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Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Stent Graft – A minimally invasive approach in the management of post-traumatic pseudoaneurysms
Stent Graft – A minimally invasive approach in the management of post-traumatic pseudoaneurysms
Contributed by : Rushabh Shirish Mehta
Contributed by : Rushabh Shirish Mehta
Introduction:
Introduction:
False aneurysms, or pseudoaneurysms, are abnormal outpouchings of arteries that are enclosed only by the tunica adventitia. Pseudoaneurysms represent a disruption in arterial wall continuity. Unlike true aneurysms, which involve all three layers of the arterial wall, pseudoaneurysms occur when the vessel wall is breached, allowing blood to escape through the inner layers. However, the blood remains contained by the adventitia or the surrounding perivascular soft tissue.
False aneurysms, or pseudoaneurysms, are abnormal outpouchings of arteries that are enclosed only by the tunica adventitia. Pseudoaneurysms represent a disruption in arterial wall continuity. Unlike true aneurysms, which involve all three layers of the arterial wall, pseudoaneurysms occur when the vessel wall is breached, allowing blood to escape through the inner layers. However, the blood remains contained by the adventitia or the surrounding perivascular soft tissue.
Some complications associated with pseudoaneurysms develop unpredictably and carry high morbidity and mortality rates. The advent of new radiologic techniques with a greater sensitivity for asymptomatic disease has allowed more frequent diagnosis of pseudoaneurysms. Conventional angiography remains the standard of reference for diagnosis but is an invasive procedure, and noninvasive diagnostic modalities (eg, ultrasonography [US], computed tomographic angiography, magnetic resonance angiography) should be included in the initial work-up if possible. Therapeutic options have evolved in recent years from the traditional surgical option toward a less invasive approach and include radiologic procedures such as US-guided compression, US-guided percutaneous thrombin injection, and endovascular management (embolization, stent-graft placement). The use of noninvasive treatment has led to marked decrease in the morbidity and mortality rates for pseudoaneurysms [1]
Some complications associated with pseudoaneurysms develop unpredictably and carry high morbidity and mortality rates. The advent of new radiologic techniques with a greater sensitivity for asymptomatic disease has allowed more frequent diagnosis of pseudoaneurysms. Conventional angiography remains the standard of reference for diagnosis but is an invasive procedure, and noninvasive diagnostic modalities (eg, ultrasonography [US], computed tomographic angiography, magnetic resonance angiography) should be included in the initial work-up if possible. Therapeutic options have evolved in recent years from the traditional surgical option toward a less invasive approach and include radiologic procedures such as US-guided compression, US-guided percutaneous thrombin injection, and endovascular management (embolization, stent-graft placement). The use of noninvasive treatment has led to marked decrease in the morbidity and mortality rates for pseudoaneurysms [1]
Case presentation:
Case presentation:
A 44 year old man with history of road traffic accident causing trauma to right side of neck and clavicle presented with complaints of gradually increasing swelling in right supraclavicular region and hoarseness of voice since 6-7 months.
A 44 year old man with history of road traffic accident causing trauma to right side of neck and clavicle presented with complaints of gradually increasing swelling in right supraclavicular region and hoarseness of voice since 6-7 months.
On clinical examination a 5 cm x 5 cm. firm swelling was palpable in right supraclavicular region. There was no restriction movements in right arm; both radial and ulnar pulses were palpable. Blood investigations revealed haemoglobin-13.4 gm%, WBC count- 5800/mm3),Platelet count: 200,000/mm3,PT/INR-1.06.
On clinical examination a 5 cm x 5 cm. firm swelling was palpable in right supraclavicular region. There was no restriction movements in right arm; both radial and ulnar pulses were palpable. Blood investigations revealed haemoglobin-13.4 gm%, WBC count- 5800/mm3),Platelet count: 200,000/mm3,PT/INR-1.06.
The frontal chest radiograph (Figure 1) shows a soft tissue lesion, about 6 cm diameter in the right paratracheal region extending from the right supraclavicular region to the right hilum.
The frontal chest radiograph (Figure 1) shows a soft tissue lesion, about 6 cm diameter in the right paratracheal region extending from the right supraclavicular region to the right hilum.
Figure 1: Frontal chest radiograph showing soft tissue lesion in right upper and mid zone
Contrast enhanced CT scan of chest (Figure 2) shows 4.5 x 4.5 x 8 cm sized pseudoaneurysm arising from the right subclavian artery.
Contrast enhanced CT scan of chest (Figure 2) shows 4.5 x 4.5 x 8 cm sized pseudoaneurysm arising from the right subclavian artery.
Figure 2 a b c d : Contrast enhanced CT scan shows a partly thrombosed pseudoaneurysm of right subclavian artery.
Interventional technique:
Interventional technique:
Under aseptic precautions and monitored anesthesia care, digital subtraction angiography was performed through 7F right femoral access and an angiogram obtained using a 4F pigtail catheter. This shows the pseudoaneurysm (Video 1, Figure 3) in the right subclavian artery ~1cm from its origin with a 6.7 mm neck.
