What is the appropriate management for a pseudoaneurysm?

Management of Pseudoaneurysm

Pseudoaneurysm repair is indicated regardless of size or position to prevent progression and rupture, though small (<2.0 cm) asymptomatic peripheral pseudoaneurysms can be managed conservatively with close surveillance. 1, 2

Diagnostic Approach

• Obtain duplex ultrasound whenever pseudoaneurysm is suspected, as physical examination alone misses more than 60% of cases 2, 3
• Ultrasound confirms diagnosis and provides critical information on size, presence of stenosis/thrombus, and impact on arterial flow 2
• CT angiography is the gold standard for surgical planning, particularly for aortic and deep vessel pseudoaneurysms 1, 4

Location-Specific Management

Aortic Pseudoaneurysms

Aortic pseudoaneurysms require repair regardless of size or position due to high risk of fatal rupture 1

• Treatment choice depends on anatomical features, clinical presentation, and patient comorbidities, decided by a multidisciplinary team 1
• Options include open surgery or endovascular treatment (occluders, stent grafts, or coils) 1
• In select circumstances with close follow-up, intervention can be postponed unless size expansion, symptoms, or compression of surrounding structures occur 1
• Monitor with CCT, CMR, or TOE if conservative approach is chosen 1

Peripheral Pseudoaneurysms (Femoral, Facial, Superficial Temporal)

Small Pseudoaneurysms (<2.0 cm, Asymptomatic)

• Conservative management is appropriate, as 61% resolve spontaneously within 7-52 days 2
• Re-evaluate by ultrasound at 1 month after original injury 2
• If still present at 2 months follow-up, proceed to more definitive treatment 2

Large Pseudoaneurysms (≥2.0 cm) or Symptomatic

Treatment algorithm in order of preference:

1. Reapplication of compression bandage (first-line)

   • Success rate of 32% for femoral pseudoaneurysms 5
   • Success correlates inversely with anticoagulant therapy and aneurysm size 5
   • Significantly enhances success rate of subsequent ultrasound-guided compression therapy 5

2. Ultrasound-guided compression therapy (if compression bandage fails)

   • Success rates of 75-90% for accessible pseudoaneurysms 2
   • Success rate of 84% in femoral pseudoaneurysms 5

3. Ultrasound-guided thrombin injection (if compression therapy fails)

   • Highly effective with success rates of approximately 93% 2
   • Requires injection of 100-3000 international units of thrombin 2
   • Rare complications include distal thromboembolism (<2% of cases) 2

4. Observation for spontaneous thrombosis (if thrombin injection fails or not feasible)

   • Spontaneous thrombosis occurs in 93% of stable lesions after 1-180 days (median 40 days) 5

5. Open surgical repair (definitive treatment)

   • Indicated for pseudoaneurysms ≥2.0 cm that persist or recur after minimally invasive treatments 2
   • Required for symptomatic, large, or rapidly expanding pseudoaneurysms 2
   • Gold standard for anastomotic pseudoaneurysms 2
   • Remains the definitive approach for giant or complex traumatic pseudoaneurysms 6

Urgent Surgical Indications

Immediate surgical repair is necessary for: 2, 3

• Rupture into surrounding tissues or retroperitoneal space
• Skin erosion
• Active hemorrhage
• Venous thrombosis or painful neuropathy from compression of adjacent structures
• Expanding rupture into adjacent tissues

Special Considerations

Traumatic Aortic Injury with Pseudoaneurysm

• For severe aortic injury (grade 4), immediate repair is mandatory 1
• TEVAR is recommended over open surgery when suitable anatomy exists 1
• Medical therapy including pain relief, blood pressure, and heart rate control is essential in all cases 1

Cerebrovascular Pseudoaneurysms

• Require rapid surgical or endovascular intervention due to high rupture risk 7
• Flow diversion can be successful for complex presentations 7
• Severe vasospasm may preclude immediate endovascular treatment 7

Common Pitfalls

• Do not rely on physical examination alone—pseudoaneurysms can mimic hematomas or abscesses 2, 3
• Femoral pseudoaneurysms often present with groin swelling, pain, and bruising following catheterization 3
• Even minor trauma can cause significant vascular injury requiring prompt evaluation 6
• Draining sinus tract is highly suggestive of underlying vascular graft infection with pseudoaneurysm 3

Follow-Up Protocol

• For conservatively managed pseudoaneurysms, follow-up ultrasound at 1 month is recommended 2
• If no resolution by 2 months, proceed to more definitive treatment 2
• Post-embolization imaging is not routinely necessary if clinical resolution occurs 4
• Consider repeat CT angiography at 1 month if symptoms persist after intervention 4