Nonsurgical closure of femoral pseudoaneurysms complicating cardiac catheterization and percutaneous transluminal coronary angioplasty

The Role of Anticoagulants and Platelet Aggregation Inhibitors in the Treatment of Pseudoaneurysms and Risk of Venous Thrombosis

Pseudoaneurysms (PSA) are one of the most common complications after arterial punctures. This retrospective study examined whether platelet aggregation inhibitors (APT) or anticoagulants (AC) lower the success rates of PSA treatment. A total of 468 patients with PSA were retrospectively analyzed between 2010 and 2018, and 238 were included in the study. Despite co-medication with APT or AC, thrombin injection (TI) was superior to compression bandage (CB) therapy in treating PSA (TIwAC 79 vs CBwAC 51%; P = .004 and TIwAPT 93 vs CBwAPT 54%; P = .001). There was no decrease in PSA-associated thrombosis in patients requiring anticoagulation after TI. The success rates of the TI and CB groups were compared in patients with and without AC therapy, and the latter was significantly lower. A reduced success rate was not observed in CB therapy patients requiring APT. In contrast, better results were seen in the TI group. Regarding PSA treatment, TI therapy is significantly superior to CB, including in patients requiring concomitant AC or APT therapy. PSA-associated thrombosis also occurs in patients requiring anticoagulation, and sonography should be performed. Concomitant medication use with APT does not significantly influence PSA therapy success or prevention of PSA-associated thrombosis.

To Explore the Haemostatic Effect of Compression Haemostasis Using an Ultrasonic Probe under the Guidance of Ultrasound after Radial Artery Puncture

OBJECTIVE

To evaluate a new haemostasis method using an ultrasound probe to compress the radial artery and haemostasis under direct vision to replace traditional manual compression of the radial artery.

METHODS

According to a random number table, 240 patients with gastrointestinal tumours who had undergone arterial puncture were divided into Group A (120 cases) and Group B (120 cases). In Group A, patients were under the guidance of ultrasound to confirm the vascular port, determine the compression position of the ultrasound probe, observe the degree of vascular deformation, and press the radial artery puncture port with pressure to stop bleeding under direct vision. In Group B, traditional manual compression was used. All patients received 5 min of compression for haemostasis, and haemostasis conditions were recorded after compression and 24 hours postoperatively.

RESULTS

The incidence of bleeding, haematoma, and skin ecchymosis at the puncture site after 5 minutes of compression in Group A was lower than that in Group B (P < 0.05). No significant difference was found between the two groups at 24 hours after the operation (P > 0.05).

CONCLUSION

The method using an ultrasound probe to guide radial artery compression to haemostasis is better than traditional manual compression when applied for compression haemostasis after removing the radial artery catheter.

High incidence of deep vein thrombosis during the treatment of pseudoaneurysms - a retrospective nonrandomized study

Background: Pseudoaneurysms (PSAs) are concerning complications after arterial invasive interventions. Therapeutic options include manual ultrasound-assisted compression, pressure dressings, surgical intervention and thrombin injection. Compression of neighboring veins is obvious. However, the incidence of deep vein thrombosis (DVT) in patients with PSA has not previously been investigated. Patients and methods: In this retrospective, nonrandomized study 238 patients with PSA were analyzed from 2013 to 2018. In 149 patients, all of the parameters were complete for participating. PSAs were treated according to the local standard therapy with either ultrasound-guided compression followed by compression bandage or thrombin injection. Treatment success was evaluated 24 hours later, and the venous system was examined for the presence of DVT. Results: Peripheral DVT was found in 25.4% patients after ultrasound-assisted compression and subsequent pressure bandages, but only 6.4% of patients had DVT after thrombin injection (p = 0.013). Lower leg veins, particularly veins of the crural muscles, were primarily affected. Significantly more PSAs were successfully treated without the occurrence of DVT in the thrombin injection group compared to the compression group (93.6 vs. 69.0%; p = 0.001). Conclusions: Our study revealed that the use of thrombin injections resulted in a significantly lower rate of postinterventional DVT and a higher total number of successfully treated PSAs compared to compression therapy.

Das moderne befund- und patientenadaptierte Management von peripheren Pseudoaneurysmen nach arteriellem Zugang

Pseudoaneurysmen (PSA) zählen zusammen mit den Hämatomen zu den häufigsten Komplikationen nach kathetergestützten Eingriffen.

Ziel und Methode Die narrative kompakte Kurzübersicht umreißt sowohl die Entstehung und Charakteristika von Pseudoaneurysmen sowie die Optionen der Diagnostik und Therapie als auch deren mögliche Komplikationen.

Ergebnisse Ätiopathogenese: Durch den nicht verschlossenen Stichkanal der Punktion kommt es zum kontinuierlichen Blutausstrom aus dem Gefäß, der im umliegenden Gewebe eine Pseudoaneurysmahöhle formt. Diese wird nicht wie beim wahren Aneurysma durch eine Gefäßwand begrenzt, sondern nur durch die umliegenden Gewebestrukturen eingedämmt. Dies ist aber meist nicht suffizient und es kommt zu einer raschen Ausbreitung und diffusen Einblutungen. Dadurch können umliegende Strukturen wie Nerven und Venen durch das expandierende Pseudoaneurysma komprimiert werden, woraus sich irreversible Schäden entwickeln können. Diagnostik: Die Duplexsonografie steht dominierend absolut im Vordergrund. Die CT-A, MR-A und DSA bleiben speziellen Fragestellungen oder klinischen Fallkonstellationen (z. B. Begleiterkrankungen etc.) vorbehalten – eine DSA ist stets mit Interventionsbereitschaft zu verbinden. Therapie: Mit der manuellen Kompression und der darauffolgenden Anlage eines Druckverbandes, einer ultraschallgestützten Kompression, der Thrombininjektion und der operativen Sanierung stehen mehrere Verfahren zur Auswahl. Die ultraschallgestützte Kompression sollte dabei immer sofort eingesetzt werden, da sie höchst effizient und ubiquitär verfügbar ist. Additiv zur Kompression kann die Thrombininjektion bei PSA ohne Nerven-/Gewebeirritation mit eingesetzt werden und bietet noch bessere Verschlussraten, ist jedoch anspruchsvoller in der Anwendung. Die operative Ausschaltung ist die effektivste Methode, bietet aber neben dem größten Aufwand die meisten Begleitkomplikationen wie Wundheilungsstörung bei mazeriertem Gewebe und den längsten Krankenhausaufenthalt. Alternative Verfahren zu den genannten haben sich bisher nicht durchsetzen können.

