Ultrasound-Guided Glue Injection as Alternative Treatment of Femoral Pseudoaneurysms

Management of Acute Complications during Endovascular Procedures in Peripheral Arterial Disease: A Review

Endovascular therapy, as opposed to surgical bypass, has become the mainstay for peripheral arterial disease even in long segment occlusions. Complications can occur during the arterial access, catheter manipulation, balloon dilation, and/or stent placement. Given the high prevalence of comorbidities such as diabetes, hypertension, renal dysfunction, and coronary artery disease in these patients, early identification of procedural complications and initiation of treatment are of paramount importance. This review aims to provide comprehensive data on the identification and management of commonly encountered endovascular complications during endovascular interventions in peripheral arterial disease.

Non-Surgical treatment Versus Surgery for Iatrogenic Femoral Artery Pseudoaneurysms: Systematic Review and Meta-Analysis

Objectives

This study compared results of non-surgical treatment (compression and ultrasound guided thrombin injection (UGTI)) and surgery to treat iatrogenic femoral artery pseudoaneurysms.

Methods

PubMed and Embase databases were searched up to October 2021. Primary outcome measure was success rate, and other outcomes examined were complication rate, reintervention rate. Two authors independently reviewed and extracted data. Data were presented as the odds ratios (ORs) with 95% confidence intervals (CIs). The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to appraise the quality of the body of evidence.

Results

Eight studies were included. A total of 623 patients with pseudoaneurysm undergoing treatment were included, of which 163 subjects underwent surgery, 397 subjects underwent compression, and 63 subjects underwent UGTI. The success rate was significantly lower in the non-surgery group (OR 0.24, 95% CI, 0.08–0.69, I²= 0%). The complication rate was significantly lower in the non-surgery group (OR 0.10, 95% CI, 0.03 –0.29, I²= 0%). Patients in the non-surgery group tended to have a lower, but statistically insignificant, reintervention rate (OR 0.11, 95% CI, 0.01–1.06, I²= 35%). Further, the GRADE assessment showed that these results (success rate, complication rate, and reintervention rate) were of very low quality.

Conclusions

Available evidence shows that it is reasonable to regard non-surgical treatment as the primary treatment for iatrogenic femoral artery pseudoaneurysms, and surgery as a remedy after failure of non-surgical treatment in some cases.

Endovascular Use of Cyanoacrylate-Lipiodol Mixture for Peripheral Embolization: Properties, Techniques, Pitfalls, and Applications

Endovascular embolization agents are particles and fluids that can be released into the bloodstream through a catheter to mechanically and/or biologically occlude a target vessel, either temporarily or permanently. Vascular embolization agents are available as solids, liquids, and suspensions. Although liquid adhesives (glues) have been used as embolic agents for decades, experience with them for peripheral applications is generally limited. Cyanoacrylates are the main liquid adhesives used for endovascular interventions and have a major role in managing vascular abnormalities, bleeding, and many vascular diseases. They can only be injected as a mixture with ethiodized oil, which provides radiopacity and modulates the polymerization rate. This review describes the characteristics, properties, mechanisms of action, modalities of use, and indications of the cyanoacrylate-Lipiodol® combination for peripheral embolization.

Percutaneous glue embolization of arteriovenous fistula of in situ saphenous vein bypass graft: Case report and literature review

OBJECTIVES

Arteriovenous fistulas (AVFs) of an in situ saphenous vein bypass can be managed surgically or through endovascular coil embolization. The complications associated with the surgical wounds required for side branch ligature can be minimized through selective vein ligature and interrupted small incisions, but endovascular methods are time-consuming and limited by vein size. In this case report, we describe percutaneous ultrasound (US)-guided balloon-assisted direct glue injection as an alternative treatment strategy for AVF closure.

METHODS

We treated a patient with a delayed AVF in a femoral-popliteal in situ saphenous vein bypass. The patient came to our attention for the recurrence of chronic limb-threatening ischemia (CTLI) 4 years after the initial bypass creation. Ultrasound and computed tomography angiography (CTA) showed a double tandem graft in significant stenosis below an AVF connected with the deep venous system. Treatment included percutaneous angioplasty of the bypass stenosis and contemporary AVF closure via ultrasound-guided glue injection.

RESULTS

We successfully performed endovascular angioplasty with a drug-eluting balloon of the bypass stenosis and ultrasound-guided fistula embolization with cyanoacrylate Glubran 2. Angiography after the procedure showed bypass graft patency, no residual stenosis, and complete closure of the AVF. Results were confirmed with US.

CONCLUSIONS

Percutaneous embolization using glue could be a useful technique for AVF closure. It is a minimally invasive method that reduces the need for skin incisions during in situ saphenous grafting or endovascular revascularization.

