Multiple aortic root pseudoaneurysms with dissecting aneurysm of the interventricular septum diagnosed by multimodal imaging.

Aortic root pseudoaneurysm is a devastating complication post aortic valve replacement with a high mortality rate. And dissecting aneurysm into the interventricular septum is a rare variant of aortic root pseudoaneurysm, which is scarcely reported. Multimodal imaging is of great value in its diagnosis and differential diagnosis.

Dissecting and fusiform aneurysms of the superior cerebellar artery: anatomy, clinical presentation, and treatment outcomes.

The management of superior cerebellar aneurysms is still controversial. Although several techniques are available, the deep localization of the lesion and the limited number of cases increase the complexity of decision-making for optimal treatment. Only a few cases of dissecting and fusiform aneurysms of the superior cerebellar artery (SCA) are described in the literature, many of which are without long follow-ups. The study aims to offer an exhaustive retrospective analysis of patients affected by SCA fusiform and dissecting aneurysms treated at our institution from 2008 to 2023, highlighting outcomes and complications. Moreover, a comprehensive narrative review was performed. A total of seven patients were treated at our institution. After a title and abstract screen, fifty-five papers met the criteria for inclusion in the review. In our case series, conservative treatment was proposed as the first therapeutic option in four cases (57.1%), while endovascular treatment (EVT) was in three cases (42.9%). A good recovery was observed in 66% of patients presenting with subarachnoid hemorrhage (SAH), while every patient without SAH achieved a good clinical outcome. A poor outcome was observed only in one patient with a dissecting aneurysm causing SAH, who also suffered a pontine infarction. In the literature review, conservative treatment was proposed as a first therapeutic option in eleven cases (16.6%), open microsurgical techniques in 19 patients (28.8%), and EVT in 31 patients (46.9%). Fatal outcome was documented in five patients (7.5%), all characterized by the rupture of the vascular lesion, while 6.1% of cases had non-fatal poor outcomes.

Ruptured carotid artery pseudoaneurysm following excision of a carotid body tumor: a rare complication managed successfully with surgery and literature review.

A 47-year-old male presented with a right-sided Shamblin type 2 carotid body tumor measuring 5*5 cm. After preoperative embolization, a sub adventitial resection of the tumor was done. He was discharged after postoperative day 5 and presented again to emergency 10 days later with a bleeding pseudoaneurysm at the surgical site causing dysphagia and dyspnea. He was taken for emergency exploration of the surgical wound and, intraoperatively, it was observed that the proximal ends of the internal carotid artery and external carotid artery close to the bifurcation were forming a pseudoaneurysm, 1 cm distal to the common carotid artery. The external carotid artery was ligated and a common carotid to internal carotid artery bypass was done with a reversed saphenous vein graft. He recovered well in the postoperative period and was discharged on day 7. Pseudoaneurysm formation following carotid body tumor resection is extremely rare and has only been reported thrice in the literature.

Um homem de 47 anos apresentou tumor carotídeo Shamblin tipo 2 no lado direito, medindo 5 x 5 cm. Após embolização pré-operatória, foi realizada ressecção subadventicial do tumor. O paciente teve alta no quinto dia pós-operatório e voltou à emergência 10 dias depois, com pseudoaneurisma hemorrágico no sítio operatório causando disfagia e dispneia. Foi levado para exploração emergencial da ferida cirúrgica, e, no intraoperatório, 1 cm distalmente à artéria carótida comum, as extremidades proximais da artéria carótida interna e da artéria carótida externa próximas à bifurcação formavam um pseudoaneurisma. A artéria carótida externa foi ligada, e foi realizada uma ponte de safena de carótida comum para a artéria carótida interna com a veia safena invertida. O paciente se recuperou bem no pós-operatório e recebeu alta no sétimo dia. A formação de pseudoaneurisma após ressecção de tumor do corpo carotídeo é extremamente rara, tendo sido relatada apenas três vezes na literatura.

AGA Clinical Practice Update on Interventional EUS for Vascular Investigation and Therapy: Commentary.

DESCRIPTION: The purpose of this AGA Institute Clinical Practice Update is to review the available evidence supporting and examine opportunities for future research in endoscopic ultrasound-guided vascular investigation and therapies. METHODS: This Clinical Practice Update was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are advanced endoscopists with expertise in endoscopic ultrasound-guided vascular investigation and therapy.

