Management and Nursing Care of a Pseudoaneurysm Caused by Inadvertent Arterial Puncture: A Case Report

Abstract

Introduction

Iatrogenic pseudoaneurysms resulting from mispuncture into adjacent arteries, though uncommon, represent a serious complication. In this study, the authors reported a nursing case where a peripheral pseudoaneurysm with associated thrombosis that developed following an accidental arterial puncture were successfully cured after effective nursing procedures.

Case Presentation

A 55-year-old female patient arrived at the dialysis center for plasma exchange therapy due to anti-neutrophil cytoplasmic antibodies-related vasculitis. A 17 G puncture needle was used for cannulation of the left median cubital vein to establish the venous access, while the needle penetrated into the adjacent artery by mistake and resulting in a pseudoaneurysm. The needle was promptly withdrawn, followed by immediate pressure bandaging, ice application, and magnesium sulfate wet compresses. After adequate evaluation, percutaneous intra-arterial balloon dilatation and left brachial artery repair were performed, and the patient achieved near-complete resolution without any complications.

Management and Outcome

Immediate hemostasis should be achieved by simultaneously withdrawing the needle and applying an elastic tourniquet. The prompt application of an ice compress is recommended to induce vasoconstriction, thereby reducing local hemorrhage and edema. Furthermore, magnesium sulfate wet compress was believed to facilitate the absorption of interstitial fluid and reduce capillary pressure. These combined measures are considered effective in preventing the formation and progression to a puncture-related pseudoaneurysm. Meticulous nursing care throughout is paramount to minimizing the risk of this complication and promoting patient recovery.

Discussion

Enhancing nurses’ puncture proficiency is the cornerstone of preventing iatrogenic pseudoaneurysms and the pseudoaneurysms can be cured by efficient nursing that should include elastic tourniquet compression, ice compression, magnesium sulfate wet compression. Although a rare event, pseudoaneurysm can result from a commonly performed procedure such as vascular puncture. Therefore, it is imperative for nursing staff to be proficient in its early recognition and initial management.

Introduction

Plasma exchange therapy (PET) is recommended as a first-line or initial treatment for various hematologic, neurologic, and oncologic conditions. Procedurally, plasma is first separated from the blood using a plasma separator made of a fibrous membrane molecular sieve and adsorbent materials in the extracorporeal circulation (Gao et al., 2018). The separated plasma is then discarded and replaced with an equivalent volume of substitution fluid before the blood is reinfused into the patient (Derebail & Falk, 2020). A new peripheral venous access for the fluid infusion should be established when there is not enough access to a dialysis machine. However, most patients undergoing PET have underlying conditions such as kidney disease, hypertension, and atherosclerosis, which are associated with fragile and narrow blood vessels, predisposing them to complications such as subcutaneous hematoma and induration at the puncture site (Morris & Geetha, 2023). Accidental arterial puncture can cause arterial wall injury and subsequent formation of a pseudoaneurysm—a contained sac of extravasated blood communicating with the arterial lumen. Although rare, iatrogenic pseudoaneurysm represents a serious complication of PET that necessitates vigilant nursing care to prevent rupture and subsequent severe outcomes (Goldshtein et al., 2006; Wang et al., 2023). There are few cases reported in previous literature discussing mispuncture-related pseudoaneurysm. Theoretically, extremity pseudoaneurysms are uncommon, and the most commonly iatrogenic factor includes puncture or arterial blood drawing. Rapid assessment with ultrasound, compression and minimally invasive artery operation are usually recommended (Bansal et al., 2021; Onur-Beyaz et al., 2022). Here, the authors presented the nursing management of a patient who developed a brachial artery pseudoaneurysm following inadvertent arterial puncture during peripheral venous cannulation for PET.