Schlussfolgerung Das diagnostische und therapeutische Management von Pseudoaneurysmen stellt eine Herausforderung im interdisziplinären befund- und patientenadaptierten Vorgehen dar, das den erfahren Gefäßmediziner erfordert.

Pseudoaneurysm

Pseudoaneurysms (PSAs) are commonly known as complications associated with invasive interventions. Because of the pulsatile in- and outflow of blood through the neck of PSAs, they tend to grow and, in the worse cases, can rupture. Therapeutic options are compression therapy, using a compression bandage and ultrasound-guided compression, and thrombin injection. Manual ultrasound-guided compression is widely performed and is successful in most cases. In general, it is combined with a subsequently applied compression bandage. Thrombin injection is a more difficult technique, but it has a higher success rate. This article gives an overview of the characteristics of PSAs, their diagnostic characteristics and the therapeutic methods used to treat them. Complications associated with compression or thrombin injection are also explained in detail.

Obliteration of femoral artery pseudoaneurysm by thrombin injection

BACKGROUND

Femoral artery pseudyoaneurysms are a common complication after femoral access for transcatheter procedures, frequently requiring operative repair. We review the safety and efficacy of a novel nonsurgical method of pseudoaneurysm treatment

METHODS

From June 1998 to November 2001, a total of 47 femoral artery pseudoaneurysms in 46 patients were treated by bedside ultrasound-guided injection of dilute topical thrombin. All pseudoaneurysms occurred after femoral access for transcatheter procedures, and were diagnosed clinically and confirmed with ultrasound imaging. Clinical follow-up was performed and included ultrasound (2 hours to 1 month) in 64.4% of patients, including any patient with a symptomatic or clinical change.

RESULTS

Pseudoaneurysms ranged in size from 1.5 to 4.5 cm. Of 47 pseudoaneurysms, 45 were successfully obliterated on the initial injection. After successful obliteration of pseudoaneurysm, 1 patient sustained thrombosis of the tibioperoneal trunk that required surgical embolectomy, yielding a complication rate of 2%. Four pseudoaneurysms recurred after initially successful obliteration. In 1 of these cases, the patient was taken directly to surgery, and 3 were successfully treated with repeat injection, for an overall success rate of 93.6%.

CONCLUSIONS

Obliteration of femoral artery pseudoaneurysm by injection is safe and effective, and may be associated with decreased morbidity. Recurrent pseudoaneurysms may be safely reinjected, with a high success rate.

Pseudoaneurysms

Vascular complications that are the result of invasive diagnostic or therapeutic procedures requiring arterial access occur frequently. A common complication, pseudoaneurysm, has significant risk of expansion, extrinsic compression on native arteries, rupture, embolization, and infection. A pseudoaneurysm represents a persistent defect in the walls of the artery, resulting in extravasation of blood outside of the artery. This extravascular blood is confined to the surrounding soft tissues. Clinical suspicion and duplex ultrasonography are the primary diagnostic modalities. There are several options for treatment of pseudoaneurysms, including surgical repair and ultrasound-guided compression. However, a new therapeutic option, ultrasound-guided thrombin injection, has become the treatment of choice for pseudoaneurysms. This procedure is highly effective, rapid, and very safe. Using direct, real-time visualization of the pseudoaneurysm, a needle is inserted percutaneously into the pseudoaneurysm sac, and a small amount of dilute bovine thrombin is injected. Thrombosis of the sac is rapidly evident. Rare complications include thromboembolism into the native artery and hypersensitivity reaction to bovine thrombin.

Efficacy and safety of percutaneous treatment of iatrogenic femoral artery pseudoaneurysm by biodegradable collagen injection

OBJECTIVES; The goal of this study was to assess the safety and efficacy of femoral artery pseudoaneurysm (FAP) closure by collagen injection. BACKGROUND; The FAP is an infrequent but troublesome complication after percutaneous transfemoral catheter procedures. If ultrasound-guided compression repair (UGCR) fails, vascular surgery is indicated. We have developed a less invasive method to close FAPs percutaneously by injecting collagen and, thus, inducing clotting within the aneurysm.

METHODS

Via a 9F needle or 11F sheath, a biodegradable adhesive bovine collagen is injected percutaneously into the FAP, guided by angiography from the contralateral site.

RESULTS

From 1993 to 2000, compression and UGCR had failed to obliterate 110 FAPs. These patients have been treated by collagen injection. Mean age of the patients was 65.6 +/- 10.2 years (range: 32 to 85 years), and 50% were women. Immediate closure of the FAP was achieved in 107/110 patients (97.3%) without any complication or adverse effect. In one patient the collagen could not be applied due to unfavorable anatomy. One patient needed a second session of collagen injection. In one patient too much collagen was inserted, which resulted in external compression of the artery, and surgical intervention was required. The overall success rate was 108/110 (98%, 95% confidence interval: 93.5% to 99.8%). Among the patients with successful procedures, there were no recurrences during six months follow-up.

