Occurrence, predictors, and management of late vascular complications following extracorporeal membrane oxygenation.

OBJECTIVE: Vascular complications (VCs) associated with extracorporeal membrane oxygenation (ECMO) during index hospitalization are prevalent and associated with increased mortality. Few studies have evaluated late VCs following ECMO; this study aims to assess occurrence and management practices of late VCs following discharge. METHODS: A retrospective single-institution review was performed of all patients surviving initial hospitalization after being cannulated for central or peripheral veno-venous (VV) or veno-arterial (VA) ECMO between January 1, 2019, and December 31, 2020. Primary outcomes were to categorize and determine the rate of late VCs. Late VCs were defined as any cannulated vessel injury resulting from ECMO cannulation presenting after discharge from index hospitalization. Analysis was conducted by cannulated vessel and stratified by VV or VA ECMO configurations. RESULTS: A total of 229 patients were identified, of which 50.6% (n = 116) survived until discharge. Late VCs occurred in 7.8% of the surviving cohort (n = 9/116); with a median time until presentation of 150 days (interquartile range, 83-251 days). The most common late VC was infection (n = 5; 55.6%) followed by progression to limb-threatening ischemia (n = 4; 44.4%). Urgent procedures were required in 55.6% of patients (n = 5), whereas 44.4% (n = 4) were elective interventions. Interventions performed for management of late VCs included lower extremity arterial revascularization (n = 6; 66.7%), major (n = 1; 11.1%) or minor amputation (n = 1; 11.1%), and wound debridement (n = 1; 11.1%). The majority of patients presenting with late VCs had initially been cannulated for peripheral VA ECMO (n = 8; 88.9%), and one patient (11.1%) was cannulated for peripheral VV ECMO. VCs during index hospitalization were seen in 77.8% of patients (n = 7) returning with late VCs. Odds for late VCs were significantly increased in patients that had been cannulated for ECMO as part of extracorporeal cardiopulmonary resuscitation (odds ratio, 8.4; P = .016) and in cases where patients had experienced an index VC during index hospitalization (odds ratio, 19.3; P = .001). CONCLUSIONS: Late vascular complications after peripheral ECMO cannulation are not rare, particularly after arterial cannulation. Patients should be followed closely early after surviving ECMO with wound evaluation and formal assessment of perfusion with ankle-branchial indices in the cannulated limb.

Incidence, risk factors, and management following cardiac catheterization via carotid and axillary artery approaches: A single-center experience on pseudoaneurysms in young infants.

BACKGROUND: Use of alternate access for complex neonatal interventions has gained acceptance with carotid and axillary artery access being used for ductal and aortic interventions. METHODS: This study was a retrospective, single-center study at Cincinnati Children's Hospital Medical Center. The study included infants, aged ≤90 days, who underwent cardiac catheterization with either carotid or axillary artery access between 2013 and 2022. Data encompassing demographics, clinical information, catheterization data, and the incidence of pseudoaneurysm as a procedural complication were collected. RESULTS: Among 29 young infants (20 males, 69%), 4 out of 15 patients (27%) who underwent the carotid approach developed pseudoaneurysms, while 1 out of 14 patients (7.1%) who underwent the axillary approach developed one. Two patients required transcatheter intervention due to enlargement of pseudoaneurysms, involving the placement of transarterial flow-diverting stent and occlusion of left common carotid artery. Longer sheath in-to-out time (135 vs. 77 min, p = 0.001), and higher closing activated clotting times (ACT) (268 vs. 197 s, p = 0.021) were observed among patients with pseudoaneurysms compared to those without. CONCLUSIONS: Young infants with alternative access via the carotid and axillary arteries may be at risk of pseudoaneurysm formation during longer procedures and with higher ACTs for closure. Ultrasound-guided compression can be employed to prevent the progression and in resolution of these lesions.

Arterial pseudoaneurysm: a rare complication following laser lithotripsy-case series and literature review.