Under aseptic precautions and monitored anesthesia care, digital subtraction angiography was performed through 7F right femoral access and an angiogram obtained using a 4F pigtail catheter. This shows the pseudoaneurysm (Video 1, Figure 3) in the right subclavian artery ~1cm from its origin with a 6.7 mm neck.
video 1.mp4Video 1 : Digital subtraction angiography shows the pseudoaneurysm of the right subclavian artery with active extravasation of contrast
Figure 3 : Pseudoaneurysm of right subclavian artery with active extravasation of contrast
Right brachial artery access was used and through it, a marker pigtail was advanced into the aortic arch. Following this, a 8mm x 37mm stent graft was deployed acrosse the neck of the pseudoaneurysm.
Right brachial artery access was used and through it, a marker pigtail was advanced into the aortic arch. Following this, a 8mm x 37mm stent graft was deployed acrosse the neck of the pseudoaneurysm.
After deployment of the stent graftm a repeat angiogram showed a small sluggish endoleak (Video 2, Figure 4).
After deployment of the stent graftm a repeat angiogram showed a small sluggish endoleak (Video 2, Figure 4).
video 2.mp4
Video 2 : Post Stent graft angiograph showing endoleak
Figure 4 : Post Stent graft angiogram showing jet of endoleak
Repeat angiogram was obtained after 72 hours through a left femoral access. It showed complete resolution of the endoleak with good flow in distal arteries (Video 3, Figure 5)
Repeat angiogram was obtained after 72 hours through a left femoral access. It showed complete resolution of the endoleak with good flow in distal arteries (Video 3, Figure 5)
video3.mp4
Video 3: No evidence of endoleak with good distal flow
Figure 5: No evidence of endoleak
Post procedure contrast enhanced CT scan (Figure 6a,6b,6c) showed no active extravasation of contrast into pseudoaneurysm with normal flow across stent graft and distal arteries.
Post procedure contrast enhanced CT scan (Figure 6a,6b,6c) showed no active extravasation of contrast into pseudoaneurysm with normal flow across stent graft and distal arteries.
Figure 6a 6b : Stent graft in the right subclavian artery with no extravasation of contrast
Figure 6c : volume rendered image shows stent the graft in right subclavian artery with normal flow in arteries of right upper limb
After confirming complete resolution of yje endoleak, the patient was discharged the following day on antiplatelet medications (Tab.Aspirin 75mg and Tab.clopidogrel 75mg) and advised follow up with Contrast enhanced CT scanafter 6 months to check resolution of residual clot.
After confirming complete resolution of yje endoleak, the patient was discharged the following day on antiplatelet medications (Tab.Aspirin 75mg and Tab.clopidogrel 75mg) and advised follow up with Contrast enhanced CT scanafter 6 months to check resolution of residual clot.
Discussion:
Discussion:
Pseudoaneurysms are usually caused by perforation of an artery leading to the formation a hematoma between the arterial wall and surrounding parenchyma. Flowing arterial blood creates a cavity that remains in continuity with the normal vessel and becomes lined by inflammatory cells and fibroblasts and is eventually replaced by fa ibrous scar tissue [2] .
Pseudoaneurysms are usually caused by perforation of an artery leading to the formation a hematoma between the arterial wall and surrounding parenchyma. Flowing arterial blood creates a cavity that remains in continuity with the normal vessel and becomes lined by inflammatory cells and fibroblasts and is eventually replaced by fa ibrous scar tissue [2] .
There are multiple etiologies for pseudoaneurysm formation like trauma, iatrogenic (arterial catheterization), Mycotic/Infective, local inflammatory process like acute/chronic pancreatitis, vasculitis, penetrating, atherosclerotic ulcer etc.
There are multiple etiologies for pseudoaneurysm formation like trauma, iatrogenic (arterial catheterization), Mycotic/Infective, local inflammatory process like acute/chronic pancreatitis, vasculitis, penetrating, atherosclerotic ulcer etc.
In the past, pseudoaneurysms warranting intervention were traditionally managed with open repair; but the emergence of therapies that are less invasive and less expensive has reduced the frequency of surgical intervention.
In the past, pseudoaneurysms warranting intervention were traditionally managed with open repair; but the emergence of therapies that are less invasive and less expensive has reduced the frequency of surgical intervention.
Open pseudoaneurysm repair is now more frequently performed in the setting of failure or contraindication to less invasive therapies. Primary open repair of femoral pseudoaneurysms should be considered in the setting of infection, skin or soft tissue ischemia, associated arteriovenous fistula, patients who are undergoing general anesthesia for another procedure (such as coronary artery bypass), or for injuries above the inguinal ligament. In the setting of infection or significant tissue ischemia, preoperative plastic surgery consultation for assistance with flap coverage may be considered.[3] Challenges like surgical site infection, prolonged hospitalization and increased risk of perioperative morbidity can be avoided by using minimally invasive techniques.
