A 65 year old male with a history of DM, A-fib, and HTN with a recent CABG 8 months prior was sent to the emergency department from his primary care doctor’s office for “I&D of an abscess”.  The patient had visited the office with a chief complaint of pain, swelling, and erythema at the medial aspect of his anterior upper thigh. The patient was febrile with a temperature of 38.5, pulse of 98, BP 158/98, RR 12 at 98% on RA. Physical exam revealed a well nourished, well hydrated gentleman with clear lungs, irregularly irregular heart sounds with no murmurs, and a soft abdomen with active bowel sounds and no tenderness or masses. His extremities were warm and well perfused and 2+ bilateral DP and PT pulses were noted.  On his left anterior thigh in the groin region a 4″x4″ erythemetous area was noted with a palpable 2″X2″ fluctuate mass.  Bedside ultrasound of the area revealed the following:

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Figure 1: A 13-6 MHz transducer (vascular probe) is used to obtain these images of the soft tissue of the patients thigh, directly over the femoral vessels. In this view the structure are oriented in transverse view, and we see what appears to be pulsatile flow directly beneath the area of warmth and erythema previously intended for I&D.

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Figure 2: Upon closer inspection of the pulsatile mass we see swirling, bidirectional or “yin-yang” color flow in the lumen.

Conclusion: Procedure-related vascular injuries often follow percutaneous procedures, and include perivascular hematomas, pseudoaneurysms, and AV fistulas.  A pseudoaneurysm is a pulsatile hematoma contained within the surrounding tissues that communicates with the artery and represents injury to all three layers of the arterial wall.  Pseudoaneurysms complicate 0.1-0.2% of diagnostic and 3.5-5.5% of interventional procedures, and represent the majority of interventional vascular complications (1). On clinical exam a pulsatile mass is noted with a palpable thrill, and color duplex sonography demonstrates the turbulent, bidirectional flow seen in figure 2.  The treatment of choice is sonographically guided thrombin injection, which will thrombose the pseudoaneurysm in seconds with a 93-100% success rate (2,3). A void of flow after injection confirms success.

1. Kronzon I. Diagnosis and treatment of iatrogenic femoral artery pseudoaneurysm: a review. J Am Soc Echocardioagraphy 1997; 10:236-245

2. Morgan R, Belli A. Current treatment methods for post-catheterization pseudoaneurysms. J Vasc Interv Radiol 2003; 14:697-710.

3. Brophy DP, Sheiman RG, Amatulle P, Akbari CM. Iatrogenic femoral pseudoaneurysms: thrombin injection after failed US-guided compression. Radiology 2000; 214: 278-282.

Recommended reading: Gaitini D, Razi N, Ghersin E, et al. Sonographic Evaluation of Vascular injuries. Journal of Ultrasound Medicine 2008; 27:95-107.

Special thanks to Dr. Kirsten Bendeck for her scanning skills and excellent clinical care!

A 53 yo woman collapsed in a crowd while celebrating inuaguration day on the mall in January of 2009. EMS was called by bystanders, who arrived to find the patient supine and in severe distress. She was able to reveal a medical history of Marfan’s disease, then became hypotensive and diaphoretic. She was immediately transported to the emergency department, where she was noted to be bradycadic, hypotensive, and unresponsive. She was intubated, central venous access was obtained, and a comprehensive workup including a chest and abdominal CT was performed.  A bedside echocardiogram and abdominal ultrasound to evaluate the aorta were also performed. Initially no contrast was seen within the aorta, limiting the study for visualization of dissection or an intimal flap. However, upon repeat evaluation, the study reveals a complex dissection flap extending from the ascending aorta to bilateral iliac arteries, involving the L subclavian, common carotid, and renal artery. These bedside ultrasound images were obtained within the initial 20 minutes of the resuscitation:

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Figure 1: Transverse view of the descending aorta. A low frequency, phased array probe is used for all images. Here the probe marker is oriented toward the patient’s R shoulder. Note the hyperechoic dissection flap seen in this cross-sectional view of the vessel.

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Figure 2: Longitudinal view of the descending aorta. In this view the bright dissection flap is seen extending the length of the vessel at its posterior aspect.

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Figure 3: A suprasternal view of the ascending aorta is obtained by placing the probe in the patient’s suprasternal notch, marker oriented straight up toward the patient’s head. The dissection flap is visible in this view as well, mandating surgical involvement.

Conclusion: The patient was taken emergently to the OR where she experienced complete hemodynamic collapse. Resuscitative efforts were unsuccessful, and she eventually died of complications of her disease.

Recommended reading: Bilku R, Steadman C, Jordan P. Acute deBakey type III (or Stanford type B) aortic dissection diagnosed by transthoracic
echocardiography. Journal of American Society of Echocardiography. 2008; 21(9): 1080-1083.

Special thanks to Dr.s Annette Dorfman and Jeremy Berman for their scanning skills and excellent clinical care!