Flow diversion using the Pipeline embolization device for intracranial and extracranial pseudoaneurysms: a systematic review and meta-analysis of the literature.

OBJECTIVE: Pseudoaneurysms (PSAs) are complex vascular lesions. Flow diversion has been proposed as an alternative treatment to parent artery occlusion that preserves laminar flow. The authors of the present study investigated the safety and short-term (< 1 year) and long-term (≥ 1 year) aneurysm occlusion rates following the treatment of intracranial and extracranial PSAs using the Pipeline embolization device (PED). METHODS: An electronic database search for full-text English-language articles in Ovid MEDLINE and Epub Ahead of Print, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus was conducted following the PRISMA guidelines. Studies of any design including at least 4 patients with intracranial or extracranial PSAs treated using a PED were included in this analysis. The primary outcome of interest was the rate of peri- and postprocedural complications. Secondarily, the authors analyzed the incidence of complete aneurysm occlusion. RESULTS: A total of 90 patients with 96 PSAs across 9 studies were included. The mean age was 38.2 (SD 15.14) years, and 37.8% of the patients were women. The mean PSA size was 4.9 mm. Most PSAs were unruptured, and the most common etiology was trauma (n = 32, 35.5%), followed by spontaneous formation (n = 21, 23.3%) and iatrogenic injury (n = 19, 21.1%). Among the 51 (53.1%) intracranial and 45 (46.9%) extracranial PSAs were 19 (19.8%) dissecting PSAs. Sixty-six (77.6%) PSAs were in the internal carotid artery and 10 (11.8%) in the vertebral artery. Thirty-three (34.4%) PSAs were treated with ≥ 2 devices, and 8 (8.3%) underwent adjunctive coiling. The mean clinical and angiographic follow-up durations were 10.7 and 12.9 months, respectively. The short-term (< 1 year) and long-term (≥ 1 year) complete occlusion rates were 79% (95% CI 66%-88%, p = 0.82) and 84% (95% CI 70%-92%, p = 0.95), respectively. Complication rates were 8% for iatrogenic dissection (95% CI 3%-16%, p = 0.94), 10% for silent thromboembolism (95% CI 5%-21%, p = 0.77), and 12% for symptomatic thromboembolism (95% CI 6%-23%, p = 0.48). No treatment-related hemorrhage was observed. The overall mortality rate at the last follow-up was 14%. CONCLUSIONS: The complete occlusion rate for PSAs treated with the PED was high and increased over time. Although postprocedural complications and mortality were not insignificant, flow diversion represents a reasonably safe option for managing these complex lesions.

Lower extremity pseudoaneurysms and their interventional radiological management: a pictorial review.

Lower extremity pseudoaneurysms (PsAs) are mostly developed after traumatic or iatrogenic injury to the arteries. Unless treated, they can be complicated by adjacent mass effects, distal embolism, secondary infection, and rupture. Imaging helps in the diagnosis and planning of therapeutic intervention. Ultrasonography (USG) is often diagnostic, while CT angiography aids in vascular mapping required for intervention. Image-guided therapy offers to manage these pseudoaneurysms in a minimally invasive approach, obviating the need for surgery. A smaller, superficial, and narrow-necked PsA can easily be managed with local USG-guided compression or thrombin injection. When the percutaneous approach is not a feasible option, PsA from expendable arteries can also be managed with coiling or glue injection. Wide-necked PsA from an unexpendable artery necessitates stent graft placement, although coiling of the neck may be a viable and cheaper alternative for a long- and narrow-necked PsA. Presently, vascular closure devices are also used to seal a small arterial rent through a direct percutaneous approach. This pictorial review entails various techniques to deal with lower extremity pseudoaneurysms. An idea about the various intervention radiological approaches will help in choosing appropriate methods to tackle lower extremity pseudoaneurysms.

Endovascular Treatment of Visceral Artery Pseudoaneurysms with Ethylene-Vinyl Alcohol (EVOH) Copolymer-Based Non-Adhesive Liquid Embolic Agents (NALEAs).

