Carolinas Research Day 2021

Brachial Artery Pseudoaneurysm: Yin-Yang Sign Kayla Baker, OMS-III, Lindsay Tjiattas-Saleski, DO, MBA, FACOEP. Edward Via College of Osteopathic Medicine, Carolinas Campus, Spartanburg, SC. Prisma Health Tuomey Hospital, Emergency Department, Sumter, SC.

CBR-10

Report of Case

Complications

Treatment

References 1. Rivera PA, Dattilo JB. Pseudoaneurysm. [Updated 2020 Sep 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK542244/ 2. Webber, GW, Jang J, Gustavson S, Olin JW. Contemporary Management of Postcatheterization Pseudoaneurysms. American Heart Association. 2007 May 22; 115(2): 2666-2674. https://doi.org/10.1161/CIRCULATIONAHA.106.681973 3. Rumack CM, Levine D; Diagnostic Ultrasound. 5 th ed. Philadelphia: Elsevier, Inc; c2018. Chapter 27, Peripheral Vessels; p. 964- 1013. 4. Heis HA, Bani-Hani KE, Elheis MA, Yaghan RJ, Bani-Hani BK. Postcatheterization femoral artery pseudoaneurysms: therapeutic options. A case-controlled study. Int J Surg. 2008 Jun;6(3):214-9. doi: 10.1016/j.ijsu.2008.03.006. Epub 2008 Mar 19. PMID: 18455971. 5. Sidawy AN, Perler BA. Rutherford’s Vascular Surgery and Endovascular Therapy. 9 th ed. Philadelphia: Elsevier, Inc; c2019. Chapter 60, Arterial Aneurysms: Etiology, Epidemiology, and Natural History; p. 875-883e1. 6. Tosti R, Özkan S, Schainfeld RM, Eberlin KR. Radial Artery Pseudoaneurysm. Journal of Hand Surgery. 2017 Apr 01; 42(4): 295.e1- 295.e6. 7. Eichhofer J, 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. American Heart Journal. 2008 Nov 01; 156(5): 864-870. 8. Kiemeneij F, Laarman GJ, Odekerken D, Slagboom T, van der Wieken R. A randomized comparison of percutaneous transluminal coronary angioplasty by the radial, brachial and femoral approaches: the access study. Journal of the American college of Cardiology. 1997;29(6):1269-1275.  Thrombin injection is the preferred treatment of pseudoaneurysms, unless a larger neck is present 3,4  Ultrasound guided direct compression 4  Surgical repair is reserved for those that fail thrombin injection or direct compression. 6  Spontaneous resolution if smaller in size (Diameter <1.8 cm) 3,4 Pseudoaneurysms are a known complication of endovascular procedures with the femoral artery as the most common arterial access. 1 However, the use of other arteries is on the rise, as the number of percutaneous procedures in the upper extremity has increased. 6 The arteries in the upper extremity are becoming more favored because of the shorter length of hospital stay and decrease in hospital complications as compared to femoral access. 7 However, the transbrachial approach, as seen in this patient, has been shown to have post procedural complications, and is therefore usually reserved for when femoral and radial access are not available. 8 With the growing use of the upper extremity for endovascular access, awareness and recognition of pseudoaneurysms is imperative due to the risk of further complications. 2 Most recent studies compare treatment options in relation specifically to the femoral artery. This information has then extrapolated for pseudoaneurysms in the upper extremity. As more data is gathered on cases like this, specific treatment options for the upper extremity may be developed in implemented. Conclusions

An 89-year-old male presented to the Emergency Department for a lump on his left upper extremity. He recently underwent a percutaneous left brachial artery access for splenic artery embolization. Post procedure, he developed swelling around the IV site. He also noted numbness in the fingers of his left hand and decreased grip strength. On physical exam, there was a mass over the left medial epicondyle region with no erythema, edema or warmth. The lesion did not feel pulsatile. His left upper extremity had decrease pincher grasp. Ultrasound of the left extremity revealed in the area of the left distal humerus soft tissues an anechoic structure measuring 7.0 x 2.6 cm with internal swirling color flow with a small neck feeding the vessel. These findings are most compatible with a pseudoaneurysm. He was referred to vascular surgery for treatment.  Pseudoaneurysms are most commonly caused iatrogenically after endovascular procedures. 1 With an incidence of 0.5% to 2%. 2  The femoral artery is the most common artery used for percutaneous access. Therefore, the femoral artery is the most common location for pseudoaneuryms. 1  This complication occurs when there is damage to at least one layer of the arterial wall causing blood to leak out into the perivascular space. A connection remains with the artery creating turbulent blood flow. 3  These is an increased risk for pseudoaneurysm as a post procedural complication if patients are placed on anti-platelet and anti-coagulation therapy 4 Etiology

Figure 1 . Image of the mass over the left medial epicondyle region.

 Potential harmful affects:  Rupture and hemorrhage 1  Compression neuropathy 5  Distal embolism 5

 Ischemia either distally due to reduced blood flow or to the overlying skin due to increase in pressure from swelling 1

Diagnosis

Figure 2 . Internal swirling on US Color Flow seen in out 89-year-old patient, demonstrating the classing “Yin-Yang” sign  Ultrasound with Doppler Color flow to show bidirectional blood flow creating a “Yin-Yang” like appearance 3

Signs & Symptoms

 The most common symptom is an acute onset localized swelling near the vascular access site with possible associated pain to the area. 1  This mass can present as pulsatile, with possible bruit on auscultation 1

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