What is the management of a pseudoaneurysm?

From the Guidelines

Pseudoaneurysm repair is always indicated regardless of size or position to prevent progression and rupture, and treatment options include open surgery or endovascular treatment with occluders, stent grafts, or coils, as decided by a multidisciplinary team in specialized centers. The management of a pseudoaneurysm is a critical decision that prioritizes preventing morbidity, mortality, and improving quality of life. According to the most recent guidelines, pseudoaneurysms can be treated by open surgery or endovascular treatment, and the choice of treatment is commonly based on anatomical features, clinical presentation, and the patient’s comorbidities 1.

Some key considerations in the management of pseudoaneurysms include:

• The size and location of the pseudoaneurysm
• The presence of symptoms such as pain or compression of surrounding structures
• The patient's comorbidities and risk factors for complications
• The availability of multidisciplinary teams and specialized centers for treatment

In some cases, pseudoaneurysms may be monitored with close follow-up using imaging modalities such as CCT, CMR, or TOE, and intervention can be postponed unless size expansion, symptoms, or compression of surrounding structures occur 1. However, the primary goal of treatment is to prevent progression and rupture, and to improve quality of life for the patient.

It is worth noting that older guidelines and studies may suggest more conservative management approaches, such as observation or ultrasound-guided compression therapy for small asymptomatic pseudoaneurysms 1. However, the most recent and highest quality evidence prioritizes a more proactive approach to pseudoaneurysm management, with a focus on preventing complications and improving patient outcomes 1.

From the Research

Management of Pseudoaneurysms

The management of pseudoaneurysms can be categorized into several approaches, including non-surgical and interventional methods.

• Non-surgical methods comprise of:
  • Ultrasound guided compression (USGC) 2, 3, 4
  • Thrombin therapy 2, 3, 4
  • Arterial embolisation 2
  • Endovascular stent graft insertion 2, 5
• Interventional methods include:
  • Percutaneous ultrasound-guided thrombin injection 3, 4
  • Endovascular procedures such as coil embolisation 2, 5
  • Surgical repair 3, 4

Treatment Outcomes

The outcomes of these treatment methods have been evaluated in various studies, with reported success rates ranging from 63.6% for ultrasound-guided compression to 100% for conservative treatment and surgery 6.

• The choice of treatment method depends on factors such as the location and size of the pseudoaneurysm, as well as the efficacy of the technique 2, 5.
• A 10-year retrospective review of pseudoaneurysm management found that endovascular treatment and surgery were more successful than ultrasound-guided compression and thrombin injection 6.

Imaging Modalities

Imaging modalities such as color doppler, multidetector computerised tomography (CT), and angiography are used to evaluate pseudoaneurysms 2, 5.

• Conventional angiography is still considered the gold standard method for diagnosis, but other imaging modalities such as duplex Doppler ultrasonography and magnetic resonance angiography are also useful in noninvasive detection 5.