A prospective, randomized evaluation of nonsurgical closure of femoral pseudoaneurysm by compression device with or without ultrasound guidance

Delayed severe median nerve palsy due to undiagnosed brachial pseudoaneurysm

Post-catheterization pseudoaneurysms are a well-known complication of many endovascular procedures at the site of arterial puncture. However, long-term neurological complications due to undiagnosed compression are rare. A 60-year-old man presented to our unit for round, non-pulsatile, painless swelling in the inner side of his upper arm. Clinical examination showed finger paralysis, associated with amyotrophy of the forearm. Large brachial pseudoaneurysm with median nerve compression was diagnosed. The patient underwent autologous vein bypass, with poor 6-month neurological recovery. Early diagnosis of pseudoaneurysms is paramount because, when associated with nerve compression, the longer the diagnostic delay, the poorer the neurological prognosis.

Successful Treatment of a Superficial Femoral Artery Pseudoaneurysm with Balloon Tamponade

The development of post-catheterization arterial pseudoaneurysms is one of the most common vascular access complications following angiographies and endovascular interventions. Different therapeutic options to treat these lesions have been used. We herein report the case of a 79-year-old woman who was referred to our service for evaluation with a post-catheterization superficial femoral artery pseudoaneurysm measuring 4 cm. Owing to the anatomical location of the arterial pseudoaneurysm and the patient’s refusal to undergo open surgery, we treated the lesion using an endovascular approach with a balloon tamponade. The procedure was successful, and the patient recovered well and was discharged from the hospital without complications. At 6-month follow-up she remained symptom-free and without recurrence.

Segmental Arterial Mediolysis: A Case Study and Review of the Literature in Accurate Diagnosis and Management

Segmental arterial mediolysis (SAM) is a rare noninflammatory, nonarteriosclerotic arteriopathy of an unknown etiology. It most commonly affects the medium-sized vessels of the abdomen and is characterized by the disruption of the arterial medial layer. Although histological confirmation remains the gold standard in diagnosis, the use of computed tomography angiography (CTA) has greatly aided the diagnosis and surveillance of SAM. Given its rarity and angiographic similarities to other vasculopathies, the diagnosis of SAM can be challenging and is often missed. We describe the case of a 46-year-old male patient who presented to our institution with abdominal pain and multiple foci of intra-abdominal arterial dissections on CTA. We report the acute management via endovascular intervention and review the literature with respect to the diagnosis and management of this rare condition. SAM remains an uncommon yet significant disease process requiring prompt and accurate diagnosis. Initiation of immediate treatment is crucial, given the knowledge gap about its natural progression.

Femoral pseudoaneurysms after percutaneous access

The femoral artery has been the primary percutaneous-based arterial access site for coronary artery catheterizations for more than three decades. Noncardiac percutaneous-based procedures have also been performed primarily with femoral access and have increased in number exponentially by vascular specialists in past decades. Groin complications are infrequent in incidence after femoral arterial access for cardiac and peripheral diagnostic and interventional cases, with groin hematomas and pseudoaneurysms being the most common. Until ultrasound-based treatment modalities became the mainstay of treatment, vascular surgeons were the primary specialty managing pseudoaneurysms, but now other specialties also manage these cases. This review outlines the clinical implications and current issues relevant to understanding the ideal treatment strategy for this common complication.

Cardiologist operated ultrasound guided thrombin injection as a safe and efficacious first line treatment for iatrogenic femoral artery pseudoaneurysms

OBJECTIVES

To assess the efficacy and safety of ultrasound guided thrombin injection (UGTI) as a first line treatment for post arterial cannulation iatrogenic femoral artery pseudoaneurysms (IFAP).

BACKGROUND

IFAPs complicate up to 1% of diagnostic and 8% of interventional cardiac catheterisation procedures. UGTI remains a second line or non-attempted treatment after ultrasound guided manual compression (UGMC) and surgical repair in many centres.

METHODS

A retrospective review was undertaken of 121 consecutive patients who received UGTI as a first line treatment for IFAPs following cardiac diagnostic, interventional or catheter ablation procedures between 1999 and 2011 at our centre. The mean patient age was 70.7 years and 63% were male. At the time of injection, 89% were on at least one antiplatelet or anticoagulant. Pseudoaneurysms had a mean maximum dimension of 26.7mm (range 10-122mm) and 25% were multilobed. UGTI was performed by an interventional cardiologist with a mean bovine thrombin dose of 648 IU (range 50-5000 IU).

RESULTS

Primary success, defined as immediate IFAP thrombosis with UGTI, was achieved in 111 (92%) patients. Recurrence occurred in seven patients, three of whom required surgical repair. Multilobed IFAPs had significantly lower primary success rates than unilobed IFAPs (80% vs. 96%, p=0.016). Antiplatelet and anticoagulant use and IFAP size did not significantly affect outcomes. UGTI was not associated with any serious complications (such as thromboembolism, aneurysm rupture, venous thrombosis or abscess formation).