Percutaneous balloon-assisted ultrasound-guided direct glue embolization of deep femoral artery pseudoaneurysm rupture

Deep femoral artery pseudoaneurysm is commonly caused by arterial access in endovascular procedures. Some therapeutic options have been applied for this lesion such as: surgery, ultrasound-guided compression, direct thrombin injection, covered stent, coil embolization. One of the effective therapeutic for treatment of femoral artery pseudoaneurysm but uncommon use is percutaneous direct glue injection. We hereby report a case of right deep femoral artery pseudoaneurysm after 2-week placement of the femoral tunneled hemodialysis catheter which was successfully treated by balloon-assisted percutaneous ultrasound-guided direct glue embolization.

Ultrasound-Guided Fibrin Glue Injection for Treatment of Iatrogenic Femoral Pseudoaneurysms

Introduction:

Arterial pseudoaneurysms (PSAs) are the most common access site complication following transarterial catheter intervention. Ultrasound-guided injection of thrombogenic substances into perfused arterial PSAs followed by compression therapy is a well-established and less invasive treatment option than surgical repair. Different agents are available to induce thrombosis including thrombin and a fibrin-based tissue glue, which is used as first-line treatment at our institution. This paper deals with our experience using ultrasound-guided fibrin glue injection (UGFI).

Materials and Methods:

Retrospective data analysis: all patients (55) treated for iatrogenic femoral PSA following digital subtraction angiography of the lower extremities between January 1, 2010, and December 31, 2018, were included. Data on epidemiology, PSA location and size, vascular risk factors, fibrin glue injection (fibrin glue volume), primary success rate of UFGI, and complications related to the treatment were analyzed.

Results:

A total of 55 consecutive femoral iatrogenic PSAs were treated during the defined period and 32 (58.2%) of the patients were female. Imaging was performed using ultrasound in all cases. The most common PSA location (80.0%) was the common femoral artery, mean PSA size (± SD) was 2.7 ± 1.2 cm, and neck length was 1.6 ± 1.0 cm. The dose (mean ± SD) of fibrin glue was 2.6 mL (± 1.0; maximum: 6 mL). Primary UGFI success rate was 87.3% and conversion rate to open surgery was 12.7%. Two (4%) patients required embolectomy for peripheral embolization after UGFI.

Conclusion:

Early results achieved with UGFI for treatment of iatrogenic femoral PSA are promising. In our cohort, UGFI was a safe and effective first-line alternative to traditional open surgery, which then was unnecessary in the vast majority of PSA cases. Further prospective studies for comparison of ultrasound-guided techniques should be encouraged.

Percutaneous ultrasound-guided balloon-assisted embolization of iatrogenic femoral artery pseudoaneurysms with Glubran®2 cyanoacrylate glue: safety, efficacy and outcomes

Background

Femoral pseudoaneurysm (PA) is a frequent complication of arterial access for endovascular procedures. Surgery has traditionally been considered as the gold standard of therapy. We aimed to report our experience of percutaneous ultrasound (US)-guided balloon-assisted embolization with cyanoacrylate glue for the treatment of iatrogenic femoral PAs.

Methods

Retrospective two-center study of patients with femoral iatrogenic PAs treated by N-butyl cyanoacrylate-methacryloxy sulfolane (NBCA-MS) Glubran^®2 glue embolization between July 2013 and November 2017. All patients underwent contralateral arterial access with balloon placement of an appropriate size in front of the PA neck before glue/lipiodol embolization in a 1:1 ratio by percutaneous US-guided puncture of the aneurysmal sac under fluoroscopy control.

Results

Twenty-three patients (12 females, 11 males; median age, 79 years; range, 18-93 years) were included. Median PA size was 34 mm (range, 17-60 mm). The median time to treatment was 5 days (range, 1-30 days). Twenty patients (86.9%) were successfully treated by glue injection alone. The three remaining patients (13.1%) with persistent PA or associated arterial-venous fistula were immediately treated during the same procedure by additional stent-graft. Then, overall immediate and 1-month clinical success rates were 100%. No surgical conversion was necessary. No recurrence was reported during the median follow-up of 11 months (range, 2-73 months). Two (8.7%) puncture-related complications occurred at the contralateral arterial access site, which spontaneously resolved. No non-target glue embolization occurred.

Conclusions

US-guided balloon-assisted glue embolization is safe and effective to treat iatrogenic femoral PAs in most cases, offering complete exclusion of the PA and avoiding the morbidity of open surgery.

