The False Aneurysm: A Comprehensive History and Modern Clinical Perspective on the Pseudoaneurysm

Introduction: Defining the "False" Aneurysm

A. The Misnomer and the Medical Reality

The term "pseudoaneurysm," often used interchangeably with "false aneurysm," is a curious and potentially misleading piece of medical nomenclature. While the prefix "pseudo" might suggest something counterfeit or insignificant, a pseudoaneurysm is a very real and often dangerous vascular pathology.¹ It represents a contained rupture of a blood vessel, a condition that demands prompt recognition and treatment to avert potentially catastrophic outcomes.³ To provide a more descriptive understanding from the outset, it is also referred to by synonyms such as "pulsatile hematoma" or "communicating hematoma," which more accurately depict its nature as a blood-filled sac that maintains a connection with the parent artery.⁴ Correcting the misconception that "false" implies benign is a critical first step in understanding this condition; in many respects, the structural deficiencies that make it "false" are precisely what make it so perilous.

B. The Fundamental Distinction: True vs. False Aneurysms and the Arterial Wall

The defining characteristic of a pseudoaneurysm lies in its fundamental structural difference from a true aneurysm, a distinction rooted in the anatomy of the arterial wall. A healthy artery is composed of three distinct layers: the tunica intima (the smooth, innermost layer), the tunica media (the muscular middle layer responsible for elasticity and strength), and the tunica adventitia (the tough, fibrous outer layer).⁶

A true aneurysm is a localized dilation or "ballooning" of an artery where the vessel wall remains intact but is weakened and stretched. Crucially, all three layers—intima, media, and adventitia—are involved in forming the wall of the aneurysm sac.⁶ It is a disease of vessel wall weakness.

A pseudoaneurysm, in stark contrast, is not a dilation of the vessel wall but a contained extravasation of blood resulting from a full-thickness injury that breaches the intima and media.³ The leaking blood is held in check not by a complete, albeit thinned, arterial wall, but by the outermost adventitial layer and/or the surrounding perivascular soft tissues.⁴ Over time, a "pseudocapsule" forms from the products of the clotting cascade, such as fibrin and platelets, along with reactive fibrosis.³ This makeshift wall lacks the organized, resilient structure of a native artery, rendering it significantly weaker and conferring a much higher risk of rupture compared to a true aneurysm of a similar size.²

C. Pathophysiology: The Anatomy of a Contained Rupture

The formation of a pseudoaneurysm begins with an injury that creates a defect in an arterial wall.¹¹ Blood, under high arterial pressure, escapes through this defect into the surrounding tissue.¹² Instead of dispersing into an uncontained hematoma (a bruise), the bleeding is confined by the adventitia or adjacent tissues, forming a sac-like structure.³

A critical feature of this pathology is the persistence of a "neck" or tract that connects the lumen of the parent artery to the newly formed sac.⁶ This communication is the pseudoaneurysm's lifeline and its liability. With each systolic pulse, blood is actively pumped into the sac, and during diastole, some blood flows back out, creating a dynamic, turbulent environment.⁷ This constant pulsatile flow prevents the hematoma from organizing and resolving, allowing the pseudoaneurysm to persist and often expand over time, increasing the risk of compression of nearby structures or, most dangerously, rupture.⁸

The historical term "false aneurysm" directly influences modern patient perception. A patient hearing the word "false" may incorrectly assume the condition is not serious, creating a significant communication challenge for clinicians. This underscores the importance of precise patient education, emphasizing that the "false" wall is, in fact, an inherently unstable, fibrous containment of an active arterial bleed, making it a more urgent and fragile condition than its "true" counterpart.

A Journey Through Time: The History of the Pseudoaneurysm

The story of the pseudoaneurysm is intricately woven into the broader history of medicine, reflecting a journey from ancient observational concepts to the high-technology interventions of the 21st century. This evolution was not a linear path but one profoundly shaped by the advancement of anatomical knowledge, the crucible of military conflict, and the development of enabling technologies.

A. Ancient Glimmers of Understanding: From Galen of Pergamon to the Renaissance

The very concept of an aneurysm has ancient roots, with the term deriving from the Greek aneurysma, meaning "a widening".¹⁵ The first conceptual leap toward identifying the pseudoaneurysm is credited to the monumental Greek physician

Galen of Pergamon (AD 129-210). Working in an era when human dissection was largely forbidden, Galen relied on astute observation of wounds and animal dissections. He was the first to formally recognize and describe two distinct forms of arterial swelling: one arising from a spontaneous "dilatation" of the artery (a true aneurysm) and another arising from a "wound of the same," where the skin heals over but the arterial wound remains (a false, or traumatic, aneurysm).¹⁵ This distinction, made nearly two millennia ago, laid the conceptual foundation for all future understanding. For centuries, however, knowledge remained stagnant, hampered by a lack of anatomical investigation.¹⁸

B. The Age of Enlightenment and Surgical Awakening (18th-19th Centuries)

The 18th century witnessed a resurgence of scientific inquiry that brought the pseudoaneurysm into sharper focus. English medical literature from 1730 explicitly linked false aneurysms to the common practice of bloodletting, noting they were caused by "wounds and punctures" and that their wall was composed of "extravasated blood".²⁰ By 1758, the clinical description had become remarkably modern: a false aneurysm was defined as a "circumscribed and pulsating" mass consisting of a "bag that communicates by an aperture with the cavity of the artery".²⁰

Despite this improving descriptive accuracy, diagnosis remained entirely dependent on the physician's physical examination. This inevitably led to disastrous errors, most notably confusing a pulsatile, inflammatory pseudoaneurysm with a simple abscess. Lancing what was believed to be an abscess could lead to catastrophic hemorrhage.²⁰ The era's primary treatment for arterial injury was ligation—tying off the vessel—a crude but often life-saving measure. A monumental shift occurred in

1759, when a surgeon named Hallowell, at the suggestion of his colleague Lambert, performed the first documented arterial repair. He closed a small wound in the brachial artery by passing a pin through its edges and wrapping it with thread, successfully preserving the vessel.²¹ This singular event marked a profound change in surgical philosophy: the goal could now be not just to stop bleeding, but to restore anatomy and function.

C. The Crucible of Conflict: Vascular Surgery in the World Wars

While the principles of vascular repair were established, it was the intense pressure of 20th-century warfare that forged them into a standardized practice. Military conflicts served as brutal, high-volume laboratories for vascular surgery, forcing rapid innovation.

During World War I, surgeons understood repair techniques, but the battlefield environment, rife with contamination and infection, made such delicate procedures exceedingly risky. Consequently, ligation remained the dominant treatment for acute vascular injuries.²³ In World War II, the landscape had improved with the availability of blood transfusions and early antibiotics. However, long evacuation times often meant that by the time a soldier reached a surgeon, the window for a complex repair had closed. Ligation was still described as a "stern necessity".²¹ During this time, the technique was refined: surgeons learned that excising the damaged arterial segment between two ligatures was superior to simple ligation in continuity, as it reduced the risk of secondary hemorrhage, thrombosis, and painful vasospasm.²⁴

The Korean and Vietnam Wars represented the definitive turning point. The advent of rapid helicopter evacuation, the placement of experienced surgeons closer to the front lines, and the widespread availability of potent antibiotics finally created an environment where arterial repair could become the standard of care, not the exception.²³ Amputation rates for major vascular injuries plummeted, cementing the principles of debridement, primary repair, and vein grafting that underpin modern vascular trauma surgery.

