Open resection for a large iatrogenic radial artery pseudoaneurysm. Case report

INTRODUCTION AND IMPORTANCE: We present the case in which a large symptomatic pseudoaneurysm (PSA), 6 × 5 cm, with one year of evolution on the path of the right radial artery (RRA) appeared after its punction and cannulation for performing cardiac catheterism in an atrial fibrillation (AF) indefinite anticoagulated patient. Diagnosis and surgical planning were consolidated only by using color duplex ultrasound (CDU), contrasted images were not indicated. The open surgical management was performed during a short-time supraclavicular blockade of peripheral nerves without stopping nor bridging anticoagulant therapy. Complete excision of the deforming mass with no blood loss, decompression of the adjacent structures and direct closure of the arterial defect without compromising of its lumen and path were also achieved. CASE PRESENTATION: A 74-year-old, Hispanic male patient and former smoker underwent coronary catheterization for thoracic typical pain. One year after, he is admitted for move restrictive pain in distal right forearm and hand paresthesia related to a rapidly growing right radial artery PSA of 6 cm in diameter where the indefinite anticoagulation, indicated for chronic AF, confers a risk of major bleeding. After clinic and exclusive CDU assessing, the patient granted us written authorization for performing an open surgery. One year follow up showed an asymptomatic patient with no RRA residual lesions. CLINICAL DISCUSSION: Although contrasted are the preferred diagnosis methods when arterial issues are suspected especially angiography since, when indicated, the endovascular treatment may be performed immediately after diagnosis. The CDU performed with a high-sensitivity transducer is the image of choice for an immediate differential diagnosis (Meola et al., 2021 [1]). In addition, it allowed us to see both, the particular PSA inside structure and the patency of ipsilateral ulnar artery, necessary details to propose the successful open surgical treatment finally conducted. CONCLUSION: Vascular and trauma surgeons should be trained to ensure the correct diagnosis based on preexisting medical conditions, clinical findings and those provided by CDU in order to offer an appropriate and definitive management to peripheral vascular iatrogenic lesions with potential bleeding risk, especially in anticoagulated patients. Since large limb deforming PSAs are recommended to be excided through open access, they should also be trained to perform it without additional risks nor sequelae. Since the number of AF patients is increasing worldwide, main aspects on anticoagulation therapy have to be taught to every surgical team.