Iatrogenic internal mammary artery pseudoaneurysm

Case contributed by Dr Ammar Ashraf

Presentation

Right-sided chest pain and shortness of breath for the last two days (after the dialysis catheter placement). No fever or cough.

Patient Data

Age: 65 years
Gender: Male

Right-sided dialysis catheter is seen in place which had been introduced via the right internal jugular vein; its tip is lying in the distal superior vena cava. A well-defined oval-shape opacity is seen along the right side of the lower trachea. Mild to moderate right pleural effusion with atelectatic changes in the right lower lung zone. 

X-ray

One day before the dialysis catheter insertion

Lungs and cardiophrenic angles are clear. No pleural effusion or right para-tracheal opacity is seen on the baseline radiograph. 

CT

One week later

A well-defined oval shape enhancing lesion measuring 8 x 8 x 12 mm is seen along the posterior aspect of the right internal mammary artery which is likely a pseudoaneurysm. A mildly hyperdense non-enhancing soft tissue is seen around it which is likely a localized hematoma. Small right pleural effusion with atelectatic changes in the right lower lobe.

Impression: Iatrogenic right internal mammary artery pseudoaneurysm with a surrounding hematoma. 

DSA (angiography)

Initial right subclavian artery angiogram showed a pseudoaneurysm arising from the right internal mammary artery, about 3 cm from its origin. Right internal mammary artery was selectively catheterized with a microcatheter and two Tornado micro coils were placed in it distal to the pseudoaneurysm and one coil was placed in it proximal to the pseudoaneurysm. Follow-up angiogram showed complete occlusion of the right internal mammary artery. 

Case Discussion

Double lumen dialysis catheter was inserted via the right internal jugular vein by the vascular surgeon under imaging guidance, for dialysis (the patient had an AV fistula in the left arm which was not still mature for dialysis). Iatrogenic pseudoaneurysm of the right internal mammary artery was diagnosed with CT chest which was later on treated was endovascular coil embolization by the interventional radiologist.  

Internal mammary artery (IMA) pseudoaneurysm is an uncommon vascular complication that frequently occurs after penetrating chest wall trauma, sternotomy, percutaneous biopsy, drainage, subclavian central venous line or cardiac pacemaker insertion (iatrogenic) or chest wall infection (tuberculosis, fungus, actinomycosis, or staphylococcus) 1,2. Symptomatic pseudoaneurysms need treatment. In the past, they were managed with conventional surgical repair (invasive approach associated with higher morbidity & mortality); however, due to recent technological developments in the interventional radiology, transcatheter endovascular coil embolization (minimally invasive approach), is currently the preferred safe & effective alternative management option. With this technique, the coils can be placed either within the pseudoaneurysm or in the feeding blood vessel of the pseudoaneurysm 1,2.

 

Case courtesy of Dr. Zahid Anwar Khan (consultant interventional radiologist).

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Case information

rID: 84947
Published: 11th Dec 2020
Last edited: 12th Dec 2020
Inclusion in quiz mode: Included
Institution: Ministry of national guard health affairs