OBJECTIVE: To perform a comprehensive narrative review that will examine the risk factors and treatment outcomes of arterial pseudoaneurysm following laser flexible ureteroscopy (F-URS). METHODS: A retrospective case series and a review of literature was performed. Clinical records from three patients treated for postoperative arterial pseudoaneurysm from January of 2021 to November 2023 were identified. A comprehensive literature review was also performed. The MEDLINE and Scopus databases were searched. The analysis was made by a narrative synthesis. RESULTS: Three cases of postoperative arterial pseudoaneurysm were included, one from our center, one from Dubai, UAE, and one from Barcelona. The literature review identified six case reports, two after endocorporeal laser lithotripsy with thulium fiber laser (TFL) and four with Ho:YAG laser. All cases, from our series and literature review, presented with macroscopic hematuria and used high-power laser settings. All cases were treated by selective embolization. CONCLUSION: Ho:YAG or TFL lasers are both capable of causing arterial pseudoaneurysms following F-URS if high-power settings are used. Selective artery embolization continues to be the treatment of choice with good outcomes.

A Hybrid Approach That May Facilitate the Repair of Traumatic Popliteal Artery Pseudoaneurysms.

PURPOSE: Traumatic popliteal pseudoaneurysms may occur in accidents or as an iatrogenic complication of a total knee arthroplasty. Complications often arise in open repair because of distorted anatomy. Up to 22% of the patients may suffer above-knee amputation. Endovascular treatment has proven to be an effective solution. However, the long-term performance of stents at the hinge point of the popliteal artery is questionable. We present a hybrid technique that was used successfully in 2 cases. TECHNIQUE: Our approach takes advantage of both open and endovascular techniques. At first, we apply a stent graft at the side of the injury to cover the arterial trauma and stop blood leakage to the aneurysm sac. This allows for a safer dissection and open repair. We clamp the artery proximally and distally, open the sac, extract the stent graft, and extend to a longitudinal arteriotomy. We then reconstruct the entire area with a standard in lay end-to-end anastomosis using a vein graft. This hybrid technique may reduce the risk of uncontrollable bleeding and allow for a safer nerve decompression. CONCLUSIONS: Repair of such injuries is technically demanding. A hybrid approach may reduce the risk of complications and offer excellent long-term outcomes. CLINICAL IMPACT: The hybrid approach to the treatment of traumatic popliteal pseudoaneurysms combines the advantages of both open and endovascular approaches. It may be possible to make an acute operation just as safe as an elective operation by implementing the proposed strategy. The procedure can be performed by surgeons of all levels, and patients may benefit from a safer surgical dissection with fewer complications and blood loss. This smart combination of standard techniques may prove invaluable in a hostile surgical environment where limb loss is likely.

REPAIRS Delphi: A UK and Ireland Consensus Statement on the Management of Infected Arterial Pseudoaneurysms Secondary to Groin Injecting Drug Use.

OBJECTIVE: Consensus guidelines on the optimal management of infected arterial pseudoaneurysms secondary to groin injecting drug use are lacking. This pathology is a problem in the UK and globally, yet operative management options remain contentious. This study was designed to establish consensus to promote better management of these patients, drawing on the expert experience of those in a location with a high prevalence of illicit drug use. METHODS: A three round modified Delphi was undertaken, systematically surveying consultant vascular surgeons in the UK and Ireland using an online platform. Seventy five vascular surgery units were invited to participate, with one consultant providing the unit consensus practice. Round one responses were thematically analysed to generate statements for round two. These statements were evaluated by participants using a five point Likert scale. Consensus was achieved at a threshold of 70% or more agreement or disagreement. Those statements not reaching consensus were assessed and modified for round three. The results of the Delphi process constituted the consensus statement. RESULTS: Round one received 64 (86%) responses, round two 59 (79%) responses, and round three 62 (83%) responses; 73 (97%) of 75 units contributed. Round two comprised 150 statements and round three 24 statements. Ninety one statements achieved consensus agreement and 15 consensus disagreement. The Delphi statements covered sequential management of these patients from diagnosis and imaging, antibiotics and microbiology, surgical approach, wound management, follow up, and additional considerations. Pre-operative imaging achieved consensus agreement (97%), with computerised tomography angiography being the modality of choice (97%). Ligation and debridement without arterial reconstruction was the preferred approach at initial surgical intervention (89%). Multidisciplinary management, ensuring holistic care and access to substance use services, also gained consensus agreement. CONCLUSION: This comprehensive consensus statement provides a strong insight into the standard of care for these patients.