Background and Objectives: Treatment of visceral artery pseudoaneurysms (VAPs) is always indicated regardless of their diameters, as their risk of rupture is significantly higher than that of visceral artery aneurysms. The invasiveness of surgery and its associated complications have led to a shift in favor of radiological interventions as the initial treatment of choice. However, there are still some unanswered questions on endovascular treatment of VAPs regarding the optimal endovascular technique and the efficacy and safety outcomes. The purpose of this multicenter study was to retrospectively evaluate the effectiveness and safety of endovascular treatment of visceral pseudoaneurysms using Ethylene-Vinyl Alcohol (EVOH) Copolymer-Based Non-Adhesive Liquid Embolic Agents (NALEAs). Materials and Methods: Consecutive patients who underwent endovascular embolization with EVOH-based NALEAs for visceral artery pseudoaneurysms between January 2018 and June 2023 were retrospectively evaluated. Results: 38 embolizations were performed. Technical success was achieved in all patients. The clinical success rate was high (92.1% overall), with no significant differences between ruptured and unruptured VAPs (p = 0.679). Seven patients (18.4%) experienced procedure-related complications, related to one case of non-target embolization, four splenic abscesses due to end-organ infarction, and two femoral pseudoaneurysms. The rates of procedure-related complications, end-organ infarction, and vascular access-site complications did not significantly differ between ruptured and unruptured VAPs (p > 0.05). Conclusions: Both ruptured and unruptured visceral pseudoaneurysms can be effectively and safely treated with NALEA-based endovascular embolization. We suggest considering the use of NALEAs, particularly in specific clinical cases that highlight their advantages, including patients with coagulopathy, fragile vessels, and embolization targets that are located at a considerable distance from the microcatheter tip and are otherwise difficult to reach.

COVID-19-associated hepatic artery pseudoaneurysms.

Cases of coronary and pulmonary artery pseudoaneurysms secondary to COVID-19 have been reported in the literature and are supposed to be secondary to inflammatory and vasculitis processes linked to a viral multisystem inflammatory syndrome. Although the incidence of COVID-19-associated liver injury ranges from 14% to 53% in hospitalized patients, COVID-19-associated hepatic artery pseudoaneurysms have never been reported so far. We present the case of a patient whose follow-up CT after cryoablation of renal cell carcinoma revealed seven fusiform pseudoaneurysms of the two hepatic arteries secondary to COVID-19. Anticoagulant or anti-inflammatory treatments were not introduced. Vascular lesions were unchanged on the 3-month follow-up CT. At 6-month CT, the proximal pseudoaneurysm was replaced by a proximal occlusion of the accessory RHA.

Low-profile visualized intraluminal support stent for the endovascular treatment of traumatic intracranial internal carotid artery pseudoaneurysms.

Optimal treatment strategies for traumatic intracranial internal carotid artery (ICA) pseudoaneurysms are controversial. The low-profile visualized intraluminal support (LVIS) device is a braided stent with a metal coverage rate between traditional laser cut stents and flow diversion devices. We report here our therapy strategy using the LVIS stent-assisted coiling for treatment of traumatic intracranial ICA pseudoaneurysms. Patients with traumatic intracranial ICA pseudoaneurysms treated by the LVIS stent-assisted coiling in our center between January 2015 and June 2021 were reviewed. The complications, radiographic, and clinical outcomes of these patients were analyzed. A total of 12 patients with 12 pseudoaneurysms were included. The mean maximum aneurysm diameter was 6.2 ± 3.1 mm. Nine patients had a subarachnoid hemorrhage; five patients with Hunt-Hess grade III and four patients with grade IV. All procedures were successfully performed without intraoperative complications. Immediate postoperative angiogram showed that six (50%) aneurysms were Raymond grade 1, four (33.3%) were grade 2, and two (16.7%) were grade 3. Postoperative multiple cerebral infarction occurred in two patients because of vasospasm. Of the ten patients with angiographic follow-up (mean, 29.9 months), two received additional coiling because of recanalization of the pseudoaneurysm, and all aneurysms were completely obliterated at the last examination of the patients. During the clinical follow-up period (mean, 26.8 months), the overall mortality and morbidity were 25% (3/12) and 8.3% (1/12), respectively. LVIS stent-assisted coiling was a feasible approach for the treatment of traumatic ICA pseudoaneurysms.

Crohn's Disease and Jejunal Artery Aneurysms: A Report of the First Case and a Review of the Literature.