D. The Modern Era: From Ligation to Repair and Minimally Invasive Techniques

The latter half of the 20th century saw the refinement of surgical techniques that built upon the foundations laid in previous eras. The innovative work of surgeons like Rudolph Matas, who introduced endoaneurysmorrhaphy (a technique of opening the aneurysm sac and suturing the arterial hole from within) in 1888, and J.B. Murphy, who performed the first successful end-to-end arterial anastomosis in 1897, had paved the way.²¹ The first use of a saphenous vein graft to bridge an arterial defect by

Goyanes in 1906 was another landmark achievement, proving that reconstruction was possible even when a segment of artery was destroyed.²¹ These pioneering efforts, combined with the lessons learned in war and the development of anesthesia and aseptic technique, transformed the management of pseudoaneurysms from a practice of damage control to one of sophisticated restoration.

The Who, What, Where, and Why: Etiology and Epidemiology

The causes and patterns of pseudoaneurysm formation have undergone a dramatic shift over the last century. What was once primarily a consequence of trauma and infection is now most frequently a complication of medical progress itself. The epidemiology of pseudoaneurysms serves as a direct barometer for the evolution of invasive medicine.

A. Iatrogenic Injury: The Price of Progress in Interventional Medicine

In contemporary medical practice, the overwhelming majority of pseudoaneurysms are iatrogenic, meaning they are an inadvertent result of a medical procedure.⁵ The rise of interventional cardiology and radiology, which rely on percutaneous arterial access to diagnose and treat a vast array of conditions, has made arterial puncture a routine event. Consequently, iatrogenic pseudoaneurysm is the most common vascular complication of these procedures.¹⁰

The incidence after a purely diagnostic catheterization is relatively low, estimated between 0.05% and 2%. However, this risk increases significantly to 2% to 6% for more complex interventional procedures (like stenting or atherectomy), which necessitate the use of larger sheaths and more aggressive anticoagulation and antiplatelet therapy.¹⁰ Some studies that have systematically screened all post-catheterization patients with ultrasound have reported incidence rates as high as 7.7%, suggesting many smaller pseudoaneurysms may go clinically undetected.¹⁰ Given that millions of these procedures are performed globally each year, even a low percentage translates into a significant number of cases, making pseudoaneurysm a familiar challenge for vascular specialists.¹⁰ This "paradox of progress"—where life-saving treatments for one condition create a new pathology—has been a powerful driver for the development of the minimally invasive treatments discussed later.

B. A Spectrum of Causes: Trauma, Infection, and Disease

While iatrogenic injuries dominate, pseudoaneurysms can arise from a wide range of other causes:

• Trauma: Both penetrating injuries (gunshot wounds, stabbings) and blunt force trauma (motor vehicle crashes, falls) remain a significant cause of pseudoaneurysms, particularly in the aorta and peripheral arteries.³
• Infection (Mycotic Aneurysm): The term "mycotic aneurysm" is a historical misnomer (it implies a fungal cause, but most are bacterial) that refers to a pseudoaneurysm formed by the infectious destruction of the arterial wall.⁴ This can occur when bacteria from a systemic infection like endocarditis or sepsis seed the vessel wall, or when bacteria are introduced directly, as with intravenous drug use.¹¹
• Disease-Related and Other Causes: A diverse group of pathologies can lead to pseudoaneurysm formation. Acute pancreatitis can cause pseudoaneurysms of nearby arteries (most commonly the splenic artery) when digestive enzymes erode the vessel wall.² They can also form at the site of a surgical anastomosis (suture line) that breaks down, often due to infection.³ Less common causes include inflammatory vasculitides (e.g., Behçet syndrome, Takayasu arteritis), penetrating atherosclerotic ulcers, and erosion of a vessel by a tumor.⁴

C. A Tour of the Body: Common and Critical Locations

Pseudoaneurysms can occur in virtually any artery in the body, but they show a distinct predilection for certain locations based on their underlying cause.³

• Femoral Artery: Located in the groin, this is by far the most common site for a pseudoaneurysm. Its accessibility and large size make it the preferred access point for the vast majority of cardiac and peripheral vascular interventions, directly linking its high incidence to iatrogenic injury.²
• Aortic Pseudoaneurysm: These are among the most lethal. Traumatic aortic pseudoaneurysms typically occur at the aortic isthmus (just beyond the arch) due to shearing forces in high-speed deceleration injuries.³ The mortality is exceptionally high, with estimates suggesting up to 85% of patients with blunt thoracic aortic injuries die before reaching a hospital.³ They can also arise from infection or as a complication of aortic surgery.²
• Cardiac (Left Ventricular) Pseudoaneurysm: This is a rare but often fatal complication of a severe myocardial infarction (heart attack). The dead heart muscle ruptures, but the subsequent hemorrhage is contained by the adherent pericardium (the sac surrounding the heart).² Lacking any myocardial tissue in its wall, it has a very high risk of delayed, complete rupture.²⁹ Other causes include cardiac surgery, trauma, and endocarditis.³
• Visceral Pseudoaneurysm: These are rare pseudoaneurysms affecting the arteries that supply the abdominal organs, such as the spleen, liver, or intestines.² They are most frequently associated with pancreatitis (eroding the splenic artery) or as a complication of abdominal surgery or trauma.³

From Physical Clues to Digital Certainty: The Evolution of Diagnosis

The diagnostic journey for a pseudoaneurysm has evolved dramatically, moving from a process reliant on the physician's senses to one empowered by advanced imaging that allows for direct visualization of the pathology. This transition from interpreting indirect clues to observing the pathophysiology in real-time has not only improved diagnostic accuracy but has also been the essential prerequisite for the development of modern, image-guided therapies.

A. The Clinical Presentation: Signs, Symptoms, and Complications

The diagnosis of a superficial pseudoaneurysm often begins with a classic constellation of signs and symptoms.