Endovascular reconstruction of high cervical and long-segment carotid artery dissections with Leo plus stent.

PURPOSE: Endovascular reconstruction has emerged as a viable alternative for carotid artery dissections (CADs) that are unresponsive to antithrombotic therapy. However, high cervical and long-segment CADs pose challenges during endovascular treatment due to their distal location and tortuous anatomy. We presented our experiences using endovascular reconstruction with the Leo plus stent for this type of CAD. METHODS: We conducted a retrospective review of patients with high cervical and long-segment CADs treated using the Leo plus stent. We analyzed patient demographics, clinical presentations, procedural features, complications, and follow-up outcomes. RESULTS: A total of 17 patients (mean age, 48.1 years) with 17 CADs were identified. Seven of these dissections were accompanied by pseudoaneurysm. The mean length of the dissection was 5.7 cm, and the mean degree of stenosis was 92.3%. A single Leo plus stent was deployed in 15 patients, while another Wallstent carotid stent was used in 2 cases. All stents were successfully positioned in their intended sites. The average degree of residual stenosis was 22.2%. There were no perioperative complications. With a median follow-up duration of 29 months, no ischemic stroke events occurred. All but one Leo plus stent remained patent during follow-up, and all 7 pseudoaneurysms had disappeared at the last radiological assessment. CONCLUSION: Our experience in treating high cervical and long-segment CADs with the Leo plus stent demonstrates that this approach is practical, safe, and effective, as evidenced by long-term observations. The Leo Plus stent appears to be a suitable option for managing this type of CAD.

Delayed development of a huge chest wall hematoma post pacemaker implantation: A case report.

An 83-year-old Chinese man presented with a huge left chest wall hematoma and hemorrhagic shock 4 months after permanent pacemaker implantation. Computed Tomography of Angiogram of the left subclavian artery revealed a pseudoaneurysm. He underwent radiologically guided stenting followed by hematoma clearance. It is rare to have delayed formation of pseudoaneurysm at 4 months post pacemaker implantation. Radiologically guided stenting is the preferred treatment, followed by hematoma clearance. It is strongly advised against blind surgery for wound debridement or bleeding detection. Familiarizing with axillary vein anatomy, improving axillary vein cannulation skills, and detecting early complications of artery injury are key strategies in preventing pseudoaneurysm formation post pacemaker implantation.

Repeat imaging increases detection of delayed pseudoaneurysms in patients with high-grade solid organ injury following abdominal trauma.

BACKGROUND: Nonoperative management of abdominal trauma can be complicated by the development of delayed pseudoaneurysms. Early intervention reduces the risk of rupture and decreases mortality. The objective of this study is to determine the utility of repeat computed tomography (CT) imaging in detecting delayed pseudoaneurysms in patients with abdominal solid organ injury. METHODS: A retrospective cohort study reviewing Montreal General Hospital registry between 2013 and 2019. Patients with The American Association for the Surgery of Trauma (AAST) grade 3 or higher solid organ injury following abdominal trauma were identified. A chart review was completed, and demographics, mechanism of injury, Injury Severity Score (ISS) score, AAST injury grade, CT imaging reports, and interventions were collected. Descriptive analysis and logistic regression model were completed. RESULTS: We identified 195 patients with 214 solid organ injuries. The average age was 38.6 years; 28.2% were female, 90.3% had blunt trauma, and 9.7% had penetrating trauma. The average ISS score was 25.4 (SD 12.8) in patients without pseudoaneurysms and 19.5 (SD 8.6) in those who subsequently developed pseudoaneurysms. The initial management was nonoperative in 57.0% of the patients; 30.4% had initial angioembolization, and 12.6% went to the operating room. Of the cohort, 11.7% had pseudoaneurysms detected on repeat CT imaging within 72 h. Grade 3 represents the majority of the injuries at 68.0%. The majority of these patients underwent angioembolization. CONCLUSIONS: In patients with high-grade solid organ injury following abdominal trauma, repeat CT imaging within 72 h enabled the detection of delayed development of pseudoaneurysms in 11.7% of injuries. The majority of the patients were asymptomatic.