CONCLUSION

Interventional cardiologist operated UGTI should be considered as a first line therapy for uncomplicated IFAPs following interventional and diagnostic cardiac procedures. Despite high rates of concomitant antiplatelet and antithrombotic therapy, initial thrombosis rates exceeded 90% and we did not experience serious complications.

Treatment for femoral pseudoaneurysms

BACKGROUND

Femoral pseudoaneurysms may complicate up to 8% of vascular interventional procedures. Small pseudoaneurysms can spontaneously clot, but sometimes definitive treatment is needed. Surgery has traditionally been considered the 'gold standard' treatment, although it is not without risk in patients with severe cardiovascular disease. Less invasive treatment options such as Duplex ultrasound-guided compression and percutaneous thrombin injection are available, however, evidence of their efficacy is limited. This is an update of a Cochrane review first published in 2006.

OBJECTIVES

To assess the effects of different treatments for femoral pseudoaneurysms resulting from endovascular procedures, specifically assessing less invasive treatment options such as blind manual or mechanical compression, ultrasound-guided compression, or percutaneous thrombin injection.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched October 2013) and CENTRAL (2013, Issue 9).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing two treatments for femoral pseudoaneurysms following vascular interventional procedures were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Four studies were included in the analyses comparing: manual compression versus ultrasound-guided compression; ultrasound-guided application of a mechanical device (FemoStop) versus blind application; and ultrasound-guided compression versus percutaneous thrombin injection (two studies). There were no studies with a surgical intervention arm. Data were extracted independently by both authors.

MAIN RESULTS

Compression (manual or FemoStop) was effective in achieving pseudoaneurysm thrombosis although ultrasound-guided application failed to confer any benefit (risk ratio (RR) 0.96; 95% confidence interval (CI) 0.88 to 1.04).Percutaneous thrombin injection was more effective than a single session of ultrasound-guided compression in achieving primary pseudoaneurysm thrombosis within individual RCTs but merged data failed to show statistical significance (RR 2.81; 95% CI 0.44 to 18.13). There was no statistically significant difference in the length of hospital stay between the two groups and no complications were reported apart from one deep vein thrombosis in the compression group.

AUTHORS' CONCLUSIONS

The limited evidence base appears to support the use of thrombin injection as an effective treatment for femoral pseudoaneurysm. A pragmatic approach may be to use compression (blind or ultrasound-guided) as first-line treatment, reserving thrombin injection for those in whom the compression procedure fails.

Sealing pseudo-aneurysms of the femoral artery with saline injection: a new technique

AIMS

Pseudo-aneurysm (PA) of the femoral artery is the most frequent complication after diagnostic or therapeutic catheterisation. PA may manifest with large and painful haematoma or compression of the adjacent nerve and vein. Among several therapeutic approaches, compression by injection of saline around the neck is a recent and promising method. To explore compression with saline as an alternative treatment for iatrogenic femoral artery PA was the aim of this study.

METHODS AND RESULTS

From December 2009 to January 2011, all consecutive patients with symptomatic PA were included in this study. After ultrasonic assessment, the PA neck was occluded by injection of a saline/lidocaïne (0.2%) mixture in the soft tissue at its vicinity, followed by a short echo-guided compression. Outcome was assessed at one and 30 days by duplex sonography. Eleven patients with PA requiring immediate treatment were included. All patients had at least one PA cavity. Moreover, four patients had multiple pulsatile cavities and seven patients had large thigh or abdominal haematoma, with either active bleeding, compression of adjacent organ or hypotension. Three patients had very short PA neck. The mean injected volume was 47±11 ml. The mean compression time until the PA was closed was 6±3 minutes. At one and 30 days, all PA remained occluded without any complication related to the procedure.

CONCLUSIONS

Saline injection to seal PA is feasible, safe and very effective. The technique is rapid and well tolerated, and allows, after limited training, the closure of very large PA, even in case of emergency. This new technique is more comfortable for the patient and the operator, and surely more economical than thrombin injection or surgical arterial suture.

Treatment for femoral pseudoaneurysms

BACKGROUND

Femoral pseudoaneurysms may complicate up to 8% of vascular interventional procedures. Small pseudoaneurysms can spontaneously clot, but sometimes definitive treatment is needed. Surgery has traditionally been considered the 'gold standard' treatment, although it is not without risk in patients with severe cardiovascular disease. Less invasive treatment options such as Duplex ultrasound-guided compression and percutaneous thrombin injection are available, however, evidence of their efficacy is limited. This is an update of a Cochrane review first published in 2006.

