80y M presents to Cath Lab 3 months post falling off ladder | Figure 1

Firstvictor

Technologist

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Case Report

Patient Presentation

80y M presents to Cath Lab 3 months post falling off ladder with severe swelling in left upper quadrant of chest. Patient had noted dislocated AC joint that he had sought pain management for. Patient on Warfarin and aspirin. Of note: Patient had worst bruising technologist had ever observed; severe bruising covered all of patient's chest, abdomen, and left leg. CT showed large pseudoaneurysm of the distal left clavicular artery. Access was made in the left brachial artery with a 5F short sheath where a glidewire and 4F NTA were advanced and an angiogram was performed revealing the clavicular pseudoaneurysm. The feeder vessel to the pseudoaneurysm was subsequently cannulated where ultrafoam in contrast solution were injected to embolize the feeder vessel. During injection, the pseudoaneurysm ruptured, but was contained due to the catheter taking up the space of the feeder vessel. Several coils were subsequently placed; complete embolisation of the pseudoaneurysm occurred. Final angiogram shows embolized pseudoaneurysm and patent flow in the left subclavian and axillary arteries. Sheath was pulled and pressure held for approximately 20 minutes. Patient transferred to observation and discharged later the next day from hospital.

Related Cases

This is a peroneal artery arteriovenous fistula with a small pseudoaneurysm. Coils were placed in the peroneal artery to occlude the fistula and pseudoaneurysm. After coiling of the peroneal artery, good anterior tibial and posterior tibial runoff with backfilling of the peroneal artery was observed. No abnormal waveform or flow was observed after coiling. There was no residual pseudoaneurysm.

79 M presents to Cath Lab following traumatic encounter with a punching bag. Patient stated they kicked a punching bag and felt a "tearing sensation" in their back. Patient noted to be severely intoxicated upon arrival and in extremely good spirits. CT showed a growing hematoma posterior to the left psoas muscle that was displacing peritoneal structures anteriorly and medially. Iliac and femoral vessels were also noted to be displaced, particularly the left common iliac which had a 180 degree bend. Access was made to the left common femoral with a 5F sheath. Following a difficult access, a 5F KMP 65 cm catheter was advanced to the left deep circumflex artery where diffuse bleeding was observed. An ultrafoam foam contrast slurry of approximately 90 cc's was introduced into the vessel to embolize it. Final angiogram shows significantly diminished flow. The inferior mesenteric artery was later attempted, but cannulation was impossible from the LFA approach and abandoned. A SOS Omni flush catheter was advanced to the abdominal aorta and angiogram showed no more appreciable bleeding. Patient was then transferred to CT for retroperitoneal drain placement and is now in MCU step-down for observation.

Follow-up Answers: Q1: CTA demonstrated right pulmonary artery pseudoaneurysm with 2 efferent vessels. Q2: The most common overall cause of pulmonary artery pseudoaneurysm in the US is iatrogenic. Additional causes include neoplastic, infectious, or congenital etiologies. Q3: The different treatment options depend on the anatomy, clinical picture, and etiology of the pseudoaneurysm.

Angiographic images: Prominent glomus jugulare tumor blush lateral to the R. internal jugular bulb. The tumor is supplied by distal branches of a prominent R. posterior auricular artery and a feeder from the occipital artery. No internal carotid artery contribution. The intervention was pre-operative embolization of the R. posterior auricular and occipital artery feeders to the tumor.

Additional Case Examples

A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis.

A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. Physical examination revealed multiple small vesicles, some clustered and others scattered.

A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.

Patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, and no history of sudden death in family.