10.4081/btvb.2022.25
A 77-year-old lady with a longstanding scleroderma, presented to the Emergency Department for a state of severe malnutrition and fluid dysphagia. On physical examination, she presented an abdominal palpable swelling, with an associated large, posterior ecchymosis. A pseudoaneurysm of the right inferior epigastric artery was diagnosed on a color Doppler ultrasound examination. After collegial discussion with the surgical and interventional-radiologist team, a percutaneous exclusion of the pseudoaneurysm through thrombin injection was successfully performed, and no complications were reported. After a thorough anamnestic record, the possible cause of the pseudoaneurysm was discovered: a few days before hospital admission the general practitioner did some intradermoclysis in the abdominal wall to hydrate the patient, damaging the inferior epigastric artery wall with subsequent development of the pseudoaneurysm. The patient completely recovered, returned home after two weeks in a subacute facility, and is awaiting evaluation for the scleroderma follow up from a rheumatologist.
video/quicktime
2785-5309
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2
en
Francesco  Dentali
https://creativecommons.org/licenses/by-nc/4.0
Bleeding, Thrombosis and Vascular Biology
Anamnestic record
Iatrogenic pseudoaneurysm of inferior epigastric artery: not only a surgical complication
Text.Serial.Journal
https://www.btvb.org/btvb
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Case Reports
2022-07-14
2022-03-14
2022-05-23
2022-07-14
Bleed Thromb Vascul Biol
Francesco  Dentali
2022/07/14
10.4081/btvb.2022.25
Department of Internal Medicine, Circolo Hospital, ASST Sette Laghi, Varese; Department of Medicine and Surgery, University of Insubria, Varese
2785-5309
2
Anamnestic record
en
Curti M, Piacentino F, Fontana F, et al. EVAR follow-up with ultrasound superb microvascular imaging (SMI) Compared to CEUS and CT angiography for detection of Type II Endoleak. Diagnostics (Basel) 2022;12:526.
Iatrogenic pseudoaneurysm of inferior epigastric artery: not only a surgical complication
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1
                                                                                                                   CASE REPORT

Iatrogenic pseudoaneurysm of inferior epigastric artery:
not only a surgical complication
Rossana Corso,1 Coppola Andrea,2 Stefano Grazioli,1 Cristina Dedionigi,1 Nicolò Tandurella,1 Venturini Massimo,2,3
Francesco Dentali1,3
1
  Department of Internal Medicine, Circolo Hospital, ASST Sette Laghi, Varese; 2Diagnostic and Interventional Radiology Department,
Circolo Hospital, ASST Sette Laghi, Varese; 3Department of Medicine and Surgery, University of Insubria, Varese, Italy



ABSTRACT
     A 77-year-old lady with a longstanding scleroderma, presented to the Emergency Department for a state of severe malnutrition and
fluid dysphagia. On physical examination, she presented an abdominal palpable swelling, with an associated large, posterior ecchymosis.
A pseudoaneurysm of the right inferior epigastric artery was diagnosed on a color Doppler ultrasound examination. After collegial dis-
cussion with the surgical and interventional-radiologist team, a percutaneous exclusion of the pseudoaneurysm through thrombin injection
was successfully performed, and no complications were reported. After a thorough anamnestic record, the possible cause of the pseudoa-
                                                                          neurysm was discovered: a few days before hospital admission




                                                                                                     ly
                                                                          the general practitioner did some intradermoclysis in the abdom-
                                                                          inal wall to hydrate the patient, damaging the inferior epigastric




                                                                                             on
   Correspondence: Rossana Corso, Department of Internal Medicine,        artery wall with subsequent development of the pseudoa-
   Circolo Hospital, ASST Sette Laghi, Ospedale di Circolo e Fon-         neurysm. The patient completely recovered, returned home after
   dazione Macchi di Varese, Viale Luigi Borri 57, 21100 Varese           two weeks in a subacute facility, and is awaiting evaluation for




                                                                                       e
   (VA), Italy.
                                                                          the scleroderma follow up from a rheumatologist.
  Tel.: +39.0332278832.
  E-mail: rossana.corso@asst-settelaghi.it                                       us
  Key words: Pseudoaneurysm of inferior epigastric artery; Ultra-
                                                                            al
  sound; Superb microvascular imaging; Anamnestic record; Colle-            INTRODUCTION
  gial discussion.
                                                                  ci

                                                                                Development of an inferior epigastric artery pseudoa-
                                                                            neurysm (IEAP) is a rare but well-documented complica-
                                                                er


