AJR 2005; 185:741-749
© American Roentgen Ray Society
Visceral and Peripheral Arterial Pseudoaneurysms
Eijun Sueyoshi1,
Ichiro Sakamoto1,
Kazuaki Nakashima1,
Kazunori Minami2 and
Kuniaki Hayashi1
1 Department of Radiology, Nagasaki University School of Medicine, 1-7-1
Sakamoto, Nagasaki 852-8501, Japan.
2 Department of Radiology, Nagasaki Municipal Hospital, 6-39 Shinchi-machi,
Nagasaki 850-0842, Japan.
Received September 5, 2004;
accepted after revision November 15, 2004.
Address correspondence to E. Sueyoshi.
Abstract
OBJECTIVE. Pseudoaneurysms are not rare, and various conditions can
cause a pseudoaneurysm in all the cardiovascular systems. In this article, we
discuss and show images of pseudoaneurysms of various arteries caused by
various conditions.
CONCLUSION. CT, MRI, sonography, and angiography may all be valuable
in the imaging workup of pseudoaneurysms. Knowledge of the various appearances
of pseudoaneurysms and of the proper management is essential to prevent a
catastrophic outcome in cases of pseudoaneurysm.
Introduction
Pseudoaneurysms can be life-threatening due to rupture and bleeding.
Therefore, pseudoaneurysms are considered an emergency disease and need to be
diagnosed accurately and quickly. Also, prompt treatment using surgical,
medial, and endovascular techniques is essential
[1]. Moreover, pseudoaneurysms
are not rare, and various conditions can cause a pseudoaneurysm in all the
cardiovascular systems [1]. It
is important to know the imaging findings of various pseudoaneurysms.
The terms "pseudoaneurysm," "false aneurysm,"
"pulsatile hematoma," and "communicating hematoma" are
synonymous and may be used interchangeably
[1]. In this article, we use
the term "pseudoaneurysm." A pseudoaneurysm is defined as a
pulsating, encapsulated hematoma in communication with the lumen of a ruptured
vessel (Figs. 1A,
1B, and
1C). A ventricular
pseudoaneurysm is a cardiac rupture contained and loculated by the
pericardium, which forms its external wall
[2] (Figs.
2A,
2B, and
2C). Pathologically, the wall
of arterial pseudoaneurysm has been breached, and the external wall of the
aneurysmal sac consists of outer arterial layers, perivascular tissue, blood
clot, or layer of reactive fibrosis
[3]
(Fig. 1C).
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Fig. 1A —53-year-old man with pseudoaneurysms in aorta after surgery
for thoracic aortic aneurysm. Two years after surgery, contrast-enhanced CT
images of thoracic aorta show pseudoaneurysms (arrows) at both
anastomotic sites of graft.
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Fig. 1B —53-year-old man with pseudoaneurysms in aorta after surgery
for thoracic aortic aneurysm. Two years after surgery, contrast-enhanced CT
images of thoracic aorta show pseudoaneurysms (arrows) at both
anastomotic sites of graft.
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Fig. 1C —53-year-old man with pseudoaneurysms in aorta after surgery
for thoracic aortic aneurysm. Surgery was performed again. Photomicrograph of
specimen of pseudoaneurysm of aorta shows that its wall consists of thrombus
(a) and reactive fibrosis (b). There is no native wall structure. (H and E,
x 40)
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Fig. 2A —68-year-old man with pseudoaneurysm of heart due to
infarction. Axial spin-echo (A) and cine (B) MR images show
pseudoaneurysm (arrows) of left ventricle due to myocardial
infarction of posterolateral wall.
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Fig. 2B —68-year-old man with pseudoaneurysm of heart due to
infarction. Axial spin-echo (A) and cine (B) MR images show
pseudoaneurysm (arrows) of left ventricle due to myocardial
infarction of posterolateral wall.
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Fig. 2C —68-year-old man with pseudoaneurysm of heart due to
infarction. Photograph of intraoperative findings reveals myocardial defect
(arrow) covered by pericardium (arrowheads). In this case,
patch graft for myocardial defect was performed.
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In this article, we discuss and show images of pseudoaneurysms of various
arteries, excluding cerebral and cervical pseudoaneurysms, that are caused by
various conditions.
Diagnosis of Pseudoaneurysm
A comprehensive imaging strategy is required for patients with
pseudoaneurysm. CT may be the first imaging technique that is performed for
the diagnosis of pseudoaneurysm
[4]. Most pseudoaneurysms are
saccular in shape. If angiography or endovascular treatment is required
promptly, radiologists should try to reduce the total dose of contrast medium.
