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Case report |
Department of Radiology, Western Infirmary NHS Trust, Dumbarton Road, Glasgow G11 6NT, UK
Correspondence: Dr G M Baxter
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Abstract |
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Introduction |
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We report a very rare case of spontaneous pseudoaneurysm arising from the inferior epigastric artery. The role of colour Doppler ultrasound in the diagnosis and management of this pseudoaneurysm are described.
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Case report |
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On arrival at hospital, physical examination revealed a tender, non-pulsatile mass in the left upper quadrant measuring 6 cm x 6 cm. The patient was haemodynamically stable. Full blood count included white blood cell count of 5.63 cells µl-1, haemoglobin level of 13.5 g dl-1, platelets 174 x 103 ml, prothrombin time of 11 s, and partial thromboplastin time of 25 s. The provisional diagnosis was carcinoma of the bowel or diverticulitis.
The patient was referred to the X-ray Department where an ultrasound examination of the abdomen, using a 3.5 MHz sector probe, revealed a large mixed echogenic mass in relation to the left of the rectus sheath, associated with a central sonolucent centre (Figure 1a
). At this point the differential diagnosis was between a rectus sheath haematoma or a rare soft tissue tumour. Using a higher frequency linear array probe (5–12 MHz), colour Doppler showed a hypervascular nidus with a feeding vessel arising from the inferior epigastric artery (Figure 1b, c). Spectral Doppler of the feeding vessel showed both forward and reverse flow, i.e. the "to and fro" sign indicative of a pseudoaneurysm (Figure 1d).
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). Follow-up ultrasound scans performed on the 4th and 14th day post procedure showed no evidence of recanalization.
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Discussion |
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Clinically, an inferior epigastric artery pseudoaneurysm is difficult to diagnose. They usually present as diffuse, tender masses that are, however, non-pulsatile. An audible bruit is the exception rather than the rule [6]. They are therefore difficult to differentiate from simple haematomas. Colour Doppler ultrasound is the imaging method of choice allowing non-invasive evaluation of such masses. On ultrasound, haematomas exhibit variable echogenicity and internal complexity but never demonstrate internal blood flow [6]. In contrast, a pseudoaneurysm will be easily demonstrated as an extravasation of blood flow outside the vessel. Characteristic appearances are seen with colour Doppler imaging. Typical ultrasonic findings include a focal area of flow with a mixed, swirling red and blue colour pattern varying with systole and diastole, a jet between the vessel and aneurysm sac and the "to and fro" sign on spectral Doppler analysis [9, 10]. Colour Doppler ultrasound has a sensitivity and specificity of 100% in differentiating false aneurysms from periarterial haematomas.
Traditionally, the management of pseudoaneurysms has been surgical resection [1]. Percutaneous embolisation has been used and recommended for smaller lesions [4]. Another technique that is widely used in the initial management of iatrogenic pseudoaneurysm of the femoral artery is ultrasound guided compression repair (UGCR). The aim of this technique is to compress the neck of the pseudoaneurysm with the ultrasound transducer to arrest blood flow within it. This may take, on average, 30–50 min. The technique is safe and effective with an overall success rate of 75%. However, as many as 10% of patients cannot be treated with UGCR because flow cannot be arrested [11].
More recently, the treatment of femoral artery pseudoaneurysms with percutaneous ultrasound guided thrombin injection has been advocated. The technique uses up to 1000 IU of human thrombin. A 22 G spinal needle is inserted percutaneously into the aneurysmal sac under ultrasound control and the thrombin injected. Thrombosis is usually observed within seconds. Complications related to this technique are rare. Lennox et al [12] report a single case in which thrombosis was induced in both the pseudoaneurysm and its parent brachial artery. However, it was felt that the needle tip had strayed into the native vessel itself.
The technique described is simple, safe, quick to perform, painless and extremely effective. In this case the pseudoaneurysm was successfully treated and further clinical follow-up showed complete resolution of the rectus sheath haematoma.
Received for publication January 2, 2002. Revision received April 2, 2002. Accepted for publication May 15, 2002.
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