  Contributions: Conception and design or analysis and interpreta-
  tion of data: RC, AC, SG, CD, NC. Drafting the article or revising        tion of abdominal wall procedures performed in the iliac
  it critically for important intellectual content: RC, AC. Final ap-
                                                               m



  proval of the version to be published: FD, VM. Agreement to be
                                                                            region. Abdominal surgery is the most frequent cause of
  accountable for all aspects of the work: SG, FD, VM.                      IEAP, mainly in wound closure and laparoscopic proce-
                                                    om




                                                                            dures.1 In the present report, we describe a case of iatro-
  Conflict of interest: The authors declare no potential conflict of in-
                                                                            genic IEAP not likely related to surgical intervention.
  terest.
                                             -c




  Funding: None.
                                    on




                                                                            CASE REPORT
  Informed consent: The informed consent was obtained from the
  patient involved in the study.                                                A 77-year-old lady with a longstanding history of
                              N




                                                                            scleroderma with pulmonary, skin and esophageal in-
  Availability of data and materials: Data and materials presented in
  this study are available on request from the corresponding author.        volvement, presented to the Emergency Department for
                                                                            a state of severe malnutrition, fluid dysphagia, thoracic
  Received for publication: 14 March 2022.                                  pain, and weight loss. The patient was hemodynamically
  Accepted for publication: 21 June 2022.
                                                                            stable, blood pressure was 110/80 mmHg, heart rate 80
  Publisher’s note: All claims expressed in this article are solely those   bpm, SpO2 on room air 94% and she was apyretic. At
  of the authors and do not necessarily represent those of their affili-    physical examination, the patient presented in very poor
  ated organizations, or those of the publisher, the editors and the re-    conditions, her weight was 42 kg with a body mass
  viewers. Any product that may be evaluated in this article or claim
  that may be made by its manufacturer is not guaranteed or endorsed
                                                                            index of 15.6 kg/m2. She also showed diffuse hypotro-
  by the publisher.                                                         phy with limitation in walking and skin ulcers from loss
                                                                            of substance at the back of the feet bilaterally. The vesic-
  ©
   Copyright: the Author(s), 2022                                           ular murmur was ubiquitously reduced with fine bibasal
  Licensee PAGEPress, Italy
  Bleeding, Thrombosis and Vascular Biology 2022; 1:25                      crackles. The abdomen was sunken and treatable but
  doi:10.4081/btvb.2022.25                                                  painful in the right lower quadrant where there was a
                                                                            tense-elastic, palpable swelling of about 40×50 mm,
  This work is licensed under a Creative Commons Attribution-
  NonCommercial 4.0 International License (CC BY-NC 4.0).
                                                                            with an associated posterior-extending skin ecchymosis.
                                                                            The peristalsis was present, and a vascular murmur was

                                              Bleeding, Thrombosis and Vascular Biology 2022; 1:25
                      Iatrogenic pseudoaneurysm of inferior epigastric artery: not only a surgical complication                  27



audible over the swelling mass. Blood test revealed a                 the pseudoaneurysm through thrombin injection was
state of mild anemia with hemoglobin 11.9 g/dl. A color               chosen as the best treatment. The procedure was per-
Doppler ultrasound (US) examination with a 5-12 MHz                   formed under US guidance (7-18 MHz linear probe -
linear probe (iu22, Philips Healthcare, Amsterdam, the                Aplio 500, Canon Medical Systems Corporation,
Netherlands) of the abdominal wall (Figure 1) was soon                Ōtawara, Tochigi, Japan) by an interventional radiologist
performed, showing a hyper-vascular nidus with the                    (A.C.) after informed consent of the patient. After accu-
“yin-yang” sign (Supplementary Video 1), that was sup-                rate disinfection, a 22-gouge Chiba needle (Chibell,
plied by the right inferior epigastric artery (IEA). Spec-            Biopsybell, Mirandola, Modena, Italia) was advanced in
tral Doppler of the feeding vessel showed both forward                the pseudoaneurysm sac and human plasma purified
and reverse flow, (i.e., the ‘‘to-and-fro’’ pattern) indica-          thrombin (500 UI/ml; Baxter, Deerfield, Illinois, US)
tive of a pseudoaneurysm. The same day the patient un-                was directly injected until a complete echo-structured
derwent a contrast-enhanced computed tomography                       appearance of the sac was obtained. Color Doppler US
(CECT) of the abdomen (Figure 2) which confirmed the                  and Superb Microvascular Imaging (SMI) were used to
presence of a broken and replenished right IEAP, asso-                assess the complete exclusion of the pseudoaneurysm
ciated with a large hematoma of the abdominal wall.                   and the correct patency of the feeding arterial vessel
After a collegial discussion with the surgical and inter-             (Figure 3). The Chiba needle was then removed, and a