Background and Objectives: Jejunal artery (JA) and ileal artery (IA) aneurysms constitute less than 3% of all visceral artery aneurysms (VAAs), carrying a risk of rupture as high as 30%, and a mortality of 20%. Though many etiologies have been reported in the literature, no mention exists on a causal association between these aneurysms and inflammatory bowel diseases (IBD). We present the first case of a JA aneurysm related to Crohn's Disease (CD) together with a review of the literature. Materials and Methods: A 74-year-old male presenting with CD intestinal relapse and an incidental finding at the computed tomography enterography (CTE) of a 53 × 47 × 25mm apparently intact JA pseudoaneurysm, arising from the first and second jejunal branches, underwent coil embolization followed by small bowel resection, with an uneventful outcome. We also included the review of literature on JA and IA aneurysms, analyzing all reports published in PubMed and Scopus from 1943 to July 2022. Results: 60 manuscripts with 103 cases of JA and IA aneurysms in 100 patients were identified. Among cases with available data, 34 (33.0%) presented acutely with rupture, 45 (43.7%) were described as non-ruptured. 83 (80.6%), and 14 (13.6%) were JA and IA aneurysms, respectively, having a median size of 15 (range:3.5-52) mm. Atherosclerosis (16.5%), infections (10.7%), and vasculitides/connective tissue disorders (9.7%) represented the main causes mentioned. Mean age was 53.6 (±19.2) years, male patients being 59.4%. One third of patients (32.4%) were asymptomatic. Overall, treatment was indicated in 63% of patients, with surgery and endovascular procedures performed in 61.9% and 38.1% cases, respectively. The technical success rate of endovascular treatment (EVT) was 95.8%. The mortality rate was 11.8%, being higher (21.2%) in the rupture group. Conclusions: The prompt treatment accomplished in our case granted a successful outcome. JA and IA aneurysms should be included among local complications of IBD. Considering their high potential for rupture, regardless of size, a low threshold for endovascular or surgical treatment should be applied.

Clinical characteristics of internal carotid artery pseudoaneurysms in the sphenoid sinus.

BACKGROUND: Internal carotid artery (ICA) pseudoaneurysms are associated with high mortality if lack of proper management. Patients with ICA pseudoaneurysms in the sphenoid sinus often visit a hospital's ear, nose and throat (ENT) department due to nasal bleeding. In such cases, simple examination and therapy will lead to misdiagnosis. OBJECTIVE: This study sought to investigate the clinical characteristics, diagnostic methods and treatment of ICA pseudoaneurysms in the sphenoid sinus. METHODS: Various data, including clinical features, imaging examination results, and treatment and prognosis information, were collected and analyzed for 8 patients who visited the Department of Otolaryngology, Head & Neck Surgery of West China Hospital from March 2008 to January 2017. RESULTS: The patients included 6 males and 2 females (ages 16 to 56 years). Repeated epistaxis was a common symptom in six of the eight patients (6/8), whereas monocular blindness and binocular blindness were observed in the other two patients. Head trauma was found to play a role in the induction of ICA pseudoaneurysms, given that five patients (5/8) exhibited a specific history of head injury. CT examination tended to result in misdiagnosis, whereas MRI and digital subtraction angiography (DSA) were helpful for obtaining a definite diagnosis with all diagnoses were confirmed via DSA. Coated stent intervention was performed in five patients, while carotid artery ligation was performed in two patients in emergency situations: one of whom exhibited paraplegia, but recovery was ultimately observed after rehabilitation. Moreover, failure of coated stent intervention in one patient was resolved via additional unilateral common carotid artery ligation. Furthermore, one patient with vision loss experienced vision restoration. One patient discontinued treatment for personal reasons and was lost to follow-up. No recurrence was observed in the other 7 patients. CONCLUSION: ICA pseudoaneurysms in the sphenoid sinus are uncommon. To accurately identify ICA pseudoaneurysms, collaboration between otolaryngologists and imaging specialists is essential. On the other hand, both surgical and interventional treatments can achieve good results; therefore, otolaryngologists should enhance their cooperation with neurosurgery and intervention departments. Accurate diagnosis and rapid treatment are keys to managing ICA pseudoaneurysms.

A novel technique for iatrogenic pseudoaneurysm obliteration with ultrasound-guided thrombin foam injection.

