[Formation, therapy and prevention of false aneurysm of the femoral artery following diagnostic and interventional heart catheterization]

Do not underestimate the femoral pseudoaneurysm

Abstract. In addition to haematoma and arteriovenous fistula, the iatrogenic pseudoaneurysm is a common complication of vascular access that is caused by a perforation in the arterial wall. Iatrogenic pseudoaneurysms can progress in size and lead to rupture and active bleeding. Over the previous few decades, therapeutic methods have evolved from surgical repair to less invasive options, such as ultrasound-guided compression therapy (UGCT) and ultrasound-guided thrombin injection (UGTI). This paper presents an overview of the diagnostic and treatment modalities used in femoral pseudoaneurysms as well as a comprehensive summary of previous studies that analysed the success and complication rates of UGCT and UGTI.

Femoral Artery Pseudoaneurysms: Risk Factors, Prevalence, and Treatment Options

Femoral artery pseudoaneurysms (PSA or false aneurysm) develop in about 1% of patients undergoing procedures that require femoral artery cannulation. PSA prolong hospitalization, consuming health-care resources, and result in significant morbidity. We designed a study to review the prevalence, risk factors, and treatment of PSA. We performed a retrospective, case-controlled study of patients diagnosed with PSA at a large, urban, tertiary-care teaching hospital. We reviewed 48 patients with PSA for our study. The estimated prevalence of PSA was 0.28%, with identical rates found for procedures done in the interventional radiology department and in the cardiac catheterization suite. Logistic regression identified three independent risk factors for developing PSA: being female (odds ratio 2.62), having an intervention performed (odds ratio 3.22), and not having a closure device used (odds ratio 10.2). Patients with PSA had longer hospital length of stay than that of patients without PSA. We found no statistically significant difference in failure or complication rates for the four treatment options and that spontaneous resolution of PSA does not correlate with its size. Thrombin injection and observation are effective, low-complication treatment options.

Thrombin injection for treatment of false aneurysms after failed compression therapy in patients on full-dose antiplatelet and heparin therapy

The aim of this study was to gauge the effectiveness of thrombin injection after failed manual compression in patients with false aneurysms receiving full-dose antiplatelet and heparin therapy. In consecutive patients with failed manual compression therapy (ultrasound-guided manual compression, compression bandage, or both), thrombin was injected under ultrasound guidance. In 23 patients, thrombin was injected into the false aneurysm (100-2,000 units; mean, 895 +/- 520 units). All patients were on aspirin (median dose, 100 mg/day), clopidogrel (median dose, 75 mg/day), and either heparin (n = 3) with a partial thromboplastin time (PTT) > 55 sec or weight-adjusted enoxaparine (0.1 ml per 10 kg; maximum, 1 ml/b.i.d.). Twelve patients had received an i.v. GB IIIb/IIa antagonist 11-72 hr prior to diagnosis of the aneurysm. The mean width of the false aneurysms was 20.8 +/- 3.2 mm (range, 8.0-52.0 mm), length 29.7 +/- 32.6 mm (range, 9.0-147 mm), and depth 19 +/- 9.1 mm (range, 5.1-35.5 mm). Thrombosis after thrombin injection occurred in 21 patients within seconds. One patient required a second injection the next day, one patient underwent surgery. Overall success rate was 96%. No in-hospital complications occurred. In patients with false aneurysms and failed compression therapy under full-dose aspirin, clopidogrel, and heparin, selective thrombin injection is highly effective and safe.

Ipsilateral femoral vein compression: a contraindication to thrombin injection of femoral pseudoaneurysms

Development of a femoral artery pseudoaneurysm occurs in 0.6% to 3.2% of interventional procedures. Nonsurgical treatment has consisted of ultrasound scan-directed compression and, more recently, direct thrombin injection into the pseudoaneurysm cavity to achieve thrombosis. Reported complications after thrombin injection are rare. We report two cases of femoral venous compression associated with pseudoaneurysm injection and review the literature. A 76-year-old man and an 86-year-old man both underwent thrombin injection of pseudoaneurysms compressing the ipsilateral common femoral vein. Both patients were diagnosed with deep venous thrombosis and subsequently needed surgical exploration for repair of the pseudoaneurysm and release of the venous compression. At exploration, both were found to have significant inflammation surrounding the femoral vessels, which made vessel exposure challenging. Because of the venous outflow obstruction involved in femoral pseudoaneurysms with secondary venous compression and the surgical difficulty caused by surrounding inflammation, avoidance of thrombin injection in favor of early surgical intervention is suggested.

