Aortic root pseudoaneurysm is a devastating complication post aortic valve replacement with a high mortality rate. And dissecting aneurysm into the interventricular septum is a rare variant of aortic root pseudoaneurysm, which is scarcely reported. Multimodal imaging is of great value in its diagnosis and differential diagnosis.

Inferior phrenic artery (IPA) aneurysms are the rarest type of visceral aneurysms. It usually occurs secondary to trauma, surgery, or as a complication of pancreatitis. In addition, it can be a manifestation of underlying systemic pathology such as vasculitis, collagen vascular disorders, sepsis, or segmental arterial mediolysis. It can be associated with hypertension in 43% of cases. The presentation of IPA aneurysm is nonspecific with abdominal pain, melena, hematochezia, and anemia. The ruptured and actively bleeding aneurysm can lead to hemorrhagic shock, and immediate management is required with angiography and endovascular embolization with coil or gel foam or stent etc. Inaccessible locations are reached with surgical intervention, but it is associated with high morbidity and mortality. We here report a rare case of spontaneously ruptured IPA pseudoaneurysm extending from the posterior mediastinum to the subdiaphragmatic area and managed with coil and gel foam embolization.

Mycotic pseudoaneurysms can be a serious and life threatening complication of left sided infective endocarditis. They most commonly affect the major axial vessels. Profunda femoris artery (PFA) aneurysms are rare and present in only 0.5% of all peripheral aneurysms, regardless of the underlying etiology. We present a case of a patient who underwent mitral valve repair for severe mitral regurgitation secondary to culture negative IE which was complicated by multiple mycotic pseudoaneurysm. The PFA pseudoaneurysm which was affected and was complicated with a large hematoma compressing the femoral nerve. This was managed by a staged hybrid approach. Endovascular stenting was performed first to seal the pseudoaneurysm and facilitate open surgical repair using a reversed interposition saphenous vein graft. To the best of our knowledge, this is the first reported case of a PFA mycotic aneurysm (MA) being managed by a hybrid approach using endo-vascular and open surgical repair. MAs and pseudoaneurysms are complex and life threatening conditions requiring meticulous planning for optimal management. Endovascular stenting can be considered as an alternative to surgical management in certain cases or as a bridge to definitive open surgical repair depending on anatomical location and associated complications.

BACKGROUND: This retrospective multicentric study aims to report on technical safety and effectiveness of pseudoaneurysms embolization with glue (N-butyl cyanoacrylate) adopting a percutaneous direct puncture approach.
RESULTS: Fifty-four patients data were collected from five centers. All patients at the time of treatment presented with unruptured PAs and were hemodynamically stable. True aneurysms and lesions treated with embolics other than glue were excluded. Pseudoaneurysms diagnosis was based on CT and anamnestic data; initial investigation with digital-subtracted arteriography was acquired in all cases; then, percutaneous embolizations were performed in the angio-suite (ultrasound, fluoroscopy, ConeBeam CT guidance) or in CT. Technical success was considered as complete pseudoaneurysm embolization at final imaging with sole percutaneous strategy, without need for additional endovascular embolization. Clinical success was intended as pseudoaneurysm resolution within one week follow-up with stabilization or restored clinical conditions. Pseudoaneurysms origins were traumatic (57.4%), inflammatory (24.1%) or spontaneous (18.5%); 39 patients (72.2%) were symptomatic, presenting with pain and/or pulsatile mass. Mean lesions diameter was 19.3 mm (range: 7-30); pseudoaneurysms were located in abdomen (48.1%), limbs (42.6%) and thorax (9.3%). Coagulation function was impaired in 16.6% and 48.1% was under antiplatelets/anticoagulation therapy. In 16.6% the percutaneous approach followed previous treatments failure. The image-guidance modality for percutaneous puncture was most often ultrasound combined with fluoroscopy (38%). Clinical success was obtained in all patients while technical success occurred in 94.4% because 3 patients required an additional endovascular embolization. Complications were registered in 14.8%, all of low grade without clinical sequelae neither prolonged recovery (7 non target embolizations, 1 post-embolization syndrome).
CONCLUSIONS: In this study, pseudoaneurysms embolization with glue via percutaneous direct puncture was safe and effective with a low rate of minor complications.

Visceral artery pseudoaneurysms is a known vascular complication of pancreatitis that can lead to life-threatening hemorrhages with a high mortality rate if left untreated. We present a case of ruptured gastroduodenal artery pseudoaneurysm in a 68-year-old male with acute pancreatitis presenting with fatal gastrointestinal and retroperitoneal bleeding that was successfully managed with endovascular coil embolization of the involved vasculature. Patients with hemorrhagic pancreatitis or those presenting with unexplained retroperitoneal or gastrointestinal bleeding in the setting of pancreatitis with an unexplained drop in hematocrit or sudden expansion of pancreatic fluid collection should be screened in a timely manner for pseudoaneurysm using CT angiogram of the abdomen, which is the gold standard imaging modality to identify pseudoaneurysms. Once pseudoaneurysm is diagnosed, it should be treated immediately. Endovascular treatment options are now favored over surgical options in most cases.