• Classic Presentation: The most common presentation, particularly for a femoral pseudoaneurysm, is a new-onset, painful, and tender pulsatile mass at the site of a recent arterial puncture or injury, typically developing within 24-48 hours.³ On physical examination, palpation reveals this tense, throbbing lump. Auscultation with a stethoscope over the mass often reveals a systolic bruit—a harsh, "whooshing" sound created by the turbulent blood flow through the narrow neck and into the sac.²
• Complications from Mass Effect: As a pseudoaneurysm enlarges, this "pulsatile hematoma" can exert significant pressure on adjacent structures, leading to a cascade of secondary complications ³:
  • Neuropathy: Compression of nearby nerves can cause pain, numbness, tingling (paresthesias), or even motor weakness in the affected limb.²
  • Venous Compression: Pressure on an adjacent vein can impede blood return, causing limb swelling (edema) and, in some cases, leading to the formation of a deep vein thrombosis (DVT).⁶
  • Skin Ischemia and Necrosis: The expanding mass can stretch and compromise blood supply to the overlying skin, causing it to become shiny, discolored (rubor or ecchymosis), and eventually break down (necrosis). This is a pre-rupture state and a surgical emergency.³
• Catastrophic Complications: The most feared outcomes are directly related to the pseudoaneurysm's unstable nature:
  • Rupture: Because its wall is composed of little more than fibrous tissue and clot, a pseudoaneurysm is prone to rupture, resulting in uncontrolled, life-threatening hemorrhage.²
  • Distal Embolization: The turbulent flow within the sac can promote thrombus (clot) formation. Pieces of this clot can break off, travel downstream (embolize), and block smaller arteries, leading to acute limb ischemia or the characteristic "blue toe syndrome".⁶

B. The Diagnostic Arsenal

While the physical exam is highly suggestive, definitive diagnosis and treatment planning require imaging.

1. Duplex Ultrasonography: The Gold Standard and the "Yin-Yang" Sign

For accessible pseudoaneurysms (e.g., in the groin, neck, or limbs), duplex ultrasound is the undisputed diagnostic gold standard. It is non-invasive, readily available, uses no radiation, and has a diagnostic accuracy approaching 100%.⁸ This modality combines traditional B-mode (grayscale) ultrasound, which visualizes anatomical structures, with Doppler ultrasound, which visualizes blood flow.³³ This combination produces pathognomonic findings:

• The "Yin-Yang" Sign: This is the hallmark visual sign of a pseudoaneurysm on color Doppler imaging. As blood swirls into the sac during systole and out during diastole, the ultrasound machine codes the flow toward the transducer as one color (typically red) and flow away as another (typically blue). This creates a characteristic circular, swirling pattern of red and blue within the sac that resembles the traditional yin-yang symbol. This sign is not merely a clue; it is the direct visualization of the turbulent, bidirectional flow that defines the pathology.³
• The "To-and-Fro" Waveform: When a spectral Doppler gate is placed in the narrow neck connecting the artery to the sac, it generates a unique and diagnostic waveform. A sharp, high-velocity forward flow peak is seen during systole (blood entering the sac), followed by a reversed flow component during diastole (blood exiting the sac). This classic "to-and-fro" pattern confirms the communication with the arterial system.⁴

2. Computed Tomography Angiography (CTA): Advantages and Limitations

For pseudoaneurysms located deep within the body—such as in the aorta, visceral arteries, or intracranial vessels—ultrasound cannot provide adequate visualization. In these cases, Computed Tomography Angiography (CTA) is the imaging modality of choice.³⁶

• Advantages: CTA uses rapid X-ray scanning combined with a timed injection of intravenous contrast dye to generate highly detailed, three-dimensional images of the vascular system. It provides an excellent anatomical roadmap, clearly delineating the pseudoaneurysm's size, location, relationship to branch vessels, and the condition of the surrounding anatomy. This information is invaluable for planning complex surgical or endovascular repairs.³⁶ The speed and wide availability of CT scanners make it ideal in trauma and emergency settings.³⁸
• Limitations: The primary drawbacks of CTA are its use of ionizing radiation and the need for iodinated contrast media. Radiation exposure is a cumulative risk, particularly in younger patients. The contrast agent carries a small risk of allergic reaction and can be toxic to the kidneys (contrast-induced nephropathy), especially in patients with pre-existing renal impairment.³⁶

3. MRA and Conventional Angiography: Specialized Roles

• Magnetic Resonance Angiography (MRA): MRA uses powerful magnets and radio waves to create images of blood vessels, avoiding the need for ionizing radiation. It can be a valuable alternative to CTA, especially in patients with allergies to iodinated contrast or severe kidney disease. However, MRA is generally more time-consuming, expensive, and less widely available than CTA. It is also less sensitive for detecting certain types of traumatic vascular injuries and is contraindicated in patients with pacemakers or other incompatible metallic implants.³⁷
• Conventional Angiography: This invasive procedure, which involves inserting a catheter into the artery and injecting contrast dye directly, was once the gold standard for both diagnosis and treatment planning. Today, its diagnostic role has been largely supplanted by non-invasive imaging. It is now primarily reserved for situations where an endovascular intervention (such as stenting or coiling) is planned to be performed during the same procedure.⁵ Its use carries the very risk—arterial injury and pseudoaneurysm formation—that it is often used to investigate.

The Healer's Hand: A History of Treatment and Modern Management

The treatment of pseudoaneurysms mirrors a dominant theme in 20th and 21st-century surgery: the relentless pursuit of minimalism. The therapeutic goal—to exclude the pseudoaneurysm sac from circulation and prevent rupture—has remained constant, but the methods for achieving it have evolved from maximally invasive open surgery to elegant, image-guided percutaneous techniques.

A. The Evolution of Intervention

1. Surgical Ligation and Repair: The Foundational Approach

For centuries, the only recourse for a pseudoaneurysm was open surgery.²² The surgeon would make an incision, expose the affected artery, and gain control of the vessel proximal and distal to the injury. The options then were twofold.

Ligation, or tying off the artery, was the simplest method to stop the bleeding but carried the significant risk of causing distal ischemia (inadequate blood flow) to the limb or organ.²² The preferred approach, when possible, was

primary repair or reconstruction. This could involve directly suturing the hole in the artery (arteriorrhaphy), widening the repair with a patch of vein or synthetic material (patch angioplasty), or, if the segment was too damaged, excising it and bridging the gap with a bypass graft.⁸ Today, open surgical repair remains the undisputed gold standard and definitive treatment for complex cases, such as infected pseudoaneurysms, those with overlying skin necrosis, or when minimally invasive techniques have failed.³

2. Ultrasound-Guided Compression: The First Minimally Invasive Revolution

A paradigm shift occurred in 1991 when Fellmeth and colleagues described ultrasound-guided compression repair (UGCR).¹³ This was the first widely adopted technique that could treat a pseudoaneurysm without an incision.

