What is vascular erosion?

Vascular Erosion Definition

Vascular erosion is the pathological process where a blood vessel wall is worn away or penetrated by an adjacent structure, resulting in vessel wall compromise that can lead to hemorrhage, thrombosis, or fistula formation.

Primary Mechanisms and Contexts

Vascular erosion occurs through several distinct pathophysiological processes depending on the clinical context:

Graft-Related Erosion

• Erosion of vascular grafts through overlying tissue represents a serious complication where the prosthetic material penetrates the skin or adjacent structures, typically occurring in extracavitary locations like the groin 1.
• This manifests as visible graft material with purulent drainage and represents a surgical emergency requiring prompt recognition and definitive management 1.
• Intra-abdominal vascular graft erosion into the duodenum or colon occurs in 1-2% of patients after aortic reconstruction, creating fistulous communications between the aorta and bowel 1.
• As many as 30% of intra-abdominal vascular graft infections result from erosion into the duodenum (most common) or colon 1.

Aneurysm-Related Erosion

• Vertebral body erosion from aortic aneurysms occurs when chronic contained rupture and pulsatile pressure cause progressive bone destruction 1.
• The mechanism involves chronic pulsatile trauma combined with inflammatory and proteolytic activity of blood against adjacent structures 1.
• This typically occurs with large aneurysms (mean diameter 7.056 cm) where chronic pressure causes vertebral lysis 1.

Catheter-Related Erosion

• Central venous catheter vascular erosion occurs when the catheter tip penetrates through the vessel wall, typically in the superior vena cava 2, 3.
• This presents with sudden onset dyspnea or chest pain with pleural effusions developing 1-7 days after catheter insertion 2, 3.
• Left-sided catheter placement is a major risk factor, particularly when the catheter tip abuts the SVC wall within approximately 45 degrees of perpendicular 3.

Clinical Presentations by Type

Dialysis Access Erosion

• Skin erosion at hemodialysis access cannulation sites represents a surgical emergency with significant risk of life-threatening infection, rupture, and bleeding 1.
• Warning signs include marked skin thinning, ulceration, eschar formation, spontaneous bleeding, or pseudoaneurysm formation 1.
• The presence of skin erosion or active hemorrhage in the setting of pseudoaneurysm necessitates prompt surgical management 1.

Endothelial Erosion (Plaque Erosion)

• Plaque erosion is characterized by defective endothelial layer in the intima promoting thrombus formation with an intact fibrous cap, causing approximately 30% of acute coronary syndromes 4, 5.
• This occurs predominantly in younger women (<50 years) and smokers exposed to elevated or oscillatory flow environments 5.

Critical Diagnostic Features

Imaging Characteristics

• Vertebral erosion from aneurysms shows smooth, well-defined lytic margins (unlike irregular margins seen in infection) on CT imaging 1.
• CVC vascular erosion presents with unilateral or bilateral pleural effusions and mediastinal widening, with pleural fluid showing transudative characteristics and glucose concentrations exceeding serum values 2, 3.

Time Course

• CVC erosions typically manifest within 60 hours of catheter placement (average), though diagnosis is often delayed 16.7 hours after symptom onset 2.
• Graft erosions can occur early (<2 months postoperatively) with systemic sepsis signs, or late (>2 months) with indolent local findings 1.

Common Pitfalls

• Misdiagnosis of vertebral erosion from aneurysm as neoplastic, infectious, or inflammatory processes is common due to the pseudotumoral appearance 1.
• Delayed recognition of CVC erosion occurs because initial presentations mimic respiratory insufficiency, cardiac failure, or pulmonary embolism rather than vascular injury 2.
• Underestimating the urgency of skin changes at dialysis access sites can lead to catastrophic hemorrhage or sepsis 1.