IEA pseudoaneurysm is a rare complication that can occur following procedures in the abdomen such as retention sutures, laparoscopy port site, drain insertion, catheter removal, needle biopsy or paracentesis (1-4). In addition, a case was reported following incisional hernia repair (5) as another interesting case of spontaneous pseudoaneurysm (6). The risk of vessel wall injury and following false aneurysm formation is due to its superficial position and its relation to the rectus muscle.
Overall review of the literature showed 20 cases of IEA pseudoaneurysm. Most of them (17 out of 20) showed no bruit and two of them had a pulsatile mass. All of these cases presented a laterally placed abdominal mass (1-8).
In our case, transplantation procedure was done two months before the patient’s complications. In the days after transplantation, we did not observe any problems. Moreover, transplantation procedure did not adjust to IEA associated complications, anatomically. The location of laparoscope insertion was far from IEA, and laparoscopy was done several days prior to these events. Therefore, the IEA pseudoaneurysm could not be related to the aforesaid procedures.
IEA pseudoaneurysm is difficult to diagnose clinically. It usually presents as a diffuse, tender mass that is, however, non-pulsatile and also no bruit may be auscultated on it (5). So it can be similar to simple hematomas, especially the ones occurring after procedures including paracentesis that can cause hematoma as a complication. This makes the physical examination less reliable for diagnosing IEA pseudoaneurysm. In our patient, there was no bruit or pulsations in the physical examination and based on the first ultrasound, simple hematoma was thought as the probable diagnosis. This shows the importance of considering IEA pseudoaneurysm as a differential diagnosis in any patient with tender bulging in the abdomen, especially after invasive procedures.
Color Doppler ultrasound is a simple and noninvasive method that helps diagnose pseudoaneurysm. It is the imaging method of choice for evaluation of suspicious masses (8). On ultrasound, hematomas exhibit variable echogenicity and internal complexity but never demonstrate internal blood flow (1). In contrast, a pseudoaneurysm will be easily demonstrated as an extravasation of blood flow outside the vessel. Characteristic appearances are seen with color Doppler imaging. Typical ultrasonic findings include a focal area of flow with a mixed, swirling red and blue color pattern varying with systole and diastole, a jet between the vessel and the aneurysm sac and the “to and fro” sign on spectral Doppler analysis (9). Review of the literature showed 100% sensitivity and specificity for Doppler US in differentiating pseudoaneurysms from peri-arterial hematomas (10). Contrast enhanced abdominal CT scan, CT angiography or conventional angiography are other diagnostic modalities.
Open surgery including suture ligation and excision, endovascular coil embolization or more recently ultrasound guided thrombin injection have been described as possible therapeutic options in the treatment of IEA false aneurysms (3, 7, 8, 11). Ultrasound-guided thrombin injection for false aneurysm has been described as an easy, safe, successful and well tolerated procedure (8). Venkatesh et al. (6) and Shabani and Baxter (9) presented two rare cases of spontaneous IEA pseudoaneurysm. Shabani and Baxter (9) reported a case in which thrombosis in a spontaneous IEA pseudoaneurysm was induced by injection of human thrombin. This technique encompasses US-guided percutaneous injection of 1000 IU of human thrombin trough a 22-gauge spinal needle inserted into the pseudoaneurysmal sac.
Nonsurgical treatment of IEA pseudoaneurysm is not acceptable enough, because it may remain unchanged in size (1, 11). US-guided compression is a nonsurgical treatment, but for deep and wide neck pseudoaneurysms it is not sufficient (11). Ferrer et al. (12) stated that surgery is appropriate for large aneurysms and embolization for small ones. Percutaneous trans-catheter approach was suggested by Lam et al. for patients with portal hypertension due to chronic liver failure (1). We chose surgery for this patient because of the contrast usage prohibition and unavailability of thrombin.
This case report has shown that IEA false aneurysm must be included in the differential diagnosis during investigation of the cause of any swelling followed by paracentesis. This would help reduce the chance of misdiagnosis and avoid any inappropriate interventions that may cause increased morbidity. Besides, cirrhotic patients may be more prone to this complication because of the thin rectus muscle that could not confine the hematoma.
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