Large pseudoaneurysms can be detected easily on contrast-enhanced CT, whereas
small lesions can be overlooked easily. In such cases, angiography is required
[4]. Angiography allows
confirmation of the site of the pseudoaneurysm and assessment of its
suitability for immediate treatment with an interventional technique if
needed.
CT angiography, MRI (including MR angiography), and sonography combined
with color Doppler study are sometimes used for the diagnosis of
pseudoaneurysm [4]. However,
MRI has not been as useful as CT angiography or sonography in the diagnosis of
pseudoaneurysm because its use is limited by the poor clinical condition of
patients. Sonography has been shown to improve the detection of
pseudoaneurysm. Although the ability to perform the examination at the bedside
and its relative low cost may make sonography an ideal first-line examination,
the ability to diagnose pseudoaneurysm using sonography may depend on the
location of the lesion and the skill of the operator
[4].
Treatment of Pseudoaneurysm
In the past, early surgical repair was recommended for the treatment of
almost all pseudoaneurysms [1].
Recently, endovascular techniques have been widely used for the treatment of
pseudoaneurysms because these techniques are minimally invasive and have a
high success rate and are associated with low mortality
[4]. However, surgery is the
first choice for the treatment of a pseudoaneurysm of the left ventricle
[5] (Figs.
2A,
2B, and
2C). Infected pseudoaneurysms
also require surgical treatment because they may expand rapidly, leading to
rupture, or may produce septic emboli that are then released into the distal
circulation [6]. Medical
treatment might be appropriate for the management of pseudoaneurysms that were
stable in size during the follow-up period
[1,
7]. However, frequent follow-up
examination is needed, and further studies are required for medical treatment
of pseudoaneurysms to become generally accepted.
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Fig. 3 —55-year-old man with pseudoaneurysm caused by angiographic
procedure (coronary artery angiography). Contrast-enhanced axial CT image
shows pseudoaneurysm of right femoral artery (arrows) after
angiography. Recently, pseudoaneurysm of femoral artery tends to be treated by
interventional techniques such as compression therapies, thrombin injection,
or both. However, surgery was selected in this case because of severe
pain.
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Fig. 4A —65-year-old man with pseudoaneurysm caused by
chemoembolization for multiple hepatocellular carcinomas. Two weeks after
chemoembolization, unenhanced CT image shows multiple areas of iodized oil
(Lipiodol, Guerbet) in tumors.
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Fig. 4B —65-year-old man with pseudoaneurysm caused by
chemoembolization for multiple hepatocellular carcinomas. Three months after
A, angiogram was obtained because recurrent tumors were suspected.
Angiogram shows tiny pseudoaneurysms of hepatic arteries (arrows).
These pseudoaneurysms were not detectable on CT (not shown). Chemoembolization
damaged vessel wall.
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Endovascular techniques, placement of a metallic coil or stent-graft, are
frequently used for the treatment of pseudoaneurysm. The success of treatment
depends on excluding the pseudoaneurysm from the circulation. Ideally, a
metallic coil or stent-graft is placed from the proximal and distal ends of
the pseudoaneurysm to avoid collateral circulation. Filling of the aneurysmal
sac with embolic material, especially metallic coils, should generally be
avoided because this often causes expansion of the pseudoaneurysm and risks
its rupture [1,
8]. In some cases,
pseudoaneurysm cannot be treated by this ideal procedure because of the
difficulty of the technique and the possibility of complications, such as
organ ischemia.
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Fig. 5B —24-year-old man with splenic pseudoaneurysm caused by blunt
abdominal trauma due to motor vehicle crash. Splenic angiogram shows
pseudoaneurysm in spleen (arrow). Metallic coil embolization was
performed.
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Fig. 6A —84-year-old woman with mesenteric pseudoaneurysm caused by
blunt abdominal trauma due to motor vehicle crash. Contrast-enhanced CT image
shows pseudoaneurysm (arrow) and hematoma in mesenterium.
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Fig. 6B —84-year-old woman with mesenteric pseudoaneurysm caused by
blunt abdominal trauma due to motor vehicle crash. Angiogram of superior
mesenteric artery shows pseudoaneurysm (arrows). Pseudoaneurysm is
relatively rare in mesenterium.
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Causes of Pseudoaneurysm
Iatrogenic Complication
This group includes pseudoaneurysms due to various medical procedures such
as surgery or angiography (Figs.
1A,
1B,
1C,
3,
4A, and
4B). The incidence of
iatrogenic pseudoaneurysms has risen exponentially in recent years
[1]. Pseudoaneurysm formation
in the femoral arteries (puncture site) is a relatively common complication of
catheterization (Fig. 3). The
reported incidence of postcatheterization pseudoaneurysm varies widely from
0.05% to 14%. Iatrogenic pseudoaneurysms are most commonly produced by
catheterization, accounting for 70-80% of the incidence
[1].