CONCLUSIONS

The percutaneous treatment of iatrogenic FAP, by injection with collagen, is an effective and safe strategy. This method provides an excellent therapeutic alternative to the traditional surgical management.

Postcatheterization pseudoaneurysms: new developments in the diagnosis and treatment with ultrasound

Postcatheterization pseudoaneurysms are an increasingly common complication of endovascular procedures. Ultrasound (US) is essential in diagnosis and in playing the key role in the noninvasive treatment of such pseudoaneurysms. The past decade has seen a shift from surgical management to US-guided therapy initially using manual compression. Recently, the minimally invasive technique of percutaneous thrombin injection has been described as an alternative to US-guided compression. This review article discusses the cause and natural history of pseudoaneurysms and describes the technique of US-guided thrombin injection.

Postinterventional transcutaneous suture of femoral artery access sites in patients with peripheral arterial occlusive disease: a study of 930 patients

The purpose of this study was to evaluate a percutaneous vascular suture (PVS) device in patients with peripheral arterial occlusive disease (PAOD) for achievement of immediate hemostasis at the vascular access site and early ambulation of fully anticoagulated patients after peripheral interventional procedures. From June 1995 to March 2000, a vascular suture using a PVS device (6-10 Fr) was applied in 930 patients with PAOD. All patients had received an endoluminal intervention in the pelvic and/or the contralateral femoropopliteal region via a retrograde access through the common femoral artery (CFA). The incidence of complications within 12 hr after intervention, prior to discharge, and at 30-day follow-up was assessed employing clinical examination, treadmill test, and color Doppler ultrasound and the safety of the PVS device was determined. The efficacy of the system was measured by the percentage of achieved immediate hemostasis and early ambulation. PVS was technically successful in 92.2% independently from the degree of calcification at the access site. In 7.8%, an appropriate suture delivery could not be performed and these patients were successfully treated by conventional compression technique. Device malfunction or insufficient suture closure occurred in 1.7% and 2.1%, respectively. In 7.0%, groin-related complications occurred. Ambulation within 2-4 hr after successful suture was possible in 96.1%. All patients were free of any local symptoms at 30-day follow-up. The PVS device provides a safe and effective solution to achieve immediate hemostasis, thus permitting early ambulation in fully anticoagulated patients with PAOD after peripheral interventional procedures.

The Efficacy of Ultrasound-guided Compression of Iatrogenic Femoral Pseudo-aneurysms

OBJECTIVE

to evaluate ultrasound guided compression (UGC) for the treatment of iatrogenic femoral pseudoaneurysms (PA).

DESIGN

retrospective follow-up of 130 patients with suspected PA referred from the cardiac catheterisation laboratory over a 36-month period.

RESULTS

the overall incidence of PA was 0.5% and was significantly higher after therapeutic (1.5%) than diagnostic (0.3%) procedures (p <0.000001). Forty-eight patients with a PA were treated with UGC with an 88% success rate. Success did not appear to be related to PA diameter.

CONCLUSION

the efficacy of UGC as treatment of PAs is confirmed.

Treatment of postinterventional pseudoaneurysms by ultrasound-guided compression

RATIONALE AND OBJECTIVES

This 3-year study was performed to evaluate the effectiveness and safety of ultrasound-guided compression (UGC) in the treatment of postinterventional pseudoaneurysms (PAs).

METHODS

One hundred ten PAs were sonographically diagnosed after peripheral or cardiac interventions. In 98 patients (65 men and 33 women; age range, 44-79 years), UGC was performed. The PAs were related to the common femoral artery (n = 78), the superficial femoral artery (n = 26), the profound femoral artery (n = 2), and the distal external iliac artery (n = 4). The PAs showed diameters ranging from 0.8 to 9.86 cm (mean, 4.8 cm) and volumes between 0.6 and 109 mL (mean, 15.6 mL). Follow-up examinations including color Doppler-coded ultrasound and peripheral Doppler were performed after 18 hours +/-6 and 28 days +/-4.

RESULTS

Complete closure of the PA and its neck was achieved by UGC in 96 of 98 cases (98%). In 86 of 98 cases (87.8%), UGC was successful during the first session; a second treatment was needed in 10 cases. The compression time varied from 12 to 85 minutes (mean, 35.6 minutes). Except for medically controllable vagal reactions in 4 of 98 cases (4.1%) and 1 easily controlled PA rupture, no treatment-related complications were observed.

CONCLUSIONS

According to the effectiveness and safety results, we conclude that UCG is the method of choice in the treatment of postinterventional PAs. Diagnosis and UGC treatment should be performed as early as possible to minimize symptoms and hospitalization time.

Postcatheterization pseudoaneurysms and arteriovenous fistulas: repair with percutaneous implantation of endovascular covered stents

PURPOSE

To assess the effectiveness and safety of endovascular covered stents in the management of pseudoaneurysms and arteriovenous fistulas after cardiac and vascular catheterization.

MATERIALS AND METHODS

Twenty-six endovascular covered stents were used to repair 16 pseudoaneurysms, nine arteriovenous fistulas, and one combined lesion after femoral arterial puncture for diagnostic coronary angiography and/or angioplasty. Fistulas and aneurysms were in the superficial femoral artery in 16 cases, in the deep femoral artery in six cases, and in the common femoral artery in four cases. Implantation was performed from the opposite femoral artery in most cases. It was not possible to treat three additional cases transcutaneously for technical reasons (three of 29 cases).

RESULTS

Percutaneous closure of the lesions with an endovascular covered stent was successful in 26 of 29 cases. Initial follow-up showed good stent patency. Two major complications were observed after stent implantation. During follow-up (about 1 year in 23 of 26 patients [88%]), stent thromboses were detected in four of 23 patients (17%) with follow-up color duplex flow imaging.