                                                                                        ly
ventional-radiologist team, a percutaneous exclusion of               compression dressing was performed. The procedure




                                                                                on
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                                            m
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Figure 1. Ultrasound (US) examination with a 5-12 MHz linear probe (iu22, Philips Healthcare, Amsterdam, Netherlands) of the
abdominal wall of a 77 years-old lady presenting with swelling at the right iliac fossa. A) B-mode US obtained at the swelling site
demonstrates a 4.73×2.25 mm heterogeneous mass (dimension markers) in the right rectus abdominis muscle (arrows), which appear
to be stretched by the mass. B) Color-Doppler US demonstrates a “yin-yang” sign (*) on the inside of an anechoic round structure
(arrow, B-mode not showed) within the heterogeneous mass, consistent with a pseudoaneurysm surrounded by hematoma. C) Color-
Doppler US demonstrates the adjoining arterial vessel (thick arrow) and the neck (*) of the pseudoaneurysm. D) Pulsed-Doppler at the
pseudoaneurysm neck level demonstrates the classic “to and fro” pattern.


                                      Bleeding, Thrombosis and Vascular Biology 2022; 1:25
28                                                        R. Corso et al.




runs without complications. In the following days, the               the pseudoaneurysm. Day by day the abdominal mass
patient remained hemodynamically stable, with no evi-                gradually reduced in size, with consensual resorption of
dence of anemia at blood tests. A 24h US control and a               the hematoma and reduction of abdominal pain. Thanks
10 days CECT documented the complete thrombosis of                   to a careful anamnestic record we eventually find the




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Figure 2. 64-row Computer Tomography Angiography examination (Revolution EVO, GE Medical Systems, Chicago, Illinois, USA).
Pre-contrast (A), angiographic (B), and portal-venous (C) phase confirms the presence of the pseudoaneurysm (arrow). Coronal (D)
and sagittal (E) maximum intensity projection reformation demonstrates that the feeding arterial vessel of the pseudoaneurysm (thin
arrow) is a branch of the epigastric artery (thick arrow).


                                      Bleeding, Thrombosis and Vascular Biology 2022; 1:25
                      Iatrogenic pseudoaneurysm of inferior epigastric artery: not only a surgical complication                    29



probable cause of the pseudoaneurysm: a few days be-
fore hospital admission the general practitioner did some             DISCUSSION
intradermoclysis in the abdominal wall to hydrate the                     The IEA usually originates from the external iliac ar-
patient, thus damaging the wall of the IEA triggering the             tery at a point cranial to the inguinal ligament. It pierces
pseudoaneurysm to develop. In the following days, the                 the transversalis fascia, runs across the transverse abdo-
patient underwent percutaneous endoscopic gastrostomy                 minis muscle, and ascends between the rectus muscle and
and started enteral nutrition. Before the discharge, the              the posterior rectus sheath. The anatomical position of the
patient was evaluated by the rheumatologist who con-                  IEA subjects it to the risk of injury during abdominal pro-
traindicated the use of prostaglandins that the patient               cedures that are close to the artery.2 A review of the liter-
usually took for the scleroderma in consideration of the              ature performed in 2014,1 shows how IEAP is a rare event
complication linked to the pseudoaneurysm. After the                  (only 32 cases have been reported worldwide in the last
discharge she was admitted to a subacute facility where               40 years). Abdominal surgery is by far the most frequent
she continued and implemented enteral nutrition and                   cause (20 out of 32 cases), mainly wound closure and la-
started the physiotherapy with a gradual improvement                  paroscopic procedures. Furthermore, rare cases of an
of her physical condition. After two weeks she returned               IEAP have been described following therapeutic paracen-
to home; she is now waiting for a revaluation from the                tesis of ascites, percutaneous vascular procedures, trauma




                                                                                        ly
rheumatologist for the possible reintroduction of the                 or following Tenckhoff catheter removal.3 Spontaneous




                                                                                 on
prostaglandins.                                                       IEAP is extremely rare: a single case has been described




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Figure 3. Ultrasound (US) guided percutaneous embolization of the pseudoaneurysm, with a 7-18 MHz linear probe (Aplio 500, Canon
Medical Systems Corporation, Ōtawara, Tochigi, Japan). In image (A), a 22-gouge needle (thin arrows) is advanced in the
pseudoaneurysm (*) and thrombin was injected in the sac. Subsequent controls with b-mode US (B, left-side), Superb Microvascular
Imaging (SMI) (B, right-side), and color-Doppler US (C) demonstrates echostructured appearance of the pseudoaneurysm sac (*);
neither SMI nor color-Doppler show any vascular signal within the sac (*). In image D, the preserved feeding vessel (thick arrows) can
be seen adjoining the thrombosed the pseudoaneurysm sac (*).