• Procedure: The operator uses a duplex ultrasound to visualize the pseudoaneurysm and its neck. Then, firm, direct pressure is applied with the ultrasound transducer onto the neck, with the goal of occluding flow into the sac long enough for a stable thrombus to form. Throughout the process, the operator must ensure that flow is maintained in the underlying parent artery.¹
• Limitations: While revolutionary, UGCR has significant drawbacks. The procedure often requires 30 to 60 minutes or more of continuous, forceful pressure, which can be extremely painful for the patient and physically demanding for the operator.⁴² Its success rates, reported between 71% and 99%, are notably lower in patients on anticoagulation therapy, who are precisely the patients most likely to develop iatrogenic pseudoaneurysms.¹³

3. Ultrasound-Guided Thrombin Injection (UGTI): The Modern Standard

The limitations of UGCR spurred the search for a better alternative, which arrived in the late 1990s with the advent of ultrasound-guided thrombin injection (UGTI). This technique has since become the first-line treatment for the majority of uncomplicated iatrogenic pseudoaneurysms.¹

• Procedure: The technique is elegant in its simplicity. Under continuous ultrasound visualization, a fine needle is guided into the center of the pseudoaneurysm sac. A very small amount of thrombin—a powerful enzyme that is the final catalyst in the natural clotting cascade—is then injected. The thrombin immediately converts the fibrinogen in the pooled blood into a stable fibrin clot, causing near-instantaneous thrombosis of the entire sac.¹²
• Outcomes: UGTI is remarkably effective, with success rates consistently reported between 91% and 100%, even in fully anticoagulated patients.⁴³ The procedure is very fast, often completed in under 15 minutes, and causes minimal discomfort.⁴³ The complication rate is low, around 1.5%, with the primary risks being inadvertent injection into the parent artery causing thrombosis, distal embolization of clot, or a rare allergic reaction to the bovine-derived thrombin.⁴⁴

B. The Endovascular Frontier: Stent-Grafts and Coil Embolization

For pseudoaneurysms in anatomically challenging locations—such as the aorta, subclavian artery, or visceral vessels—where direct puncture for UGTI is unsafe and open surgery carries high morbidity, endovascular repair offers a powerful, minimally invasive solution.²⁸ These procedures are performed from within the blood vessel, typically via access from a remote artery like the femoral.

• Stent-Grafts: A stent-graft is a metal mesh tube (stent) covered with a durable, waterproof fabric. It is delivered in a collapsed state on a catheter to the site of the arterial injury. Once in position, it is expanded, effectively creating a new lining for the artery and sealing the hole that feeds the pseudoaneurysm. The pseudoaneurysm is thus "excluded" from circulation and will typically thrombose and shrink over time.²⁸
• Coil Embolization: This technique involves navigating a tiny microcatheter into the pseudoaneurysm sac itself. Once in position, soft platinum coils are deployed through the catheter, packing the sac until it is filled. The coils provide a scaffold that promotes thrombosis, occluding the pseudoaneurysm.⁴⁶ This method is particularly useful for saccular pseudoaneurysms with a narrow neck, often in visceral or intracranial locations.

C. The Modern Treatment Algorithm: A Framework for Clinical Decisions

The choice of treatment depends on a careful assessment of the pseudoaneurysm's size, location, and symptoms, as well as the overall condition of the patient.

Pseudoaneurysms in the Public Consciousness: Famous Cases and Clinical Illustrations

The story of a disease is often best understood through the stories of its patients. While documented cases of pseudoaneurysms in famous individuals are scarce, examining well-known cases of true aneurysms and related aortic pathologies provides a powerful educational tool. By contrasting these conditions, the unique nature of the pseudoaneurysm is thrown into sharp relief. Juxtaposing these historical accounts with illustrative modern clinical cases makes the abstract concepts of pathophysiology and treatment tangible and memorable.

A. Aneurysms in the Spotlight: Using Famous Cases to Explain the Difference

1. The Royal Dissection: King George II (d. 1760)

On the morning of October 25, 1760, King George II of Great Britain collapsed and died suddenly. The subsequent autopsy, performed by his physician Dr. Frank Nicholls and published by the Royal Society, is a landmark document in medical history.⁴⁹ Nicholls described finding the pericardial sac filled with a "pint of congealed blood" that had escaped from a "fissure of the aorta".⁵⁰ His detailed account is recognized as the first clear description of a fatal

aortic dissection with rupture into the pericardium.⁴⁹

• The Teaching Point: King George II's case illustrates an aortic dissection, a condition where a tear in the intima allows blood to surge between the layers of the aortic wall, creating a "false lumen." This is distinct from a pseudoaneurysm, where blood escapes outside all but the final layer of the vessel. However, a dissection can weaken the aortic wall to the point of rupture, leading to a contained pseudoaneurysm or, as in the King's case, a fatal, uncontained hemorrhage. His case provides a dramatic historical anchor for the lethality of aortic pathology.

2. The Physicist's Aneurysm: Albert Einstein (d. 1955)

For years, physicist Albert Einstein suffered from abdominal pain. In 1948, exploratory surgery revealed the cause: a large abdominal aortic aneurysm (AAA).⁵³ At the time, surgical options were limited and risky. His surgeon, Dr. Rudolph Nissen, performed a novel procedure, wrapping the aneurysm in cellophane. The idea was that the cellophane, as a foreign body, would induce an intense inflammatory and fibrotic reaction, reinforcing the weakened aortic wall and preventing rupture.⁵³ The ingenious, if crude, technique was successful for a time, granting Einstein seven more years of life. In April 1955, the aneurysm finally ruptured. Hospitalized and offered emergency surgery, the 76-year-old Einstein refused, stating, "I want to go when I want. It is tasteless to prolong life artificially. I have done my share; it is time to go".⁵⁴

• The Teaching Point: Einstein's case is the archetypal example of a true aneurysm. His aorta had slowly weakened and dilated over years, involving all three layers of the vessel wall. This slow, degenerative process contrasts sharply with the often acute, injury-induced formation of a pseudoaneurysm. The cellophane wrap was a conceptual forerunner to the modern synthetic grafts used to repair and exclude aneurysms. His story highlights the natural history of a true aneurysm and provides a poignant humanistic perspective on end-of-life decisions.

B. Illustrative Case Studies from Clinical Practice

These anonymized vignettes, synthesized from clinical reports, demonstrate how pseudoaneurysms present and are managed in the modern era.

• Case 1: The Post-Catheterization Femoral Pseudoaneurysm. A 70-year-old male with atrial fibrillation, on anticoagulation therapy, undergoes a cardiac catheterization via his right femoral artery. Six days later, he presents to his doctor complaining of a painful, throbbing swelling in his right groin, accompanied by bruising.²⁷ A duplex ultrasound is performed, which reveals a 3.5 cm pseudoaneurysm with the classic "yin-yang" sign on color Doppler and a "to-and-fro" waveform in its neck, confirming the diagnosis. Due to its size and symptoms, he is treated with ultrasound-guided thrombin injection (UGTI). A small amount of thrombin is injected into the sac, which thromboses immediately. A follow-up ultrasound the next day confirms complete and stable occlusion.¹
• Case 2: The Traumatic Femoral Pseudoaneurysm. A 27-year-old man presents to the emergency department one week after accidentally injuring his thigh with a piece of iron while working. He noticed a progressively enlarging, painful, and pulsatile mass at the injury site.⁵⁶ Fearing an imminent rupture, he is taken for urgent surgery. The surgeon finds a large hematoma and a 1.5 cm defect in the superficial femoral artery. The arterial wall is healthy and not infected, so the defect is closed with a direct suture repair. The patient has an uneventful recovery with restored distal blood flow.⁵⁶
• Case 3: The Post-Pancreatitis Visceral Pseudoaneurysm. A 50-year-old man with a history of heavy alcohol consumption presents with a multi-day history of severe abdominal pain, nausea, and vomiting.⁵⁸ A CT scan reveals signs of pancreatitis and, unexpectedly, a large, ruptured pseudoaneurysm arising from the pancreaticoduodenal artery, contained within the abdominal cavity. Given the deep location and active bleeding, he is taken for angiography. A vascular surgeon navigates a catheter to the bleeding vessel and successfully occludes the pseudoaneurysm by deploying several tiny platinum coils, stopping the hemorrhage without the need for a major open operation.⁵⁸
• Case 4: The Post-Traumatic Left Ventricular Pseudoaneurysm. A 27-year-old woman presents with symptoms of heart failure, including shortness of breath and leg swelling. Her history is notable for a severe motor vehicle accident with blunt chest trauma seven years prior.⁶⁰ An echocardiogram shows a large, abnormal outpouching on the left ventricle. A subsequent cardiac MRI confirms the diagnosis: a large left ventricular pseudoaneurysm filled with thrombus, a delayed consequence of the original trauma. She undergoes open-heart surgery, where the fragile, fibrous sac is resected and the defect in the ventricular wall is repaired with a sturdy bovine pericardial patch.⁶⁰

