Vascular Pseudoaneurysms in Urology:
Clinical Characteristics and Management
Douglas E. Sutherland, M.D.,1Stephen B. Williams, M.D.,2Dana Rice, M.D.,3
Thomas W. Jarrett, M.D.,3and Jason D. Engel, M.D.3
Background and Purpose: Vascular pseudoaneurysm is a well-documented complication that results after injury
to an arterial wall. We review the urologic literature for all reported postprocedural and post-traumatic cases of
Methods: A comprehensive review of the peer-reviewed literature was performed for reported cases of vascular
pseudoaneurysm, with emphasis on clinical presentation and treatment options.
Results: Vascular pseudoaneurysm is a high-pressure collection of blood that communicates directly with an
arterial vessel. The clinical presentation varies, depending on the location and size of the lesion, and can be quite
dramatic and potentially life threatening. There may be an increasing incidence of pseudoaneurysms after
minimally invasive and laparoscopic techniques. Selective and superselective embolization is the preferred
treatment for patients with vascular pseudoaneurysms.
Conclusions: Vascular pseudoaneurysm is an important but rare complication that is increasingly reported after
minimally invasive urologic surgery. This diagnosis necessitates a high index of suspicion and radiologic acu-
men. Treatment is individually tailored to each patient, but selective embolization appears to be the standard
surgery. Certainly, it can be argued that the primary
responsibility of the surgeon is to circumnavigate hemor-
rhage, regardless of the procedure. Delayed hemorrhage after
surgery is an especially frustrating reality that can be a major
source of postoperative morbidity.
hemorrhage after several surgical procedures. Pseudoaneur-
ysms result from subtotal injury to an arterial wall, allowing
protrusion of the inner layers of the arterial wall under pres-
sure, resulting in a ‘‘pulsatile hematoma’’ that can dissect
tissue planes and fill potential spaces. Rupture of a pseu-
doaneurysm is potentially a fatal event, particularly pseu-
doaneurysms that occur in large visceral arteries.
The incidence of reported cases of this relatively rare
complication is on the rise, and treatment for patients with
pseudoaneurysms has become commonplace in the field of
interventional radiology. Given the recent surgical trend in
emorrhage is a common complication after all major
urology and other surgical specialties to adopt minimally
reasons, it is essential to understand the diagnostic hallmarks
and treatment options for pseudoaneurysms.
In this article, we will discuss the natural history of pseu-
doaneurysms, in general and within the context of a urologic
practice, as well as how best to diagnose and manage them.
PubMed and MEDLINE searches were performed in May
2008 using the terms pseudoaneurysm, false aneurysm, pul-
satile hematoma, and pulsatile mass. Only titles in English
were considered. All abstracts were reviewed and assessed
for relevance to the topic. Appropriate manuscripts were
collected electronically or by hand. The rarity of the diagnosis
resulted in no prospective investigations; therefore, stringent
application of data quality was not applied to this analysis,
particularly in the arena of pseudoaneurysm diagnosis and
1Department of Urology, Multicare Health System, Tacoma, Washington.
2Division of Urology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts.
3Department of Urology, George Washington University, Washington, District of Columbia.
JOURNAL OF ENDOUROLOGY
Volume 24, Number 6, June 2010
ª Mary Ann Liebert, Inc.
an injury to the outermost layer of an arterial wall (tunica
adventitia). The inner layers (tunica intima and tunica media)
of the arterial wall protrude through the defect, resulting in a
pressurized sac that can dissect into potential spaces and
through tissue planes. Continuity with the arterial lumen is
maintained via the aneurysmal neck that can be variable in
width. They differ from true vascular aneurysms (whose di-
verticular protrusions are composed of all three wall layers)
and therefore are termed pseudoaneurysms, false aneurysms,
pulsatile hematomas, or pulsatile masses.
Pseudoaneurysms can occur to any artery after physical
injury or inflammation to the vessel wall.1Iatrogenic pseu-
doaneurysms are significantly more common than primary
pseudoaneurysms. The most common iatrogenic etiology is
femoral arterial access with a large-bore catheter for various
endovascular procedures, such as cardiac catheterization.2
Pseudoaneurysms, however, have been widely reported after
both vascular and nonvascular surgical procedures; within
the field of urology, they have been reported after percuta-
neous nephrolithotomy (PCNL), partial nephrectomy, radical
nephrectomy, radical prostatectomy, and radical cystect-
omy.3–11Surgery can result in a pseudoaneurysm directly or
indirectly if a postoperative infection or abscess develops.
