Discussion
Iatrogenic pseudoaneurysm is one of the most common vascular complications of cardiac and peripheral angiographic procedures. The incidence of pseudoaneurysm after interventional procedure ranges from 2% to 6%.1 Most patients with uncomplicated pseudoaneurysms can be managed with ultrasound-guided techniques. Ultrasound-guided thrombin injection (UGTI) is the first-line technique, rather than ultrasound-guided compression, because of the high success rate (97.5%) and acceptably low rate of thrombotic complications (0.5%).2 However, it should be noted that this is off-label use of thrombin.
For complicated pseudoaneurysm, defined as cases with hemodynamic instability, extensive skin and subcutaneous damage, or soft tissue infection, the common treatment strategy is open surgical repair.3 The present patient showed progressive anemia and aneurysmal wall rupture, suggesting complicated pseudoaneurysm. Due to the size and ruptured nature of the wall, coil embolization or UGTI was not suitable for this case. However, because there were no signs of infection, the management goal was simply to close the related arterial wall. Based on the duplex echo findings, we considered ultrasound-guided puncture of the pseudoaneurysm and passage of a guidewire through the wide aneurysmal neck (6.1 mm) to be feasible. Perclose ProglideTM was thus applied, and we adopted a low-invasiveness strategy involving percutaneous suture with a Perclose ProglideTM to successfully repair this case of complicated large pseudoaneurysm. No recurrence has yet been noted.
In the literature, only one report has described two cases of successful pseudoaneurysm repair with Perclose ProglideTM.4 Although the previous report described the difficulties with this method, several tips would help overcome these problems. First, it is important to evaluate pseudoaneurysms and the neck using duplex echo to determine whether or not it is feasible to pass a guidewire through the aneurysmal neck. In addition, performing puncture near the previously punctured skin mark is essential. Second, angiography of the related lesion should be performed, and the aneurysmal neck should be visualized to facilitate guidewire passage. Third, to deploy the foot of the device at the appropriate position, confirmation by fluoroscopy guidance is vital, as bleeding from the indicator of the device indicates an inappropriate position.