2. Title CM is a 42 year-old female who presented to the ED complaining of pulsatile bleeding from a small wound in her left antecubital fossa. Patient described a raised, tender “scab” in her left antecubitalfossa which had been present for 3 months. The lesion bled intermittently, but was controllable by application of pressure. On the day of presentation, the patient had picked the scab, and blood began “squirting from the area”
17. Post-op Left PSA H/H fell to 8.1/23.3 – patient transfused 2 units PRBCs Intraoperative cultures demonstrated methicillin-sensitive Staphylococcus aureus, and antibiotics were adjusted accordingly Patient met with psychiatrist and drug counselor prior to discharge on POD #3
18. Developed pain on r Approximately 2 months after her left pseudoaneurysm repair, CM developed worsening pain, increased finger cyanosis and episodic bleeding from the right side
25. What is a pseudoaneurysm? Disruption of the vessel wall leading to extravasation of blood which is contained by surrounding tissues Etiology Penetrating injury most commonly Stab wounds, iatrogenic arterial injury, IVDA Other causes include infection, connective tissue disease, bacterial endocarditis Mechanisms at work in the IV drug user Direct trauma, peri-vascular abscess, chemical arteritis
26. Epidemiology A study by Tsao et al. estimates the annual prevalence of arterial pseudoaneurysm in IV drug users presenting to the ED to be 0.03% Pseudoaneurysm secondary to drug abuse has been reported in the subclavian, axillary, brachial, radial, external iliac, femoral, popliteal, and carotid arteries The femoral artery is the most common location, as the groin is a preferred injection site One report of Bilateral PSA
27. Sign and Syptoms Painful, expanding mass Overlying erythema and induration Pulsatility, a palpable thrill, or audible bruit Paresthesias Loss of pulses and evidence of ischemia in the distal extremity – decreased temperature, pallor, cyanosis The triad of infected pseudoaneurysm – pus, blood, and a pulsatile mass – Staph A. most common Arterial thrombi may develop in the pseudoaneurysm cavity, giving rise to embolic events distally
28. Diagnosis Duplex Ultrasound Least invasive method for confirming diagnosis Flow within the cavity produces the characteristic “yin-yang” sign “to-and-fro” signal at the neck as flow enters and exits during systole and diastole
29. Diagnosis CT Angiography More invasive, but better for demonstrating arterial anatomy and defining surrounding structures Invasive angiography Gold standard, particularly for surgical planning Most reliable for defining arterial anatomy, anatomic variants, and involvement of other vessels
30. Non-surgical options: Simple compression Ultrasound-guided compression Ultrasound-guided thrombin injection Percutaneous coil embolization Given the extensive damage and presence of infection often seen in IV drug users, resection of the pseudoaneurysm and removal of infected and necrotic tissue is often required
31. Debate exists over treatment by excision and primary grafting or simple excision and ligation of the brachial artery Simple exision and ligation avoids the risks of graft sepsis and hemorrhage, as well as the risk of the patient using the graft for continued drug injection 75% experience forearm claudication during exericse following brachial artery occlusion IV drug users may not have the collateral blood flow necessary to prevent ischemia and gangrene of the extremity Patient was showing signs of distal ischemia preoperatively, immediate revascularization was warranted
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