Noniatrogenic etiologies are less common and include
vasculitis, inflammation, or infection of an adjacent organ
(eg, pancreatitis) or trauma (both blunt and penetrating).1
Incidence and clinical impact
are the cause of more than 50% of delayed hemorrhage after
PCNL and partial nephrectomy.3Not all pseudoaneurysms
are symptomatic and subsequently may never be identified.
As in the case of renal masses, pseudoaneurysms are in-
creasingly being found incidentally on imaging that is per-
formed for another indication.1,2
Pseudoaneurysms can follow three general courses:
Thrombosis, symptomatic progression=enlargement, and
rupture. Unstable pseudoaneurysms that occur within large
potential spaces (eg, the retroperitoneum) may enlarge, re-
sulting in compression of adjacent organs or nervous struc-
tures. These pseudoaneurysms are at high risk of rupture.
Small, stablepseudoaneurysms typically occurin close spaces
and are capable of spontaneous thrombosis. Such thrombosis
can predispose to vascular thromboembolism. Lastly, pseu-
doaneurysms can also become infected, which poses a par-
ticularly difficult clinical dilemma.12
General clinical characteristics
Pseudoaneurysms can be divided simply into superficial
and deep visceral pseudoaneurysms. By far, superficial
pseudoaneurysms after arterial catheterization predominate.
These small, postcatheterization pseudoaneurysms are typi-
cally managed differently because of their size and accessi-
The clinical diagnosis of a deep visceral pseudoaneurysm
can be challenging. The classic palpable pulsatile mass, with
an audible thrill, may be found on abdominal examination,
but its absence certainly does not exclude the diagnosis. In
fact, very few pseudoaneurysms are diagnosed in this man-
effect that can compress abdominal and retroperitoneal
structures and resulting in referred pain or organ dysfunction
(eg, hydronephrosis, bowel obstruction), vague abdominal
the surrounding tissues.1,2
Patients most commonly present with signs and symptoms
of hemorrhagic shock several days after a surgical procedure.
Gross hematuria after renal surgery is a sensitive indicator
of pseudoaneurysm formation, but its absence does not rule
out the diagnosis.3,4,6,7The diagnosis is usually confirmed on
Rupture, fistulization, and local compression are the most
common complications thatare associated withthe diagnosis.
Compared with true aneurysms, pseudoaneurysms are sig-
nificantly more likely to be symptomatic, associated with
clinically detectable hemorrhage, and necessitate medical or
catastrophic of these complications, with associated mortality
rates ranging from 40% to 100% when affecting deep visceral
arteries.1,2,14Depending on the location of the pseudoaneur-
(eg, hematuria, hematochezia, or hematemesis), and hemo-
dynamic instability. Pseudoaneurysm fistulization is a rare
occurrence, but fistulae with adjacent ureters, bowel, and
gynecologic structures have been reported.
Pseudoaneurysms in urology
Pseudoaneurysm formation complicates percutaneous re-
of the plentiful microvasculature intrinsic to the renal paren-
chyma. After these procedures, pseudoaneurysm is the most
common cause of delayed hemorrhage.3,4,6,7
Major hemorrhage after PCNL is a rare event that affects
approximately 1% to 3% of patients undergoing the proce-
dure. Patients typically present with gross hematuria, retro-
peritoneal hematoma,bleedingfromthenephrostomy tubeor
tract, and symptoms that are consistent with hypovolemia.3,15
In the majority of cases, delayed bleeding can be managed
expectantly with fluid resuscitation and blood transfusion as
needed. Only persistent or symptomatic hemorrhage neces-
sitates treatment. In the largest single institution series,
Richstone and associates3found 57 cases of major postoper-
ative hemorrhage out of nearly 4700 (1.2%) patients treated
with percutaneous renal surgery, and pseudoaneurysm was
the most common etiology, found in 53%, followed by renal
vessel laceration and arteriovenous (AV) fistula (25% each).
The vast majority of these patients (95%) were successfully
treated with selective embolization (SE). Large stone size
appears to be the only preoperative predictor of delayed
hemorrhage and pseudoaneurysm formation after PCNL.4
Delayed bleeding is a rare complication after partial ne-
phrectomy, slightly more so when performed laparoscopi-
cally (4%–6%) than via an open approach.15Pseudoaneurysm
formation is a common cause of postoperative hemorrhage in
patients who are undergoing partial nephrectomy.6,7Most
episodes of delayed bleeding occur 1 week to 5 months
postoperatively and present in a nearly identical manner as
916 SUTHERLAND ET AL.
post-PCNL hemorrhage.7Diagnosis of a pseudoaneurysm
in the nephrectomy bed is dependent on the size of the
pseudoaneurysm, and most pseudoaneurysms cannot be
positively identified except on contrast angiography.
