Rare case of axillary pseudoaneurysm subsequent to an intra-arterial percutaneous cannulation

Arwa Badeeb; Abdullah Taiyeb; Jana Hudcova

doi:10.4103/sccj.sccj_26_18

CASE REPORT

Year : 2018 | Volume : 2 | Issue : 3 | Page : 45-47

Rare case of axillary pseudoaneurysm subsequent to an intra-arterial percutaneous cannulation

Arwa Badeeb¹, Abdullah Taiyeb², Jana Hudcova³
¹ Department of Radiology, Lahey Medical Center, Tufts University, USA; Department of Dignostic Radiology, King Abdulazziz University, Jeddah
² Department of Anesthesia and Critical Care Medicine, St. Elizabeth Medical Center, Tufts University, USA; King Faisal Specialist Hospital and Research Center, Jeddah Branch
³ Associate Professor of Anesthesiology and Perioperative Medicine, Lahey Medical Center, Tufts University, USA

Date of Web Publication

25-Feb-2019

Correspondence Address:
Abdullah Taiyeb
Anesthesia and Critical Care Medicine Department, St Elizabeth Medical Center, 736 Cambridge St, Brighton, MA 02135, USA

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/sccj.sccj_26_18

Abstract

Axillary pseudoaneurysm (PSA) is a rare condition that mainly presents with traumatic injury. In this case report, we show an iatrogenic axillary PSA, following an intra-arterial line (A-line) removal. A 75-year-old with an extensive past medical history including diabetes hypertension, peripheral vascular disease, and atrial fibrillation on Warfarin came to the hospital for an elective abdominal aortic aneurism repair. During her postsurgical stay, she had multiple A-line placements due to recurrent malfunctions and ended up having an axillary A-line. The development of a PSA complicated the removal of the line; an infrequent complication. This was treated with thrombin injection a couple of times after which homeostasis was achieved. Although axillary PSAs are rare, especially iatrogenic ones, individual attention and care should be taken while handling axillary A-lines. Furthermore, one should have a low level of suspicion, especially in patients with multiple predisposing risk factors such as ours.

Keywords: Axillary artery, catheter, complication, hemodynamic monitoring

How to cite this article:
Badeeb A, Taiyeb A, Hudcova J. Rare case of axillary pseudoaneurysm subsequent to an intra-arterial percutaneous cannulation. Saudi Crit Care J 2018;2:45-7

How to cite this URL:
Badeeb A, Taiyeb A, Hudcova J. Rare case of axillary pseudoaneurysm subsequent to an intra-arterial percutaneous cannulation. Saudi Crit Care J [serial online] 2018 [cited 2023 Mar 24];2:45-7. Available from: https://www.sccj-sa.org/text.asp?2018/2/3/45/252890

Introduction

Axillary arterial lines (A-lines) are not usually placed as they are considered technically tricky and carry a risk of injury to the adjacent neurovascular bundle. In spite of that, they have a lower complication profile compared with other sites. Axillary A-lines are highly reliable in low blood pressures and have a low risk of infection when compared with femoral lines. Furthermore, they are less thrombogenic due to the sizeable arterial caliber compared to radial and brachial lines.^[1]

Arterial pseudoaneurysm (PSA) is a complication that may develop although rare after arterial cannulation. They occur because there is a breach in the vascular wall integrity. Blood leaks through the wall but remains contained by the perivascular soft tissues. Given the absence of a true wall, these carry a higher risk of rupture compared with true aneurysms of similar size.^[2],[3]

We report a case of axillary artery PSA following a 20G A-line removal. Most of the reported cases were following axillary cannulation with larger catheters in the setting of cardiac catheterization or following traumatic shoulder injury.^[4],[5]

Case Report

A 75-year-old female presented to the hospital with a past medical history significant for diabetes, hypertension, chronic kidney disease, peripheral vascular disease, mechanical aortic valve replacement and atrial fibrillation on Warfarin. She came for an elective abdominal aortic aneurism repair. The surgery was uneventful. Her postoperative stay required admission to the surgical intensive care unit (ICU) for further postoperative care. Routine hemodynamic monitoring was conducted through invasive arterial and venous catheters, including a radial A-line.

Throughout the patient's ICU course, the A-line required multiple replacements, where it became nonfunctioning. She had a right radial, a left radial and finally a right axillary A-line placed. The right axillary A-line placement was uneventful. It was a single stick with proper backflow.

