PMC8516530_01
(a) Chest X-ray showing two double lumen hemodialysis central vascular access. (b) Chest X-ray after the removal of the one on the left side with significant soft tissue swelling around the left shoulder associated with left lateral displacement of the scapula.
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Another line was inserted on the 25th of May on the right internal jugular using ultrasound guidance, and at this time, it worked well (Figure 1(a)). The left internal jugular catheter was removed, and pressure dressing was applied (Figure 1(b)).
(a) CT coronal section showing the left subclavian artery (white arrow) with pseudoaneurysm (black arrow) and large intra- and extramuscular chest wall and left side hematoma (red arrow). (b, c) Ultrasonography showing a pseudoaneurysm originating from the subclavian artery (white arrow).
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CT scan of the neck and upper chest, but because of acute kidney injury and risk of more nephrotoxicity, the CT scan was postponed until the 9th of June when his kidney function improved and his last hemodialysis was on the 7th of June. CT angiogram for the head, neck, and chest revealed a large homogenously hyperdense sac-like structure with a tongue projecting superiorly noted posterior to the left clavicle and in close proximity to the anterior wall of the proximal part of the left subclavian artery possibly arising from it with narrow neck, measuring 2.1 x 3.5 x 4.5 cm (Figure 2). Ultrasound showed pseudoaneurysm originating from the subclavian artery (Figures 2(b) and 3(c)).
(a, b) Pigtail catheter (blue arrow) arteriogram showed pseudoaneurysm (white arrow) arising from the proximal part of the left subclavian artery (red arrow) distal to the origin of the left vertebral artery (black arrow). (c) Angioplasty balloon-tipped catheter (yellow arrow) covering the neck of the pseudoaneurysm. Bedside ultrasound documents the absence of the flow within the pseudoaneurysm by inflating the balloon, and injection of thrombin was done under ultrasound guidance ((c) and US). (d) Arteriogram after the thrombin injection shows no pseudoaneurysm, and it shows the left subclavian artery (red arrow), left vertebral artery (black arrow), and left internal mammary artery (green arrow).
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Flush aortic angiogram was done using a 4-French pigtail catheter; it showed pseudoaneurysm arising from the proximal part of left subclavian artery distal to the origin of left vertebral artery and left internal mammary artery (Figures 3 and 3(b)). Bedside ultrasound documented the absence of the flow within the pseudoaneurysm by inflating the balloon (Figure 3(c)). After inflation of the balloon, injection of 2000 U of thrombin was done under ultrasound guidance (Figure 3(c)). Follow-up left subclavian angiogram showed good opacification of the left vertebral artery and internal mammary artery with nonopacification of the pseudoaneurysm (Figure 3(d)).
Nerve conduction studies of the upper limbs.
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The patient was extubated 2 days after the procedure; however, he had no movement in the left arm which was considered secondary to the compression of the brachial plexuses from the hematoma which was confirmed by electromyography (EMG) and nerve conduction studies (Figure 4).