Albani and Novick6reported an incidence of pseudoa-
neurysm formation within the partial nephrectomy bed of
0.43% in their series of 698 open procedures, compared with
1.7% after a laparoscopic approach reported by Singh and
Gill.7Although thesame operative steps are followed for both
procedures, laparoscopicsuturingistechnically moredifficult
and can result in inferior tension applied to transected vessels
compared with hand suturing. Also, overreliance on pro-
thrombotic materials after laparoscopic partial nephrectomy,
such as Floseal,?may result in incomplete physical ligation
and predispose to pseudoaneurysm formation. Indiscrimi-
nate placement and replacement of suture needles into the
renal parenchyma may also inadvertently injure deep vessels,
resulting in pseudoaneurysm formation. Lastly, partial ne-
phrectomy commonly necessitates hilar clamping with Sa-
tinsky or bulldog clamps, which can result in renal artery
injury and pseudoaneurysm formation.16
Delayed hemorrhage after radical nephrectomy occurs less
commonly than after partial nephrectomy, but pseudoa-
neurysm has been reported as a rare complication.9,10,16
Bluebond-Langner and colleagues10reported on persistent
hemorrhage from an intercostal artery pseudoaneurysm that
resulted from injury during port placement for a retroperito-
neal radical nephrectomy. Another group reported on an
adrenal bed pseudoaneurysm after laparoscopic nephrou-
reterectomy that formed after arteriolar injury from a poorly
applied surgical clip, eventually resulting in patient death.9
Pseudoaneurysms after pelvic surgery are much less
common than after renal surgery, and typically result from
collateral damage during the operation. Hampson and
assisted prostatectomy; (B) contrast pelvic CT demonstrating the contrast blush suggestive of a pseudoaneurysm; (C) su-
perselective contrast angiography of the prostate pedicle pseudoaneurysm; (D) successful coil embolization of the pelvic
(A) Noncontrast pelvic CT demonstrating a hematoma adjacent to the left ligated prostate pedical after robot-
PSEUDOANEURYSMS IN UROLOGY 917
coworkers8reported a pseudoaneurysm of the common iliac
artery 2 weeks after radical cystectomy and pelvic lympha-
denectomy for muscle invasive transitional-cell carcinoma.
The patient presented in abdominal pain with evidence of
hypovolemia; the diagnosis was confirmed on contrast im-
aging, and the lesion was controlled with SE. Beckley and
associates11reported an accessory obturator artery pseudoa-
neurysm after robot-assisted radical prostatectomy, and we
have recently seen a prostatic pedicle pseudoaneurysm after
the same procedure (Fig. 1). Prolonged gross hematuria de-
veloped in both patients, resulting inrepeated episodes ofclot
retention. After expectant management failed in both cases,
angiography successfully identified the vascular lesion and
SE successfully controlled the hemorrhage.
Trauma commonly results in bleeding complications, in-
cluding pseudoaneurysm formation.17–19Renal artery pseu-
doaneurysm has been reported after both penetrating and
blunt trauma. These patients commonly present several days
after the initial injury with persistently but slowly developing
anemia and signs of hypovolemia. Gross hematuria is not
always present, but should increase suspicion for a renal
Diagnosis. Currently, the vast majority of pseudoaneur-
ysms are diagnosed radiographically on imaging performed
for suspected delayed hemorrhage. Important clinical hall-
marks of the diagnosis include evidence of bleeding, hypo-
tension, tachycardia, localized pain, palpable pulsatile mass,
and anemia.1,2In addition to surgery and percutaneous bi-
opsy, risk factors include anticoagulant use, antiplatelet
therapy, liver dysfunction, alcoholism with history of pan-
creatitis, and autoimmune vasculitis syndromes, such as
Behc ¸ets syndrome, polyarteritis nodosa, and lupus.1
diagnosed by contrast CT angiography. Suspected pseudoa-
neurysms can then be confirmed with Doppler ultrasonog-
raphy. CT angiography is quick, nonoperator dependent, and
can provide a three-dimensional reconstruction of the hema-
toma, affected vasculature, and adjacent organs. A large he-
matoma is differentiated from a pseudoaneurysm on CT by
the presence of confined enhancement within the hematoma
scopic partial nephrectomy; (B) superselective contrast angiography differentiating the contrast blush seen in Figure 1A as a
pseudoaneurysm, not an arteriovenous fistula; (C) successful endoluminal embolization of the pseudoaneurysm with a coil.
