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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 6  |  Issue : 4  |  Page : 282-284

A case report of iatrogenic radial artery pseudoaneurysm: Avoidable complication with the need of early intervention


1 Department of Cardiovascular Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
2 Department of Radiodiagnosis, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
3 Department of Anesthesia, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission09-Jul-2022
Date of Acceptance20-Sep-2022
Date of Web Publication16-Dec-2022

Correspondence Address:
Dr. Anshuman Darbari
Department of Cardiovascular Surgery, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hm.hm_17_22

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  Abstract 

It is crucial to clinically differentiate true aneurysms from pseudoaneurysms. Here, we are reporting a case of postintervention, iatrogenic distal radial artery pseudoaneurysm, which was successfully managed surgically. The present case scenario signifies the clinical features of pseudoaneurysm and relevant discussion with early treatment needs for this iatrogenic complication.

Keywords: Aneurysm, pseudoaneurysm, radial artery, vascular intervention


How to cite this article:
Darbari A, Sharma R, Dev R, Sharma R. A case report of iatrogenic radial artery pseudoaneurysm: Avoidable complication with the need of early intervention. Heart Mind 2022;6:282-4

How to cite this URL:
Darbari A, Sharma R, Dev R, Sharma R. A case report of iatrogenic radial artery pseudoaneurysm: Avoidable complication with the need of early intervention. Heart Mind [serial online] 2022 [cited 2023 Feb 7];6:282-4. Available from: http://www.heartmindjournal.org/text.asp?2022/6/4/282/363947


  Introduction Top


In this current era, most of the radial artery pathology at the wrist are pseudoaneurysms, iatrogenically caused due to the increasing number of interventions through the radial artery, which is now preferred over the femoral artery due to fewer number of complications.[1] True idiopathic radial artery aneurysms are rare, with few case reports in the literature.


  Case Report Top


A 65-year-old male, known diabetic on oral hypoglycemic for 20 years, known hypertensive for the past 22 years on antihypertensives, nonsmoker, and occasional alcoholic, presented to us with painful swelling at the left wrist, which has been progressively increasing for the past 1 month. The patient was a known case of coronary artery disease who underwent primary percutaneous transluminal angioplasty 3 months ago at another center for lesions in the left anterior descending and right coronary artery for acute anterior wall myocardial infarction. He was on dual antiplatelets, beta-blockers, and statins after this. After intervention, compression over the puncture site was given for 15 min but compression dressing was not done afterward. He noticed a minor swelling in the left wrist after 7 days. After 1 month of the procedure, it became painful with a gradual increase in size [Figure 1]. He consulted his primary cardiologist but was referred to higher center for further management. On presentation to us, this mass was pulsatile, and bruit was present. Signs of local inflammation were absent, and distal digits were warm with a capillary refill time of <2s. Sensory and motor functions of the left hand and wrist were normal without deficits. Modified Allen's test was normal. The color Doppler ultrasound showed the presence of pseudoaneurysm arising from the distal left radial artery and continuous bidirectional blood flow in the neck of the pseudoaneurysm, and the “yin-yang” sign was present within the lesion with the presence of thrombus. Ulnar artery and palmar arch integrity were confirmed. The left radial artery was explored under local anesthesia. Both ends of the radial artery related to pseudoaneurysm were identified, and control was taken. The large radial pseudoaneurysm was opened, and the contents were evacuated [Figure 2] and [Figure 3]. Pseudoaneurysm excision with all hematoma evacuation was done. The left radial artery was ligated proximally and distally due to badly damaged arterial wall situation and adjoining inflammation. On the table, finger pulse oximetry was used to examine intraoperative and postoperative proper blood flow to all fingers. The patient was discharged from the hospital on the 2nd postoperative day with no sensory-motor deficit or distal ischemia. A follow-up visit after 2 months showed a healthy wound without any distal neurovascular complications.
Figure 1: Swelling at the radial artery puncture site in the left distal forearm, outlined in red

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Figure 2: Intraoperative photograph showing dissected outer fibrous capsule of radial pseudoaneurysm

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Figure 3: Intraoperative photograph showing the opening of the fibrous capsule of radial pseudoaneurysm with clot content inside

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  Discussion Top


An aneurysm is defined as the dilatation at the weakened wall of an artery containing all the layers of the arterial wall. An artery is aneurysmal if its focal diameter is 1.5 times the standard size.[2] True aneurysms develop as a result of the weakening of the arterial wall. A pseudoaneurysm generally developed secondarily due to rent through the artery's wall with persistent flow outside the artery but contained by the nearby tissue.[3]

True radial artery aneurysms are rare, accounting for 2.9% of all upper limb true aneurysms.[4] Pathologies associated with true radial artery aneurysms include connective tissue disorders such as Marfan's disease, neurofibromatosis, infections, vascular tumors, and arteriosclerosis.