Conclusion: The Enduring Influence of the False Aneurysm

The pseudoaneurysm, born from the ancient observations of Galen and forged in the crucible of war and medical innovation, stands today as a testament to the dynamic nature of disease and treatment. Its story is one of profound transformation. Once an obscure and often fatal consequence of physical trauma, it has evolved into a common, manageable complication of the very interventional procedures designed to extend and improve life. This journey encapsulates a core narrative of modern medicine: progress begets new challenges, and clinical necessity drives the development of ever more elegant solutions.

The fundamental distinction between the "false" wall of a pseudoaneurysm—a fragile container of fibrous tissue and clot—and the stretched but intact wall of a "true" aneurysm remains the bedrock of its pathology. This structural inferiority dictates its clinical urgency and has guided the evolution of its management. The historical arc of treatment is a clear trajectory toward minimalism, moving from the maximal trauma of open ligation and repair to the pinpoint precision of ultrasound-guided thrombin injection and the internal scaffolding of endovascular stent-grafts.

This evolution was made possible only by a parallel revolution in diagnostics. The ability to move beyond the indirect clues of a physical examination to the direct, real-time visualization of pathophysiology with technologies like duplex ultrasound was the critical enabler. The "yin-yang" sign is more than a diagnostic curiosity; it is a symbol of this shift from inference to observation, a change that empowered clinicians to develop the targeted, image-guided therapies that now define the standard of care. The pseudoaneurysm, therefore, serves as a remarkable case study in the co-evolution of our ability to see a problem and our ability to solve it, reminding us that in medicine, every challenge is an invitation for ingenuity.

Visual Timeline of the Pseudoaneurysm

• AD 129-210: Galen of Pergamon makes the first conceptual distinction between true aneurysms (from dilatation) and false aneurysms (from trauma).¹⁵
• 1730: English medical literature describes false aneurysms from bloodletting, with walls of "extravasated blood".²⁰
• 1759: Hallowell performs the first documented arterial repair, a crucial shift from simple ligation.²¹
• 1888: Rudolph Matas introduces endoaneurysmorrhaphy, a technique for intrasaccular suture repair.²¹
• 1897: J.B. Murphy reports the first successful end-to-end arterial anastomosis, a landmark in reconstructive surgery.²¹
• 1950s: The Korean War solidifies arterial repair as the standard of care for vascular injuries, driven by rapid evacuation and antibiotics.²³
• 1980s: The proliferation of percutaneous cardiac and vascular interventions begins to significantly increase the incidence of iatrogenic pseudoaneurysms.¹⁰
• 1991: Fellmeth and colleagues describe Ultrasound-Guided Compression Repair (UGCR), the first major minimally invasive treatment.¹³
• 1997: Liau et al. and others report on the use of Ultrasound-Guided Thrombin Injection (UGTI), heralding a new, more effective standard of care.⁴³
• 2000s-Present: UGTI becomes the widespread first-line therapy for accessible pseudoaneurysms, while endovascular techniques like stent-grafting and coil embolization are refined for complex, deep-seated cases.²⁸