OBJECTIVES

To assess the effects of different treatments for femoral pseudoaneurysms resulting from endovascular procedures, specifically assessing less invasive treatment options such as blind manual or mechanical compression, ultrasound-guided compression, or percutaneous thrombin injection.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched December 2008) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 4). Additional searches were also made of the bibliographies of papers found through the electronic searches, and by handsearching relevant journals.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing two treatments for femoral pseudoaneurysms following vascular interventional procedures were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Four studies were included in the analyses comparing: manual compression versus ultrasound-guided compression; ultrasound-guided application of a mechanical device (FemoStop) versus blind application; and ultrasound-guided compression versus percutaneous thrombin injection (two studies). There were no studies with a surgical intervention arm. Data were extracted independently by both authors.

MAIN RESULTS

Compression (manual or FemoStop) was effective in achieving pseudoaneurysm thrombosis although ultrasound-guided application failed to confer any benefit (risk ratio (RR) 0.96; 95% confidence interval (CI) 0.88 to 1.04).Percutaneous thrombin injection was more effective than a single session of ultrasound-guided compression in achieving primary pseudoaneurysm thrombosis within individual RCTs but merged data failed to show statistical significance (RR 2.81; 95% CI 0.44 to 18.13). There was no statistically significant difference in the length of hospital stay between the two groups and no complications were reported apart from one deep vein thrombosis in the compression group.

AUTHORS' CONCLUSIONS

The limited evidence base appears to support the use of thrombin injection as an effective treatment for femoral pseudoaneurysm. A pragmatic approach may be to use compression (blind or ultrasound-guided) as first-line treatment, reserving thrombin injection for those in whom the compression procedure fails.

Interventional radiology in the diagnosis, management, and follow-up of pseudoaneurysms

Arterial wall disruption, as a consequence of inflammation/infection, trauma (penetrating or blunt), or iatrogenic causes, may result in pseudoaneurysm formation. Currently, iatrogenic causes are increasing as a result of the growth of endovascular intervention. The frequency of other causes also seems to be increasing, but this may simply be the result of increased diagnosis by better imaging techniques, such as multidetector contrast-enhanced computed tomography. Clinically, pseudoaneurysms may be silent, may present with local or systemic signs, or can rupture with catastrophic consequences. Open surgical repair, previously the mainstay of treatment, has largely been replaced by image-guided occlusion methods. On the basis of an experience of over 100 pseudoaneurysms, treatments at various anatomical sites, imaging modalities used for accurate diagnosis, current changing therapeutic options for pseudoaneurysm management, approved embolization agents, and clinical follow-up requirements to ensure adequate treatment will be discussed. Image-guided direct percutaneous and endovascular embolization of pseudoaneurysms are established treatment options with favorable success rates and minimal morbidity. The pendulum has now swung from invasive surgical repair of pseudoaneurysms to that of image-guided interventional radiology.

Surgery versus non-surgical treatment for femoral pseudoaneurysms

BACKGROUND

Femoral pseudoaneurysms may complicate up to 8% of vascular interventional procedures. Small pseudoaneurysms can spontaneously clot, while others need definitive treatment. Surgery is considered the gold-standard treatment, although is not without risk in patients with severe cardiovascular disease. Less invasive treatment options, such as Duplex ultrasound-guided compression and percutaneous thrombin injection are available, however, evidence of their efficacy is limited.

OBJECTIVES

To assess the effects of different treatments for femoral pseudoaneurysms resulting from endovascular procedures, specifically assessing less invasive treatment options such as ultrasound-guided compression or percutaneous thrombin injection.

SEARCH STRATEGY

We searched the Cochrane Peripheral Vascular Diseases Review Group's Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 3, 2005 (last searched October 12, 2005). Additional searches were also made of bibliographies of papers found through these searches and by handsearching relevant journals.

SELECTION CRITERIA

Randomised controlled trials comparing two treatments for femoral pseudoaneurysms following vascular interventional procedures were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two studies were included in the analysis: ultrasound-guided application of a mechanical device (FemoStop) versus blind application; ultrasound-guided compression versus percutaneous thrombin injection. Data were extracted independently by both authors.

MAIN RESULTS

Mechanical compression with a FemoStop was effective in achieving thrombosis of the pseudoaneurysm although ultrasound-guided application of this failed to confer any benefit (relative risk (RR) 1.07; 95% confidence intervals (CI) 0.75 to 1.53, P = 0.7). Percutaneous thrombin injection was more effective than ultrasound-guided compression in achieving thrombosis of a pseudoaneurysm (RR 7.50; 95% CI 2.06 to 27.25, P = 0.002 at 24 hours after treatment; RR 2.50; 95% CI 1.35 to 4.65, P = 0.004 at 48 hours after treatment). There was no statistically significant difference in the length of hospital stay between the two groups and no complications were reported.