BACKGROUND: Iatrogenic pseudoaneurysms (IPA) are treated with ultrasound-guided thrombin injections (UGTI). We describe a novel technique for IPA repair that applies UGTI with thrombin foam (UGTFI). METHODS AND RESULTS: Successful obliteration of 6 IPAs (IPA without a neck, n = 5; with a neck, n = 1) in 6 patients (2 males, aged 68 ± 1 years, 4 females, aged 59 ± 11 years) was performed by using UGTFI. The dose of administered thrombin was 25-75 IU. No microembolization phenomenon and no serious clinical complications were observed. CONCLUSIONS: Treatment of IPA with UGTFI may reduce the embolization rate, risk of IPA cavity thrombin leakage, required drug dose. Use of the thrombin foam could be the next step in the development of the UGTI, particularly in the treatment of IPA without a neck.

Pediatric intracranial aneurysms: changes from previous studies.

PURPOSE: To develop a better understanding of pediatric intracranial aneurysms (PIAs). METHODS: All PIAs treated in our center from January 2012 to April 2017 were retrospectively included. Clinical data, treatment summaries, and follow-up outcomes were retrieved and analyzed. RESULTS: A total of 66 PIAs were found in 64 patients with a mean age of 11.4 ± 5.7 years, 68.8% of whom were male. The most common symptoms were seizure (n = 7, 63.6%) for the 0-5 age group and headache (n = 38, 71.7%) for the 6-18 age group. Fifty-one PIAs (77.3%) were located in the anterior circulation, with the middle cerebral artery (MCA) being the most common site (n = 28, 42.4%). Fifteen patients (23.4%) had PIAs that were pseudoaneurysms, and nine of them (60%) had a combined history of head trauma. Thirty-five patients (54.7%) had distal arterial aneurysms, and 21 of them (60%) presented with seizure. During a mean follow-up time of 1.6 ± 1.2 years, 79.7% of patients (n = 51) had favorable outcomes, 5 patients (7.8%) died, and the remaining 8 patients (12.5%) had unfavorable outcomes with severe neurological deficits. CONCLUSION: Apart from characteristics consistent with previous studies, several new findings regarding PIAs were reported, including a difference in the most common symptoms in different age groups, the MCA as the predominant location of PIAs, the high ratio of pseudoaneurysms and their head trauma etiology, and the incidence of distal arterial aneurysms and their relationship with the risk of seizures.

Utilization of stent grafts in the management of arteriovenous access pseudoaneurysms.

Objective Endovascular stent graft repair for exclusion of pseudoaneurysm is currently being explored to replace open surgical repair as current management. The objective of the study was to evaluate the clinical safety and efficacy of endovascular stent graft intervention in pseudoaneurysms complicating arteriovenous reconstructions in patients on chronic hemodialysis. Methods A retrospective analysis of all pseudoaneurysms treated with stent grafts at our institution over a period of five years was performed. The indications for endovascular intervention included bleeding from the pseudoaneurysm, infection, and significant skin compromise overlying the pseudoaneurysm or combination of the above. The rates of technical success, complication, and primary patency were measured at one-week, one-month, and six-month follow-up. Results A total of 33 endovascular stent graft interventions in 29 patients were performed for the treatment of pseudoaneurysms. The average age of patients was 68 years (range 31-90 years), with 13 female. Diabetes and hypertension were present in 15 and 22 patients, respectively. In eight patients, there was evidence of active infection at the fistula site. The choice of stent grafts include Viabahn ( n = 31), Wallgraft ( n = 1), and i-Cast ( n = 1). The initial technical success rate was 94%. The two failed interventions included occlusion of inflow artery with immediate conversion to open procedure ( n = 1) and incomplete pseudoaneurysm exclusion ( n = 1). Primary patency at one month and six months was 83 and 60%, respectively. An additional balloon angioplasty of outflow tract or central stenosis was performed in 18 cases (54%). The explanation of stent grafts due to persistent or recurrent bacteremia/site infection was required in four out of eight patients. The average time to explanation was 93 days (range 6-204 days). Conclusion The stent graft implantation is a safe, minimally invasive and efficient way to control and manage arteriovenous accesses with pseudoaneurysms. In the presence of infection, this approach may be less durable.

Removal of retained products of conception showing marked vascularity without uterine artery embolization: Two case reports.

Retained products of conception with marked vascularity can cause massive postabortal or post-partum bleeding. Uterine artery embolization is effective for uterus preservation but does not assure fertility preservation. Thus, the optimal treatment for retained products of conception with marked vascularity is uncertain. Here, we report two cases of retained products of conception with marked vascularity: one early abortion and one hydatidiform mole, which were successfully resolved by dilation and removal of the retained products, without uterine artery embolization. We pretreated the cervical dilation using two or more laminaria tents and named this technique the 'maximum laminaria procedure'. We observed that the vascularity disappeared just after the laminaria tents were removed, and subsequently, we could remove the retained products with minimal bleeding, without uterine artery embolization. This protocol might become a standard treatment for retained products of conception with marked vascularity.