Incidence of pseudoaneurysm after follow-up computed tomography for nonoperatively managed splenic injury: Systematic review.

BACKGROUND: The aim of this systematic review was to assess the estimated incidence of pseudoaneurysm (PSA) with follow-up computed tomography (CT) for adult splenic injury with nonoperative management (NOM). METHODS: A systematic literature search was conducted in MEDLINE, Central, CINAHL, Clinical Trials, and ICTRP databases between January 1, 2010, and December 31, 2023. Quality assessment was performed using the Risk of Bias in Non-randomized Studies of Exposures (ROBINS-E) tool. Adult splenic injury patients who were initially managed with NOM and followed-up by protocolized CT were included. The primary outcome was the incidence of delayed PSA. Secondary outcome measures were delayed angiography and delayed splenectomy. Subgroup analyses were performed between NOM patients without initial splenic angioembolization (SAE) and NOM patients with initial SAE. RESULTS: Twelve studies were enrolled, including 11 retrospective studies and one prospective study, with 1746 patients in total. The follow-up CT rate in the included patients was 94.9%. The estimated incidence of PSA was 14% (95% confidence interval (CI), 8%-21%). The estimated delayed angiography and delayed splenectomy incidence rates were 7% (95% CI, 4%-12%) and 2% (95% CI, 1%-6%), respectively. Subgroup analyses showed that the estimated PSA incidence was 12% in NOM patients without initial SAE (95% CI, 7%-20%) and was also 12% in NOM patients with SAE (95% CI, 5%-24%). CONCLUSIONS: The estimated incidence of delayed PSA after follow-up CT for adult splenic injury with NOM was 14%. The estimated incidence of PSA in NOM with initial SAE was similar to that in NOM without initial SAE.

De novo cerebral pseudoaneurysm formation: a rare delayed complication of stereotactic electroencephalography in children.

OBJECTIVE: To describe the rare complication of cerebral pseudoaneurysm formation following stereotactic electroencephalography (sEEG) lead implantation in children. METHODS: A retrospective chart review of all pediatric patients undergoing sEEG procedures between 2015 and 2020 was performed. Cases of pseudoaneurysm were identified and reviewed. RESULTS: Cerebral pseudoaneurysms were identified in two of 58 total cases and 610 implanted electrodes. One lesion was detected 1 year after sEEG explantation and required craniotomy and clipping. The other was detected 3 months post-explantation and underwent coil embolization. Neither patient had any neurologic deficits associated with the pseudoaneurysm before or after treatment. CONCLUSIONS: Pseudoaneurysm formation post-sEEG explantation is rare and likely underreported. Routine, post-explantation/treatment imaging is warranted to detect this rare but potentially lethal complication.

Echocardiography in the Recognition and Management of Mechanical Complications of Acute Myocardial Infarction.

PURPOSE OF REVIEW: Although rare, the development of mechanical complications following an acute myocardial infarction is associated with a high morbidity and mortality. Here, we review the clinical features, diagnostic strategy, and treatment options for each of the mechanical complications, with a focus on the role of echocardiography. RECENT FINDINGS: The growth of percutaneous structural interventions worldwide has given rise to new non-surgical options for management of mechanical complications. As such, select patients may benefit from a novel use of these established treatment methods. A thorough understanding of the two-dimensional, three-dimensional, color Doppler, and spectral Doppler findings for each mechanical complication is essential in recognizing major causes of hemodynamic decompensation after an acute myocardial infarction. Thereafter, echocardiography can aid in the selection and maintenance of mechanical circulatory support and potentially facilitate the use of a percutaneous intervention.

Pathological changes in the lenticulostriate artery indicate the mechanisms leading to intracranial hemorrhage in Moyamoya disease: a case report.

This case report details the pathological findings of a vessel wall identified as the bleeding point for intracranial hemorrhage associated with Moyamoya disease. A 29-year-old woman experienced intracranial hemorrhage unrelated to hyperperfusion following superficial temporal artery-middle cerebral artery bypass surgery. A pseudoaneurysm on the lenticulostriate artery (LSA) was identified as the causative vessel and subsequently excised. Examination of the excised pseudoaneurysm revealed a fragment of the LSA, with a disrupted internal elastic lamina and media degeneration. These pathological findings in a perforating artery, akin to the circle of Willis, provide insights into the underlying mechanisms of hemorrhage in Moyamoya disease.

