Case Reports

Bedside Ultrasound for Pulsatile Hand Mass

Emergency Medicine. 2018 March;50(3):77-80 | 10.12788/emed.2018.0086

References

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2. Aufderheide TP. Peripheral arteriovascular disease. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine Concepts and Clinical Practice. Vol 1. 8th ed. 2014:1147-1149.

3. Anderson SE, De Monaco D, Buechler U, et al. Imaging features of pseudoaneurysms of the hand in children and adults. AJR Am J Roentgenol. 2003;180(3):659-664. doi:10.2214/ajr.180.3.1800659.

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6. Huang SW, Wei TS, Liu SY, Wang WT. Spontaneous totally thrombosed pseudoaneurysm mimicking a tendon tear of the wrist. Orthopedics. 2010;33(10):776. doi:10.3928/01477447-20100826-23.

7. Belyayev L, Rich NM, McKay P, Nesti L, Wind G. Traumatic ulnar artery pseudoaneurysm following a grenade blast: report of a case. Mil Med. 2015;180(6):e725-e727. doi:10.7205/MILMED-D-14-00400.

8. Pero T, Herrick J. Pseudoaneurysm of the radial artery diagnosed by bedside ultrasound. West J Emerg Med. 2009;10(2):89-91.

9. Bosman A, Veger HTC, Doornink F, Hedeman Joosten PPA. A pseudoaneurysm of the deep palmar arch after penetrating trauma to the hand: successful exclusion by ultrasound guided percutaneous thrombin injection. EJVES Short Rep. 2016;31:9-11. doi:10.1016/j.ejvssr.2016.03.002.

10. Komorowska-Timek E, Teruya TH, Abou-Zamzam AM Jr, Papa D, Ballard JL. Treatment of radial and ulnar artery pseudoaneurysms using percutaneous thrombin injection. J Hand Surg. 2004;29A(5):936-942. doi:10.1016/j.jhsa.2004.05.009.

11. Falk PS, Scuderi PE, Sherertz RJ, Motsinger SM. Infected radial artery pseudoaneurysms occurring after percutaneous cannulation. Chest. 1992;101(2):490-495.

12. Kang SS, Labropoulos N, Mansour MA, et al. Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms. J Vasc Surg. 2000;31(2):289-298.

Treatment

Treatment of pseudoaneurysms includes conservative compression therapy, surgical excision, or anastomosis, and more recently, ultrasound-guided thrombin injection (UGTI).

Compression Therapy. Compression therapy is often used for femoral artery pseudoaneurysms that develop after iatrogenic injury. However, this technique is time consuming, is uncomfortable for patients, is not effective in treating large pseudoaneurysms, and is contraindicated in patients on anticoagulation therapy. Compression therapy also has a high-failure rate of resolving pseudoaneurysms. Traditionally, surgical excision or anastomosis has been the definitive treatment for palmar pseudoaneurysms.

Ultrasound-Guided Thrombin Injection. A more recent treatment option is UGTI, which is usually performed by an interventional radiologist. Although there is no consensus on exact dose of thrombin for this procedure, the literature describes UGTI to treat both the radial and ulnar arteries.^9,10 One study of 83 pseudoaneurysms demonstrated a relationship between the size of the palmar pseudoaneurysm and the number of thrombin injections required to resolve it. Depending on the size of the palmar pseudoaneurysm, the effective thrombin doses ranged from 200 to 2,500 U. Regarding adverse effects and events from treatment, this study reported one case of transient distal ischemia.¹¹

Intravascular balloon occlusion of the pseudoaneurysm neck has also been recommended for UGTI in the femoral artery if the neck is greater than 1 mm, but there is currently nothing in the literature describing its use in palmar pseudoaneurysms.¹²

Complications

There are more descriptions of palmar, radial, and ulnar pseudoaneurysms in critical care patients due to the frequent, but necessary, use of invasive lines. Emergency physicians frequently place radial or femoral arterial lines for hemodynamic monitoring in critically ill patients. However, the incidence of pseudoaneurysms and its sequelae from these lines are not usually observed in the ED setting.

Radial arterial lines may cause thrombosis in 19% to 57% of cases, and local infection in 1% to 18% of cases.¹⁰ In a study of 12,500 patients with radial artery catheters, the rate of radial pseudoaneurysm was only 0.05%.¹¹ Although this is a small complication rate, pseudoaneurysms can lead to significant loss of function. To decrease the number of attempts and penetrating injuries to the arteries, ultrasound guidance for these procedures in the ED is strongly recommended. In addition to decreasing the risk of developing a pseudoaneurysm, ultrasound-guidance decreases the discomfort level of the patient and reduces the risk of bleeding, hematoma formation, and infection. Arterial line placement in the ED using ultrasound guidance decreases the risk of developing pseudoaneurysms and their sequelae, such as distal embolization.

Case Conclusion

The patient in this case underwent an arterial duplex study, which found a partially thrombosed right superficial palmar arch pseudoaneurysm measuring 1.91 cm x 2.08 cm, with an active flow area measuring 0.58 cm x 0.68 cm. The flow to the index finger medial artery and middle finger lateral artery was also diminished. The patient was discharged home with a bulky soft dressing and underwent excision and repair by hand surgery 3 days later. At the 1-month postoperative follow-up visit, the patient had full sensation but mildly decreased range of motion in his fingers.

Summary

Hand pseudoaneurysms are often associated with penetrating injuries—as demonstrated in our case—or repetitive microtrauma. Hand pseudoaneurysms can present with minimal findings such as isolated soft-tissue swelling, pain, or neuropathy. The EP should consider vascular pathology in the differential for patients who present with posttraumatic neuropathy. Regarding imaging studies, ultrasound is the best imaging modality to assess for pseudoaneurysms, and EPs should have a low threshold for its use at bedside—especially prior to attempting any invasive procedure. Patients with a confirmed pseudoaneurysm should be referred to a hand or vascular surgeon for surgical repair, or to an interventional radiologist for UGTI.