The development of renal pseudoaneurysms following percutaneous kidney biopsy is a rare but potentially dangerous complication due to the risk of rupture with subsequent hemorrhage. We describe a female patient in her 20s with long-standing lupus nephritis who presented to the hospital for elective CT-guided left renal biopsy that was complicated by pseudoaneurysms in the bilateral kidneys. Post-biopsy, she developed a perinephric hematoma that extended to the upper pelvis with resultant superior displacement and diminished blood flow to the left kidney. Successful endovascular coil embolization was performed after left renal artery angiography confirmed contrast extravasation in one of the branches that supplied the inferior pole of the left kidney. Despite the embolization, her hemoglobin continued to decline, and a subsequent CT-scan demonstrated a persistent loculated hyperdense fluid collection in the beforementioned area. Repeat angiography revealed multiple left renal pseudoaneurysms and a single pseudoaneurysm in the upper pole of the right kidney, neither of which were previously visualized. The acute development of pseudoaneurysms due to accidental or non-accidental trauma is a well-established entity. Here we present a patient that acutely developed numerous arterial pseudoaneurysms after renal biopsy and has never been reported in the literature. Special caution should be undertaken in the case of high-risk patients predisposed to these pseudoaneurysms.

Lower extremity pseudoaneurysms (PsAs) are mostly developed after traumatic or iatrogenic injury to the arteries. Unless treated, they can be complicated by adjacent mass effects, distal embolism, secondary infection, and rupture. Imaging helps in the diagnosis and planning of therapeutic intervention. Ultrasonography (USG) is often diagnostic, while CT angiography aids in vascular mapping required for intervention. Image-guided therapy offers to manage these pseudoaneurysms in a minimally invasive approach, obviating the need for surgery. A smaller, superficial, and narrow-necked PsA can easily be managed with local USG-guided compression or thrombin injection. When the percutaneous approach is not a feasible option, PsA from expendable arteries can also be managed with coiling or glue injection. Wide-necked PsA from an unexpendable artery necessitates stent graft placement, although coiling of the neck may be a viable and cheaper alternative for a long- and narrow-necked PsA. Presently, vascular closure devices are also used to seal a small arterial rent through a direct percutaneous approach. This pictorial review entails various techniques to deal with lower extremity pseudoaneurysms. An idea about the various intervention radiological approaches will help in choosing appropriate methods to tackle lower extremity pseudoaneurysms.

We present a case report of a male patient who underwent modified Bentall surgery with a mechanical valved conduit due to severe aortic regurgitation and ascending aortic aneurysm. Four years later, the patient developed a cascade of events as acute stoke, infective endocarditis due to Brucella abortus complicated by pseudoaneurysms of aortic graft with left ventricular outflow tract communication. A multi-modality approach, included a three-dimensional printing, facilitated the diagnosis and surgical planning. During surgery, the team opted for a salvage approach, and the patient showed continued improvement during follow-up. This case highlights the importance of careful monitoring and detection of potential complications after Bentall surgery, as well as the value of 3D printing in pre-operative planning.

The purpose of this AGA Institute Clinical Practice Update is to review the available evidence supporting and examine opportunities for future research in endoscopic ultrasound-guided vascular investigation and therapies.
This Clinical Practice Update was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through standard procedures of Clinical Gastroenterology and Hepatology. This expert commentary incorporates important as well as recently published studies in this field, and it reflects the experiences of the authors who are advanced endoscopists with expertise in endoscopic ultrasound-guided vascular investigation and therapy.

Pseudoaneurysms (PSAs) are complex vascular lesions. Flow diversion has been proposed as an alternative treatment to parent artery occlusion that preserves laminar flow. The authors of the present study investigated the safety and short-term (< 1 year) and long-term (≥ 1 year) aneurysm occlusion rates following the treatment of intracranial and extracranial PSAs using the Pipeline embolization device (PED).
An electronic database search for full-text English-language articles in Ovid MEDLINE and Epub Ahead of Print, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus was conducted following the PRISMA guidelines. Studies of any design including at least 4 patients with intracranial or extracranial PSAs treated using a PED were included in this analysis. The primary outcome of interest was the rate of peri- and postprocedural complications. Secondarily, the authors analyzed the incidence of complete aneurysm occlusion.
A total of 90 patients with 96 PSAs across 9 studies were included. The mean age was 38.2 (SD 15.14) years, and 37.8% of the patients were women. The mean PSA size was 4.9 mm. Most PSAs were unruptured, and the most common etiology was trauma (n = 32, 35.5%), followed by spontaneous formation (n = 21, 23.3%) and iatrogenic injury (n = 19, 21.1%). Among the 51 (53.1%) intracranial and 45 (46.9%) extracranial PSAs were 19 (19.8%) dissecting PSAs. Sixty-six (77.6%) PSAs were in the internal carotid artery and 10 (11.8%) in the vertebral artery. Thirty-three (34.4%) PSAs were treated with ≥ 2 devices, and 8 (8.3%) underwent adjunctive coiling. The mean clinical and angiographic follow-up durations were 10.7 and 12.9 months, respectively. The short-term (< 1 year) and long-term (≥ 1 year) complete occlusion rates were 79% (95% CI 66%-88%, p = 0.82) and 84% (95% CI 70%-92%, p = 0.95), respectively. Complication rates were 8% for iatrogenic dissection (95% CI 3%-16%, p = 0.94), 10% for silent thromboembolism (95% CI 5%-21%, p = 0.77), and 12% for symptomatic thromboembolism (95% CI 6%-23%, p = 0.48). No treatment-related hemorrhage was observed. The overall mortality rate at the last follow-up was 14%.
The complete occlusion rate for PSAs treated with the PED was high and increased over time. Although postprocedural complications and mortality were not insignificant, flow diversion represents a reasonably safe option for managing these complex lesions.