What are the treatment options for pseudoaneurysm (false aneurysm) repair?

Pseudoaneurysm Repair Treatment Options

Patients with anastomotic pseudoaneurysms or symptomatic pseudoaneurysms should undergo repair to reduce the risk of thromboembolic complications and limb loss. 1

Diagnostic Approach

• Duplex ultrasound should be obtained whenever a pseudoaneurysm is suspected, as physical examination alone may miss more than 60% of pseudoaneurysms 1, 2
• Ultrasound helps confirm diagnosis and provides information on size, presence of stenosis/thrombus, and impact on arterial flow 1, 2
• For femoral or popliteal aneurysms, additional imaging (ultrasound, CT, or MRI) is recommended to exclude contralateral aneurysms and abdominal aortic aneurysm 1

Treatment Algorithm Based on Size and Symptoms

Small Asymptomatic Pseudoaneurysms (<2.0 cm)

• Conservative management is appropriate for small asymptomatic pseudoaneurysms, as studies show 61% resolve spontaneously within 7-52 days 1, 2
• Re-evaluation by ultrasound is recommended 1 month after the original injury 1
• If still present at 2 months follow-up, consider more definitive treatment 2

Larger or Symptomatic Pseudoaneurysms

• For pseudoaneurysms ≥2.0 cm or symptomatic, more aggressive treatment is warranted 1
• Treatment options include:

1. Minimally Invasive Options

• Ultrasound-guided compression therapy:

  • First-line treatment for accessible pseudoaneurysms 2, 3
  • Success rates of 75-90% 2, 4
  • Less effective for pseudoaneurysms after coronary stenting (67% success) compared to those after diagnostic catheterization (95% success) 4

• Ultrasound-guided thrombin injection:

  • Highly effective with success rates of approximately 93% 2, 5
  • Requires injection of 100-3000 international units of thrombin 2
  • Rare complications include distal thromboembolism (<2% of cases) 2, 5
  • Contraindicated in pseudoaneurysms with wide "neck" due to risk of arterial occlusion 6

2. Surgical Management

• Open surgical repair is indicated for:

  • Pseudoaneurysms ≥2.0 cm that persist or recur after ultrasound-guided compression or thrombin injection 1
  • Anastomotic pseudoaneurysms 1
  • Symptomatic, large, or rapidly expanding pseudoaneurysms 1, 2, 7
  • Complications such as rupture, skin erosion, or expanding rupture into adjacent tissues 1, 2

• Endovascular treatment options:

  • Covered stents (stent grafts) may be used in special circumstances when surgery is contraindicated 1, 3
  • Cannulation over stent graft segments should be avoided when possible 1
  • Note: Use of stent grafts for pseudoaneurysm management is not FDA-approved 1

Special Considerations

Urgent Surgical Intervention Required For:

• Rupture into surrounding tissues 1, 2, 7
• Skin erosion 1, 2
• Venous thrombosis or painful neuropathy from compression of adjacent structures 2, 7
• Active hemorrhage 2, 7

Arteriovenous Access Pseudoaneurysms

• Surgical management is the preferred treatment for symptomatic, large, or rapidly expanding AV access aneurysm/pseudoaneurysm 1
• Avoid cannulating the access segment(s) involving the aneurysm/pseudoaneurysm if alternative sites are available 1
• If no alternative cannulation sites exist, cannulate the sides (base) of the aneurysm/pseudoaneurysm, avoiding the top 1

Aortic Pseudoaneurysms

• Repair is generally indicated regardless of size or position to prevent progression and rupture 1
• Treatment options include open surgery or endovascular approaches (occluders, stent grafts, or coils) 1
• Treatment choice should be based on anatomical features, clinical presentation, and patient comorbidities 1

Monitoring and Follow-up

• For conservatively managed pseudoaneurysms, follow-up ultrasound is recommended at 1 month 1
• If no resolution by 2 months, consider more definitive treatment 2
• Administration of antiplatelet medication may be beneficial in patients with femoral or popliteal artery aneurysms 1