(A) Contrast renal CT, arterial phase, demonstrating a small pseudoaneurysm (white arrow) after a right laparo-
918 SUTHERLAND ET AL.
during the arterial phase. The entire hematoma may not en-
hance completely. The pseudoaneurysm may contain a sig-
nificant volume of clot formation; therefore, evidence of even
suspicion of a pseudoaneurysm. Pseudoaneurysms of small
arterioles and intraparenchymal pseudoaneurysms (eg, after
partial nephrectomy) can be more challenging to diagnose on
CT, and differentiation from an AV fistula is not always
possible (Fig. 2). MRI is an expensive alternative to CT that
necessitates a substantial amount of time to perform and is
poorly suited in the diagnosis of a suspected pseudoaneur-
Doppler ultrasonography is a sensitive method to confirm
thepresence ofapseudoaneurysm.1,2,18The hematomacan be
echogenicity, and the pseudoaneurysm will appear as a cen-
tral hypoechoic cystic-like lesion immediately adjacent to
an artery (Fig. 3A). Doppler ultrasonography allows for de-
tection of arterial flow within the cystic lesion. Classically,
pseudoaneurysms demonstrate a yin-yang flow pattern,
whereby arterial inflow during systole is followed immedi-
ately by outflow during diasystole (Fig. 3B). Sensitivity and
specificity of Doppler ultrasonography for the detection of
pseudoaneurysms in most studies is in excess of 90%, re-
spectively.1,2,13,18The primary disadvantage of the technol-
ogy is the operator-dependent nature of ultrasonography.
The gold standard study for the detection of pseudoa-
angiography is that it allows for real-time estimation of arte-
rial collateralization to the affected vessel, and it allows for
concurrent therapeutic SE. Angiography is typically more
sensitive than other modalities and can identify additional
vascular lesions at the time of the procedure. The diameter of
the pseudoaneurysm neck can also be established with angi-
ography, which is an important factor in treatment planning.
The disadvantages to angiography include the invasive na-
ture of the technique with its own associated morbidity and
the necessity of using potentially nephrotoxic contrast mate-
rial. In general, contrast angiography should be used once the
diagnosis is made or suspected on initial abdominal imaging.
Treatment. It is evident that not all pseudoaneurysms need
treatment. Spontaneous thrombosis does occur and probably
results in the underestimation of the incidence of this com-
plication. It is generally recommended that small (<1cm),
asymptomatic, parenchymal pseudoaneurysms that are inci-
dentally found be observed and treated only if they become
symptomatic, do not resolve on further imaging, or enlarge.2
All symptomatic and extravisceral pseudoaneurysms should
be treated because of the risk of spontaneous rupture and
Traditionally, the treatment of pseudoaneurysms consisted
of open surgical ligation with arterial bypass when necessary.
This procedure can be technically difficult because of the
potential for uncontrolled bleeding, which can obscure the
vascular anatomy. This was particularly true for small, pa-
renchymal pseudoaneurysms that commonly ultimately re-
sult in complete extirpation.
Percutaneous injection of thrombin as a treatment for
pseudoaneurysm was first used by Cope and Zeit20using
ultrasonographic guidance. Currently, 0.5 to 1.0mL of a
1000IU=mL concentration of thrombin is slowly injected di-
rectly into the center of the pseudoaneurysm until thrombosis
of the pseudoaneurysm is confirmed with ultrasonography.21
The success rate of the technique approaches 90%, and it can
be used in the setting of systemic anticoagulation or anti-
platelet therapy. It is used largely to treat postcatheterization-
induced pseudoaneurysms, but has also been described for
deep visceral pseudoaneurysms with success and pseu-
doaneurysms that are not accessible with current SE tech-
complication of pseudoaneurysm thrombin injection, and it is
is themost significant
structure within a poorly defined collection, immediately
adjacent to a large vessel, suggestive of a pseudoaneurysm;
(B) Doppler ultrasonography demonstrating the classic yin-
(A) B-mode ultrasonographic image of a cystic
PSEUDOANEURYSMS IN UROLOGY919
recommended that the treating physician be capable of distal
thrombolytic injection if necessary.
