Frequency and causes of delayed diagnosis of visceral artery pseudoaneurysms with CT: Lessons learned

Abstract

Visceral artery pseudoaneurysms (VAPA) are associated with a high morbidity and mortality, but sometimes are missed in initial computed tomography (CT) examinations. The aims of this study were to determine the frequency and causes of misdiagnoses of VAPA with CT. Materials and Methods: We retrospectively identified 77 patients with VAPA in our database who underwent contrast-enhanced CT. The frequency of delayed diagnosis was determined and the reasons were noted. We identified the etiology of VAPA, measured size, and noted the affected vessels. Results: Forty-five of the 77 patients (58 %) had a delayed diagnosis of VAPA. There was no difference in the rate of missed VAPA in symptomatic compared to asymptomatic patients (p = 0.255). The majority of VAPA were associated with previous surgery or interventions (n = 48/62 %). The major affected vessel was the hepatic (n = 31) followed by the splenic artery (n = 17). The main reasons for misdiagnosis were a missed arterial phase in CT (n = 16/36 %), artifacts masking the aneurysm (n = 9/20 %), overlooked pseudoaneurysm (n = 19/42 %), and misinterpretation by attending radiologists (n = 1/2 %). Missed VAPA were smaller (median 8 mm) than those VAPA that were initially diagnosed (median 13 mm, p < 0.01), but occurred with a similar frequency in larger and smaller visceral arteries (p = 0.601). Conclusions: Our study showed that 58 % of VAPA were diagnosed with delay, with the following four reasons for misdiagnosis: Lack of an arterial contrast phase in CT, no techniques for artifact reduction, and lack of awareness of the radiologists. Avoiding delayed diagnosis will most probably improve outcome of patients with VAPA.

Overt gastrointestinal bleeding secondary to left inferior phrenic artery pseudoaneurysm postgastric bypass surgery

“…Bleeding in the context of bariatric surgery could be caused by various aetiologies, originating from staple lines, incomplete haemostasis postdissection or marginal ulceration 7. Pseudoaneurysms could be an overlooked source of bleeding, especially in the context of intermittent bleeding and small pseudoaneurysm size 8 9. Although GI haemorrhage from pseudoaneurysms is a rare event, missed diagnoses delay treatment and lead to rapid deterioration and potential mortality.…”

“…Pseudoaneurysms can be misdiagnosed as a result of a missed arterial phase in CT, artefacts masking the aneurysm, overlooked pseudoaneurysm and misinterpretation by attending radiologists 9. Approximately 58% (n=78) of visceral artery pseudoaneurysm (VAPA) cases had a delayed diagnosis, as reported in a retrospective study conducted between 2001 and 2018, and only 62% of patients with VAPA had previously undergone medical procedures, including approximately 5% of cases that underwent GI procedures.…”

“…Approximately 58% (n=78) of visceral artery pseudoaneurysm (VAPA) cases had a delayed diagnosis, as reported in a retrospective study conducted between 2001 and 2018, and only 62% of patients with VAPA had previously undergone medical procedures, including approximately 5% of cases that underwent GI procedures. Missed VAPA were smaller with a median size of 8 mm, in contrast to those that were initially diagnosed (median size, 13 mm) 9. The presence of a hyperattenuating material, such as surgical sutures or clips, can be challenging to differentiate from active extravasation of contrast, and may even obscure areas of bleeding 10…”

Clinical Profile, Management, and Outcome of Visceral Artery Pseudoaneurysms: 5-Year Experience in a Tertiary Care Hospital

“…We also employ rotational angiography as a problem-solving tool if the DSA and CT angiography remains inconclusive or discordant and the clinical suspicion of a pseudoaneurysm remains high. 24…”

“…We also employ rotational angiography as a problem-solving tool if the DSA and CT angiography remains inconclusive or discordant and the clinical suspicion of a pseudoaneurysm remains high. 24 In conclusion, visceral pseudoaneurysms are not uncommonly encountered potentially fatal lesions, commonly encountered after trauma, pancreatitis, surgeries, and interventional procedures. These lesions are easily salvageable by minimally invasive interventional techniques (endovascular embolotherapy), and surgeries carry a lot of morbidity and mortality in such cases and a prolonged hospital stay.…”