0:00

Okay, so here this is a 67-year-old woman

0:04

who had complex cardiac history, uh,

0:07

underwent cardiac catheterization, which was complicated

0:10

by brainin abscess with MRSA.

0:13

She also had DDTs.

0:14

Anyway, she had a very, very complicated history,

0:18

and we were doing a lower extremity venous doppler,

0:21

but removing the IVC filter.

0:23

So what do we see here?

0:25

Well, the, the veins were okay,

0:28

but there is here a focal outpouching

0:33

coming off the femoral auto.

0:35

Okay? And the vein here, the segment of the vein was patent,

0:39

but there is a focal outpouching here

0:43

and with, you know, maybe some internal echo.

0:46

So what are we dealing with?

0:47

Well, we're dealing with an aneurysm.

0:50

An aneurysm coming from the artery.

0:52

Now, what is important here? So that's a first diagnosis.

0:56

There is a auto aneurysm.

0:58

There's an extre outpouching,

1:00

there's yang yang color doppler within the lesion

1:03

that's classic for a aneurysm or pseudo aneurysm.

1:10

Uh, there is normal triassic fcom femoral artery,

1:13

normal physics foc common femoral vein.

1:16

And so you see that there is an aneurysm.

1:19

Now, what you have to decide then, is that a pseudo aneurysm

1:22

or is that a mycotic aneurysm of the white common fem?

1:26

It's really difficult to see just based on those findings.

1:29

I think we can favor the fact that a pseudo aneurysm,

1:31

because it's an centric out pouching as opposed to more

1:36

formm dilatation of the artery.

1:38

Uh, and here the history is very, very important.

1:42

We know that she had MRSA infection and

1:45

therefore you are concerned about a mycotic aneurysm.

1:48

And that's very important because it's gonna be treated very

1:51

differently if it's just a pseudo aneurysm.

1:54

Uh, it could be potentially just injected with thrombin.

1:57

And this is a CT in this patient, again,

1:59

showing the pseudo aneurysm with surrounding soft tissue.

2:04

Um, stranding here, you can see it on the map.

2:08

And so if it's just a plain, uh, pseudo aneurysm, then um,

2:13

you can treat it with thrombin.

2:14

But if you're suspecting a mycotic aneurysm, then you have

2:19

to resect it surgically, which is

2:21

what was done in this patient.

2:23

So what a pseudo aneurysm.

2:25

Basically pseudo aneurysm, I contain art osteo wall defect

2:29

that affect all layers of the artery.

2:32

Usually you see a neck from the rt, uh, defect,

2:35

and the vast majority are due to catheterization, right?

2:40

Uh, you can have non genic trauma,

2:42

but the vast majority are due to, uh, catheterization.

2:46

And the management, as I discussed it,

2:48

you can do ultrasound gathered compression,

2:52

you can do till it's MOUs.

2:54

You can do thrombin injection,

2:56

and if nothing of this works,

2:57

you can do surgical repair. But

2:58

In this case, because we were concerned about the presence

3:01

of a infection, this had to be surgically, uh, resected.

3:06

Okay? This is another example.

3:08

This is a more classic example of a pseudo aneurysm.

3:13

Uh, this, this, this patient had a,

3:15

some sort of catheterization.

3:17

So here's the, uh, still image, here's the color image

3:20

that nicely show the jet from the artery here going

3:24

to the pseudo aneurysm and the, the, the, the sort of in

3:29

and out doppler in the neck,

3:30

the yin yang in the do in the neck.

3:32

And it's important to demonstrate the

3:34

neck, measure the neck.

3:35

If the neck is narrow, then you can really do, um,

3:41

ing injection, which was attempted in this case,

3:47

like a very big scary one.

3:50

So this patient presented with discoloration

3:52

and large bruise in the, in the, in the thigh, in the bone,

3:56

extending in the left thigh

3:58

after a cardiac, uh, catheterization.

4:01

So there's a very large hematoma.

4:04

And even on the gray scale, uh, you can see

4:08

that there is a pseudo aneurysm.

4:10

You can see the movement of the red blood cell

4:12

within the aneurysm.

4:13

And of course, we will use color to confirm this.

4:16

And here's yin yang flow in the neck of the pseudo aneurysm.

4:21

So this is a pseudo aneurysm, uh, surrounded

4:23

by a very large hematoma.

4:27

Now, just a word about mycotic, aneurysms, complication

4:29

of endocarditis, sepsis,

4:31

and bacteremia as we saw in our patients.

4:34

So patients who have IV drug use or at much higher risk,

4:38

or if they have, you know, uh, septicemia form

4:42

and abscess somewhere else

4:44

because of vessel war in infected, you really need

4:48

to initially treat with antibiotic therapy

4:51

and then often have to resect them

4:53

and prepare them surgically.

4:58

So this is another example of mycotic aneurysm.

5:01

This patient had had a history of IVDU.

5:03

So again, look at the history.

5:05

If you have the history's really important

5:07

'cause you know what patient is at risk for what, right?

5:09

So if it's an IVDU, he's at risk for, um,

5:13

just pseudo aneurysm 'cause they inject, but also infected

5:17

because they, they, they are at high risk

5:19

for having endocarditis.

5:20

So we have an eccentric outpouching arising from the artery

5:24

here, uh, with again, a yin yang san.

5:27

And this, again, needed to be treated surgically.

5:30

And the path confirmed

5:31

that there were gram positive cox side in the

5:33

wall of the aneurysm.

5:38

So our challenge is really to differentiate pseudo aneurysm

5:42

and mycotic aneurysm from two auto aneurysms.

5:45

Now two auto aneurysm

5:47

of focal dilatation of the artery.

5:51

The aneurysm has vessel wall layers as opposed

5:53

to pseudo aneurysm, which is simply a contained break

5:56

Within a vessel.

5:58

Usually you have sfor dation

6:00

of the artery risk factories atherosclerotic disease.

6:03

And what is important also is that it is a, the,

6:06

the traditional teaching is that if there is a, uh,

6:09

peripheral aneurysm, especially a probably artery aneurysm,

6:12

just look around for other aneurysm especially

6:16

and including aortic abdominal aortic aneurysm

6:20

because, you know, obviously if it's an untreated

6:22

rupture, the patient can die.

6:24

So this is an example of a

6:28

fusiform dilatation of the popal artery with a lot of clot.

6:33

So the lumen is narrowed.

6:36

Uh, and so this is a pop tail artery aneurysm.

6:39

And again, the traditional teaching is, I, I'm not sure

6:43

how often I've seen it,

6:44

but if you see a pop tail artery aneurysm,

6:46

look at the abdominal aorta

6:48

and make sure the patient does not have an abdominal aortic

6:50

candle.