Citations

1. ³ Rivera, P. A., & Dattilo, J. B. (2024).
   Pseudoaneurysm. In StatPearls. StatPearls Publishing.
2. ²⁰ Viduetsky, A., Nalleballe, K., & Ginzburg, E. (2018). Venous Pseudoaneurysms: Sonographic Presentation, Differential Diagnosis, and Treatment.
   Journal of Diagnostic Medical Sonography, 34(5), 390–396.
3. ¹⁵ Al-Khayat, H., Al-Khayat, B., & Beshay, J. (2017). From Aneurysm to Subarachnoid Hemorrhage: A Historical Review.
   Stroke, 48(8), e204–e207.
4. ¹⁸ Al-Khayat, H., Al-Khayat, B., & Beshay, J. (2017).
   From Aneurysm to Subarachnoid Hemorrhage: A Historical Review. American Heart Association.
5. ¹⁹ Dobson, J. (1962). History of Aneurysms.
   Medical History, 6(3), 274–278.
6. ²¹ Freeman, N. E. (1955).
   Maintenance of Arterial Continuity. In Vascular Surgery in World War II. Office of the Surgeon General, Department of the Army.
7. ²³ Clouse, W. D. (n.d.).
   An historical tour of vascular injury management. Bohrium.
8. ²⁴ DeBakey, M. E., & Simeone, F. A. (1946).
   Acute Battle-Incurred Arterial Injuries. In Vascular Surgery in World War II. Office of the Surgeon General, Department of the Army.
9. ²¹ Freeman, N. E. (1955).
   Maintenance of Arterial Continuity. In Vascular Surgery in World War II. Office of the Surgeon General, Department of the Army.
10. ²² Feliciano, D. V. (2023).
    Control of Hemorrhage. In Trauma, 10e. McGraw Hill.
11. ¹³ Saad, N. E., Saad, W. E., Davies, M. G., Waldman, D. L., Fultz, P. J., & Rubens, D. J. (2005). Pseudoaneurysms and the role of minimally invasive techniques in their management.
    Radiographics, 25(Suppl 1), S173–S189.
12. ⁵ Sueyoshi, E., Sakamoto, I., Nakashima, K., Minami, K., & Hayashi, K. (2005). Visceral and Peripheral Arterial Pseudoaneurysms.
    American Journal of Roentgenology, 185(3), 741–749.
13. ¹⁰ Webber, G. W., Jang, J., Gustavson, S., & Olin, J. W. (2007). Contemporary management of postcatheterization pseudoaneurysms.
    Circulation, 115(20), 2666–2674.
14. ¹² UC Davis Health. (n.d.).
    Pseudoaneurysm evaluation and treatment.
15. ²⁵ Vydt, T., Lambert, M., De Vleeschauwer, P., Van den Heuvel, P., & Claeys, M. J. (2007). The recurrence of iatrogenic femoral artery pseudoaneurysm after occlusion by ultrasound-guided percutaneous thrombin injection.
    EuroIntervention, 3(1), 93–97.
16. ²⁶ Khan, S. U., Khan, M. Z., & Khan, M. U. (2021). Iatrogenic femoral pseudoaneurysm after cardiac catheterization: A case report and review of literature.
    Journal of Radiation and Oncology, 2(1), 1068.
17. ¹⁰ Webber, G. W., Jang, J., Gustavson, S., & Olin, J. W. (2007). Contemporary management of postcatheterization pseudoaneurysms.
    Circulation, 115(20), 2666–2674.
18. ³ Rivera, P. A., & Dattilo, J. B. (2024).
    Pseudoaneurysm. In StatPearls. StatPearls Publishing.
19. ¹¹ University of Michigan Health. (n.d.).
    Pseudoaneurysm and Mycotic Aneurysm.
20. ⁴ Gaillard, F. (n.d.).
    False aneurysm. Radiopaedia.org.
21. ¹¹ University of Michigan Health. (n.d.).
    Pseudoaneurysm and Mycotic Aneurysm.
22. ⁶² Nakahara, I., & Taha, M. M. (2020). Traumatic Intracranial Pseudoaneurysms.
    Neurosurgery Clinics of North America, 31(3), 343–349.
23. ⁵ Sueyoshi, E., Sakamoto, I., Nakashima, K., Minami, K., & Hayashi, K. (2005). Visceral and Peripheral Arterial Pseudoaneurysms.
    American Journal of Roentgenology, 185(3), 741–749.
24. ² Cleveland Clinic. (2022).
    Pseudoaneurysm.
25. ⁴ Gaillard, F. (n.d.).
    False aneurysm. Radiopaedia.org.
26. ² Cleveland Clinic. (2022).
    Pseudoaneurysm.
27. ²⁸ Al-Thani, H., El-Menyar, A., Asim, M., & El-Hennawy, H. (2018). Endovascular repair of a leaking aortic-arch pseudoaneurysm using graft stent combined with chimney protection to left common carotid artery: Case report and review of literature.
    International Journal of Surgery Case Reports, 49, 131–135.
28. ²⁹ Galea, N., Carerj, S., Zito, C., & Khandheria, B. K. (2012). Case 14-12: Left Ventricular Pseudoaneurysm.
    Journal of Cardiovascular Magnetic Resonance, 14(Suppl 1), P245.
29. ³⁰ Mohanty, B. D., Sahoo, D., Jagia, P., & Gulati, G. S. (2016). Left ventricular pseudoaneurysm versus aneurysm a case report with a brief review of the literature.
    Journal of the Practice of Cardiovascular Sciences, 2(2), 143–147.
30. ³¹ Iosifescu, A. G., Iosifescu, T. A., Timisescu, A. T., Antohi, E. L., & Iliescu, V. A. (2022). Left Ventricular Pseudoaneurysms Discovered Early After Acute Myocardial Infarction: The Surgical Timing Dilemma.
    Texas Heart Institute Journal, 49(6), e217793.
31. ⁷ MSK Ultrasound. (n.d.).
    Pseudoaneurysm.
32. ⁸ TeachMeSurgery. (2023).
    Pseudoaneurysm.
33. ⁶ Rivera, P. A., & Dattilo, J. B. (2024).
    Pseudoaneurysm. In StatPearls. StatPearls Publishing.
34. ³² Gurien, L. A., & Wulkan, M. L. (2018).
    Femoral Artery Aneurysm. In StatPearls. StatPearls Publishing.
