Clinical introduction A 93-year-old woman presented electively for transaortic valve implantation (TAVI), for severe aortic stenosis. She had a history of hypertension and hypothyroidism, and she was taking clopidogrel, antihypertensives and levothyroxine. In preparation for her TAVI procedure she underwent coronary angiography 4 months previously. Her coronary angiogram revealed severe three vessel disease, however, the consensus from the multidisciplinary team meeting, at that time, was to manage the coronary disease medically. Physical examination revealed a large, non-tender swelling on the volar aspect of her wrist (figure 1). The swelling had progressively enlarged in size over the preceding 4 months. Duplex ultrasonography was performed, but was technically difficult. Turbulent bidirectional flow was seen within the wrist swelling, however the connecting tract from which the flow originated was not adequately visualised. The greyscale ultrasound is shown (figure 1).
Question What is the next most appropriate management step?
Antibiotics and drainage
Urgent ultrasound guided thrombin injection
Non-emergent vascular surgery
Conservative management, with observation and follow-up
Ultrasound guided compression
- peripheral vascular disease
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Correct answer: C
The image on the left panel is pathognomonic of radial pseudoaneurysm, therefore choice A is incorrect. The ultrasound image illustrates mural thrombus within the radial pseudoaneurysm sac and shows the maximum anteroposterior diameter was 2.94 cm. Duplex ultrasonography (not shown) did not clearly demonstrate the pseudoaneurysm neck, therefore thrombin injection (choice B) was unsuitable. Careful assessment of neck size is crucial, because positioning of the needle opposite to the neck is needed to avoid thrombin injection into systemic circulation.1 The on call vascular surgeon elected to repair the pseudoaneurysm non-emergently. Therefore, the patient underwent TAVI the next day, followed 3 days later by elective surgical repair of the radial artery and excision of the pseudoaneurysm under local anaesthetic. Surgical treatment was necessary due to the large size of the pseudoaneurysm, causing potential skin necrosis, therefore choices D and E are incorrect. In patients without limb-threatening signs (expanding haematoma, skin compromise, compartment syndrome) a conservative strategy may be acceptable.2 Successful treatment with compression has also been described, however compression is less likely to be successful for late-presenting, large pseudoaneurysms.3 Interestingly, compared with other reports4 this case is a particularly striking example of late-presenting radial pseudoaneurysm, whereas typically pseudoaneurysms present within weeks following arterial cannulation.
The authors thank Rafal Dworakowski for his contribution towards preparation of the manuscript.
Contributors AMM, JB and DV were clinicians in management of the patient during her hospital admission. AMM wrote the report, with guidance from JB and DV.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.
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