PMC6243352_01
Clinical image of the patient showing a large pulsatile mass in the right antecubital fossa (arrows).
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fig1
A 32-week preterm twin baby male was referred to us at 7 weeks of age (3 kg) with a large, readily palpable pulsatile mass in the upper portion of the right antecubital fossa, which was increasing since day 14 of life (Figure 1).
(a) Longitudinal view of the pulsatile mass on colour Doppler ultrasound. This study demonstrated typical features of a large PSA. (b) Transverse view on grey scale ultrasound imaging illustrating that the PSA was secondary to a defect in the posterior wall of the brachial artery (arrows). (c) Colour Doppler study of the same area as in (b) showing that the neck of the PSA was large and wide (arrows), with significant flow (F) into the lesion. PSA, pseudoaneurysm.
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fig2
Ultrasound examination of the lesion showed a large (3.2 x 2.3 x 1.8 cm) PSA secondary to a small defect in the posterior aspect of the distal brachial artery (visible, wide and short neck) (Figure 2).
CT angiogram confirmed the sonographic findings. (a) On this longitudinal MIP reformat the PSA is seen displacing the brachial artery (***). (b) Three-dimensional reformat of the lesion performed for surgical planning showing its relationship with the brachial artery (**) and the humerus (H). MIP, maximum intensity projection; PSA, pseudoaneurysm.
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fig3
CT imaging of the area was performed for treatment planning (Figure 3).
(a) Thrombin was injected into the lesion under real-time sonographic guidance and sterile conditions with a 25-gauge needle. (b) Transverse sonographic view showing the needle (arrow) positioned in the sac of the PSA prior to the injection. PSA, pseudoaneurysm.
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fig4
Under sterile conditions and using sonographic guidance, 5 units of thrombin were injected with a 25-gauge needle into the sac of the PSA, (Figure 4) obtaining complete thrombosis (Figure 5); however, there was immediate compromise of the distal perfusion of the arm.
Tranverse sonographic view of the pseudoaneurysm after injecting thrombin (5 units). It shows complete and abrupt cessation of flow in the colour Doppler image within the lesion owing to clot (C) formation.
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fig5
Under sterile conditions and using sonographic guidance, 5 units of thrombin were injected with a 25-gauge needle into the sac of the PSA, (Figure 4) obtaining complete thrombosis (Figure 5); however, there was immediate compromise of the distal perfusion of the arm.
Colour Doppler study performed 24 h after the initial thrombin injection showing partial reopening of the lesion: colour Doppler flow (F) around the clot (C).
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Intravenous heparin and topical nitroglycerin were used, resulting in total recovery of the extremity; however, the PSA reopened in 24 h (Figure 6).
Colour Doppler study in a longitudinal plane after the second thrombin injection. It shows that the PSA reopened again with normal perfusion of the arm, normal flow through the brachial artery (***) and without loss of function. PSA, pseudoaneurysm.
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fig7
A second injection of 45 units of thrombin was given 7 days later, obtaining good initial results, but partial reopening was observed the following day (Figure 7), mainly in the area adjacent to the neck of the PSA.
(a) Colour Doppler study on a transverse plane performed after 3 months of expectant management. It shows complete thrombosis (T) and absence of flow within the pseudoaneurysm. (b) Same finding as that in (a) on a longitudinal plane. In this image, good colour Doppler signal can be seen in the brachial artery (*).
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fig8
Complete thrombosis and absence of flow was observed 3 months after the second injection (Figure 8).