Cases of pseudoaneurysm in the artery of vascular
access have been increasingly reported with the
growing number of invasive cardiac (coronary
angiography, angioplasty, and stenting) and vascular
interventions each year.[
1] Furthermore, rates of
pseudoaneurysm are increased with antithrombotic
therapy (heparin, warfarin, antiplatelet agents) given as an adjunct to interventional therapies due to
inhibition of coagulation cascade.[
2] Norwood et al.[
3]
reported in a retrospective study that pseudoaneurysm
was located in femoral artery in 79 (83%) of 95
patients, whereas iliac arteries (common, external) were
affected in only three (3.1%) cases. In our patient, the
pseudoaneurysm was situated in the external iliac artery.
The aforementioned study also found that the risk
of pseudoaneurysm significantly increased in patients
receiving Glycoprotein IIb/IIIa inhibitors.[
3] Coronary
angiography (with or without angioplasty/stenting) is the leading cause of pseudoaneurysms involving femoral
artery (40.5% of cases), followed by pseudoaneurysms
due to vascular graft anastomoses (29.15%), and
peripheral vascular angiography (10.1%).[
3] Currently,
ultrasound-guided thrombin injection (UGTI) remains
the mainstay of radiological pseudoaneurysm treatment.
Studies have shown that UGTI is more effective than
ultrasound-guided compression used in the past.[
3-
6]
Surgery remains the treatment of choice in 41.8% of
patients, followed by graft revision in 27.8%, UGTI in
24.1%, UG compression in 2.5% and stenting in 1.3%.[
3]
Management approaches to pseudoaneurysms have been
changed, since 1995.[
3] Today, surgical approach has
been increasingly less common, while UGTI has
become the treatment of choice.[
3,
7] We first employed
UGTI method and performed surgical intervention,
when the former failed.
Furthermore, endovascular therapy has some
challenges related to iliofemoral access, despite the
ever improving logistics provided by advancing stent
graft technology and delivery platforms. Murray et
al.[8] in a systematic review of studies on endovascular
access techniques performed between 1994 and 2005,
reported that majority of access problems are brought
about by overly tortuous iliac arteries, circumferential
vessel wall calcification, severe vessel obstruction,
and small vessel caliber. It is usually not possible to
use covered endovascular stent grafts, since there is a
significant size mismatch between the common and
external iliac arteries.[9]
The success and complication rates of non-surgical
treatments of this pathology are heavily dependent on
the width and length of pseudoaneurysm neck.
In conclusion, conventional surgical approach
remains the gold standard for the management of
pseudoaneurysms, although endovascular techniques
and ultrasonographically-guided vessel compression
and thrombin injection are increasingly used.[10,11] The
primary surgical approach should be aneurysmectomy
and arterial reconstruction. End-to-end anastomosis
or primary repair with an appropriate graft should be
performed, where possible.
Declaration of conflicting interests
The authors declared no conflicts of interest with
respect to the authorship and/or publication of this
article.
Funding
The authors received no financial support for the
research and/or authorship of this article.