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Fig. 7B —19-year-old man with thoracic aortic pseudoaneurysm caused by
blunt trauma due to motor vehicle crash. Thoracic aortogram shows
pseudoaneurysm in region of aortic isthmus (arrow). This case is
typical of thoracic aortic pseudoaneurysm caused by trauma. Surgery was
performed. After surgery, patient has been doing well.
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Fig. 8A —44-year-old man with pseudoaneurysm caused by
neurofibromatosis. Contrast-enhanced CT image shows large masses
(neurofibromas) around sacrum and left buttock. Hematomas (arrows)
are seen around tumor, but pseudoaneurysm is not detectable on CT.
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Trauma
This group of pseudoaneurysms includes those caused by accidents, such as
car crashes, or by blunt or penetrating trauma (Figs.
5A,
5B,
6A,
6B,
7A, and
7B). The patient sometimes has
multiple injuries. Most pseudoaneurysms that result from penetrating or blunt
traumas are caused by gunshot injuries, stabbing wounds, and motor vehicle
crashes [9]. The exact
incidence of traumatic pseudoaneurysms is difficult to ascertain, but
traumatic aortic pseudoaneurysm is the second most common form of thoracic
aortic aneurysm and is most common in young adults.
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Fig. 9B —35-year-old man with pseudoaneurysm caused by malignant
lymphoma. Seven days after A, patient complained of severe abdominal
pain. Unenhanced CT image shows spleen has rapidly decreased in size, and
hematoma (arrows) is seen in spleen.
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Ninety percent of the thoracic aortic injuries occur in the region of the
aortic isthmus. Shearing stress and bending stress are forces that frequently
involve the aortic isthmus (Figs.
7A, and
7B). The treatment for
traumatic aortic pseudoaneurysm is urgent surgical repair. Traumatic
pseudoaneurysm of the abdominal aorta is rare. Most (79%) are caused by
penetrating injury [9]. In the
abdomen, the spleen is the most frequently injured solid parenchymal organ,
followed by liver, kidney, gastrointestinal tract, and pancreas
[9] (Figs.
5A, and
5B).
Injury by Tumor
Vessel injury by tumor is a relatively rare cause of pseudoaneurysm. Both
benign and malignant tumors can cause pseudoaneurysm due to vessel erosion
[10] (Figs.
8A,
8B,
9A,
9B,
9C, and
9D). Pseudoaneurysms that are
caused by osteochondroma are relatively common. In patients with
neurofibromatosis, pseudoaneurysms also have been reported. Pseudoaneurysms
are caused by degenerative changes of the vessel wall or secondary erosion by
adjacent tumor in patients with neurofibromatosis
[10] (Figs.
8A, and
8B).
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Fig. 9D —35-year-old man with pseudoaneurysm caused by malignant
lymphoma. Splenectomy was performed. Photomicrograph of specimen of spleen
shows that lymphoma cells (arrows) invade arterial wall
(arrowheads). This is not a site of pseudoaneurysm. (H and E, x
10)
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Malignant tumor often causes life-threatening bleeding, and it may,
although rarely, cause pseudoaneurysm. The incidence of pseudoaneurysm caused
by malignant tumor is uncertain, but choriocarcinoma has been reported to
account for approximately one quarter of neoplastic aneurysms
[11]. Several cases of
pseudoaneurysm associated with leukemia and lymphoma have been reported.
Leukemic cells or lymphomas damage the arterial wall and cause the formation
of a pseudoaneurysm [12]
(Figs. 9A,
9B,
9C, and
9D).
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Fig. 10B —56-year-old man with pseudoaneurysm caused by
Salmonella infection in abdominal aorta. Aortogram shows
pseudoaneurysm (arrow). Usually, surgery is first choice of treatment
for infected aneurysm. In this case, stent-graft placement was selected
because this patient was a poor surgical candidate. Although patient was
placed on antibiotics during and after this procedure; he died of rupture of
pseudoaneurysm.
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Infection
Infection includes both primary vessel wall infection and infection
secondary to adjacent focus (Figs.
10A, and
10B). It can occur in any
vessels, but the incidence of infected (mycotic) pseudoaneurysm is uncertain
[13]. Infection can cause both
true aneurysms and pseudoaneurysms. However, pseudoaneurysms may be more
frequent because infection can easily disrupt the arterial wall. The most
common location of an infected aneurysm is the femoral artery, followed by the
abdominal aorta. The incidence of infected aortic aneurysms is reported to be
0.06-2.60% of all aneurysms; they often lead to uncontrolled sepsis and
catastrophic hemorrhage if not treated
[13]. In infected aortic
aneurysms, the hematogenous spread of infections into the vasa vasorum of the
aortic wall is thought to be the most common pathogenesis, and the organisms
that most commonly cause infected aortic aneurysm are Staphylococcus
aureus and Salmonella
[13].
