What is the treatment for a pseudoaneurysm?

Treatment of Pseudoaneurysm

For small (<2.0 cm) asymptomatic pseudoaneurysms, conservative management with ultrasound surveillance is appropriate, while pseudoaneurysms ≥2.0 cm, symptomatic, or rapidly expanding require definitive treatment with ultrasound-guided thrombin injection as first-line therapy (93% success rate) or open surgical repair. 1

Diagnostic Confirmation

• Duplex ultrasound must be obtained whenever pseudoaneurysm is suspected, as physical examination alone misses more than 60% of cases 1
• Ultrasound provides critical information on size, presence of stenosis/thrombus, arterial flow status, and helps differentiate pseudoaneurysms from hematomas or abscesses 2, 1
• For complex cases (particularly intracranial or aortic), digital subtraction angiography (DSA) provides superior anatomic definition compared to MRA or CTA 3

Treatment Algorithm Based on Size and Clinical Presentation

Small Asymptomatic Pseudoaneurysms (<2.0 cm)

• Conservative management is the appropriate initial approach, as 61% resolve spontaneously within 7-52 days 1
• Perform follow-up ultrasound at 1 month after initial diagnosis 1
• If pseudoaneurysm persists at 2 months, proceed to definitive treatment 1
• The presence of pseudoaneurysm alone without symptoms is not an indication for immediate intervention 2

Large or Symptomatic Pseudoaneurysms (≥2.0 cm)

First-line minimally invasive options:

• Ultrasound-guided thrombin injection is highly effective with 93% success rates, requiring 100-3000 international units of thrombin 1
  • Rare complication: distal thromboembolism occurs in <2% of cases 1
• Ultrasound-guided compression therapy achieves 75-90% success rates for accessible pseudoaneurysms 1
  • Less effective after coronary stenting procedures (67% success vs 95-100% for other procedures) 4
  • Large arterial defects (≥9F sheath size) predict compression failure 4
  • Abnormal coagulation parameters do not contraindicate compression attempts 4

Definitive surgical treatment indications:

• Open surgical repair is the gold standard and definitive treatment for pseudoaneurysms 2, 5
• Specific surgical indications include:
  • Pseudoaneurysms ≥2.0 cm that persist or recur after minimally invasive treatments 1
  • Anastomotic pseudoaneurysms (usually require definitive surgical treatment) 2
  • Large, rapidly expanding, or symptomatic pseudoaneurysms 2, 1
  • Giant pseudoaneurysms (surgical resection with interposition grafting using saphenous vein) 5

Emergency/Urgent Surgical Indications

Immediate surgical assessment and treatment required for:

• Active hemorrhage or rupture 2, 1
• Skin erosion or breakdown 2, 1
• Expanding rupture into adjacent tissues 1
• Venous thrombosis or painful neuropathy from compression of adjacent structures 1
• Airway compromise (particularly cervical pseudoaneurysms) 6

Special Considerations by Location

AV Access (Dialysis) Pseudoaneurysms

• Avoid cannulating the aneurysm segment; if absolutely necessary, cannulate the sides (base) rather than the top 2
• Assess arterial inflow and venous outflow for stenosis requiring correction before definitive treatment 2
• Consider staged repair of multiple aneurysms to avoid bridging central venous catheters 2

Endovascular Alternatives

• Covered stent grafts (stent grafts) may be used only in special circumstances when surgery is contraindicated or unavailable, due to infection risk 2
• This is not an FDA-approved indication for stent grafts 2
• If stent graft is placed, avoid cannulation over the stent segment 2
• For traumatic aortic pseudoaneurysms, immediate endovascular treatment (≤2 weeks) offers advantages over delayed approach, with complete healing and shorter hospital stays 7

Intracranial/Carotid Pseudoaneurysms

• If endoscopic hemostasis fails, emergent parent vessel occlusion may be necessary 3
• Requires dual antiplatelet therapy (aspirin 325 mg daily + clopidogrel 75 mg daily) for minimum 4 weeks before transitioning to single agent 3
• Maintain ACT 300-350 seconds during procedure; continue heparin 24 hours postoperatively if arterial dissection present 3
• Assess collateral circulation via balloon test occlusion before permanent vessel occlusion 3

Critical Pitfalls to Avoid

• Do not mistake pseudoaneurysms for hematomas, abscesses, or other soft tissue masses—always obtain imaging confirmation 1, 6
• Do not attempt incision and drainage of suspected neck masses without imaging, as unrecognized pseudoaneurysms can cause life-threatening hemorrhage 6
• Even minor penetrating trauma can cause significant vascular injury requiring high index of suspicion 5
• Delayed diagnosis of deep pseudoaneurysms (e.g., superficial femoral artery) can lead to limb ischemia or rupture 5