CONCLUSION

Implantation of endovascular covered stents is an effective and safe method for the percutaneous closure of pseudoaneurysms and arteriovenous fistulas. Thus, endoluminal vascular repair with covered stents offers an alternative therapeutic approach to vascular surgery in selected patients.

Thrombin injection versus compression of femoral artery pseudoaneurysms

OBJECTIVE

The compression of femoral artery pseudoaneurysms is a time consuming, painful, and sometimes unsuccessful procedure. Thrombin injection has been advocated as a superior alternative. In this study, we compare our experiences with both techniques.

METHODS

All the records of femoral artery false aneurysms that were treated in the vascular laboratory from January 1996 to April 1999 were retrospectively reviewed. Treatment with ultrasound scan-guided compression was compared with treatment with dilute thrombin injection (100 U/mL).

RESULTS

Both groups had similar demographics and aneurysm sizes (P >.2). Of the pseudoaneursyms, 88% were caused by cardiac catheterization and the others were the results of femoral artery access for cardiac surgery (6%), arteriography (5%), and renal dialysis (1%). Compression was successful in 25 of 40 patients (63%). Nine persistent aneurysms necessitated operation, and six were treated successfully with thrombin injection. Primary thrombin injection successfully obliterated 21 pseudoaneurysms in 23 patients. Overall, 27 of 29 pseudoaneurysms were treated successfully with thrombin injection (93%). Thrombosis occurred within seconds of the thrombin injection and required, on average, 300 units of thrombin (100 to 600 units). The patients who underwent successful compression required an average of 37 minutes of compression (range, 5 to 70 minutes) and required analgesia on several occasions. No patients in the thrombin group required analgesia or sedation. Neither group had complications. A cost analysis shows that thrombin treatment results in considerable savings in vascular laboratory resource use but not in overall hospital expenditures.

CONCLUSION

Ultrasound scan-guided thrombin injection is a safe, fast, and painless procedure that completely obliterates femoral artery pseudoaneurysms. The shift from compressive therapy to thrombin injection reduces vascular laboratory use and is less expensive, although it does not significantly impact hospital costs.

[Peripheral arterial complications after heart catheterization]

After diagnostic and interventional cardiac catheterization, local vascular complications at the arterial entry site must be expected. With respect to the method applied for catheterization and the puncture site, the type of complications may vary. With transfemoral approach a large variety of vascular complications have to be feared, mostly in the form of bleeding complications and hematomas, arterial dissections or occlusions, pseudoaneurysms and AV-fistulas. Each of these complications may have the potential for serious morbidity. When cardiac catheterization is performed via the arteries of the arm (either in the classical Sones technique by arterial cutdown to the brachial artery or by direct puncture of the brachial or radial artery) vascular occlusions will mostly occur as local vascular complications. These occlusions can often be managed conservatively or by a surgical procedure. The incidence of a vascular complication is mainly dependent on patient-related (sex, age, height, weight, arterial hypertension, diabetes, presence of peripheral vascular disease and compliance of the patient after withdrawal of the sheath) and procedure-related (arterial access site, diagnostic or interventional study, sheath size, periprocedural anticoagulation, duration of intra-arterial sheath placement, faulty puncture technique, operator skill) factors. In addition, the definition of a complication, the publication year of a certain study and the technique used for identification of complications seem to play a role for the reported incidence of peripheral vascular complications after cardiac catheterization. Currently, incidences of 0.1 to 2% for significant local vascular complications after diagnostic transfemoral catheterization are reported, after interventional transfemoral treatment 0.5 to 5% and after complex procedures using large sheath sizes with periprocedural anticoagulation (directional atherectomy, IABP, left-heart assist, valvuloplasty) up to 14%. Following transbrachial and transradial catheterization, local vascular complications at the entry site amount to 1 to 3% after diagnostic and 1 to 5% after interventional procedures. Local vascular complications may be diminished by a cautious and sensitive puncture technique with additional care in patients at higher risk for vascular complications (females, prediagnosed peripheral vascular disease, mandatory anticoagulation, necessity for large sheaths). By using smaller sized catheters and an adequate, defensive anticoagulation regimen, the rate of arterial access site complications may be reduced. Proper methods for achievement of hemostasis as well as a close and careful observation after sheath withdrawal are required.

Technical report: an alternative mechanical technique of pseudoaneurysm compression therapy

Graded manual compression therapy under ultrasound guidance has become the standard first line treatment of post-catheterization femoral pseudoaneurysms. Although effective, this treatment is often poorly tolerated by both patient and operator. We describe a new mechanical technique which has proven successful in our department, and is well tolerated by both patients and staff.

Femoral complications and bed rest duration after coronary arteriography

This randomized study using a pneumatic compression device found no significant difference in the femoral complication rate between 4 and 6 hours of bed rest after Judkin's coronary arteriography. The positive implications for the organization of an efficient service in busy tertiary centers include reduced patient discomfort, earlier ambulation and discharge, efficient staff deployment, and enhanced throughput.

Treatment of iatrogenic femoral artery pseudoaneurysm with percutaneous thrombin injection

PURPOSE

Local compression has been advocated for the treatment of femoral artery pseudoaneurysms. Although it is effective and has a high success rate, this method bears some limitations; among them are prolonged procedure time, discomfort for patients, and recurrence. As a potent thrombosis-inducing agent, thrombin has been used topically, and occasionally intravascularly, for hemostasis. Pseudoaneurysms with a narrow connecting tract to the native artery may be suitable for treatment with thrombin injection to induce intracavitary coagulation.

