A 58 y.o. presents with an expanding abdominal wall hematoma six days after having an "abscess" aspirated

needle aspiration of an “abscess” after appendectomy; only blood returns

needle aspiration of an “abscess” after appendectomy; only blood returns

she returns six days later with an expanding hematoma; What happened?

she returns six days later with an expanding hematoma; What happened?

Our patient developed a pseudoaneursym which is  a collection of blood between the two outer layers of an artery, the tunica media and the tunica adventitia.  The damage probably happened when the interventionalist tried to aspirate what they thought was an abscess. 

aneursym.JPG

A pseudoaneursym is a common complication after a cardiac cath and occurs in 0.8 to 8% of vascular interventional procedures.

Pseudoaneursyms can occur in association with inflammation. In pancreatitis they occur in the superior mesenteric, and   pancreaticoduodenal artery.  In the heart pseudoaneursyms most often occur in the lateral wall and true aneurysms occur in the apex.

pseudoheart.JPG

Doppler flow mapping establishes the diagnosis. Diagnostic criteria include: swirling color flow in a mass separate from the main artery and a typical to and fro pattern in the pseudoaeursym neck. Ultrasound compression has been useful in occluding the pseudoaneursym neck allowing the aneurysm neck to thrombose.  Stents, percutaneous thrombin, percutaneous fibrin adhesive, coiling and surgery are also used to repair pseudoaneursyms.

In our patient, the superficial circumflex iliac artery was feeding the pseudoaneursym and was embolized.

The following is a question from USMLE

a. septal rupture  b. left ventricular free wall rupture  c. right ventricular free wall rupture  d. mitral regurgitation  e. left ventricular aneursym

a. septal rupture

b. left ventricular free wall rupture

c. right ventricular free wall rupture

d. mitral regurgitation

e. left ventricular aneursym

The answer is E. A thin fibrous scar is seen in the myocardial tissue. The patient presented with CHF which is the most common cause of death in patients with ventricular aneursyms. CHF is caused by poor contractility of the scarred myocardium and dyskinesis (paradoxical ballooning of the aneurysm with contraction). A pseudoaneursym( where there is no endocardium in the aneurysm) is more likely to rupture since only fragile scar tissue prevents cardiac wall rupture.

 

Lenartoya, M, Tak T. Iatrogenic pseudoaneursym of femoral artery: case report and literature review. Clin Med Res 2003 Jul;1(3):243-247.

Hamraoui K, Ernst S, et al. Efficacy and safety of percutaneous treatment of iatrogenic femoral artery pseudoaneursym by biodegradable collagen injection. J Am Coll Cardiol. 2002;39:1297-1304.

Messina L, Brothers T, Wakefield T, Zelenock G, et al. Clinical characteristics and surgical management of vascular complications in patients undergoing cardiac catheterization: interventional versus diagnostic procedures. J Vasc Surg. 1991;13:593-600.