What is the management approach for pseudoaneurysm?

Pseudoaneurysm Management

Pseudoaneurysms require intervention if symptomatic, rapidly expanding, or at risk of complications, with surgical repair being the preferred definitive treatment for most cases. 1

Definition and Classification

A pseudoaneurysm (false aneurysm) is a dilation of an artery due to disruption of all wall layers, which is only contained by periarterial connective tissue. Unlike true aneurysms, pseudoaneurysms lack a complete arterial wall structure.

Diagnosis

• Duplex ultrasound is the primary diagnostic tool to confirm pseudoaneurysm and assess:
  • Size
  • Presence of thrombus
  • Flow characteristics
  • Status of arterial inflow and outflow 1
• CT or MRI may be needed for deeper or more complex pseudoaneurysms 1

Management Algorithm

1. Asymptomatic Pseudoaneurysms

• Small (<2.0 cm) asymptomatic pseudoaneurysms:

  • Observation with follow-up ultrasound at 1 month 1
  • Many will thrombose spontaneously (up to 61% resolve within 7-52 days) 1

• Asymptomatic pseudoaneurysms ≥2.0 cm:

  • Consider intervention based on location and risk factors
  • Femoral pseudoaneurysms ≥2.0 cm that persist should undergo repair 1

2. Symptomatic Pseudoaneurysms

• All symptomatic pseudoaneurysms require intervention regardless of size 1
• Symptoms/complications include:
  • Pain
  • Rapid expansion
  • Skin erosion/breakdown
  • Compression of adjacent structures
  • Risk of rupture
  • Hemorrhage

3. Anastomotic Pseudoaneurysms

• All anastomotic pseudoaneurysms require definitive surgical treatment 1

4. Treatment Options

A. Surgical Treatment

• First-line therapy for:
  • Symptomatic pseudoaneurysms
  • Large or rapidly expanding pseudoaneurysms
  • Anastomotic pseudoaneurysms
  • Failed non-surgical management
  • Infected pseudoaneurysms
  • Pseudoaneurysms with skin erosion or hemorrhage 1

B. Non-surgical Options

• Ultrasound-guided compression:

  • For smaller, uncomplicated pseudoaneurysms
  • Less effective for large pseudoaneurysms or in anticoagulated patients 1

• Ultrasound-guided thrombin injection:

  • Effective for most femoral pseudoaneurysms
  • Success rates of 91-98% 2
  • Contraindicated in pseudoaneurysms with wide necks due to risk of arterial thrombosis

• Endovascular stent grafting:

  • Reserved for special circumstances:
    • Patients with contraindications to surgery
    • Lack of surgical options
  • Caution: increased risk of infection compared to other approaches 1

Special Considerations

Femoral Artery Pseudoaneurysms

• Most common type, often iatrogenic after catheterization
• Management based on size:
  • <2.0 cm: Observation with follow-up ultrasound at 1 month
  • ≥2.0 cm: Intervention if persistent 1

Visceral Pseudoaneurysms

• Higher risk of rupture compared to peripheral pseudoaneurysms
• Intervention indicated for visceral pseudoaneurysms ≥2.0 cm 1
• Open repair or endovascular approach based on anatomy and patient factors

Aortic Pseudoaneurysms

• Require urgent intervention due to high risk of fatal rupture 1
• Endovascular approaches often preferred if anatomically suitable

Pitfalls and Caveats

1. Delayed recognition: Regular monitoring of at-risk patients is essential
2. Underestimating urgency: Symptomatic pseudoaneurysms require prompt intervention
3. Inappropriate cannulation: Avoid cannulating pseudoaneurysms for dialysis access; if absolutely necessary, cannulate only at the base, never the top 1
4. Incomplete imaging: Always assess for associated arterial stenosis or other vascular abnormalities that may need correction during definitive treatment
5. Infection risk: Infected pseudoaneurysms require surgical debridement and targeted antibiotic therapy

Follow-up

• For conservatively managed pseudoaneurysms: Ultrasound follow-up at 1 month
• For treated pseudoaneurysms: Clinical and ultrasound follow-up to ensure resolution and detect recurrence