Successful percutaneous treatment for massive hemorrhage due to infectious pseudoaneurysm in the abdominal wall after percutaneous endoscopic gastrostomy: a case report

Background

Percutaneous endoscopic gastrostomy (PEG) is often performed for alimentation and to prevent weight loss in patients with feeding problems due to central neurologic diseases such as cerebral infarction or intracranial hemorrhage. Although infection at the skin site after PEG placement is a typical late complication of PEG, a ruptured infectious pseudoaneurysm caused massive bleeding adjacent to the tract is rare. Prompt treatment is required to avoid the hemorrhage shock, however surgical ligation is difficult to obtain the arrest of bleeding in damaged skin due to the infection.

Case presentation

A 70-year-old male was bedridden due a cerebral infarction suffered 1 year previously. APEG was placed because of feeding problems, and a push-type, 20-Fr gastrostomy tube was inserted through the anterior abdominal wall. On day 16 after PEG placement, the patient had massive bleeding from the PEG site due to the rupture of infectious pseudoaneurysm and developed a decreased level of consciousness and hypotension. Treatment by percutaneous direct injection of a mixture of n-butyl-cyanoacrylate (NBCA)-lipiodol was performed and achieved good hemostasis is obtained.

Conclusions

A rare case of an infectious pseudoaneurysm that developed in the abdominal wall and caused massive bleeding at a PEG placement site was described. Percutaneous injection of a mixture of n-butyl-cyanoacrylate (NBCA)-lipiodol under ultrasound guidance is an effective treatment in this case.

Percutaneous cyanoacrylate glue embolization for peripheral pseudoaneurysms: an alternative treatment

Post-traumatic pseudoaneurysms are rare in the peripheral arteries and usually occur as a late sequel of trauma. Surgery has traditionally been considered as the gold standard of therapy for traumatic peripheral pseudoaneurysms. We report 2 cases of post traumatic pseudoaneurysms successfully treated by percutaneous cyanoacrylate glue (N-Butyl 2 cyanoacrylate) embolization. This method offers complete exclusion of the pseudoaneurysm, at the same time avoiding the morbidity of open surgery.

Ultrasound-guided thrombin injection for treatment of iatrogenic femoral pseudo-aneurysm: a nursing protocol

Femoral pseudo-aneurysm (FPA) is a pulsatile hematoma (false aneurysm) of the femoral artery that communicates with an artery through a disruption in the arterial wall. Most often, FPA develops after an injury or angiographic access to the femoral artery with bleeding into the adjacent tissue. FPA is an uncommon complication, but a very significant one, that can have serious consequences. FPA can initially present as a new thrill or bruit, a pulsatile hematoma, or marked pain and tenderness near the site of arterial puncture. Doppler flow imaging has been the mainstay of diagnosis. Ultrasound (US)-guided compression was the treatment of choice. However, it carries drawbacks including length of time to compress for adequate closure of the artery, discomfort to patients, high recurrence rate in patients receiving anticoagulation, femoral artery thrombosis, and a success rate of only 75% overall. An alternative to compression is US-guided thrombin injection (UGTI) of the FPA. This is a safe procedure that can be done as an outpatient or in an office setting. This paper will provide nursing guidelines and rationale as well as a nursing protocol for the management of patients who undergo UGTI for FPA.

Percutaneous treatment of iatrogenic pseudoaneurysms by cyanoacrylate-based wall-gluing

PURPOSE

Although the majority of iatrogenic pseudoaneurysms (PSAs) are amenable to ultrasound (US)-guided thrombin injection, patients with those causing neuropathy, claudication, significant venous compression, or soft tissue necrosis are considered poor candidates for this option and referred to surgery. We aimed to test the effectiveness and feasibility of a novel percutaneous cyanoacrylate glue (NBCA-MS)-based technique for treatment of symptomatic and asymptomatic iatrogenic PSA.

MATERIAL AND METHODS

During a 3-year period, we prospectively enrolled 91 patients with iatrogenic PSA [total n = 94 (femoral n = 76; brachial n = 11; radial n = 6; axillary n = 1)]. PSA were asymptomatic in 66 % of cases, and 34 % presented with symptoms due to neuropathy, venous compression, and/or soft tissue necrosis. All patients signed informed consent. All patients received NBCA-MS-based percutaneous treatment. PSA chamber emptying was first obtained by US-guided compression; superior and inferior walls of the PSA chamber were then stuck together using NBCA-MS microinjections. Successfulness of the procedure was assessed immediately and at 1-day and 1-, 3-, and 12-month US follow-up.

RESULTS

PSA occlusion rate was 99 % (93 of 94 cases). After treatment, mean PSA antero-posterior diameter decrease was 67 ± 22 %. Neuropathy and vein compression immediately disappeared in 91 % (29 of 32) of cases. Patients with tissue necrosis (n = 6) underwent subsequent outpatient necrosectomy. No distal embolization occurred, nor was conversion to surgery necessary.

