Background

Percutaneous vascular access is now routine for a growing number of diagnostic and interventional procedures. Closure devices, like the Perclose ProStyle, are used to minimize bleeding and speed up recovery. However, these devices are not without risk. While rare, infected pseudoaneurysms represent a serious complication that can lead to significant morbidity, including sepsis, limb ischemia, and even death. The challenge lies in early diagnosis, as initial symptoms can be subtle and easily overlooked. The 2018 AHA/ACC guidelines on management of patients with lower extremity peripheral artery disease recommend careful site monitoring following arterial puncture; however, they do not specifically address the risk of pseudoaneurysm formation at the umbilical site.

Case Presentation

The case involves a patient who developed an infected pseudoaneurysm at the umbilical puncture site following a procedure using the Perclose ProStyle Suture®. What's striking is the initial presentation: a seemingly minor umbilical depression. There were no overt signs of infection - no significant redness, swelling, or purulent drainage initially. However, the subtle depression prompted further investigation, ultimately revealing the infected pseudoaneurysm. Angiography confirmed the diagnosis, and culture data guided targeted antimicrobial therapy, leading to successful resolution of the infection and preservation of vascular integrity.

Discussion

This case underscores a crucial point: vigilance and a high index of suspicion are paramount, even when dealing with seemingly minor post-operative findings. The umbilical depression, easily dismissed as a normal variation, was the key to unlocking the diagnosis. This highlights the importance of thorough physical examination and a willingness to pursue further investigation when clinical suspicion is raised. Furthermore, this case reinforces the need for adherence to strict sterile technique during percutaneous procedures. While closure devices aim to improve outcomes, they also introduce a potential source of infection if proper protocols are not followed. Appropriate antimicrobial therapy is critical.

Beyond technique, patient-specific factors play a role. Patients with diabetes, immunocompromised states, or a history of prior vascular procedures may be at increased risk for such complications. A thorough patient history and risk assessment are therefore essential. This case does not contradict current guidelines, but rather provides granular detail emphasizing the importance of adherence and awareness, especially in a growing population undergoing percutaneous interventions. The current Society for Vascular Surgery guidelines outline best practices for managing pseudoaneurysms, but this case adds a unique perspective on atypical presentation and location.

Limitations

This is a single case report, and therefore its generalizability is limited. We cannot extrapolate broad conclusions about the incidence or risk factors for infected pseudoaneurysms based on this one observation. Furthermore, the specific mechanism by which the umbilical depression developed is not fully elucidated. It's possible that the suture placement contributed to the localized tissue ischemia, creating a nidus for infection. Further research is needed to understand the pathophysiology of this complication and to identify potential preventative strategies. Additionally, it's worth noting that the Perclose ProStyle Suture® is just one of several closure devices available, and the risk profile may vary among different devices. The absence of a control group limits the study's ability to draw definitive conclusions about the device's safety in relation to others.