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.