Introduction

Pseudoaneurysm are well documented complication after surgery, arterial puncture, and trauma.₁ However, pseudoaneurysm of the inferior epigastric artery are rare.₂ We report a case of pseudoaneurysm of the inferior epigastric artery due to abdominal wall sutures diagnosed on high resolution color Doppler imaging and treated successfully with surgical extirpation.

Case Report

A 28-year-old male presented to us with blunt abdominal trauma following a vehicular accident. There were no associated injuries. On examination, he had tachycardia with pulse of 110/min, and blood pressure recorded was 80 mmHg systolic. Abdominal examination revealed guarding and rigidity with bruising over left hypochondrium. Plain radiograph of chest and abdomen were normal while ultrasonography revealed laceration of spleen with perisplenic hematoma.

After resuscitation, the patient was explored through midline incision and splenectomy was done. Rest of the solid viscera and the bowel were normal. Monolayer closure of the anterior abdominal wall was done with number 1 monofilament polyamide suture. Considerable bleeding was noted at the puncture site of one of the suture, which appeared to cease after the sutured was tied. The skin was sutured with number 3.0-monofilament polyamide suture.

The patient received pneumococcal vaccine postoperatively and was discharged on the 7th day. He was asymptomatic later and presented one month later with diffuse painful swelling over the left paraumbilical region. He gave no history of repeat trauma or reducibility. On palpation, diffuse tender swelling could be palpated measuring 4x5 centimeters. The swelling was firm, noncompressible without any palpable thrill.

Ultrasonography (USG) revealed ill-defined hypoechoic collection with anechoic areas within the parietal wall as shown in Figure 1. High-resolution color Doppler imaging demonstrated pulsatile flow within the anechoic area as seen in Figure 2, while spectral waveform obtained showed monophasic arterial flow confirming pseudoaneurysm as seen in Figure 3.

Figure 1

Figure 1: Sagittal Ultrasonography of the abdominal wall along the left paraumbilical region shows an illdefined hypoechoic collection with relatively anechoic area within.

Figure 2

Figure 2: High-resolution color Doppler reveals the vascular nature of the anechoic area by demonstrating pulsatile flow in it.

Figure 3

Figure 3: The spectral waveform obtained being pulsatile and monophasic confirms the presence of arterial pseudoaneurysm within the collection.

Figure 4

The patient was subjected to ligation of the inferior epigastric artery with extirpation of pseudoaneurysm along with fragment of artery. The abdominal wall was repaired with polypropylene mesh to cover the deficit of muscles. The patient is totally asymptomatic at 6 months follow-up.

Discussion

Pseudoaneurysm develops after any procedure that causes partial disruption of vessel wall.₃ Pseudoaneurysms have been documented following surgery, arterial puncture, and trauma.₁

The inferior epigastric artery lies within the rectus sheath just anterior to its posterior layer and hence is susceptible to injury during abdominal wall procedures.₂ Only 8 cases of inferior epigastric artery pseudoaneurysm have been reported, five following extraction of retention suture, two following paracentesis, and one following tenckhoff catheter removal.₂

Direct puncture of artery, partial rupture of artery, decubitus have been documented as the eitopathological reasons for its formation.₄ If accidentally bleeding is noted while taking sutures, it is probably best to remove the suture and apply pressure as it might continue to bleed through the penetrated suture.₅

Clinically, inferior epigastric artery pseudoaneurysm simulates abdominal wall abscess and hematoma and high index of suspicion is necessary to diagnose this condition.₃ An audible bruit over this swelling is usually an exception than a rule.₆ Contrast enhanced computerized tomography, angiography and high-resolution duplex color Doppler are useful to confirm the diagnosis. Duplex color Doppler has been the only noninvasive investigation of choice with a sensitivity and specificity of 100% in differentiating pseudoaneurysm from periarterial hematoma.₇ Pseudoaneurysms exhibit a characteristic extraluminal pattern of blood flow, which is not demonstrated in hematoma, which shows variable echogenicity and interval complexity on Doppler as was demonstrated in our patient. ₇

Surgical excision of the pseudoaneurysm is treatment of choice to abolish pain and possibility of rupture with haemorrhage.5 Angiographic coil embolisation is beneficial in management of small sized lesions.₈ Percutaneous embolisation has also been beneficial for small lesions but usually reserved for patients who are surgically unfit.₉

Conclusion

Pseudoaneurysm of the inferior epigastric artery can occur as a complication of abdominal wall suturing. Diagnosis can be confirmed with color Doppler imaging and surgical intervention may be required to prevent complications.

Acknowledgement

Correspondence to

Dr Rege Sameer A C-201, Gagangiri Park Co-op. Hsg. Society, Samata nagar, Thane (west). 400606. India. Phone: 09869178040 Fax: 91 –22- 24143435 E-mail: samrege@yahoo.com