Open pseudoaneurysm repair is now more frequently performed in the setting of failure or contraindication to less invasive therapies. Primary open repair of femoral pseudoaneurysms should be considered in the setting of infection, skin or soft tissue ischemia, associated arteriovenous fistula, patients who are undergoing general anesthesia for another procedure (such as coronary artery bypass), or for injuries above the inguinal ligament. In the setting of infection or significant tissue ischemia, preoperative plastic surgery consultation for assistance with flap coverage may be considered.[3] Challenges like surgical site infection, prolonged hospitalization and increased risk of perioperative morbidity can be avoided by using minimally invasive techniques.
Complete work-up to determine the location of the pseudoaneurysm and to evaluate surrounding structures and relevant vascular anatomy is essential in the selection of the treatment technique.[1]
Complete work-up to determine the location of the pseudoaneurysm and to evaluate surrounding structures and relevant vascular anatomy is essential in the selection of the treatment technique.[1]
Mycotic etiology should be ruled out before placement of stent grafts as it can lead to graft site infection. In the above mentioned case, the pseudoaneurysm was of traumatic etiology and had a wide neck; mycotic etiology could be ruled out as patient had no history of fever or raised WBC counts. The subclavian artery is principal artery supplying upper limbs having large caliber and less tortuosity, any vascular compromise could lead to limb ischemia and gangrene.
Mycotic etiology should be ruled out before placement of stent grafts as it can lead to graft site infection. In the above mentioned case, the pseudoaneurysm was of traumatic etiology and had a wide neck; mycotic etiology could be ruled out as patient had no history of fever or raised WBC counts. The subclavian artery is principal artery supplying upper limbs having large caliber and less tortuosity, any vascular compromise could lead to limb ischemia and gangrene.
When the neck of the pseudoaneurysm is wide, a stent-graft (covered stent) placement across the neck to exclude the pseudoaneurysm is the treatment of choice. Stent-graft placement requires a higher profile and a stiffer delivery system than does catheter-directed coil embolization. As a result, the arterial anatomy and the caliber of the arteries leading to and at the pseudoaneurysm site should be favorable (ie, reduced arterial tortuosity and large-diameter arteries). An additional reason for placing stent-grafts only in larger arteries is that in small arteries they pose a higher risk of thrombosis. Visceral pseudoaneurysms, which are usually smaller and located off small and tortuous donor arteries, pose a particular challenge for stent-graft placement.
When the neck of the pseudoaneurysm is wide, a stent-graft (covered stent) placement across the neck to exclude the pseudoaneurysm is the treatment of choice. Stent-graft placement requires a higher profile and a stiffer delivery system than does catheter-directed coil embolization. As a result, the arterial anatomy and the caliber of the arteries leading to and at the pseudoaneurysm site should be favorable (ie, reduced arterial tortuosity and large-diameter arteries). An additional reason for placing stent-grafts only in larger arteries is that in small arteries they pose a higher risk of thrombosis. Visceral pseudoaneurysms, which are usually smaller and located off small and tortuous donor arteries, pose a particular challenge for stent-graft placement.
This method is relatively contraindicated in mycotic pseudoaneurysms due to potential stent- graft infection.[1]
This method is relatively contraindicated in mycotic pseudoaneurysms due to potential stent- graft infection.[1]
References :
References :
1. Saad NE, Saad WE, Davies MG et-al. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics. 2005;25 Suppl 1 : S173-89. doi:10.1148/rg.25si055503 - Pubmed citation
1. Saad NE, Saad WE, Davies MG et-al. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics. 2005;25 Suppl 1 : S173-89. doi:10.1148/rg.25si055503 - Pubmed citation
2. : S. E. Anderson, D. De Monaco, U. Buechler, J. Triller, U. Gerich, M. Dalinka, E. Stauffer, L. Nagy, A. Niedecker, R. Campbell, P. A. Araoz, and L. S. Steinbach Imaging Features of Pseudoaneurysms of the Hand in Children and Adults: AJR Am J Roentgenol . 2003 Mar;180(3):659-64. .
2. : S. E. Anderson, D. De Monaco, U. Buechler, J. Triller, U. Gerich, M. Dalinka, E. Stauffer, L. Nagy, A. Niedecker, R. Campbell, P. A. Araoz, and L. S. Steinbach Imaging Features of Pseudoaneurysms of the Hand in Children and Adults: AJR Am J Roentgenol . 2003 Mar;180(3):659-64. .
Corriere MA, Guzman RJ. True and false aneurysms of the femoral artery. Semin Vasc Surg. 2005;18:216–223. doi: 10.1053/j.semvascsurg.2005.09.008. [DOI] [PubMed] [Google Scholar]
Corriere MA, Guzman RJ. True and false aneurysms of the femoral artery. Semin Vasc Surg. 2005;18:216–223. doi: 10.1053/j.semvascsurg.2005.09.008. [DOI] [PubMed] [Google Scholar]
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