Pseudoaneurysm (False aneurysm)

Prepared by A. Floh (08/04/02)

Vascular injury is a well known complication of cardiac catheterization. In the pediatric

population a retrospective study from the Hospital for Sick Children demonstrated that
vascular injuries comprised approximately 34% of all catheter associated complications
with an arterial complication rate of 3.7% (7.3% in those below 1 year).(1)

Psuedoaneurysm formation is an uncommon occurrence associated with arterial

perforation (traumatic or iatrogenic). It is defined as a pulsatile hematoma caused by
leakage of blood through a defect in the arterial wall and contained by surrounding
adventitial and perivascular tissue. This is usually attributed to poor hemostasis during
procedure. Patients are usually on anticoagulation therapy. Overall incidence has been
noted at 1-8% in adults.(2)(Cochrane) Studies into incidence in pediatric population are
lacking, but thought to be much more rare. An analysis at the Children’s Hospital of
Philadelphia has shown of incidence of <0.01% based on discharge diagnoses from 2001
through June 2004.(3)

Clinical presentation varies from an asymptomatic bulge, to painful pulsatile mass or

compression of surrounding structures leading to ischemia or neuropathy.

Historically, all patients required surgical correction. However in attempts to limit

operative exposure, external compression and thrombin injection techniques have been
validated as safe and effective first-line alternatives.

Proposed treatment algorithm:

1) Ultrasound guided compression
- Initially described by Fellmeth et al in 1991(4)
- aim to impede flow into the false aneurysm and promote thrombosis.
- compress at 20-30 minute intervals up to 60 minutes (as tolerated)
- success rates do not vary significantly between ultrasound guided or blind compression
- success rate 40-75%(5,6)

Complications:
Lengthy procedure
Poorly tolerated Pain/discomfort
Recurrence

2) Sonographic Guided thrombin injection(3,7) – may be fluoro-guided(8)

Peformed by the interventional radiologists at SickKids Hospital

- Effective even in anticoagulated patients

- May be more difficult following attempts at compression repair(9)
- Guided by real-time US using 2D gray-scale and color Doppler
- bovine thrombin (1000 U/ml) through 22 guage needle, volume approximately 0.1ml,
sufficient to impede inflow through pseudoaneurysm neck
- Usual time to thrombosis <5 seconds
- success rates of 63-98% in adults(9)

- Ultrasound follow-up following injection, 1day and 1 week post injection

Complications:
Rates 0-4%(6)
Embolization to native circuation
Pseudoaneurysm recurrence
Allergic reaction tobovine thrombin including generalized urticaria and anaphylaxis
Abscess/cellulites at injection site

3) Surgical repair
- primary treatment if ischemia, infection , or compression of femoral nerve and resultant
neuropathy

Complication:
General anaesthesia
Incision
Infection

Others treatment strategies that are not practical or widely used in pediatric population:
Coil embolization
Covered stent

References:
1. Vitiello R, McCrindle BW, Nykanen D, Freedom RM, Benson LN.
Complications associated with pediatric cardiac catheterization. J Am Coll
Cardiol 1998;32(5):1433-40.
2. Fitts J, Ver Lee P, Hofmaster P, Malenka D. Fluoroscopy-Guided Femoral Artery
Puncture Reduces the Risk of PCI-Related Vascular Complications. J Interv
Cardiol 2008.
3. Pelchovitz DJ, Cahill AM, Baskin KM, Kaye RD, Towbin RB. Pseudoaneurysm
in children: diagnosis and interventional management. Pediatr Radiol
2005;35(4):434-9.
4. Fellmeth BD, Roberts AC, Bookstein JJ, Freischlag JA, Forsythe JR, Buckner
NK, Hye RJ. Postangiographic femoral artery injuries: nonsurgical repair with
US-guided compression. Radiology 1991;178(3):671-5.
5. Chatterjee T, Do DD, Mahler F, Meier B. A prospective, randomized evaluation
of nonsurgical closure of femoral pseudoaneurysm by compression device with or
without ultrasound guidance. Catheter Cardiovasc Interv 1999;47(3):304-9.
6. Lonn L, Olmarker A, Geterud K, Risberg B. Prospective randomized study
comparing ultrasound-guided thrombin injection to compression in the treatment
of femoral pseudoaneurysms. J Endovasc Ther 2004;11(5):570-6.
7. Frush DP, Paulson EK, O'Laughlin MP. Successful sonographically guided
thrombin injection in an infant with a femoral artery pseudoaneurysm. AJR Am J
Roentgenol 2000;175(2):485-7.
8. Samal AK, White CJ, Collins TJ, Ramee SR, Jenkins JS. Treatment of femoral
artery pseudoaneurysm with percutaneous thrombin injection. Catheter
Cardiovasc Interv 2001;53(2):259-63.
9. Paulson EK, Sheafor DH, Kliewer MA, Nelson RC, Eisenberg LB, Sebastian
MW, Sketch MH, Jr. Treatment of iatrogenic femoral arterial pseudoaneurysms:
comparison of US-guided thrombin injection with compression repair. Radiology
2000;215(2):403-8.