Pseudoaneurysms/Arterial Injury

Abstract

Unlike a true aneurysm, a pseudoaneurysm does not contain all or any layer of the vessel wall. The “wall” of the pseudoaneurysm can be the thin layer of tunica adventitia or a membrane, which forms from fibrin/platelet crosslinks. The etiologies of the pseudoaneurysm are reviewed. Open or closed artery injury presented with different symptoms is often associated with the pseudoaneurysm. Given that both are associated closely, and treatment for both is commonly planned and performed together, the pseudoaneurysm and artery injury are discussed together. Based on the different etiologies, there are different types of pseudoaneurysms and artery injuries. The appropriate corresponding treatment strategies and techniques are discussed in detail. Traumatic carotid-cavernous fistula as a special type of pseudoaneurysm and artery injury is introduced in detail with different endovascular intervention strategies and techniques.

Case Presentation

Case 15.1 Cervical ICA Cancer Erosion-Related Pseudoaneurysm and Active Bleeding

Case Pearls

• 1. Laryngectomy/neck/oral cancer is the common reason for cervical artery injury and associated pseudoaneurysm.

• 2. Covered stent is possibly the best way to reconstruct the vessel injury.

• 3. For associated large pseudoaneurysm with wide/extended vessel injury, coil may provide additional benefit for better bleeding control.

(a) CTA for work-up of profuse oral bleeding, s/p laryngectomy/neck dissection showing large pseudoaneurysm arising from likely the mid left internal carotid artery with a large adjacent hematoma measuring approximately 4 × 3.6 cm; (b–d) left carotid angiograms showing flow jet of pseudoaneurysm associated with mid ICA rupture; (e) loose coil placement for promoting thrombosis and stent support; (f) deployment of covered stent (6 × 38 iCAST covered stent); (g) final run after stent placement; (h) single-shot X-ray showing the stent location; (i) 3-month follow-up angiogram

Case 15.2 Cervical ICA Cancer-Related Active Bleeding

Case Pearls

• 1. Cancer erosion into the adjacent ICA with open wound can cause devastating bleeding.

• 2. Covered stent for cervical carotid injury is often the first option.

• 3. The large difference of artery diameter at carotid bifurcation can be overcome by overlapping two or more different sizes of stents.

• 4. ECA needs to be occluded to prevent recurrent retro-flow bleeding from ECA to the stent covered carotid bifurcation.

(a) A picture of open wound with known left cervical cancer and previous surgical resection/radiation and sudden increased hemorrhage from the wound; (b) CTA confirmed the deepest location of the open wound is at the carotid bifurcation level (circles); (c) right carotid angiogram for deciding the size of the stent; (d) coil occlusion of external carotid artery before the stent placement to eliminate the potential retrograde flow causing bleeding given that the stent will cross the carotid bifurcation. There is a large difference of lumen diameter at carotid bifurcation; overlapping two different sizes of stents was planned. (e) deployment of smaller balloon-mounted covered stent (iCAST 6×22); (f) deployment of the larger stent (iCAST 8×38); (g) final run after stent placement; (h) single shot for showing the two overlapped stents with different size

Case 15.3 CCF and Pseudoaneurysm from Skull Base Fracture

Case Pearls

• 1. Traumatic CCF and ICA pseudoaneurysm is often seen on skull base fracture.

• 2. Traumatic pseudoaneurysm needs to be treated emergently.

• 3. Flow diverter is a good option for treating traumatic CCF.

• 4. FD-sealed CCF can recur; early angiogram follow-up is recommended.

(a) Traumatic head injury with CT showing SAH around suprasellar region; (b) CTA: paraclinoid ICA pseudoaneurysm (arrow heads) and multiple skull base fractures (arrow); (c–e) initial angiogram confirmed the left ICA pseudoaneurysm and a high-flow left CCF (Barrow type A); (f) right ICA run showed the sign of limited flow from left ICA; the decision was made to coil the pseudoaneurysm loosely followed with multiple FD device treatment for CCF; (g) pre-embo working view to facilitate catharizing the pseudoaneurysm and FD placement. (h) stent delivering catheter in place, insert: micro run demonstrates the aneurysm clearly without contrast extravasation or flow to cavernous sinus; (i) angiogram after coiling the aneurysm. (j–m) multiple flow diversion device placement with gradually decreased CCF flow until completely stopped; after the first PED stent (j), after the second stent (k), after the third stent (l), single shot showing contour of FD devices (m); (n, o) 1-week follow-up angiograms showing recurrence of the CCF; the pseudoaneurysm remained occluded; retreatment through transvenous approach for embolization of the cavernous sinus was planned; (p, q) micro run showing microcatheter tip unable to be navigated into the anterior compartment of the cavernous sinus through inferior petrosal sinus approaches; the tip is located in the posterior compartment; (r, s) final coil mass and Onyx cast (Onyx injection through the right and intercavernous sinus also performed); (t) final run showing still mild CCF flow; (u–w) 1-month follow-up angiograms showing complete obliteration of the CCF flow and no more right to left flow through anterior communicating artery

Case 15.4 Petrosal ICA Large Pseudoaneurysm Treated with FD Stent

Case Pearls

• 1. Petrosal ICA pseudoaneurysm occurred in different clinical situation, such as tumor, ear infection, and trauma.

• 2. The FD treatment is straightforward with low risk and effective.

• 3. CTA vs MRA TOF are good for checking recurrence/residual. Contrast-enhanced time-resolved MRA has advantages for in-stent stenosis follow-up.

(a, b) MRI for work-up of neck mass showing left petrosal mass lesion with pseudoaneurysm associated with ICA (circles); (c, d) pre-embo 3D and 2D views of carotid angiogram confirmed the pseudoaneurysm with flow jet; (e) angiogram after PED (4×30) placement; (f) single-shot X-ray for PED contour; (g) 6-month follow-up angiogram with small neck residual and no in-stent stenosis; (h, i) 18-month CTA (h) and MRA TOF (i) follow-up showing no residual of the pseudoaneurysm

Case 15.5 Covered Stent for Intraoperative Repair of Iatrogenic VA Injury

Case Pearls

• 1. Intraoperative iatrogenic VA injury or carotid injury from spine/neck surgery is a common complication.

• 2. Covered stent with intraoperative portable fluoroscopy is quick and effective. It can preserve the artery and make the surgery continue as planned from the beginning.

(a, b) Intraoperative angio at the request of the surgeon for left VA laceration injury from cervical fusion procedure with Cottonoid patty (arrow) tamponade. Gushing arterial bleeding once patty was removed. Severe arterial stenosis at laceration site (arrowhead). (c) Right VA intracranial run; (d) covered stent (iCAST 5×22, arrowhead) advanced in place, undeployed with Cottonoid patty tamponade (arrow); (e) mounted balloon inflated; (f) stent fully deployed with Cottonoid patty removed; (g) post-stent placement run: no contrast extravasation with no significant stenosis with good distal flow; (h, i) 3-month follow-up angiograms showing stable diameter of the lumen of stent with good flow. (Reproduced from Wangqin et al. [7] with permission from Elsevier)