METHODS

Patients with pseudoaneurysms of the femoral artery were evaluated by ultrasonography. Under ultrasound guidance, an intravenous catheter was introduced percutaneously into the pseudoaneurysm, with the catheter position confirmed by contrast ultrasonography. One thousand units of thrombin dissolved in normal saline solution was then injected slowly into the pseudoaneurysm through the catheter to induce thrombosis. The patients were monitored closely for any adverse effects after thrombin injection.

RESULTS

A total of five patients with femoral artery pseudoaneurysms were treated with direct percutaneous thrombin injection under ultrasound guidance. Within seconds of thrombin injection thrombus formation was evident, and blood flow in the pseudoaneurysm soon ceased when the thrombosis extended to the connecting tract. All procedures were uneventful and successful. No recurrence was noted during follow-up periods of 1 to 28 months.

CONCLUSION

Our initial experience with the small number of patients demonstrates the simplicity, lack of morbidity, and high success rate for ultrasound-guided percutaneous thrombin injection for the treatment of femoral artery pseudoaneurysms.

Diagnosis and treatment of iatrogenic femoral artery pseudoaneurysm: a review

A pseudoaneurysm is a pulsatile hematoma that communicates with an artery through a disruption in the arterial wall. Femoral pseudoaneurysm is a common complication of invasive procedures. It occurs in 0.1% to 0.2% of diagnostic angiograms and 3.5% to 5.5% of interventional procedures. Longer procedures, large-bore catheters, anticoagulation, and a faulty lower site of puncture are associated with a higher incidence of femoral pseudoaneurysm. Pseudoaneurysms are associated with the characteristic findings of a pulsatile mass, a palpable thrill, and an audible to-and-fro murmur. The diagnosis is confirmed by imaging of the pseudoaneurysm. A femoral arterial duplex study is the diagnostic imaging modality of choice. It can show the pseudoaneurysm, the degree of clotting, the communication with the femoral artery, and the blood flow velocity pattern within the artery, the communication, and the pseudoaneurysm. Small (less than 2 cm) femoral pseudoaneurysms clot spontaneously and usually require no treatment. Larger femoral pseudoaneurysms may lead to complications including rupture and compression of the adjacent femoral vein (with resulting venous thrombosis) or of the femoral nerve. Treatment may be surgical. However, recently it has been shown that direct, noninvasive compression of the pseudoaneurysm stops the blood flow in the communication and leads to pseudoaneurysm clotting and obliteration.

Pseudoaneurysm after cardiac catheterization: therapeutic interventions and their sequelae: experience in 86 patients

After diagnostic cardiac catheterization in 8,715 patients, a pseudoaneurysm was diagnosed in 86 (1%) patients. Primary conservative management by repeated compression bandages (CB) or ultrasound guided compression (UGC) was attempted in all patients. Occlusion of the pseudoaneurysm was achieved significantly more often by UGC (41/47; 87%) than by CB (22/39; 56%; P = 0.016). Of 86 patients, 23 (27%) required surgical treatment. Major clinical acute complications occurred after surgery in 8/23 cases (35%) versus 4/63 (6%; P = 0.0004) following successful CB or UGC. However, intention-to-treat analysis showed no difference in the rate of acute complications in the CB or UGC group (15.4% versus 12.8%, P = 0.7272), because of a trend towards a higher complication rate following secondary surgery in the UGC (4/6 = 66.7%), as compared to the CB group (4/17 = 23.5%, P = 0.1589). During follow up, 22/64 (34%) patients reported persistent inguinal complaints, 9/15 (60%) after surgery and 13/49 (27%) after successful CB or UGC (P = 0.0169). However, according to the intention-to-treat analysis, there was no significant difference between the initial groups (CB: 26.1% versus UGC: 39.0%, P = 0.2958). Despite a higher effectiveness of UGC to achieve occlusion of a pseudoaneurysm compared to CB (87% vs. 56%), UGC is not superior to CB because of a higher rate of acute complications as well as long-term complaints in those patients requiring secondary surgery in the UCG group as compared to the CB group.

Closure of an iatrogenic femoral artery pseudoaneurysm by transcutaneous coil embolization

Pseudo-aneurysm following diagnostic or interventional procedures is a well-recognized complication. Ultrasound guided compression repair is routinely used to close an uncomplicated pseudo-aneurysm. We describe a patient with a femoral artery pseudo-aneurysm following iliac angioplasty and stenting in which ultrasound guided compression repair failed. Pseudoaneurysm was successfully closed by transcutaneous coil embolization technique.

Use of a pneumatic compression system (FemoStop) as a treatment option for femoral artery pseudoaneurysms after percutaneous cardiac procedures

Pseudoaneurysm (PA) formation is a well-documented complication of femoral arterial puncture in patients undergoing percutaneous cardiac procedures. Besides surgical repair, there has been success in obliterating the PAs by Duplex ultrasound guided compression (mostly those < 4.0 cm). We analyzed the use of prolonged femoral compression using a pneumatic compression system (FemoStop by USCI) in 10 patients who developed femoral PAs following an interventional cardiac procedure. All PAs were diagnosed by ultrasound and had unsuccessful duplex-guided compression. The size of the PA ranged from 2.8-4.0 cm in diameter. All patients had the FemoStop system placed over the PA with continuous pressure for 12-18 hr. PA obliteration was successful in 90% of cases as confirmed by ultrasound. The only complication observed was skin abrasion in two patients. Our results indicate that the FemoStop system is a simple and effective technique for treatment of femoral artery PAs.

Determinants of success of color-flow duplex-guided compression repair of femoral pseudoaneurysms

BACKGROUND

Ultrasonography-guided compression repair is reported to be effective therapy for femoral pseudoaneurysms that develop after catheterization procedures. This study summarizes our experience with color-flow duplex-guided repair of these lesions.