Percutaneous SE and superselective embolization is
the contemporary standard of care for most pseudoaneur-
ysms.1–3,13,23–26As stated, digital subtraction angiography
allows for excellent identification of the pseudoaneurysm as
well as collateralization to the affected vessel, in addition to
the vascular defects such as AV fistulas and vascular stenosis.
Current SE techniques are associated with a better morbidity
profile than traditional surgical management. Several differ-
ent thrombotic materials, such as coil deployment and gel-
foam, can be used to tailor treatment based on the unique
features of the given pseudoaneurysm. Alternatively, coated
vascular stents can be used to isolate the pseudoaneurysm
from the arterial lumen.
The nuances of SE are beyond the scope of this article but
are well described in recent reviews.1,2,14,23,24The critical pa-
rameters necessary to successfully treat pseudoaneurysms
with SE include the pseudoaneurysm size, the width of the
pseudoaneurysm neck, evidence of collateral arterial supply
to the affected artery, and the expendability of the affected
artery (Table 1). Percutaneous direct embolization of the
pseudoaneurysm is best used when the affected artery can-
not be sacrificed (eg, renal artery) or the lesion cannot be ac-
arises from an expendable artery, thrombosis of the artery
distal to the pseudoaneurysm is preferred. In the setting of
arterial collateralization, complete exclusion of the pseudo-
Outcomes of SE. Successful vascular control with a sin-
gle SE procedure has been reported to range from 89% to
100%.1–3,13,23–26Initial failure from recanalization is a rare
SE is well tolerated with few treatment-related complications;
however, these patients commonly have complications from
the hemorrhage itself. Complications of SE include access-site
bleeding, infection and pseudoaneurysm formation, contrast
toxicity, recanalization of the pseudoaneurysm, and rarely,
iatrogenic rupture of the pseudoaneurysm.
Renal function after SE for renal pseudoaneurysm corre-
lates directly with the amount of kidney parenchyma embo-
lized and is typically self-limiting. El-Nahas and associates27
followed 30 patients who were treated with SE for post-PCNL
hemorrhage an average of 3.9 years with intravenous uro-
graphy and dimercaptosuccinic acid scans. Bleeding was
successfully controlled in more than 90% of patients with no
long-term evidence of renal dysfunction. Two (7%) patients
lost all renal function in the affected kidney. On average, a
10% increase in renal function of the treated renal unit was
seen at 30 months. Poulakis and colleagues28studied five
patients with iatrogenic and trauma-related renal pseudoa-
neurysm who were treated with SE. Bleeding was controlled
in all patients. Post-SE azotemia (measured by serum creati-
nine) resolved in all patients within 10 days of the procedure,
and the average percentage of photopenia demonstrated on
diethylene triamine pentaacetic acid scan was 9% (0%–20%)
6 months after the procedure.
As expected, the management of pseudoaneurysm forma-
tion in a solitary kidney poses the greatest risk to renal func-
tion.3,27,28There is no generally accepted approach to this
and bypass should be considered for large pseudoaneurysms
of the main renal artery because of the risk of thromboem-
bolism or renal infarction after SE.
Pseudoaneurysms are a rare but potentially lethal compli-
cation of urologic surgery whose incidence appears to be in-
creasing as our field embraces minimally invasive techniques.
Pseudoaneurysms account for the most common etiology of
delayed hemorrhage after percutaneous renal surgery and
partial nephrectomy. SE is the most appropriate initial man-
agement strategy, followed by percutaneous injection of
thrombin.Surgicalmanagementisreserved for SE failuresand
patients with clinically unstable hemorrhage. Meticulous vas-
cular control with surgical clips or suture followed by a clean
ligation of isolated vessels and vascular pedicles is the best
method to prevent iatrogenic pseudoaneurysm formation.
Thomas W. Jarrett, consultant, Gyrus=ACMI; Jason D.
Engel, investigator, Vivus. No competing financial interests
exist for the other authors.
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SE success rate (%)
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9096.7 3.3100 14.3Death, rupture, postinfarct
Death, postinfarct syndrome,
Lagana et al24a
Richstone et al3
Gablemann et al23a
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Address correspondence to:
Stephen B. Williams, M.D.
75 Francis Street
Boston, MA 20015
MRI¼magnetic resonance imaging
PSEUDOANEURYSMS IN UROLOGY 921
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