35. ¹⁴ PubMed. (n.d.).
    Pseudoaneurysm.
36. ²⁷ Kwak, D. (2023).
    Groin Pain and Swelling after Cardiac Catheterization. KwakTalk.
37. ⁸ TeachMeSurgery. (2023).
    Pseudoaneurysm.
38. ³³ MedlinePlus. (n.d.).
    Duplex ultrasound.
39. ³⁴ UT Southwestern Department of Radiology. (n.d.).
    Ultrasound Protocol: Pseudoaneurysm.
40. ³⁵ Müller-Hülsbeck, S., et al. (2014). A treatment algorithm for postcatheterization pseudoaneurysms.
    JACC: Cardiovascular Interventions, 7(5), 517–526.
41. ³⁶ Number Analytics. (n.d.).
    Vascular Imaging in Pseudoaneurysm Diagnosis.
42. ³⁷ Number Analytics. (n.d.).
    Thoracic Imaging in Pseudoaneurysm Diagnosis.
43. ³⁶ Number Analytics. (n.d.).
    Vascular Imaging in Pseudoaneurysm Diagnosis.
44. ³⁸ Artemis Cardiac Care. (n.d.).
    CT Angiography: Indications, Advantages, and Disadvantages.
45. ³⁹ Satti, S. R., et al. (2019). Traumatic vertebral artery injury: a review of the screening criteria, imaging spectrum, and management.
    Polish Journal of Radiology, 84, e329–e342.
46. ⁴⁰ Saad, N. E., Saad, W. E., Davies, M. G., Waldman, D. L., Fultz, P. J., & Rubens, D. J. (2005). Pseudoaneurysms and the role of minimally invasive techniques in their management.
    Radiographics, 25(Suppl 1), S173–S189.
47. ²² Feliciano, D. V. (2023).
    Control of Hemorrhage. In Trauma, 10e. McGraw Hill.
48. ⁸ TeachMeSurgery. (2023).
    Pseudoaneurysm.
49. ⁴² Dean, S. M., Olin, J. W., Piedmonte, M., Grubb, M., & Young, J. R. (1995). Ultrasound-guided compression repair of postcatheterization pseudoaneurysms.
    Radiology, 194(2), 551–555.
50. ⁴³ Liau, C. S., Ho, F. M., Chen, M. F., & Lee, Y. T. (2000). Treatment of iatrogenic femoral artery pseudoaneurysm with percutaneous thrombin injection.
    Journal of Vascular Surgery, 31(5), 925–931.
51. ⁴⁴ Sheiman, R. G., & Brophy, D. P. (2000). Treatment of iatrogenic femoral pseudoaneurysms with percutaneous thrombin injection: experience in 54 patients.
    Radiology, 217(1), 138–142.
52. ¹ Mayo Clinic. (2022).
    Should a pseudoaneurysm always be treated?.
53. ⁴³ Sheiman, R. G., & Brophy, D. P. (2000). Treatment of iatrogenic femoral pseudoaneurysms with percutaneous thrombin injection: experience in 54 patients.
    Radiology, 217(1), 138–142.
54. ⁴⁵ Krüger, K., Zähringer, M., Söhngen, F. D., Gossmann, A., & Lackner, K. (2003). Percutaneous injection of thrombin for the treatment of pseudoaneurysms: the German multicentre registry.
    EuroIntervention, 1(1), 50–55.
55. ⁴⁶ Spatola, C., et al. (2024). Endovascular Repair of Splenic Artery Aneurysms and Pseudoaneurysms Using Stent-Grafts: A Comprehensive Review.
    Journal of Clinical Medicine, 13(10), 2802.
56. ⁴⁷ Number Analytics. (n.d.).
    Advanced Vascular Graft Pseudoaneurysm Treatment.
57. ⁶³ Liu, J., et al. (2025). Endovascular repair of a giant hepatic artery pseudoaneurysm: a case report and literature review.
    Frontiers in Medicine, 12, 1579860.
58. ⁴⁸ Patel, D. N., et al. (2018). Iatrogenic profunda femoris artery pseudoaneurysm: late presentation with successful endovascular microcoil embolisation.
    BMJ Case Reports, 2018, e228314.
59. ⁴¹ Dr. Oracle AI. (n.d.).
    Pseudoaneurysm Management.
60. ¹ Mayo Clinic. (2022).
    Should a pseudoaneurysm always be treated?.
61. ⁵¹ Smith, T. B., & Elefteriades, J. A. (2021). Revisiting the Death and Autopsy of King George II.
    AORTA (Stamford), 9(5), 196–198.
62. ⁴⁹ Dunea, G. (2020). The death of King George II.
    Hektoen International.
63. ⁵⁰ Royal Society. (2020).
    Dissecting a King.
64. ⁵² Elefteriades, J. A. (2010). On the Death of King George II in 1760: Aortic Dissection in Perspective.
    Vascular Disease Management.
65. ⁵³ Columbia Surgery. (2015).
    History of Medicine: The Ingenious Surgery that Saved the World's Smartest Man.
66. ⁵⁵ Cervantes, J. (2008). Albert Einstein and his abdominal aortic aneurysm.
    Revista de Gastroenterología de México, 73(1), 40–43.
67. ⁵⁴ Isaacson, W. (2016).
    What Killed Albert Einstein?. Not Even Past.
68. ⁶⁴ UNC Health. (2014).
    Aneurysms: The Silent Killer.
69. ⁵⁶ Dieng, K., et al. (2021). An unusual cause of femoral pseudoaneurysm.
    International Journal of Case Reports and Images, 12, 101204Z01DK2021.
70. ⁵⁷ Le, L. V. (2025).
    Femoral artery pseudoaneurysm due to penetrating trauma. Radiopaedia.org.
71. ⁵⁸ Kling, K. M., et al. (2018). Spontaneous Pancreaticoduodenal Artery Pseudoaneurysm Rupture.
    ACS Case Reviews in Surgery, 2(5).
72. ⁵⁹ Chien, C. Y., et al. (2025). Gastroduodenal artery aneurysm/pseudoaneurysm: a systematic review of reported cases.
    PeerJ, 13, e19115.
73. ⁶⁰ Khan, A. A., et al. (2024). Cardiac pseudoaneurysms: a clinical case series.
    European Heart Journal - Case Reports, 8(1), ytad696.
74. ⁶¹ Mount Sinai Health System. (2024).
    Left Ventricular Pseudoaneurysm: A Surprising Case Study.

