|True, this is a Yin & Yang on the groin, |
but not quite what we're aiming for...
The patient had undergone emergent angiography and PCI for a STEMI. Access for the PCI was gained through the radial artery, which is associated with fewer complications than femoral artery access. Unfortunately, they also required placement of an intra-aortic balloon pump, which was placed through the right femoral artery.
At a follow-up appointment soon after discharge, examination revealed swelling in the right inguinal crease. The swelling was both pulsatile and had a sharp systolic bruit.
Point-of-care ultrasound (POCUS) of the area of pulsatility was conducted with both B-mode and color Doppler.
The physical exam, of course, had been strongly suggestive of a pseudoaneurysm of the femoral artery. The POCUS is diagnostic!
The B-mode image shows a large pulsatile hypoechic structure, but a post-operative hematoma might have the same appearance (e.g. if an adjacent artery was causing pseudo-pulsation).
Color Doppler is required to exclude hematoma by demonstrating pulsatile flow within the structure. Such flow may appear as a "swirling" or "to and fro" pattern.
Even more "colorfully" (pun intended), the pattern has been described as the Yin-Yang sign.
Treatment can be as simple as ultrasound-directed compression of the pseudoaneurysm sac, or as invasive as surgical management. The majority of post-cathetererization pseudoaneurysms, however, are managed with injection of thrombin into the sac. This is almost always successful.
And lastly, speaking of things that required fixing...
Contemporary Management of Postcatheterization Pseudoaneurysms
Sonographic Evaluation of Vascular Injuries