Synopsis
Recognise false aneurysm caused by arterial anastomotic disruption, identify rupture, infection and limb-threat features, define the reconstruction with imaging, and select urgent or elective repair without confusing it with a simple puncture-site lesion.
- A painful, rapidly enlarging or skin-threatening mass beside a vascular anastomosis is a rupture emergency: do not compress or aspirate it; obtain urgent vascular control and CTA when the patient can tolerate imaging.
- In every late para-anastomotic aneurysm, consider infection using history, examination, blood cultures, inflammatory markers and CTA; use deep samples and FDG-PET/CT or labelled-white-cell imaging when uncertainty remains.
- CTA must define true and false components, proximal and distal landing or clamp zones, graft patency, branch involvement, distal runoff, active bleeding and signs of infection before definitive repair.
Key red flags
A rapidly enlarging pulsatile mass, severe pain, bruising, thinning skin or a new sentinel bleed indicates threatened rupture and needs immediate vascular assessment.
Fever, wound drainage, bacteraemia, perigraft gas or fluid, or early para-anastomotic failure suggests graft infection rather than sterile degeneration.
Coolness, rest pain, sensory or motor loss, absent distal Doppler signals or sudden graft dysfunction indicates thrombosis or distal embolisation with limb threat.
Haemodynamic instability, abdominal or back pain, gastrointestinal bleeding or an unexplained fall in haemoglobin after aortic repair suggests concealed rupture or fistulation.
Shiny, thinned, erythematous, ulcerated or bleeding skin over a superficial pseudoaneurysm indicates diminishing containment and impending external rupture.
Reduced graft flow, absent pulses, blue toes, rest pain or neurological deficit can arise from mural thrombus, embolisation, kinking or complete graft thrombosis.
Investigation priorities
Define the pseudoaneurysm, active bleeding, graft and branch anatomy, clamp or landing zones, distal perfusion and evidence of infection.
Management branches
The lesion is bleeding, rapidly enlarging, painful with threatened skin, haemodynamically unstable or causing acute limb ischaemia.
- Protect the lesion, avoid compression or needle puncture, activate senior vascular and anaesthetic support, cross-match blood and resuscitate while maintaining awareness that temporary hypotension may limit uncontrolled bleeding.
- Obtain immediate CTA if stable enough; otherwise proceed to the fastest method of proximal and distal control, using open exposure, balloon occlusion or endovascular exclusion according to location and resources.
The patient is stable, imaging shows a contained lesion and a structured infection assessment is negative.