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by the American Institute of Ultrasound in Medicine J Ultrasound Med 23:1675-1678 • 0278-4297
Iatrogenic Pseudoaneurysm of the Superior Thyroid ArteryColor Doppler Ultrasonographic Diagnosis and Treatment ApproachGazi University School of Medicine, Ankara, Turkey. Address correspondence and reprint requests to Halil Celik, MD, Department of Radiology, Gazi University School of Medicine, Besevler, Ankara 06510, Turkey. E-mail: celik72{at}yahoo.com.
Abbreviations: STA, superior thyroid artery • UGCT, ultrasonographically guided compression therapy
A pseudoaneurysm is a pulsating hematoma that results from disruption of a portion of the arterial wall. Clotting occurs in the peripheral limits of the hematoma, whereas the center remains fluid and communicates with the arterial lumen, causing a pulsatile mass. Femoral artery pseudoaneurysms are potentially serious complications of arterial catheterization. Various studies have shown that the pseudoaneurysm rate after cardiac catheterization is 1.6%, and it is 0.7% to 6.3% after percutaneous transluminal coronary angioplasty.1 A pseudoaneurysm arising from the superior thyroid artery (STA) is extremely rare. Two cases of STA pseudoaneurysms have been reported after ultrasonographically guided chemical parathyroidectomy and after radiotherapy for hypopharyngeal cancer.2,3 To the best of our knowledge, any case of an STA pseudoaneurysm due to fine-needle aspiration biopsy has not been reported. We report a case of an STA pseudoaneurysm during fine-needle aspiration biopsy, which showed spontaneous thrombosis.
A 39-year-old woman with a 1.5-cm-diameter solitary nodule in the right upper pole of her thyroid gland was admitted to our radiology department for fine-needle aspiration biopsy. Ultrasonographically guided biopsy was performed with 20-gauge needle by a freehand technique. The ultrasonographic scanning plane was axial, and the direction of the needle was mediolateral. During placement of the needle, within seconds after gulping, a hypoechoic collection appeared anterior to the gland. Within minutes, a 3-cm heterogeneous echogenic swirling mass (Figure 1A  ) was identified adjacent to the STA, which showed flow on color flow Doppler imaging (Figure 1B). Spectral Doppler tracing from the neck of the pseudoaneurysm showed a typical to-and-fro flow pattern (Figure 1C).
On examination, the patient was conscious, and her cardiovascular condition was stable. She had considerable neck swelling. There was no evidence of stridor, and the patient’s chest was clear on auscultation.
After the diagnosis was established, ultrasonographically guided compression was attempted immediately. Because there was no bony structure behind the area that could support ultrasonographically guided compression, transcutaneous compression was not effective for closing the communication between the pseudoaneurysm and the arterial lumen. Therefore, we decided to wait for spontaneous thrombosis and performed serial color Doppler examinations. Examinations were repeated every day. On the third day, the pseudoaneurysm became smaller, and a thrombus filled the whole cavity (Figure 1
A pseudoaneurysm results from a tangential injury to an arterial vessel wall, with subsequent hemorrhage into the defect and formation of a hematoma contained by adventitia or perivascular tissue. In systole with high intra-arterial pressure, the flow is antegrade toward the pseudoaneurysm, whereas in diastole, flow direction is retrograde. Pseudoaneurysm formation is a well-known complication of vascular injury. Real-time ultrasonography provides a simple, reliable, and inexpensive assessment. The ultrasonographic signs consist of expansile pulsations in the pseudoaneurysm and a point of communication with the artery. The to-and-fro sign observed at the neck of the pseudoaneurysm with the turbulent or arterial-like flow within it helps confirm the real-time ultrasonographic diagnosis. Treatment options for femoral artery pseudoaneurysms include conservative measures, surgical repair, ultrasonographically guided compression therapy (UGCT), transcatheter coil embolization, and percutaneous thrombin injection. The traditional surgical repair of iatrogenic pseudoaneurysms is an effective treatment option. However, surgical treatment results in considerable expense and prolonged hospitalization. Associated wound infections and scarring make future procedures difficult. Ultrasonographically guided compression therapy induces spontaneous thrombosis within the pseudoaneurysm by transiently occluding blood flow by compressing the neck of the pseudoaneurysm with the ultrasonic probe. Success rates have varied widely from 55% to 90% in published series. Obesity, a large hematoma, concomitant anticoagulation therapy, and groin discomfort are predictors for UGCT failure. Ultrasonographically guided compression therapy is contraindicated in the presence of infection, a tense hematoma, and limb-threatening ischemia.4 Long-standing lesions have been reported as unsuitable for UGCT, but Schaub et al1 attempted UGCT in 3 pseudoaneurysms older than 4 weeks and successfully repaired all of them. There have been sporadic previous reports about successful UGCT in patients receiving oral anticoagulant therapy. In one study, 14 of 26 patients receiving oral anticoagulants were successfully treated with UGCT.1 It has been observed that many postcatheterization pseudoaneurysms will thrombose spontaneously and thus will not require any therapy but will require only reduced activity and serial ultrasonographic evaluation. Several features have been suggested as predisposing pseudoaneurysms to spontaneous healing. The longer the neck of the pseudoaneurysm, the shorter the time required for the healing process. Paulson et al5 suggested that pseudoaneurysms with small volumes of flow in the lumen are more likely to thrombose than are those with large volumes of flow in the lumen. The natural history of stable pseudoaneurysms is benign and frequently results in spontaneous resolution, which allows properly selected patients to be treated without surgery. Toursarkissian et al6 reported that 89% of selected pseudoaneurysms that they observed resolved spontaneously. In that study, prompt surgical treatment criteria included pseudoaneurysm size greater than 3 cm, pseudoaneurysm expansion, hematoma expansion on clinical examination, severe local symptoms, groin infection, the need for long-term anticoagulation therapy, inability of the patient for follow-up, and simultaneous repair during another surgical intervention.6 There are a limited number of reports concerning spontaneous thrombosis of non–femoral artery pseudoaneurysms in the literature. Soudack et al7 reported a case of a child involved in a motor vehicle collision who had liver lacerations with subsequent development of hepatic artery pseudoaneurysms. In that case, embolization was not performed, and the pseudoaneurysms regressed spontaneously.7 Spontaneous occlusion of a traumatic false aneurysm of the peroneal artery was described by Kocakoc et al.8 There is no standard treatment protocol because of the relative rarity of STA aneurysms. To our knowledge, only 2 cases of iatrogenic pseudoaneurysms involving the STA have been reported previously. The first case was a patient with a known history of hypertension, renal failure, and secondary hyperparathyroidism in whom a pseudoaneurysm of the STA occurred after ultrasonographically guided chemical parathyroidectomy. The diagnosis was made by angiography and treated by selective embolization.2 The second case was a ruptured pseudoaneurysm of the STA in a patient with dorsal pharyngeal wall squamous cell carcinoma that was probably induced by radiation vasculopathy and was treated by embolization.3 In our patient, the diagnosis of the pseudoaneurysm was made after ultrasonographic and color Doppler examination. The patient was stable, and angiographic embolization was not planned. Because UGCT did not close the communication between the STA and the pseudoaneurysm, we preferred to wait for spontaneous thrombosis. In conclusion, iatrogenic pseudoaneurysms involving the STA are rare. To our knowledge, this case is the third reported, and it had a unique occurrence of spontaneous thrombosis that obviated the need for further radiologic or surgical intervention.
Received July 12, 2004, from Gazi University School of Medicine, Ankara, Turkey. Revision requested August 11, 2004. Revised manuscript accepted for publication August 17, 2004.
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