The ICU team removed the axillary A-line with caution. Since the patient was on anticoagulation, the team applied 30 min of local compression, reaching homeostasis at the end with no evidence of bleeding or local swelling. Twenty-four hours after that axillary A-line removal, the patient had ecchymosis, swelling, and tenderness to palpation at the removal site.

An upper extremity ultrasound with color Doppler flow showed a 10 cm hypoechoic soft-tissue collection with a narrow neck connecting it to the axillary artery with to-and-fro flow between the axillary artery and the collection. This was consistent with a PSA radiologically [Figure 1], [Figure 2], [Figure 3]. Next day, the interventional radiologist evacuated the hematoma collection and injected thrombin into the hematoma sac [Figure 4]. Twenty-four hours later, an ultrasound showed mild enlargement of the PSA, which was again evacuated and injected with thrombin. Two days after this second injection, there was no further reaccumulation. During this period, her anti-coagulations were held to manage the bleeding. On cessation of bleeding, she was restarted on enoxaparin injection to bridge her back to Warfarin.

Figure 1: Grayscale ultrasound image of an 11 cm hypoechoic collection adjacent to the axillary artery at previous puncture site representing a hematoma formation (pseudoaneurysm)

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Figure 2: Color Doppler ultrasound image is showing communication of the hematoma with the axillary artery (pseudoaneurysm neck), confirming the diagnosis of pseudoaneurysm. The waveforms are of the axillary artery

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Figure 3: Turbulent flow within the pseudoaneurysm forms the sonographic Yin-Yang sign

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Figure 4: Post-ultrasound-guided thrombin injection. Color Doppler US with no residual flow through the neck. The echogenic appearance of the hematoma is related to clotted blood products

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Discussion

Arterial PSA is a contained rupture; where there is disruption of all the three layers of an arterial wall. PSAs may occur in four conditions: postcatheterization, at the site of native artery-synthetic graft anastomosis (e.g., aortofemoral bypass graft), trauma and in infections (e.g., mycotic PSA).^[6]

This is true for axillary PSAs. However, the most common etiology would be blunt trauma to the shoulder such as anterior shoulder dislocation, or a fracture.^[7] Catheter-related and arterial puncture PSAs are rare. A few cases reported the development of axillary PSA post catheterization and only one before our case that was related to A-line placement.^[8]

Arterial PSA incidence has increased in hospital-based practices due to a large number of invasive procedures and the extensive use of anticoagulation therapy.^[3] The incidence, in general, is low.^[9] Upper limb PSAs carry even lower incidence of occurrence (<2% of all PSAs).^[10] Scheer et al.^[11] reported catheter-related axillary PSA to be 0.1% (1 of 1989 patients) whereas Bryan-Brown et al.^[5] reported cases as high as (1 of 251 patients).

Axillary A-lines are not commonly used for hemodynamic monitoring due to their technical difficulty and proximity to the neurovascular bundle. However, these have a lower risk of infection compared to a femoral line and less likely to be thrombogenic due to large arterial caliber compared to the radial and brachial lines.^[1]

Reported factors associated with the formation of PSAs are antiplatelet therapy, anticoagulation, a vascular sheath >8 French, age >65 years, obesity, poor post-procedure compression, hypertension, peripheral arterial disease, hemodialysis, complex interventions, low or high puncture sites and simultaneous arterial and venous interventions.^[6] Our patient had a lot of these risk factors. Moreover in spite of good local compression and small cannula size (20G), she developed a large PSA.

Currently, the treatment options for PSAs include ultrasound-guided compression, thrombin therapy, arterial embolization, endovascular stent graft placement and surgery. The method of treatment for PSAs depends on factors such as the size, location, and availability of treatment material, expertise, and cost factors. Thrombin therapy is successful in treating PSAs with a reported success rate of 93%–100%.^[3]

However, complications of thrombin injection include limb ischemia, a condition that occurs when thrombin enters the natural circulation causing distal thrombosis. That is why this treatment is contraindicated in PSAs with large necks. Other contraindications include active infection in the region, a large hematoma, skin necrosis, and lower limb ischemia.^[3]

In general, ultrasound-guided percutaneous thrombin injection is a rapid, cheap, and safe method for the treatment of iatrogenic PSAs when the neck is narrow. We, therefore, recommend that it becomes the treatment of choice in such circumstances such as in our case.^[12]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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