Endovascular management of internal carotid artery pseudoaneurysms: A single-centre experience of 20 patients.

BACKGROUND: Pseudoaneurysms (PSAs) of the internal carotid artery (ICA) are uncommon lesions. Various surgical and endovascular options are available for the management of these lesions. We describe our experience in using a spectrum of endovascular management strategies for ICA-PSA and present their outcome. AIMS: To evaluate the role and efficacy of endovascular intervention in the management of ICA PSA. MATERIALS AND METHODS: The clinical and angiographic data of 20 ICA PSAs from January 2008 till July 2016 were reviewed retrospectively. A meticulous evaluation of all the patients regarding their clinical symptoms, imaging findings (Ultrasound Doppler/CTA/MRI) and the endovascular techniques was performed. Clinical and imaging follow up for at least 1 year was also assessed. RESULTS: There were 15 (75%) male and 5 (25%) female patients, with their age ranging from 11 months to 60 years. Eleven patients (55%) were of the paediatric age group. PSAs were seen in the cervical ICA in 12 patients (60%) and in the intracranial ICA in 8 patients (40%). The most common causes of PS formation were iatrogenic (n = 8), followed by trauma (n = 7), and infection (n = 5). Parent artery occlusion was performed in 10 patients (50%), stenting in 7 patients (35%), and PSA coiling in 3 patients (15%). Immediate and complete obliteration of the PSAs was achieved in all cases without any major procedural complication. Recurrence was diagnosed at 2 years, in one patient who had undergone parent artery occlusion. This was successfully retreated. None of our patients had immediate or delayed major neurological deficits. CONCLUSIONS: Endovascular treatment provides a safe and minimally invasive management option in patients with ICA PSA. It helps in the prevention of rupture of the PS and also its thromboembolic complications.

Pseudoaneurysm of the superior lateral genicular artery following anterior cruciate ligament repair.

BACKGROUND: Pseudoaneurysm is a rare complication of surgery of the knee. The pathogenesis of false aneurysm involves partial arterial laceration, which allows hemorrhage into surrounding soft tissues that confine it. Although most cases in literature described pseudoaneurysms after total knee arthroplasty, it can be associated with arthroscopic knee surgery too. METHODS: Here, we report an uncommon case of a false aneurysm of the superior lateral genicular artery following anterior cruciate ligament ligamentoplasty using an autograft semitendinosus-tendon. RESULTS: Three weeks after anterior cruciate ligament repair, a 25-year old man presented with a painful swelling on his right knee. Computed tomography angiography demonstrated a false aneurysm of the superior lateral genicular artery. Ultrasound-guided percutaneous thrombin injection was performed to exclude the pseudoaneurysm, and the patient recovered well. CONCLUSION: Pseudoaneurysm is an uncommon complication of surgery or trauma of the knee. Although most cases in literature described pseudoaneurysms after total knee arthroplasty, it can be associated with arthroscopic knee surgery too. Ultrasound-guided thrombin injection can be a valuable treatment option.

Post-procedural pseudoaneurysms: Single-center experience.

Objectives Pseudoaneurysms are a well-recognized complication of percutaneous angiographic procedures. Ultrasound-guided thrombin injection is currently the preferred treatment modality. This study was undertaken to evaluate our experience with the management of post-procedure pseudoaneurysms. Methods A retrospective study was undertaken of all patients who developed a post-procedure pseudoaneurysm between March 2004 and January 2013. Data were obtained from our prospectively maintained non-invasive vascular laboratory data base. Results Overall, 167 patients (80 men) with post-procedure pseudoaneurysms were identified. The mean age was 66 years. Post-procedure pseudoaneurysms developed following diagnostic coronary angiography (38%), coronary angioplasty (37%), peripheral vascular interventions (14.7%), or other access procedures (7.6%). Mean post-procedure pseudoaneurysm diameter was 2.8 ± 1.8 cm. One hundred forty-two post-procedure pseudoaneurysms were injected with thrombin under ultrasound guidance. Primary success rate was 93.5%. There were 12 (8.5%) procedural failures of which seven (58%) responded to reinjection, three (25%) required operative management, one was treated with ultrasound-guided compression, and one (8.3%) was simply observed. On multivariate analysis, failures were associated with increased aneurysm diameter ( p = 0.006; odds ratio 2.23, 95% CI 1.25 to 3.96), end-stage renal disease ( p = 0.013; odds ratio 1.15, 95% CI 1.09 to 1.78) and superficial femoral artery aneurysm origin ( p = 0.031; odds ratio 0.20, 95% CI 0.04 to 0.86). There were two episodes of thrombus formation in the femoral artery; one resolved with anticoagulation alone, and the other required thrombectomy. Conclusions Percutaneous ultrasound-guided thrombin injection is an effective and safe method for managing post-procedure pseudoaneurysms. Failure rates are low and associated with large aneurysm size, superficial femoral artery origin and end-stage renal disease.

