Color duplex sonographically guided obliteration of pseudoaneurysm

Ultrasound-Guided Compression Repair of Catheter-Related Femoral Artery Pseudoaneurysms is Impaired by Anticoagulation

Ultrasound-guided compression repair (UGCR) of catheter-related femoral artery pseudo aneurysms (CFAP) was retrospectively reviewed. Variables including etiology, size, location, age of pseudoaneurysm, depth and length of neck, coagulation status, number of attempts at compression, and total time of compression were studied. Five of 15 pseudoaneurysms were successfully occluded by use of UGCR. Reasons for failure included compression without occlusion (7), inability to arrest flow in the pseudoaneu rysm during compression (2), and inability of the patient to tolerate compression (1). Two patients who had pseudoaneurysms that we were unable to occlude on initial compression thrombosed their pseudoaneurysms spontaneously on follow-up examina tion. No patient (0/9) who was anticoagulated at the time of compression had a successful occlusion. All five patients with a normal coagulation profile at the time of compression were successfully occluded. One of these pseudoaneurysms recurred, however, after heparin was resumed. Size of pseudoaneurysm, depth or length of neck, time to presentation, or total time of compression did not predict success of UGCR. There were no complications in our series. UGCR is a safe, cost-effective treatment for patients with catheter-related femoral pseudoaneurysms and a normal coagulation profile.

Integration and added value of the modern noninvasive vascular laboratory in vascular diseases management

BACKGROUND AND PURPOSE

Today's vascular laboratory technology offers broad applications throughout vascular medicine. We explore the diagnostic work-up and management of selected peripheral vascular diseases by benchmarking the institutional mix of invasive and noninvasive technology utilization and associated cost burdens.

METHODS

Specialized diagnostic studies for prevention of stroke and pulmonary embolism, and diagnosis and management of femoral pseudoaneurysm were reviewed for our 355-physician clinic and hospital practice. The proportions and costs for invasive and noninvasive diagnostic procedures were tabulated for carotid stenosis, deep venous thrombosis (DVT), and iatrogenic femoral pseudoaneurysm. Current technology utilization mix cost burdens were compared to projected cost burdens for hypothetical equivalent medical value (i.e., the same total test volume) in the theoretical absence of noninvasive laboratory services.

RESULTS

The technology utilization mix was dominated by noninvasive duplex ultrasonography for all 3 vascular disease workups. The technology utilization mix benchmarks were 92% noninvasive for carotid stenosis, 98% noninvasive for DVT, and 100% noninvasive for pseudoaneurysm. Under hypothetical constant test volume normalized to utilization level for the 2-year period, the maximal range in cost burdens between current reliance on noninvasive diagnoses versus projected 100% reliance on invasive procedures for the 3 vascular applications is approximately $6 million.

CONCLUSION

Benchmark indices reveal near total adoption of noninvasive technology for vascular diagnostic workups at our center. The benefits to institutions of benchmarking their technology utilization mix and costs are discussed in relation to identifying potential for cost-containment from modifying technology utilization practices.

Peripheral arterial pseudoaneurysm treated by ultrasound-guided compression

Ultrasound-guided compression repair of a pseudoaneurysm is a simple, safe and effective therapy, and has been proposed as a first-line treatment for pseudoaneurysms caused by catheterization. Herein, we report a case of a pseudoaneurysm arising from a sport injury which was treated by this method. Obliteration of the track of the pseudoaneurysm induced manual thrombosis and successfully converted the pseudoaneurysm to haematoma. Understanding the mechanism and the procedure is the basis of success in the use of this treatment.

Pseudoaneurysm

Percutaneous large core needle biopsy of the breast is recognized as an important tool in the current management of breast disease. Ths technique is safe, accurate, and has a very low complication rate. We present a rare complication of a pseudoaneurysm after large core needle biopsy of the breast, diagnosed by means of ultrasound and color Doppler exam-inatin. Pathophysilogic characteristics, diag-nosis, treatment options, and potential pre-vention of this complication are discussed.

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.

Ultrasound-guided compression of iatrogenic femoral pseudoaneurysm failure, recurrence, and long-term results

PURPOSE

Iatrogenic femoral pseudoaneurysms (IFP) have traditionally been treated surgically. Recently, this common problem has been successfully treated without operation by use of ultrasound-guided compression (UGC) to induce thrombosis of the false aneurysm cavity, but the risk factors for failure and the long-term outcome have not been defined.

METHODS

All patients referred to the vascular laboratory from June 1992 to November 1994 whose femoral pseudoaneurysms were treated by UGC were included in the study. Data were collected prospectively during the last 18 months of the study. Data regarding the location and morphologic characteristics of the pseudoaneurysms and anticoagulation status were documented. Patients who had successful UGC underwent follow-up duplex scanning and ankle-brachial arterial pressure evaluations.

RESULTS

Fifty-seven patients with IFP were treated with UGC over a 30-month period; the last 34 were evaluated prospectively. UGC was successful at obliterating the false aneurysm cavity with the initial attempt in 47 (83%). Thrombosis of seven additional pseudoaneurysms was achieved on subsequent UGC attempts for an overall success rate of 95%. Recurrent false aneurysms were noted in two patients 2 and 10 days after initially successful UGC. Both were treated successfully with repeat UGC. Multivariate analysis of 14 variables revealed heparin anticoagulation (chi-square 9.025, p = 0.001) as the only significant risk factor for failure of UGC. There were no episodes of arterial thrombosis, embolization, or femoral nerve injury associated with UGC. Temporary occlusion of femoral artery during UGC and compression intervals of 20 minutes were well tolerated. Long-term follow-up from 30 to 400 days after UGC was available in 36 patients. There was no late recurrence or significant change in ankle-brachial pressures (p > 0.05).

CONCLUSION

UGC is a safe and effective treatment for most catheter-induced femoral pseudoaneurysms with a low complication rate and excellent long-term results at a cost substantially lower than operative treatment. Because the natural history of IFP is unpredictable, UGC appears to be the preferred treatment for all IFPs persisting after cessation of heparin anticoagulation.