Delayed ulnar artery pseudoaneurysm presentation after percutaneous cardiac intervention: A case report and review of the literature.

PURPOSE: Here we present a case of a 62-year-old female with a delayed ulnar artery pseudoaneurysm presentation after cardiac catheterization. CASE REPORT: A 62-year-old woman with multiple medical comorbidities including end-stage renal disease (ESRD) on hemodialysis (HD) and atrial fibrillation on tablet apixaban who presented 8 weeks after cardiac catheterization through right ulnar artery access with a pulsatile mass, pain, and tingling of her right-hand fingers. Ultrasound exam confirmed presence of ulnar artery pseudoaneurysm with >2 cm active chamber. This pseudoaneurysm was repaired via forearm exploration, evacuation of hematoma, and primary repair with non-absorbable sutures. CONCLUSION: We report a case of delayed ulnar artery pseudoaneurysm presentation following cardiac catheterization through the right ulnar artery. Open surgical repair offers a definitive addressal of ulnar artery pseudoaneurysm and removes ulnar nerve compressive neuropathy with less risk of distal embolization in patients with delayed pseudoaneurysm presentation whenever ultrasound-guided thrombin injection (UGTI) is contraindicated.

Comparison between covered-stents grafting and ligation in the treatment of infected femoral pseudoaneurysm due to intravenous drug abuse.

OBJECTIVES: The study compared the outcomes between covered-stents grafting (CSG) and ligation of femoral artery (LFA) in the treatment of infected femoral pseudoaneurysm (IFP) caused by intravenous drug injection. METHODS: From 1st January 2016 to 30th November 2021, the clinical data of patients with IFP caused by intravenous drug injection who underwent CSG (n = 31, 55.4%) and LFA (n = 25, 45.4%) are retrospectively analyzed. We compared the baseline characteristics and clinical outcomes of the two groups, including early and late mortality and morbidity. RESULTS: A total of 56 patients were enrolled in the study, comprising 50 (89.3%) men and 6 (10.7%) women, with a mean age of 34.3 years. There was no significant difference observed between the two groups in terms of 30-day mortality (3.2% vs 0%, p = .365) and length of stay (9 [7, 12] vs 11 [8.5, 12.5] days, p = .236). However, group CSG exhibited a lower rate of intermittent claudication (0% vs 32%, p = .001), less blood loss (67.1 ± 22.5 mL vs 177.0 ± 59.8 mL, p < .001), and shorter surgery duration (57.5 ± 9.9 min vs 84.4 ± 22.8 min, p < .001) compared to group LFA. The LFA group were divided into subgroups according to the ligation site. The amputation rate of superficial femoral artery ligation group (0 vs 27.3%, p = .014) was significantly lower than common femoral artery ligation. CONCLUSIONS: Covered-stents grafting may be a preferable treatment to LFA for IFP due to intravenous drug abuse, particularly when the entry tear is located in the common femoral artery.

Sphenopalatine artery pseudoaneurysm masquerading as a second primary maxillary carcinoma.

PURPOSE: Maxillary sinus carcinomas usually present as a locally advanced disease at the time of diagnosis and it is extremely unusual to have a second primary maxillary carcinoma on the contralateral side after many years of completion of treatment of the first malignancy. We present here a case report of a sphenopalatine artery (SPA) pseudoaneurysm mimicking the second primary maxillary carcinoma. METHODS: We reviewed the literature for SPA pseudoaneurysm. RESULTS/CASE REPORT: This report describes the case of a 90-year-old man with a background of adenoid cystic carcinoma of the right maxillary sinus, diagnosed and treated with surgery and radiotherapy 14 years ago, who presented with a history of multiple episodes of epistaxis. The radiological evaluation showed a heterogeneously enhancing mass with a central hemorrhagic component and surrounding bony erosions in the left maxillary sinus and the patient was planned for biopsy from the suspicious mass along with SPA ligation. However, on opening the maxillary antrum there was excessive bleeding and it was determined unsafe to proceed further. The patient was subsequently taken to interventional radiology for diagnostic angiography which revealed an SPA pseudoaneurysm that was subsequently embolized successfully. CONCLUSIONS: Sphenopalatine artery pseudoaneurysms should be considered as a differential for recurrent epistaxis in patients with a history of sinonasal malignancy. In such cases, endovascular embolization is a viable management option.