METHODS

A retrospective chart review of all patients who underwent this procedure was undertaken, with statistical analysis to identify factors associated with success.

RESULTS

Compression repair of 69 pseudoaneurysms was attempted. Pseudoaneurysms developed after therapeutic catheterization in 48 patients and after diagnostic procedures in 21. Sites of arterial puncture were the common femoral artery in 59 patients and the superficial femoral or profunda femoris arteries in 10. Diameters of the pseudoaneurysms ranged from 3 to 60 mm (mean, 28 mm). Compression was attempted at a mean of 5 days (range, 1 to 21 days) after catheterization. Compression produced complete thrombosis of the pseudoaneurysm at the initial attempt in 43 (62%) of 69 patients. With repeated attempts the ultimate success was 47 (68%) of 69. Success was achieved in 44 (75%) of 59 common femoral pseudoaneurysms but in only 3 (30%) of 10 superficial femoral or profunda femoris lesions (p = 0.009). Anticoagulation, sheath size, pseudoaneurysm chamber size, and time between catheterization and compression were not significantly different between lesions that were successfully compressed and those that were not. No ischemic or embolic complications were observed.

CONCLUSIONS

Color-flow duplex-guided compression repair can be safely attempted as the initial therapy for all uncomplicated pseudoaneurysms arising from the common femoral artery after catheterization, with the expectation of success in most.

Peripheral Artery Pseudoaneurysm: Treatment by Transcutaneous Compression Guided by Ultrasonography

Pseudoaneurysm is a well-recognized complication of invasive arterial procedures that is easily diagnosed with ultrasound. While most pseudoaneurysms will be resolved spontaneously within 3 months, some may lead to limb swelling, ischemia, thromboembolism, or nerve damage. To forestall such complications, we attempted to close the lesion using ultrasound to guide application of pressure in 13 patients with pseudoaneurysms following arterial catheterizations. Successful closure averaged 64 minutes (range 20-180) with successful results achieved in 11 (85%) of the 13 patients. No complications followed the application of either manual or device-assisted pressure. We conclude that transcutaneous compression is a generally safe and successful treatment of uncomplicated pseudoaneurysm and should be used as the treatment of choice for this lesion. (ECHOCARDIOGRAPHY, Volume 13, September 1996)

Ultrasound-guided compression repair for treatment of femoral artery pseudoaneurysm: acute and follow-up results

Femoral artery pseudoaneurysm is a significant problem in patients undergoing arterial diagnostic or therapeutic catheterization. The aim of this investigation was to report the incidence of pseudoaneurysm after arterial catheterization and the success rate of ultra-sound-guided compression repair. During a 3-year period (11/91-11/94) 9,051 patients underwent 7,312 cardiac catheterizations and 1,739 peripheral percutaneous transluminal coronary angioplasty procedures. Patients suspect of pseudoaneurysm were referred for a color Doppler ultrasound examination. All patients with pseudoaneurysm were considered for ultrasound-guided compression repair. Pseudoaneurysm occurred more frequently after interventional procedures with new devices (valvuloplasty 2.3%, stent 3.2%) than after conventional catheterization diagnostic cardiac catheterization 0.2%, electrophysiology 1.3%, percutaneous transluminal coronary angioplasty 0.2%). The incidence of pseudoaneurysm after peripheral percutaneous coronary transluminal angioplasty, including intra-arterial lysis and stent, was 1%. Ultrasound-guided compression repair was successfully performed in 37 of 41 cases with pseudoaneurysm (90%). Ultrasound-guided compression repair was successfully performed in 30 of 31 patients (97%) without anticoagulation and in 7 of 10 patients (70%) receiving anticoagulants (P < 0.05). There was no correlation between mean diameter of the pseudoaneurysm, age of the lesion, or antiplatelet therapy. Color Doppler ultrasound re-examination at up to 3 months indicated successful treatment in all patients. The use of complex interventional catheterization procedures leads to an increased frequency of pseudoaneurysms compared with conventional angiography and percutaneous transluminal coronary angioplasty. Ultrasound-guided compression repair is a non-invasive, efficient, safe and cost-effective therapy for post-catheterization pseudoaneurysm.

Color duplex-guided compression therapy for postcatheterization pseudoaneurysms in a community hospital

Diagnostic or therapeutic arterial catheterization may be complicated by postcatheterization pseudoaneurysm. Pseudoaneurysms have generally been treated surgically, but more recently, encouraging results with duplex-guided compression therapy (DGCT) of pseudoaneurysms have been reported from university hospitals. We reviewed our experience with DGCT to assess the applicability of DGCT in a community hospital setting. Sixty-two patients presented with 63 symptomatic postcatheterization pseudoaneurysms between January 1, 1990, and December 31, 1993. Prior to October 28, 1991, all pseudoaneurysms were treated surgically. Subsequently we initiated DGCT as primary treatment for pseudoaneurysms, reserving surgery for DGCT failures and unstable patients. DGCT patients were indistinguishable from primary surgery patients, and the number of pseudoaneurysms treated did not appear to increase during the study period. DGCT was initially successful in 27 (75%) of 36 patients. Three pseudoaneurysms recurred, yielding cumulative success in 24 (67%) of 36 patients. Three of 12 DGCT failures were due to patient intolerance. DGCT was unsuccessful in three of four intra-aortic balloon pump (IABP)-associated pseudoaneurysms. There was some variation in pseudoaneurysm volume between the successful and failed groups, and a trend toward failure with larger pseudoaneurysm was not significant (13 vs. 6 cm3, p > or = 0.25). DGCT failure appears more likely in post-IABP pseudoaneurysms and possibly with larger pseudoaneurysms. Anticoagulation, type of procedure (exclusive of IABP), obesity, and other patient characteristics examined did not appear to predict success or failure of DGCT. Treatment was reserved for symptomatic patients throughout the period of study and there was no evidence that patients were more likely to be treated for pseudoaneurysms after DGCT was initiated. We conclude that DGCT is usually successful and is appropriate primary treatment for all symptomatic postcatheterization pseudoaneurysms in stable patients.

