83 y/o male with PMHx of HLD, former smoker, CAD s/p recent LHC complicated by dissection, pericardial effusion, respiratory failure requiring intubation, and Impella placement in right groin 2 months ago presents to the ED with worsening swelling in the right groin over the past several weeks that was pulsatile on physical exam.
Clip 1 shows a transverse view of the femoral artery and the large approximately 6cm x 4cm x 5cm pseudoaneurysm sac with "echo-smoke" which is turbulent blood flow from the femoral artery causing a "flame-like" or "swirling" pattern on ultrasound.
Clip 2 shows components of clotted blood and unclotted blood in the pseudoaneurysm.
Clip 3 shows a longitudinal view of the femoral artery with the neck connecting it to the pseudoaneurysm.
Clip 4 shows color doppler over the neck of the pseudoaneurysm and the "to-and-fro" or "yin-yang" flow pattern.
Vascular surgery performed an ultrasound guided thrombin injection of the right groin pseudoaneurysm and the next day patient was taken to the OR for hematoma evacuation and repair of the right femoral artery pseudoaneurysm.
POCUS pearls for pseudoaneursyms:
Pulsatile mass with "yin-yang" or "to-and-fro" flow pattern in the neck = pseudoaneurysm
Large sac (>2 cm), narrow neck; first line treatment is thrombin injection
Rapid expansion, infection, hypotension, or wide neck; may require emergent vascular surgery
Avoid compressing a large pulsatile mass without plan due to rupture risk
References
Toursarkissian B. Pseudoaneurysm from iatrogenic femoral artery injury. J Am Coll Surg.
Webber GW. Pseudoaneurysm: diagnosis and management. Clin Radiol.
Schaub F. Thrombin injection for postcatheterization pseudoaneurysm. J Am Coll Cardiol.
Mahler B. POCUS for vascular complications. Ann Emerg Med.