Intervention for Arterial Pseudoaneurysm

1. Intervention for
Arterial Pseudoaneurysm
ThS BS Lê Văn Duy
Khoa Tim Mạch Can Thiệp
Bệnh Viện Trung Ương Huế

2. Overview
• The increase in the number of surgical and arteriographic procedures
has caused a higher prevalence of pseudoaneurysms.
• Conventional angiography is still the gold standard method for
diagnosis, but other imaging modalities such as duplex Doppler
ultrasonography, magnetic resonance angiography and computed
tomographic angiography are useful in noninvasive detection.
• Over the past few years, interventional radiological treatment has
evolved and taken the place of surgery in management.

3. in this presentation, we will use 6 special case to discuss
pseudoaneurysms and their appropriate treatment by interventional
radiological methods. What for:
1. Understanding more cause, some apropriate strategies and suitable
devices.
2. Sharing our experiences to deal some difficle cases at Hue Central
Hospital.

4. • Pseudoaneurysms are common vascular abnormalities
that occur from a defect in the arterial wall.
• Blood leaks through the disrupted wall into the
surrounding tissue, which leads to a persistent
communication between the originating artery and the
nearly cavity.
• Pseudoaneurysms have a variety of causes, such as
inflammation, trauma, and various iatrogenic causes
such as surgery, percutaneous biopsy, drainage, and
postcatheterization
• Pseudoaneurysms may occur in any damaged vessel
including the carotid, extremity and visceral arteries

5. Epidemiology
• The reported incidence of postcatheterization pseudoaneurysms ranged
from 0.05% to 2%
• The increasing use of large-sized catheters and periprocedural
anticoagulation and antiplatelet therapy has caused higher incidence of
pseudoaneurysms

6. Ultrasonography
• US is a useful, easy, cost-effective method and mostly the first choice
in diagnosis of femoral artery pseudoaneurysms.
• A prospective study proved high sensitivity (94%) and specificity
(97%) for the diagnosis of peripheral pseudoaneurysms by using
duplex.

8. CT Scaner
• Contrast-enhanced helical CT angiography has been reported as a
convenient imaging modality in the detection of neck, chest, abdomen,
pelvis and extremity pseudoaneurysms
• Hemorrhage may be detected with intermediate or high attenuation
adjacent to the pseudoaneurysm. Thrombosis can also be seen as
high attenuation within the sac in unenhanced CT scans
• High attenuation adjacent to the pseudoaneurysm reveals the most
serious complication, rupture

9. Conventional angiography
• Conventional angiography continues to be the standard method for the
diagnosis of pseudoaneurysm
• conventional angiography provides endovascular treatment options
including embolization and stent-graft placement.
• Deciding on the appropriate treatment option for a pseudoaneurysm is
an important issue. Angiography helps to solve this problem.
• Donor artery, the neck of the pseudoaneurysm, vascular supply, and
collateral vascular structures can be evaluated with angiography.
Sacrification of the donor artery and the treatment choice depend on
these conditions

10. Treatment
• As a general consensus, symptomatic pseudoaneurysms should be
treated.
• On the other hand, it is a controversial issue that asymptomatic
pseudoaneurysms should be treated or followed up.
• Depending on size and location, it is reported in the literature that
some pseudoaneurysms may undergo non-surgical treatment:
ultrasound guided compression (USGC), thrombin therapy, arterial
embolisation, endovascular stent graft insertion

11. Surgical treatment
• Disadvantages: long hospitalization time, requirement of general
anesthesia and bad wound healing in patients with comorbidities.
• Surgery has higher morbidity and mortality rates compared to
interventional radiological treatment options.
• Complications: bleeding, infection, myocardial infarction, and death…

12. • With technological development, interventional radiological treatment
methods have taken the first place in the treatment of pseudoaneurysms.
• Nevertheless, surgery is still the gold standard treatment method in
infected pseudoaneurysms, rapid growth, ischemia, neuropathy, and
failure of percutaneous or endovascular treatment

13. Ultrasound-guided compression

14. Ultrasound-guided compression

15. Percutaneous thrombin injection
• Thrombin, which is the active form of
prothrombin,converts inactive fibrinogen
into fibrin.
• Fibrindirectly takes part in the formation
of a thrombus.

16. Endovascular approach
• Endovascular management helps to eliminate the pseudoaneurysms
from the circulation.
• There are two main methods in general practice: embolization and
stent placement
• Placement of covered stents should be performed in large-diameter
and relatively smooth vessels due to the need of stiffer and larger
systems

17. Vascular access and Closure

18. Case 1
• Bệnh nhân nam 40 tuổi, có tiền sử tăng
huyết áp vào viện vì đau ngực
• CT scanner: túi giả phình động mạch chủ
lớn sau động dưới đòn trái
• Được chỉ định can thiệp đặt stentgraft
động mạch chủ sau khi phẫu thuật mở
rộng vùng landingzone

19. Case 1

22. Case 2
• Bệnh nhân nữ 28 tuổi đang điều trị lao
màng phổi và cột sống. Phát hiện đau nhiều
vùng thượng vị xuyên ra sau lưng
• CT Scaner: phát hiện túi giả phình lớn ở
đoạn trên động mạch chủ bụng, trên thân
tạng; dọa vỡ/vỡ
• Sử dụng miếng phụ stentgraft ĐMC ngực
phủ kín hoàn toàn túi phình, phía trên ĐM
thân tạng

23. Case 2

25. Case 3
• Bệnh nhân nam 30 tuổi, vào viện
vì vết thương thấu bụng do dao
đâm. Được phẫu thuật cầm máu,
xúc rửa ổ bụng.
• CT Scaner: ghi nhận túi giả
phình lớn ở động mạch thận trái
• Chỉ định: đặt Coverstent
(BeGraft)

26. Case 3

29. Case 4
• Bệnh nhân nam 35 tuổi, vào viện vì chấn thương gia tốc vùng ngực.
Sau đó được dẫn lưu tràn khí màng phổi.
• CT Scaner: phát hiện túi giả phình ĐM dưới đòn phải, ĐM đốt sống
bên trái ưu thế
• Chỉ định: đăt stent Coverstent nong bằng bóng (BeGraft)

30. Case 4

32. Case 5
• Bệnh nhân nam 50 tuổi, u đầu
tụy, đã phẫu thuật bóc U
• CT Scaner hậu phẫu kiểm tra:
phát hiện túi giả phình lớn ở
động mạch mạc treo tràng trên,
doa vỡ/ vỡ
• Chỉ định: đặt coverstent tự bung

33. Case 5

36. Case 6
• Bệnh nhân nam 50 tuổi đang điều trị áp xe vùng thắt lưng đùi đã
phẫu thuật
• CT Scaner: túi giả phình ĐM chậu chung phải
• Chỉ định: đặt Coverstent nong bằng bóng

37. Case 6

39. Conclusion
1. The increase in the number of surgical and arteriographic procedures
has caused higher prevalence of pseudoaneurysms recently.
2. Diagnosis and optimal management are crucial due to the fact that
pseudoaneurysms have life-threatening complications if not treated.
3. Radiology offers alternative minimally invasive techniques that are
associated with lower morbidity and mortality rates and have taken
the place of surgery in the treatment