Ultrasound-guided compression closure of postcatheterization pseudoaneurysms during concurrent anticoagulation: a review of seventy-seven patients

PURPOSE

Data from our institution and elsewhere have demonstrated that ultrasound-guided compression closure (UGCC) is an effective method of treating postcatheterization pseudoaneurysms. Whereas patients receiving anticoagulation do not have as high a success rate as those not receiving anticoagulants, there have been no large series evaluating the factors associated with success or failure in patients receiving anticoagulation. The purpose of this study is to determine whether uninterrupted anticoagulation interferes with successful UGCC of pseudoaneurysms and to identify factors associated with success or failure.

METHODS

From May 1991 to September 1994, 238 cases of attempted UGCC of pseudoaneurysms were performed in our vascular laboratory. Only patients who received uninterrupted heparin, warfarin, or both at the time of pseudoaneurysm compression were eligible for inclusion into the study. Seventy-seven patients were identified who met the study criteria.

RESULTS

Successful pseudoaneurysm compression was obtained in 56 (73%) patients, whereas 21 (27%) patients had a failed UGCC. In the successfully treated group, seven (12.5%) required between two to three compression attempts to induce sustained thrombosis. There was no statistical difference in age, sex, sheath size, days after procedure, location of pseudoaneurysm, or number of chambers in the pseudoaneurysm between those patients who had a successful repair and those who did not. If the pseudoaneurysm was less than 4 cm in diameter, 51 of 65 patients (78%) had a successful repair compared with 5 of 12 patients (42%) with a pseudoaneurysm of 4 cm or greater (p = 0.013). There was no statistical difference between success and failure in patients receiving warfarin alone (3.73 mean international normalized ratio, 72% success rate), heparin alone (mean activated partial thromboplastin time of 63 seconds, 92% success rate), or heparin and warfarin (mean activated partial thromboplastin time of 70 seconds, mean international normalized ratio of 4, success rate of 67%). No arterial or venous thrombosis occurred during pseudoaneurysm compression.

CONCLUSION

Successful UGCC of pseudoaneurysms occurred in a large percentage of patients receiving full-dose, uninterrupted anticoagulation. The only factor influencing success was the size of the pseudoaneurysm.

Closure of a persistent femoral artery pseudoaneurysm complicating coronary angioplasty using the femostop compression device and direct ultrasound visualization

Nonsurgical closure of femoral artery pseudoaneurysm (PSA), using ultrasound guidance and compression with the ultrasound probe or a C-clamp, has been previously described. We report a patient in whom a different compression device was used (the Femostop) which also allows direct ultrasound visualization of the PSA and femoral vessels at the site of compression. This resulted in adequate PSA with preservation of flow in both artery and vein throughout the procedure.

Peripheral vascular complications following coronary interventional procedures

We report the incidence, diagnosis, prevention, and treatment of peripheral vascular complications following coronary interventional procedures as reviewed in the English-language literature. Peripheral vascular complications include hematomas, pseudoaneurysms, arteriovenous fistulae, acute arterial occlusions, cholesterol emboli, and infections that occur with an overall incidence of 1.5-9%. Major predictors of such complications following coronary interventional procedures include advanced age, repeat percutaneous transluminal coronary angioplasty, female gender, and peripheral vascular disease. Minor predictors include level of anticoagulation, use of thrombolytic agents, elevated creatinine levels, low platelet counts, longer periods of anticoagulation, and use of increased sheath size. Ultrasound-guided compression repair of pseudoaneurysms and arteriovenous fistulae are discussed, as are newer methods of treatment such as hemostatic puncture closure devices. Anticipation and early recognition of possible peripheral vascular complications in conjunction with careful attention to the optimal activated clotting time for sheath removal following coronary interventional procedures may translate into fewer vascular complications as well as into shorter and less costly hospital stays.

Postarteriographic femoral pseudoaneurysms: treatment with ultrasound-guided compression

Pseudoaneurysms following femoral arterial catheterization are increasingly common and are related to factors such as catheter size, periprocedural anticoagulation, hypertension, and improper technique. Ultrasound-guided compression as a noninvasive technique for repair of these lesions was prospectively evaluated in 16 patients whose mean age was 61 years. Nine patients were on anticoagulants and six had hypertension. All patients presented with an enlarging groin hematoma, a pulsatile mass, and/or a bruit following femoral catheterization. Seventeen femoral artery pseudoaneurysms, including one with an associated arteriovenous fistula, were detected using color-flow Doppler imaging. Three pseudoaneurysms thrombosed spontaneously. The remaining 14 were managed with compressive therapy lasting from 20 to 100 minutes. No complications were encountered during the compressions and 10 false aneurysms (71%) responded completely (mean time to thrombosis of 38 minutes). Two lesions responded partially to compression and there were two failures, the latter associated with excessive anticoagulation in one patient and a well-established pseudoaneurysm in the second patient. Only one pseudoaneurysm (6%) in the series required surgical correction. Ultrasound-guided compression of acute pseudoaneurysms in the groin is a safe, inexpensive, and effective method of treatment.

Pseudoaneurysm of the femoral artery after cardiac catheterisation: diagnosis and treatment by manual compression guided by Doppler colour flow imaging

OBJECTIVE

To assess the value of Doppler colour flow imaging for diagnosing and guiding non-surgical treatment of pseudoaneurysm of the femoral artery complicating cardiac catheterisation.