Treatment of postcatheterisation false aneurysms: ultrasound-guided compression vs ultrasound-guided thrombin injection

OBJECTIVES

to compare the efficacy and cost-effectiveness of ultrasound-guided compression (UGC) with ultrasound-guided thrombin injection (UGTI) for treatment of postcatheterisation arterial false aneurysms (cFA).

DESIGN

prospective clinical study using historical controls.

MATERIALS AND METHODS

we prospectively collected data on 33 consecutive patients diagnosed with cFA larger than 1.5 cm in diameter. These were treated with UGTI. We performed a retrospective review of data on a former group of 33 consecutive historical control patients that were treated by UGC.

RESULTS

the groups were similar in respect of demographic and clinical variables. Thirty patients were suitable for UGC and 33 patients were suitable for UGTI. The success rate for UGC was 26/30 (87%) compared to 33/33 (100%) for UGTI (p<0.05). Thrombosis was achieved during the first treatment session in 7/26 patients treated by UGC, compared to 26/33 in the UGTI group (p<0.0001). Four patients that failed UGC and two patients that were unsuitable for UGC required surgical repair. UGTI as compared to UGC was shorter in duration (25 vs 75 min) and required no sedation. No thromboembolic or systemic complications occurred in either group. Cost analysis revealed savings of $US 517 for each patient treated by UGTI as compared with UGC.

CONCLUSIONS

in our study, UGTI is superior to UGC, and we suggest that UGTI should become the procedure of choice for the treatment of cFA.

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.

Percutaneous duplex-guided thrombin injection for treatment of iatrogenic femoral artery pseudoaneurysms

OBJECTIVES

to evaluate the feasibility of treatment of post-catheterisation pseudoaneurysms with duplex-guided thrombin injection.

TECHNIQUE

the technique of duplex-guided injection of thrombin in post-catheterisation pseudoaneurysms of the femoral artery is described and illustrated.

RESULTS

between December 1998 and October 1999, eight post-catheterisation pseudoaneurysms of the femoral artery were successfully thrombosed with thrombin injection. One patient developed a new pseudoaneurysm within 6 hours and this was also successfully treated with thrombin. Follow-up duplex-scanning at 3 months revealed no recurrences. No other adverse events occurred.

CONCLUSIONS

this initial experience suggests that duplex-guided thrombin injection in the treatment of post-catheterisation pseudo-aneurysms is feasible and safe.

Percutaneous induced thrombosis of iatrogenic femoral pseudoaneurysms following catheterization

Femoral pseudoaneurysms are one of the common iatrogenic complications following catheterization procedures done via the femoral approach. Their treatment has evolved over the last decade from operative repair to ultrasound-guided compression (USGC) and more recently to thrombin injection of the pseudoaneurysm. We report our experience with that technique and compare the results of thromboobliteration to those of the compression method. All consecutive iatrogenic femoral pseudoaneurysms diagnosed in the vascular laboratory of two large community hospitals were referred for the study. Under ultrasound guidance, percutaneous thromboobliteration (PTO) of the pseudoaneurysms was done by injecting thrombin solution (500-unit increments) into the pseudoaneurysm. Time to thrombosis, dose of thrombin, patient's discomfort, and ease of procedure were recorded and analyzed. Comparison with results of USGC reported in the literature was made. Percutaneous thromboobliteration may be a simple and very effective treatment of femoral pseudoaneurysms. The high success rate, ease of procedure, and cost benefit over USGC are noteworthy. A larger trial is currently under way. If results are duplicated, PTO will emerge as the preferred treatment for iatrogenic femoral pseudoaneurysms.

[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.