AUTHORS' CONCLUSIONS

The limited evidence base appears to support the use of thrombin injection as an effective treatment for femoral pseudoaneurysm. A pragmatic approach may be to use ultrasound-guided compression as first-line treatment, reserving thrombin injection for those in whom the procedure fails.

Prospective randomized study comparing ultrasound-guided thrombin injection to compression in the treatment of femoral pseudoaneurysms

PURPOSE

To compare in a randomized prospective study the treatment of femoral pseudoaneurysms with ultrasound-guided thrombin injection versus ultrasound-guided compression.

METHODS

Thirty consecutive patients (22 men; mean age 67+/-8 years, range 53-82) with iatrogenic femoral pseudoaneurysms were randomized to treatment with either ultrasound-guided compression (n=15) or injection of bovine thrombin (n=15). The primary outcome measure was thrombosis of the pseudoaneurysm within 24 hours. Secondary outcome measures were complications and hospitalization time (LOS).

RESULTS

Thrombosis within 24 hours was achieved in 15 (100%) patients given thrombin versus 2 (13%) in the compression group (p<0.001). Of 13 pseudoaneurysms failing the initial compression treatment, 7 were retreated, 4 successfully. Thus, only 6 (40%) lesions were thrombosed within 48 hours after 1 or 2 compression sessions. The other 9 cases were successfully treated with thrombin injection. LOS was 2.8+/-1.5 days and 3.5+/-2.4 days in the thrombin and compression groups, respectively (p>0.05). No complications were noted in either group.

CONCLUSIONS

Ultrasound-guided thrombin injection induces a fast, effective, and safe thrombosis of postcatheterization pseudoaneurysms. The technique is clearly superior to compression treatment and is recommended as the therapy of choice.

Current treatment methods for postcatheterization pseudoaneurysms

Pseudoaneurysms are a recognized complication of arterial catheterization. Until recently, the standard method of treatment has been surgical. The past decade has seen the introduction of several minimally invasive techniques that have largely replaced surgical treatment of pseudoaneurysms. The most commonly used methods are ultrasound-guided compression and percutaneous injection of thrombin into the pseudoaneurysm. This review article describes all the methods available for the treatment of postcatheterization pseudoaneurysms, presents results from the largest published series, and discusses the relative merits of each technique.

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.

Electron beam tomography of interpulmonary saddle embolism: extent and vascular distribution

PURPOSE

The purpose of this work was to assess morphology and secondary signs of interpulmonary emboli extending across the bifurcation of the main pulmonary artery (PA).

METHOD

Retrospective evaluation of 780 electron beam tomographic studies of the chest yielded 17 cases of interpulmonary saddle embolism. Length, diameter, vascular distribution of the emboli, and secondary findings were prospectively assessed by two blinded reviewers. Follow-up studies were carried out in 12 of 17 patients (71%).

RESULT

Mean total length of the emboli was 46.6 cm (range 20.9-81.5 cm). The mean diameter of the saddle embolus was significantly smaller at the level of the bifurcation than in the left or right PA (4.5, 7.7, and 7.4 mm, respectively; p < 0.01). Dilatation of the right heart was found in 10 of 17 cases (59%). At follow-up, the saddle state was no longer present in 8 of 12 patients (67%).

CONCLUSION

Interpulmonary saddle emboli appear to be a transient form of acute pulmonary embolism, the site of predilection for rupture of the embolus being the level of the bifurcation. Their frequency may therefore be underestimated.

Percutaneous treatment of pseudoaneurysms using fibrin adhesive

This study was performed to assess the safety and efficacy of treatment of iatrogenic pseudoaneurysms with fibrin adhesive. 28 patients with iatrogenic pseudoaneurysms were treated. The first 20 patients had either at least one previously unsuccessful treatment of ultrasound guided compression repair (UGCR), a contraindication to UGCR or could not tolerate the procedure. Diagnosis was confirmed on ultrasound and angiography and a balloon inflated across the neck of the pseudoaneurysm. Fibrin adhesive was injected under ultrasound control directly into the pseudoaneurysm sac. The balloon was deflated after 15 min and check ultrasound and angiography performed, with a further ultrasound at 24 h. The subsequent eight patients underwent embolisation as the first line treatment without use of a protective balloon. 16 of the first 20 patients (80%) and all of the subsequent 8 patients had successful embolisation of the pseudoaneurysm after a single treatment. Two pseudoaneurysms failed to thrombose despite two treatments in one case and three treatments in the other, and both required surgery. The only significant complication was the development of local cellulitis in one patient. In conclusion, embolisation of iatrogenic aneurysms with fibrin adhesive is a safe and effective treatment. It should be considered as an alternative to surgery and UGCR.

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.