With coronary angiography and percutaneous coronary intervention preferred through the transradial approach, the risk of traumatic pseudoaneurysm formation has been estimated to be at 0.6%. Risk factors for the development of radial artery pseudoaneurysm include multiple arterial punctures, prolonged arterial hemodynamic monitoring and vascular catheter infections, and prolonged bleeding due to aggressive use of anticoagulants, broader sheath size, and inadequate compression postprocedure.[5] Pseudoaneurysm formation rate can be reduced using ultrasound-guided cannulation to decrease trauma to the arterial wall due to multiple trails, good compression bandage postprocedure, using adequately sized sheaths, maintain complete sterility, and timely removal of catheters.

Both true radial artery aneurysm and pseudoaneurysm may present as asymptomatic pulsatile swellings. Depending on size and location, the aneurysms carry the risk of thromboembolization, leading to distal ischemic changes and presenting as painful, cold limb with pallor with limb-threatening conditions. Involvement of adjoining neural tissue may also lead to severe pain and ischemic changes. Ultrasound/duplex scan and coronary tomography angiography are the routinely used modalities for confirmation of the diagnosis of an aneurysm. Doppler ultrasound can confirm the diagnosis by demonstrating laminar flow through a neck region (yin-yang sign) between true vessel lumen and pseudoaneurysm.[6]

Management modality is dependent on clinical history, presenting features, size, wall defect, and amount of hematoma in the pseudoaneurysm. Ultrasound-guided compression to occlude flow may suffice in smaller pseudoaneurysms, but larger pseudoaneurysms require surgical intervention. In selected cases of pseudoaneurysm with a narrow neck, an external compression device or direct thrombin injection may be a consideration a treatment strategy.[7] Furthermore, for arterial rents which are not amenable for external device compression or direct thrombin/glue injection, endovascular coil or stent graft placement is advocated.[8]


  Conclusion Top


True aneurysms are thin-walled due to weakened and stretched vascular wall layers. In pseudoaneurysm, the wall is formed by surrounding tissue which forms a thick capsule. It has been documented that clot is absent in most true aneurysms. Whereas, in pseudoaneurysms, small communication leads to clot formation in peripheral layers leading to thickening of the capsule, which may get infected, leading to sepsis or rupture if not treated early. Hence, early management of radial pseudoaneurysm is warranted. Management modality is case based which depends on the size and constitutional symptoms. Most small-sized pseudoaneurysms get thrombosed after few days of intervention. Pseudoaneurysm with narrow neck can be managed by endovascular intervention. Surgery is offered to patients with big thrombus load with broad neck.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eichhöfer J, Horlick E, Ivanov J, Seidelin PH, Ross JR, Ing D, et al. Decreased complication rates using the transradial compared to the transfemoral approach in percutaneous coronary intervention in the era of routine stenting and glycoprotein platelet IIb/IIIa inhibitor use: A large single-center experience. Am Heart J 2008;156:864-70.  Back to cited text no. 1
    
2.
Zegrí I, García-Touchard A, Cuenca S, Oteo JF, Fernández-Díaz JA, Goicolea J. Radial artery pseudoaneurysm following cardiac catheterization: Clinical features and nonsurgical treatment results. Rev Esp Cardiol (Engl Ed) 2015;68:349-51.  Back to cited text no. 2
    
3.
Madeline Chee YM, Lew PS, Darryl Lim MJ. True idiopathic radial artery aneurysm: A case report and review of current literature. EJVES Vasc Forum 2020;49:34-9.  Back to cited text no. 3
    
4.
Hamid T, Harper L, McDonald J. Radial artery pseudoaneurysm following coronary angiography in two octogenarians. Exp Clin Cardiol 2012;17:260-2.  Back to cited text no. 4
    
5.
Sharma R, Patel P, Catanzaro JN. Late massive radial artery pseudoaneurysm following cardiac catheterization: A case report. Int J Surg Case Rep 2021;81:105774.  Back to cited text no. 5
    
6.
Mahanta D, Mahapatra R, Barik R, Singh J, Sathia S, Mohanty S. Surgical repair of postcatheterization radial artery pseudoaneurysm. Clin Case Rep 2020;8:355-8.  Back to cited text no. 6
    
7.
Bhat T, Teli S, Bhat H, Akhtar M, Meghani M, Lafferty J, et al. Access-site complications and their management during transradial cardiac catheterization. Expert Rev Cardiovasc Ther 2012;10:627-34.  Back to cited text no. 7
    
8.
Bansal A, Gorsi U, Farook S, Savlania A, Sandhu MS. Interventional radiology management of extremity pseudoaneurysms: A pictorial essay. Emerg Radiol 2021;28:1029-39.  Back to cited text no. 8
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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