CONCLUSION

PSA treatment by way of NBCA-MS glue injection proved to be safe and effective in asymptomatic patients as well as those with neuropathy, venous compression, or soft-tissue necrosis (currently candidates for surgery). Larger series are needed to confirm these findings.

Sonographically guided hand kneading and compression for treatment of femoral artery pseudoaneurysms

OBJECTIVES

The purpose of this study was to evaluate the effectiveness of sonographically guided hand kneading and compression for the treatment of femoral artery pseudoaneurysms after percutaneous intervention.

METHODS

Twenty-four patients who had post-percutaneous intervention femoral artery pseudoaneurysms treated with sonographically guided compression from 2001 to 2004 and 2008 to 2009 were compared with 25 patients who had postintervention pseudoaneurysms treated with sonographically guided hand kneading and compression from 2005 to 2009.

RESULTS

All 25 patients (100%) treated with 1-stage sonographically guided hand kneading and compression had pseudoaneurysm occlusion; the median treatment time was 10 minutes. Twenty-two of the 24 patients (91.7%) treated with conventional sonographically guided compression had pseudoaneurysm occlusion. One-stage compression was successful in 10 patients; 9 and 3 patients had pseudoaneurysm occlusion after 2 and 3 compression treatments, respectively. Two other patients who underwent compression treatment 3 and 4 times did not have pseudoaneurysm occlusion and required surgery. The median treatment time for sonographically guided compression was 30 minutes. The treatment time was significantly shorter for the hand-kneading and compression technique (P < .001), and significantly fewer procedures were needed (P < .001).

CONCLUSIONS

Sonographically guided hand kneading and compression is as effective as sonographically guided compression alone for pseudoaneurysm occlusion after femoral artery percutaneous intervention and requires significantly less time to perform.

An animal model for femoral artery pseudoaneurysms

PURPOSE

To prepare a porcine model for femoral artery pseudoaneurysm via a one-step surgical procedure without the need for microsurgery.

MATERIALS AND METHODS

This pseudoaneurysm model involves the preparation of an arteriovenous shunt between the femoral artery and femoral vein in which approximately 2 cm of the vein is segmented by proximal and distal closure with the use of ligatures. The femoral pseudoaneurysm models were evaluated by angiography, Doppler auscultation, and histologic examination.

RESULTS

In seven of eight pigs, angiography and Doppler auscultation showed that the pseudoaneurysm models were open and that there was communication between the pseudoaneurysm model and the femoral artery. The mean length (+/-SD) of the pseudoaneurysm model was 1.9 cm +/- 0.3 (n= 7), with a neck region of 4 mm. Histologic analysis confirmed that pseudoaneurysm models were open and no thrombi were observed.

CONCLUSIONS

The principal advantages of this model are the location of the pseudoaneurysm model, the short period of clamping, and the controllable size. The pig pseudoaneurysm model is straightforward and reproducible, and may serve as a useful tool in the evaluation of interventional strategies for treatment of pseudoaneurysms.

Delayed femoral pseudoaneurysm formation after percutaneous coronary intervention

Five femoral pseudoaneurysms were treated among 573 patients who underwent percutaneous coronary interventions. Four of the five patients suffered from diabetes mellitus and four patients needed regular hemodialysis due to chronic renal failure. One patient's course was complicated by infection. One patient was healed by compression therapy and four patients were treated successfully by surgery, which included an extraanatomic bypass and a thromboendoarterectomy. Diabetes and regular hemodialysis are major risks for the formation of femoral pseudoaneurysm after catheter intervention at present.

Experiência inicial com o uso de adesivo tissular contendo trombina para tratamento do pseudo-aneurisma femoral

O pseudo-aneurisma (PSA) após cateterização femoral tem sido diagnosticado com regularidade em serviços com grande movimento de intervenções percutâneas, com incidência variando de 0,05 a 6%. PSA femorais pequenos podem ser acompanhados até a resolução espontânea. As opções de tratamento são: compressão guiada por ultra-som, injeção de trombina para trombose do PSA e tratamento cirúrgico. A injeção percutânea de trombina tem a vantagem de ser um procedimento indolor e rápido. Podem ser utilizados trombina isolada ou preparados contendo trombina associada a fibrinogênio e fatores de coagulação. A experiência inicial dos autores de cinco casos tratados com injeção de adesivo tissular contendo trombina mostrou resultado satisfatório em quatro; um caso necessitou tratamento cirúrgico. Não houve sucesso com uso isolado de trombina humana, porém, ocorreu trombose imediata após injeção de preparado de trombina associada a fibrinogênio/fator XIII. Neste artigo, são discutidas as opções de tratamento dos PSA femorais e a técnica do uso de trombina percutânea.