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Works cited

1. Pseudoaneurysm: What causes it? - Mayo Clinic, accessed August 9, 2025, https://www.mayoclinic.org/tests-procedures/cardiac-catheterization/expert-answers/pseudoaneurysm/faq-20058420
2. Pseudoaneurysm: Symptoms, Causes & Treatment - Cleveland Clinic, accessed August 9, 2025, https://my.clevelandclinic.org/health/diseases/23250-pseudoaneurysm
3. Pseudoaneurysm - StatPearls - NCBI Bookshelf, accessed August 9, 2025, https://www.ncbi.nlm.nih.gov/books/NBK542244/
4. False aneurysm | Radiology Reference Article | Radiopaedia.org, accessed August 9, 2025, https://radiopaedia.org/articles/false-aneurysm
5. Visceral and Peripheral Arterial Pseudoaneurysms | AJR - American Journal of Roentgenology, accessed August 9, 2025, https://ajronline.org/doi/10.2214/ajr.185.3.01850741
6. Femoral Artery Pseudoaneurysm - StatPearls - NCBI Bookshelf, accessed August 9, 2025, https://www.ncbi.nlm.nih.gov/books/NBK493210/
7. Pseudoaneurysm - Internet Book Of MSK Ultrasound, accessed August 9, 2025, https://mskultrasound.net/pseudoaneurysm/
8. Pseudoaneurysm - TeachMeSurgery, accessed August 9, 2025, https://teachmesurgery.com/vascular/peripheral/pseudoaneurysm/
9. Aneurysm - Wikipedia, accessed August 9, 2025, https://en.wikipedia.org/wiki/Aneurysm
10. Contemporary Management of Postcatheterization Pseudoaneurysms | Circulation, accessed August 9, 2025, https://www.ahajournals.org/doi/10.1161/circulationaha.106.681973
11. Pseudoaneurysm and Mycotic Aneurysm | Frankel Cardiovascular Center | Michigan Medicine, accessed August 9, 2025, https://www.umcvc.org/conditions-treatments/pseudoaneurysm-and-mycotic-aneurysm
12. Pseudoaneurysm Evaluation and Treatment | Vascular Center | UC ..., accessed August 9, 2025, https://health.ucdavis.edu/vascular/lab/exams/pseudoaneurysm.html
13. Pseudoaneurysms of the Peripheral Arteries - PMC - PubMed Central, accessed August 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC6417897/
14. pubmed.ncbi.nlm.nih.gov, accessed August 9, 2025, https://pubmed.ncbi.nlm.nih.gov/30261523/#:~:text=Pseudoaneurysms%20(PSAs)%20are%20commonly%20known,the%20worse%20cases%2C%20can%20rupture.
15. History of Aneurysmal Spontaneous Subarachnoid Hemorrhage | Stroke, accessed August 9, 2025, https://www.ahajournals.org/doi/10.1161/strokeaha.117.017282
16. en.wikipedia.org, accessed August 9, 2025, https://en.wikipedia.org/wiki/Aneurysm#:~:text=11%20External%20links-,Etymology,aneurynein%2C%20%22to%20dilate%22.
17. Aneurysm - Etymology, Origin & Meaning, accessed August 9, 2025, https://www.etymonline.com/word/aneurysm
18. History of Aneurysmal Spontaneous Subarachnoid Hemorrhage - American Heart Association Journals, accessed August 9, 2025, https://www.ahajournals.org/doi/pdf/10.1161/strokeaha.117.017282
19. HISTORY OF ANEURYSMS - Cambridge University Press, accessed August 9, 2025, https://www.cambridge.org/core/services/aop-cambridge-core/content/view/FF3A232BAE3DDE238C5253FB1E62C3E7/S0025727300023978a.pdf/history_of_aneurysms.pdf
20. Venous Pseudoaneurysms: Sonographic Presentation, Correlation with Other Diagnostic Imaging Techniques, and Supported by the Lit, accessed August 9, 2025, https://www.sdms.org/docs/default-source/jdmspdf/pdf-of-article-venous-pseudoaneurysms-sonographic-presentation.pdf?sfvrsn=2
21. History | AMEDD Center of History & Heritage, accessed August 9, 2025, https://achh.army.mil/history/book-wwii-vascularsurgery-ch08maintenancearterialcontinuity/
22. A Brief History of Vascular Injury | Vascular Injury: Endovascular and ..., accessed August 9, 2025, https://accesssurgery.mhmedical.com/content.aspx?bookid=3334§ionid=278066328
23. An historical tour of vascular injury management - Bohrium, accessed August 9, 2025, https://www.bohrium.com/paper-details/an-historical-tour-of-vascular-injury-management/811826356470939648-11278
24. History | AMEDD Center of History & Heritage, accessed August 9, 2025, https://achh.army.mil/history/book-wwii-vascularsurgery-ch032acutebattle/
25. The recurrence of iatrogenic femoral artery pseudoaneurysm after ..., accessed August 9, 2025, https://eurointervention.pcronline.com/article/the-recurrence-of-iatrogenic-femoral-artery-pseudoaneurysm-after-occlusion-by-ultrasound-guided-percutaneous-thrombin-injection
26. Post-catheterization Common Femoral Artery Pseudoaneurysm in a Patient with a Mechanical Mitral Valve Requiring Anticoagulation: A Case Report - Journal of Radiology and Oncology, accessed August 9, 2025, https://www.radiooncologyjournal.com/articles/jro-aid1068.php
27. Pseudoaneurysm Post-Cardiac Catheterization - Kwak Talk, accessed August 9, 2025, https://kwaktalk.org/ultrasound-case-of-the-week/2023/1/19/groin-pain-and-swelling
28. Endovascular repair of a leaking aortic-arch pseudoaneurysm using graft stent combined with chimney protection to left common carotid artery: Case report and review of literature, accessed August 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC6026385/
29. The Truth Behind False Aneurysms | Society for Cardiovascular Magnetic Resonance - SCMR, accessed August 9, 2025, https://scmr.org/cases-of-scmr/number-14-12/
30. Left ventricular pseudoaneurysm versus aneurysm a diagnosis dilemma - PMC, accessed August 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC4900369/
31. Left Ventricular Pseudoaneurysms Discovered Early After Acute Myocardial Infarction: The Surgical Timing Dilemma, accessed August 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC9632371/
32. Femoral Aneurysm Repair - StatPearls - NCBI Bookshelf, accessed August 9, 2025, https://www.ncbi.nlm.nih.gov/books/NBK470329/
33. Duplex ultrasound : MedlinePlus Medical Encyclopedia, accessed August 9, 2025, https://medlineplus.gov/ency/article/003433.htm
34. UT Southwestern Department of Radiology - Ultrasound – Doppler Pseudoaneurysm Evaluation, accessed August 9, 2025, https://www.utsouthwestern.edu/education/medical-school/departments/radiology/protocols/assets/US%20Pseudoaneurysm.pdf
35. Safety and Efficacy of a Potential Treatment Algorithm by Using Manual Compression Repair and Ultrasound-Guided Thrombin Injection for the Management of Iatrogenic Femoral Artery Pseudoaneurysm in a Large Patient Cohort | Circulation: Cardiovascular Interventions, accessed August 9, 2025, https://www.ahajournals.org/doi/10.1161/circinterventions.113.000836
36. Vascular Imaging for Pseudoaneurysm - Number Analytics, accessed August 9, 2025, https://www.numberanalytics.com/blog/vascular-imaging-pseudoaneurysm-diagnosis
37. Thoracic Imaging for Pseudoaneurysm Diagnosis - Number Analytics, accessed August 9, 2025, https://www.numberanalytics.com/blog/thoracic-imaging-pseudoaneurysm-diagnosis
38. Advantages and Disadvantages of CT Angiography | Artemis Cardiac Care, accessed August 9, 2025, https://artemiscardiac.com/blog/ct-angiography-indications-advantages-and-disadvantages
39. Traumatic vertebral artery injury: a review of the screening criteria, imaging spectrum, mimics, and pitfalls - Polish Journal of Radiology, accessed August 9, 2025, https://www.polradiol.com/Traumatic-vertebral-artery-injury-a-review-of-the-screening-criteria-imaging-spectrum,109122,0,2.html
40. Pseudoaneurysms and the role of minimally invasive techniques in their management - PubMed, accessed August 9, 2025, https://pubmed.ncbi.nlm.nih.gov/16227490/
41. What is the management approach for pseudoaneurysm? - Dr.Oracle, accessed August 9, 2025, https://www.droracle.ai/articles/203775/pseudoaneurysm-management
42. Postangiographic femoral artery pseudoaneurysms: further ..., accessed August 9, 2025, https://pubs.rsna.org/doi/10.1148/radiology.194.2.7824703
43. Percutaneous Injection of Thrombin for the Treatment of ..., accessed August 9, 2025, https://ajronline.org/doi/10.2214/ajr.175.4.1751035
44. Ultrasound-Guided Thrombin Injection for the Treatment of Postcatheterization Pseudoaneurysms | Circulation - American Heart Association Journals, accessed August 9, 2025, https://www.ahajournals.org/doi/10.1161/01.cir.102.19.2391
45. Percutaneous injection of thrombin for the treatment of pseudoaneurysms: the German multicentre registry | EuroIntervention, accessed August 9, 2025, https://eurointervention.pcronline.com/article/percutaneous-injection-of-thrombin-for-the-treatment-of-pseudoaneurysms-the-german-multicentre-registry
46. Endovascular Stent-Graft Repair of True and False Aneurysms of the Splenic Artery - MDPI, accessed August 9, 2025, https://www.mdpi.com/2077-0383/13/10/2802
47. Advanced Vascular Graft Pseudoaneurysm Treatment - Number Analytics, accessed August 9, 2025, https://www.numberanalytics.com/blog/advanced-vascular-graft-pseudoaneurysm-treatment
48. Iatrogenic profunda femoris artery pseudoaneurysm: late presentation with successful endovascular microcoil embolisation | BMJ Case Reports, accessed August 9, 2025, https://casereports.bmj.com/content/11/1/e228314
49. The death of King George II - Hektoen International, accessed August 9, 2025, https://hekint.org/2020/03/10/the-death-of-king-george-ii/
50. Dissecting a King | Royal Society, accessed August 9, 2025, https://royalsociety.org/blog/2020/02/dissecting-a-king/
51. Revisiting the Death and Autopsy of King George II - PMC, accessed August 9, 2025, https://pmc.ncbi.nlm.nih.gov/articles/PMC8654515/
52. On the Death of King George II in 1760: Aortic Dissection in Perspective, accessed August 9, 2025, https://www.hmpgloballearningnetwork.com/site/vdm/content/death-king-george-ii-1760-aortic-dissection-perspective
53. History of Medicine: The Ingenious Surgery that Saved the World's Smartest