0:01

All right. For our next case, we're going to look at a bypass graft with a

0:04

pseudoaneurysm. So this patient has this incompletely

0:08

imaged axillofemoral bypass graft that you can see in this

0:12

left anterior chest wall. We're scrolling through the arterial phase

0:16

images right now, and then we'll problem solve using our non-contrast

0:20

and our delayed phase images. So looking at this arterial phase

0:24

image and really just doing a focused evaluation for this

0:28

purpose of this course and this case.

0:31

As we're scrolling down, we can see that this graft is patent.

0:34

This was obviously placed because there's an occlusion of the left

0:38

external iliac artery, and there's a stent in that native

0:41

occluded vessel.

0:44

As we're coming down into the groin, where just by the

0:47

area of touchdown, we can see that there is fluid all along that

0:51

graft suggestive of a hematoma. As I'm scrolling down even

0:55

further,

0:57

in distinction to the prior scan,

1:00

right here at that level of that anastomosis with

1:04

the common femoral artery, there is a outpouching that is seen

1:07

arising from the bypass graft at the

1:11

anastomosis. And if I cross-correlate this to the

1:14

non-contrast images at that same

1:18

place,

1:20

there is no corresponding hyperdensity that you see.

1:24

And so that definitely suggests that this is not a post-surgical change or an

1:27

inherently hyperdense material. It's definitely contrast.

1:31

And now really the question is: Is it a pseudoaneurysm with a hematoma

1:35

around it, or is it an active extravasation?

1:39

So having a delayed phase is really helpful here.

1:42

We know this is venous delay phase because the veins here, this is the

1:46

inferior vena cava, is nicely opacified, as are the iliac veins.

1:51

And so as we're scrolling down here and looking at the

1:55

morphology of this outpouching that we saw, this

1:58

morphology never really changed, and so this is

2:01

suggestive of a pseudoaneurysm. When we see a pseudoaneurysm,

2:05

it's important to assess the size of the pseudoaneurysm, the

2:09

neck of the pseudoaneurysm, because if a person has a long neck, then

2:13

they might be amenable for an ultrasound-guided thrombin

2:17

injection so that they can coagulate off that

2:21

pseudoaneurysm rather than it needing a more

2:24

extensive intervention. The size of the pseudoaneurysm

2:27

is also important. So again, you would

2:30

make a double oblique through that pseudoaneurysm, and

2:35

in addition to the neck, just measure the size of that pseudoaneurysm.

2:38

So in this person, the size of the pseudoaneurysm would

2:42

be approximately seven millimeters.