Endovascular Therapy for Large Vessel Vasculopathy in HIV-infected Patients.

OBJECTIVES: To evaluate outcomes after endovascular treatment of patients with aneurysmal or occlusive vasculopathy in HIV-infected patients. METHODS: Retrospective analysis of a prospective database of treatment outcomes in patients with HIV related vasculopathies between April 2005 and September 2015. RESULTS: Sixty HIV patients presented with post-traumatic pseudoaneurysm formation (n = 7), aneurysmal disease (n = 24) or occlusive disease (n = 29 (48%)). The majority were male (42/60 (70%)), with a mean age of 43.9 years (SD ± 12.6). All seven patients with a post-traumatic pseudoaneurysm were treated by insertion of a covered stent (n = 6) or coiling (n = 1). All were successfully treated at 30 days, but only one patient returned for late surveillance. 23/24 patients who underwent insertion of a stent graft/covered stent for aneurysmal disease returned for 30 day review (one asymptomatic stent graft occlusion). Only 11 patients attended for late surveillance; 9/11 were asymptomatic with patent stent grafts. Late stent occlusion occurred in two (no further action (n = 1), major limb amputation (n = 1). In the 29 patients who underwent endovascular treatment for occlusive disease, 9 (31%) had immediate treatment failure (including 8 amputations (28%)). Of the sixteen who returned for serial review, 8 (50%) suffered further complications including 4 amputations. Overall, 12/29 treated patients (41%) ultimately underwent amputation. CONCLUSIONS: In the immediate short term, an 'endovascular first' strategy was associated with good outcomes in HIV patients with aneurysmal disease. By contrast, outcomes were poor in HIV patients with occlusive disease. Whether this relates to the underlying natural history of HIV occlusive vasculopathies remains unclear. One major problem in trying to formulate meaningful management strategies is a generalised reluctance for HIV patients to return for surveillance.

Radial artery pseudoaneurysms after transradial cardiac catheterisation.

BACKGROUND: Although uncommon, radial artery access site complications are likely to become more frequent with the increased adoption of transradial cardiac catheterisation. There is a lack of data regarding the incidence and clinical features of radial artery pseudoaneuryms. We aimed to describe the incidence, clinical features and management of radial artery pseudoaneurysms in a high-volume transradial cardiac catheterisation centre. PATIENTS AND METHODS: We performed a search of the Vancouver Island Health Authority medical imaging database from 1st Jan 2008 to April 2012 looking for all radial and femoral artery pseudoaneuryms occurring after cardiac catheterisation. Hospital charts were reviewed to determine patient and procedural characteristics as well as management and outcome. RESULTS: There were a total of 14,968 coronary procedures performed over the four year search period, of which 13,216 (88%) were trans-radial. The incidence of radial artery pseudoaneurysm after cardiac catheterisation was 0.08%, and did not differ between transradial diagnostic angiography and PCI (0.07% vs 0.08%; P = 0.90). In contrast, the incidence of femoral artery pseudoaneurysm was higher, at 1.4% (P < 0.0001). Patients with radial pseudoaneurysms were generally elderly, with a median age of 77 years, and there were no gender differences. Only one patient had received a glycoprotein IIb/IIIa inhibitor, whilst two received warfarin post-procedure. The majority of cases (80%) were treated with surgical repair. CONCLUSIONS: We have demonstrated that radial artery pseudoaneuryms are a rare but important complication of transradial cardiac catheterisation, with patients generally requiring surgical repair. Most patients were elderly, but surprisingly only a minority were anti-coagulated with warfarin.