DESIGN

A prospective study.

SETTING

Cardiac department in a teaching hospital.

PATIENTS

9 patients (8 female, 1 male) who presented with pseudoaneurysm 1-15 days after cardiac catheterisation.

INTERVENTIONS

The femoral arterial communication to the false aneurysm was localised by Doppler colour flow imaging. Manual pressure was then applied to the ultrasound transducer which was positioned directly over the site of the arterial communication. Pressure was progressively increased until it was sufficient to prevent colour flow from the artery into the false aneurysm cavity while allowing Doppler flow to continue within the arterial lumen.

MAIN OUTCOME MEASURES

Characteristics of pseudoaneurysm, duration of manual compression, success rate, follow up.

RESULTS

The pseudoaneurysms ranged from 1.3 to 5.5 cm in length. Six pseudoaneurysms were 1.3-2.0 cm away from the arterial puncture. The pseudoaneurysm was closed in 8/9 patients by compression exerted manually through the transducer for 25-40 minutes (3 successful cases required two or three periods of compression within 48 hours). No pseudoaneurysm recurred during 14-61 days of follow up.

CONCLUSIONS

Most pseudoaneurysms of the femoral artery can be treated by a period of manual pressure applied with an ultrasound transducer and guided by Doppler colour flow.

Percutaneous coil embolization of iatrogenic femoral arteriovenous fistula or pseudo-aneurysm

Five male patients aged 43-67 years (mean, 60) with four iatrogenic femoral arteriovenous fistula and two pseudo-aneurysms (1 and 4 cm in diameter) were treated by percutaneous embolization, with coils. One coil migrated during placement to the pulmonary artery without clinical symptoms. All lesions remained obliterated after a mean follow-up of 10 months on Duplex-Doppler control. External manual compression under color-coded-Doppler was tried in three patients and failed.

Management of the arterial puncture site

With more complex interventional procedures, such as intracoronary stent placement, there is a higher incidence of procedural related peripheral vascular complications including pseudoaneurysm and hemorrhage. In these procedures, the amount of anticoagulation as well as the use of thrombolytic agents intraprocedurally increases the risk of complication. Meticulous care during vascular access, careful use and monitoring of anticoagulation, and patient selection are helpful in reducing the risk. Newer vascular hemostatic devices utilizing biodegradable collagen plugs might be of advantage since they allow early sheath removal without interrupting anticoagulation and, therefore, early ambulation. However, it remains to be determined, whether these devices are effective in reducing complications, duration of bed rest and hospitalization, or improvement of stent patency. Newer designs, e.g., coated or biodegradable stents, or different deployment strategies might reduce the need of anticoagulation and lower the risk of peripheral vascular complications.

Ultrasound-guided compression repair of postcatheterization pseudoaneurysms: results of treatment in one hundred cases

PURPOSE

The purpose of this report is to describe the indications, technique, and results for ultrasound-guided compression repair (UGCR) of postcatheterization pseudoaneurysms at a large medical center in which catheter-based diagnostic and interventional procedures are frequently used.

METHODS

We reviewed the initial series of 100 consecutive patients who underwent UGCR in our noninvasive vascular laboratory from May 1991 through August 1992. Nearly all (n = 95) of these pseudoaneurysms involved the common femoral artery or its major branches, and each was manually compressed with a 5 MHz linear transducer for 10-minute intervals until the pseudoaneurysm was completely occluded or the procedure was considered to be a failure.

RESULTS

UCGR was immediately successful in 94 patients, including 30 (86%) of 35 patients who were receiving anticoagulants and 64 (98%) of the 65 who were not (p = 0.019). The average compression time to achieve occlusion was 33 minutes (range 10 to 120 minutes), but was nearly twice as long (51 minutes) for pseudoaneurysms that had been present for more than 14 days. There were no related complications, but recurrent pseudoaneurysms occurred in six (20%) of 30 patients who continued to receive formal anticoagulation, compared with only four (6%) of 64 who did not (p = 0.074). Eight of the 10 recurrences were discovered within 24 hours after primary UGCR, but two others presented at 16 and 35 days, respectively. Eight recurrent lesions were corrected by repeat UGCR, whereas the remaining two required surgical repair.

CONCLUSIONS

UGCR provides a reliable alternative to surgical treatment for postcatheterization pseudoaneurysms. Adequate follow-up is important, however, especially in patients for whom continued anticoagulation is necessary.

Clinically guided closure of femoral arterial pseudoaneurysms complicating cardiac catheterization and coronary angioplasty

Femoral artery pseudoaneurysm formation is a significant problem in patients undergoing cardiac catheterization and interventional cardiac procedures. It is especially more common with the use of anticoagulant and antiplatelet therapy and the use of intracoronary stents. We describe our initial experience with clinically guided bedside compression of femoral pseudoaneurysms in such patients. Eleven patients, 10 undergoing coronary angioplasty (including 3 with intracoronary stents) and 1 undergoing diagnostic cardiac catheterization, developed a femoral pseudoaneurysm. All patients had a femoral bruit and 9 had an expansile groin hematoma. The diagnosis was confirmed in each case by Doppler ultrasound. Seven patients were receiving heparin while 4 were on oral anticoagulants at the time of detection of the pseudoaneurysm. These patients underwent clinically guided graded external compression to close the pseudoaneurysm neck while maintaining femoral arterial flow. External compression for 104.1 +/- 63 min resulted in successful clinical resolution of pseudoaneurysm in all patients without complications. The results were confirmed by Doppler ultrasound at least 12 hr later. Bedside compression of femoral pseudoaneurysms guided by clinical clues is simple and appears to be an effective and safe technique to manage this iatrogenic problem.