Septic pulmonary embolism complicates postoperative tetralogy of fallot: unveiling pulmonary artery pseudoaneurysms.

A 12-year-old female with pulmonary artery stenosis developed pseudoaneurysms due to septic embolism, requiring close follow-up.

Iatrogenic Pseudoaneurysm-Associated Cerebral Hemorrhage: A Rare Complication of Burr Hole Drainage - A Case Report.

BACKGROUND: Nontraumatic intracranial hemorrhage occurs most commonly due to hypertension and is treated nonoperatively. Iatrogenic pseudoaneurysm from prior neurosurgical therapy represents a rarely described etiology for intracranial hemorrhage that may require emergent surgical therapy. CASE REPORT: An elderly female patient was brought to the emergency department with fatigue but no recent trauma. Subsequent computed tomography of the brain revealed a right-sided intraparenchymal hematoma. Her history included burr hole drainage of a subdural hematoma near the site, so additional imaging was performed and revealed an arteriovenous malformation, later discovered on operative findings to be a pseudoaneurysm, as the cause of the current bleeding episode. Why Should an Emergency Physician Be Aware of This? Awareness of prior neurosurgical treatment, even including minor procedures, in patients with apparent spontaneous intracranial bleeding should prompt angiographic evaluation for arteriovenous malformation. If found, these lesions are more likely to benefit from surgical treatment.

A Rare Case of Page Kidney in a Young Man with Flank Pain.

BACKGROUND: Page kidney is a rare condition in which an external compression of the kidney as a result of a hematoma or mass causes renal ischemia and hypertension. In a patient with flank pain, elevated blood pressure, and recent trauma, this condition should be considered. Since this condition was first described in 1939, more than 100 case reports have surfaced. CASE REPORT: We describe the case of a 26-year-old man who presented to the Emergency Department with flank pain, vomiting, and elevated blood pressure. A computed tomography scan of the abdomen and pelvis confirmed the presence of a perinephric hematoma, and the interventional radiology team was consulted to resolve the Page kidney. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Symptoms seen in Page kidney may be similar to other more common diagnoses encountered in the emergency department. It is important to maintain a high suspicion and order imaging studies as needed, especially in the setting of trauma, or a recent procedure in the vicinity of the renal parenchyma.

Hybrid extracorporeal cannulation for aortic root pseudoaneurysm re-operation: The role of a multidisciplinary team.

Introduction: Adequate cerebral protection for aortic reoperation is challenging and optimal technique is still controversial.Case Report: We report a hybrid cannulation approach to achieve safe cerebral protection during circulatory arrest to repair an aortic root pseudoaneurysm.Conclusion: A multidisciplinary approach combining conventional techniques and interventional expertise could be considered in complex aortic scenario.

3D Cinematic rendering for evaluating femoral pseudoaneurysms in injection drug users.

The inguinal region, specifically the femoral vasculature, is a commonly used site of injection for intravenous drug users (IVDU). Repeated puncture of the vessel wall results in breakdown and subsequent arterial pseudoaneurysm- dilatations or outpouching of blood vessels, which, if left untreated, can result in fatal complications such as rupture with hemorrhage, sepsis, or even limb loss. The current modalities for arterial pseudoaneurysms include Doppler ultrasound and computed tomography (CT) angiography, both of which play important roles in management and surgical planning. However, 3D cinematic rendering (CR), a novel CT post-processing technique, offers timely, highly detailed photorealistic images that more clearly display the relation of anatomical structures, allowing for greater diagnostic confidence and precise surgical planning, particularly useful in the emergency setting. In this pictorial review, we demonstrate role of 3D CR in diagnosis and management of femoral pseudoaneurysms in IVDU through 9 illustrative cases.