose
to
aforementioned
complication.

13. Discussion
— Recommendation:
— Considering
alternatives
to
diagnostic
angiography
— MSCT/SPECT/CMR
— Close
follow-­‐up
is
warranted
in
patients
predisposed
to
this
complication.
— Issues
of
controversy
— Anticoagulation
— Option
I:
Due
to
its
short
half-­‐life,
a
continuation
of
LMWH
for
one
week
before
re-­‐initiation
of
warfarin
is
suggested.
— Option
II:
Performing
the
procedure
on
warfarin
with
low
initial
INR
— Sheath
removal
and
compression
(manual
vs.
mechanical)