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Fig. 11B —45-year-old man with pseudoaneurysm caused by Behçet's
syndrome in pulmonary artery. Pulmonary arteriogram shows pseudoaneurysm of
segmental branch of pulmonary artery (arrow). Patient died of rupture
of this pseudoaneurysm.
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Vasculitis and Inflammation
Vasculitis includes both primary vasculitis and vasculitis secondary to
adjacent inflammation. Primary vasculitis can be seen in systemic vasculitis,
such as Behçet's syndrome, polyarteritis nodosa, systemic lupus
erythematosus, giant cell arteritis, Takayasu's arteritis, and so on
[14] (Figs.
11A,
11B, and
12). As the vessels become
inflamed, the elastic fibers of the media are destroyed, thus resulting in
pseudoaneurysm formation [14].
Pseudoaneurysms caused by primary vasculitis are relatively rare, but many
cases of pseudoaneurysm caused by Behçet's syndrome have been reported
[14] (Figs.
11A, and
11B). The frequency of
vascular involvement in Behçet's syndrome is estimated to range from 2%
to 46%. Pseudoaneurysms are more common than arterial occlusions or stenoses,
and pseudoaneurysm rupture is a major cause of death
[14]. The aorta is the most
frequently affected site of pseudoaneurysm, followed by pulmonary, femoral,
subclavian, and popliteal arteries
[14].
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Fig. 12 —34-year-old woman with severe abdominal pain and
pseudoaneurysm caused by Takayasu's arteritis. Contrast-enhanced oblique
coronal reformatted CT image shows large pseudoaneurysm in abdominal aorta.
Although emergency surgery was planned, this patient died of rupture of
pseudoaneurysm.
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Vasculitis secondary to adjacent inflammation associated with pancreatitis
is rather common (Figs. 13A,
and 13B). The splenic artery,
because of its contiguity with the pancreas, is the vessel most commonly
involved in pancreatitis. However, virtually all the pancreatic and
peripancreatic vessels and superior mesenteric artery can be involved
[15]. The most serious
complication of visceral artery pseudoaneurysms is hemorrhage, with a
mortality rate of 12.5-37%. When visceral artery pseudoaneurysms are not
treated, the mortality rate becomes significantly higher, increasing to 90%
[15].
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Fig. 14A —82-year-old woman with chest pain and pseudoaneurysm caused
by penetrating atherosclerotic ulcer. Contrast-enhanced axial CT image
(A) and coronal reformatted image (B) show large pseudoaneurysm
in descending thoracic aorta (arrow). In this case, penetrating
atherosclerotic ulcer may be cause of pseudoaneurysm. Surgery was performed.
After undergoing surgery, patient has been doing well.
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Fig. 14B —82-year-old woman with chest pain and pseudoaneurysm caused
by penetrating atherosclerotic ulcer. Contrast-enhanced axial CT image
(A) and coronal reformatted image (B) show large pseudoaneurysm
in descending thoracic aorta (arrow). In this case, penetrating
atherosclerotic ulcer may be cause of pseudoaneurysm. Surgery was performed.
After undergoing surgery, patient has been doing well.
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Atherosclerosis
Atherosclerotic changes usually cause true aneurysms of the vessel.
However, recent reports suggest that penetrating atherosclerotic ulcer can
cause a pseudoaneurysm of the aorta (Figs.
14A, and
14B). Penetrating
atherosclerotic ulcer is defined as an atheromatous plaque with an ulcer of
the aortic wall. It most often occurs in elderly patients and typically
involves the descending aorta. It can disrupt the internal elastic lamina and
can cause aortic dissection, pseudoaneurysm, or rupture of aorta
[16].
Infarction
Infarction is a common cause of pseudoaneurysm of the left ventricle (Figs.
2A,
2B, and
2C). Rupture of the wall of the
left ventricle is a catastrophic complication of myocardial infarction,
occurring in approximately 4% of patients with infarcts and about 23% of those
who have fatal infarct. Rarely, wall rupture is contained by overlying,
adherent pericardium, thereby producing what has been termed
"pseudoaneurysm of the left ventricle"
[5].
Conclusion
Pseudoaneurysms can occur in all vascular beds. CT, MRI, sonography, and
angiography may all be valuable in the imaging workup of pseudoaneurysms.
Prompt diagnosis and treatment of pseudoaneurysms are necessary to avoid the
morbidity and mortality associated with hemorrhage and rupture. Treatment can
involve surgical, medical, and endovascular methods.
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Abstract
Introduction