                                       Bleeding, Thrombosis and Vascular Biology 2022; 1:25
30                                                        R. Corso et al.




in the literature in which the wall of the pseudoaneurysm            speed flows with high image resolution with an elevated
was analyzed histologically with evidence of myxoid                  frame rate (>50 fps). SMI is less susceptible to motion ar-
changes within it but in the absence of signs of inflamma-           tifact rather than conventional color and power-Doppler
tion.4 In our clinical case, we suppose IEAP has an iatro-           imaging and requires neither contrast media administra-
genic genesis but interestingly, not related to any surgical         tion nor ionizing radiations.6
act. To our knowledge, there is no prior description of
IAEP related to intradermoclysis in the abdominal wall.
For the diagnostic work-up of the pseudoaneurysm, color              CONCLUSIONS
Doppler US is a good imaging method with a sensitivity
                                                                         IEAP is a rare but well-documented complication of
and specificity of 100% in differentiating false aneurysms
                                                                     abdominal procedures performed across the abdominal
from periarterial hematomas,5 allowing non-invasive eval-
                                                                     wall. Even if surgery is the most frequent cause of
uation of such a mass. On b-mode US, a pseudoaneurysm
                                                                     pseudoaneurysm development, this complication should
is easily displayed as an outpouching of the feeding ves-
                                                                     be suspected after any kind of procedure performed in the
sel. Due to the turbulent forward and backward flow, a
                                                                     iliac region. In conclusion, in our case the most probable
characteristic yin-yang sign may be seen on color flow
                                                                     cause of the pseudoaneurysm is intradermoclysis, as the
while a “to-and-fro” pattern may be seen with pulsed




                                                                                              ly
                                                                     patient did not undergo any other abdominal procedures
Doppler (Figure 1 and Supplementary Video 1). However,
                                                                     and spontaneous IEAP is only anecdotal in literature.




                                                                                      on
there is not a definitive imaging modality of choice: in our
                                                                         Moreover, our experience underlines the primary role
case, we did firstly an US exam, faster and more easily
                                                                     of multimodality imaging and collegial discussion in mak-
performed, and then a CECT to obtain a more detailed
                                                                     ing early diagnosis and performing the correct treatment.




                                                                                 e
anatomic map useful in terms of treatment planning. The
treatment of IEAP is wide-ranging:5 traditionally, the
management of pseudoaneurysms has been surgical liga-
                                                                            us
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techniques are US-guided compression repair – used es-
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                                                     er


                                                                      2. Edwards KJ, Avula SK, Babu BDH, England RA. Inferior
neurysm of the femoral and radial artery – and
                                                                         epigastric artery pseudoaneurysms. Ann R Coll Surg Engl
percutaneous US-guided thrombin injection. In our case,
                                                    m



                                                                         2015;97:255-8.
after collegial discussion, the last treatment option was             3. Venkatesh SK, Reynolds VB, Sidhu HR, Maran PK. Spon-
                                           om




chosen considering the technique feasible and simple to                  taneous inferior epigastric artery pseudoaneurysm. Wiley
perform, relatively safe (the complications are rare) and                Periodicals, Inc. J Clin Ultrasound 2010;38:259-62.
very effective. US is also an excellent method for intra-             4. Werner M, Bernheim J, Witz M. Pseudoaneurysm of the in-
                                     -c




and post-procedural monitoring during percutaneous em-                   ferior epigastric artery: a rare complication of Tenckhoff
bolization. In fact, it is able to detect even very slow flows           catheter removal. Nephrol Dial Transplant 1999;14:1297-9.
                              on




                                                                      5. Shabani GS, Baxter GM. Inferior epigastric artery pseudoa-
that can persist after a percutaneous embolization, espe-
                                                                         neurysm: ultrasound diagnosis and treatment with percuta-
cially if auxiliary techniques such as Color- or Power-
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                                                                         neous thrombin. Br J Radiol 2002;75:689-91.
Doppler, contrast-enhanced US, or SMI are used. SMI is                6. Curti M, Piacentino F, Fontana F, et al. EVAR follow-up
a recently developed ultrasound imaging technique that                   with ultrasound superb microvascular imaging (SMI) Com-
filters the signal originating from tissue movement, en-                 pared to CEUS and CT angiography for detection of Type
abling selection and analysis of both high-speed and low-                II Endoleak. Diagnostics (Basel) 2022;12:526.




                                      Bleeding, Thrombosis and Vascular Biology 2022; 1:25
