Endovascular repair of radial artery non-anastomotic pseudoaneurysm in a radial forearm free flap

Abstract

The development of pseudoaneurysm is an uncommon, life-threatening complication of head and neck microvascular surgery. Only a handful of reports have been published describing microvascular pseudoaneurysms, which usually occur at the arterial anastomosis and present as a pulsatile neck mass or as haemorrhage in case of pseudoaneurysm rupture. Management is highly variable, especially in the acute setting. In patients with pseudoaneurysm where flap inosculation is inadequate, endovascular approaches may be appropriate. In this report, we describe a ruptured distal pedicle pseudoaneurysm of a radial forearm free flap salvaged with a flow-diverting stent with complete flap survival and pedicle preservation. We demonstrate further evidence and feasibility of endovascular treatment of a non-anastomotic pseudoaneurysm arising from small vessels when parent vascular integrity is critical to flap survival.

Keywords: Clinical neurophysiology; Ear, nose and throat; Head and neck surgery; Neuro ITU; Neuroimaging.

Figure 1

CT and PET axial images. High resolution axial CT slice demonstrating cortical discontinuity of the lateral wall of the maxillary sinus due to invading tumour (A). PET axial image demonstrating high metabolic activity in corresponding region of invading tumour (B).

Figure 2

2D angiogram image demonstrating outpouching of pseudoaneurysmal sac in distal radial artery pedicle of the radial forearm free flap (red arrow) (A). Note the location deep to the mandibular hardware. 3D reconstructed image further demonstrating outpouching of pseudoaneurysmal sac (red arrow) (B). The pseudoaneurysm’s location distal to the inferiorly positioned loop of the vascular pedicle demonstrates postanastomotic location of the pseudoaneurysm.

Figure 3

Stent placement across pseudoaneurysmal sac. 3D reconstructed angiographic image showing successful deployment of the stent evenly across the aneurysmal sac (red circle) (A). High resolution magnified image further demonstrating spiral stent mechanism evenly deployed across the area of the pseudoaneurysm deep to the mandibular hardware (B).