Case Presentation, Management, and Outcomes

A 55-year-old female patient arrived at the dialysis center on the day of admission, for PET due to anti-neutrophil cytoplasmic antibodies-related vasculitis. It was the first time for the patient to receive PET and the patient exhibited poor filling of the peripheral venous, and a venous access was required for the preoperative fluid replacement. A nurse with 5 years’ PET experience used a 17 G puncture needle (JMS, Dalian, China) to puncture the left elbow median vein to establish the venous access. Upon needle withdrawal, arterial bleeding was observed, indicating inadvertent arterial puncture. The needle was immediately removed, and the site was managed with pressure bandaging and 30 min of ice application. Subsequently, the right median cubital vein was successfully cannulated for PET. The procedure lasted 3 h, during which 0.4 mL of low-molecular-weight heparin sodium was administered for anticoagulation, with a blood flow rate of 150 mL/min, temperature maintained at 36–37 °C, and a total replacement fluid volume of 2500 mL. The patient returned to the ward post-procedure without signs of active bleeding or hematoma. Six hours later, the patient complained of swelling and pain in the left upper limb. Physical examination revealed mild swelling compared to the contralateral arm, scattered subcutaneous ecchymosis, and normal motor function. The attending physician attributed these findings to coagulation dysfunction secondary to coagulation factor consumption during PET. Management included 50% magnesium sulfate wet compresses (applied for 20–30 min, 3–4 times daily) and hourly monitoring of the left limb, with continued local pressure. The following morning, the patient still complained of swelling, pain, and numbness of the left upper limb (Figure 1a). The limb exhibited elevated skin temperature, palpable ulnar and radial pulses, normal hand motion, and distal finger numbness. Bedside ultrasound suggested a pseudoaneurysm in the mid-left elbow region (Figure 1c). The medical team concluded that both the hypofibrinogenemia (1.16 g/L, the normal range is 1.8–3.7 g/L) and the arterial puncture contributed to pseudoaneurysm formation, and advised fibrinogen supplementation, localized compression, plasma transfusion, and an ultrasound re-evaluation. Twelve hours later, the patient's symptoms showed no significant improvement. Subcutaneous ecchymosis remained, with an upper arm circumference of 32 cm and forearm circumference of 25.5 cm (Figure 1b). Repeat ultrasound confirmed a left elbow pseudoaneurysm with thrombosis and hemorrhage. After thorough preoperative assessment, the patient underwent percutaneous intra-arterial balloon dilatation and left brachial artery repair under local anesthesia at 23:20 on the second day. The next morning, the patient reported reduced swelling but persistent numbness in the left hand. Follow-up ultrasound demonstrated patent flow in the left brachial artery and vein, periarterial soft tissue edema, and increased flow velocities in the ulnar and radial arteries (Figure 1d). With continued nursing care, by day 8 the patient exhibited only mild pain and occasional numbness, with marked resolution of swelling and ecchymosis. The patient was discharged five days later without complications. The patient consent and Ethics Committee approval have been obtained for this study.

Figure 1.

(a) The swollen, painful, and numb left upper limb of the patient. (b) The left limb was swollen with an upper arm circumference of 32 cm and a lower arm circumference of 25.5 cm, and subcutaneous ecchymosis. (c) The bedside ultrasound revealed that a pseudoaneurysm might have formed in the middle of the left elbow. (d) The ultrasound image revealed that the blood flows of the left brachial artery and vein were unobstructed, the surrounding soft tissue was edematous.

Discussion

Because of the large size of the puncture needle and the anatomical proximity of the artery and vein, an artery puncture by mistake can easily occur during PET, which may lead to subcutaneous bleeding or hematoma. In addition, the hypocoagulable state of the PET patient, inaccurate siting, insufficient compression time and force will eventually contribute to the formation of a puncture-related pseudoaneurysm. Therefore, improving puncture accuracy remains the most critical measure to reduce pseudoaneurysm formations. Ultrasound-guided puncture is recommended in patients with poor vascular conditions (Piton et al., 2018). Once the artery is punctured by mistake, an elastic tourniquet should be applied immediately upon needle withdrawal to achieve hemostasis. Concurrent ice application can induce vasoconstriction, reduce local bleeding, and minimize hematoma expansion (Shreve et al., 2020). Prolonged and accurately localized compression with careful monitoring for signs of ongoing bleeding is also essential to avoid puncture-related pseudoaneurysm formation (Henry & Franz, 2019).

Magnesium sulfate wet compress is a common local nursing practice. The hyperosmotic property generated from the 50% MgSO₄ solution can promote the absorption of interstitial fluid, thereby alleviating localized edema. In addition, Mg²⁺ ions have an antagonistic effect on voltage-gated Ca²⁺ channels that can reduce capillary pressure and induce peripheral vasodilation, which collectively help minimize vascular exudation. MgSO₄ wet compresses can also improve microcirculation and vasospasm, and are widely used in the management of phlebitis and postoperative limb swelling (Zou et al., 2024). Therefore, magnesium sulfate wet compresses were employed in this case study and believed to have helped prevent puncture-related pseudoaneurysm formation and progression.

Diligent nursing care plays a critical role in the early detection of rare complications and improving patient outcomes (Kudu et al., 2024). To reduce the risk of pseudoaneurysm formation and facilitate recovery, nurses should regularly assess hematoma sites and monitor skin temperature, arterial pulses, limb mobility, and sensation. The bedside handover should be conducted during each shift, and thorough clinical documentation are essential. If abnormalities are found, they should be dealt with as soon as possible. Additionally, nurses need to provide adequate patient education and introduce the importance of preventing puncture-related complications. This should consist of patient self-observation and self-nursing after the puncture. This can eliminate patient and family concerns and make patients and families actively cooperate with nurses to prevent the formation of puncture-related pseudoaneurysms (Henry & Franz, 2019; Roberge & McLane, 1999).

There is a limitation to this study. As a single case report, the conclusions drawn require validation through larger, more comprehensive investigations. Future studies should systematically evaluate the effectiveness of the proposed nursing strategies in preventing puncture-related pseudoaneurysms.

In a conclusion, pseudoaneurysm is a rare yet serious complication of peripheral vascular access. Given the ubiquity of vascular punctures in clinical practice, nurses must be proficient in recognizing and managing such complications at an early stage. The present case demonstrates that puncture-related pseudoaneurysms can be effectively managed through a structured nursing protocol involving elastic tourniquet compression, ice application, magnesium sulfate wet compression, and careful nursing.