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Li XL, Xie CY, Xu HX, Yu SY. Contrast-enhanced ultrasound-guided thrombin injection in the management of iatrogenic pseudoaneurysm (PSA): A case report and review of literatures. Clin Hemorheol Microcirc 2020; 76:549-557. [PMID: 32924996 DOI: 10.3233/ch-200923] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Pseudoaneurysm (PSA) formation is the most common arterial complication of endovascular procedures requiring arterial puncture. The present study reported a case of a 72-year-old male patient with iatrogenic femoral artery PSA treated with contrast-enhanced ultrasound (CEUS)-guided thrombin injection. Conventional ultrasound (US) and CEUS were used to diagnose, guide treatment, and evaluate the treatment efficacy. In the case, the PSA was successfully occluded with 1000 IU of thrombin. During the follow-up after 48 hours of thrombin injection, US found that the PSA had complete thrombosis without arterial supply. No complications occurrence in the course of the treatment. CEUS-guided thrombin injection for the treatment of PSA was effective and safety and the associated literatures were also reviewed.
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Affiliation(s)
- Xiao-Long Li
- Interventional Ultrasound Unit, Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
| | - Chen-Yi Xie
- Interventional Ultrasound Unit, Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
| | - Hui-Xiong Xu
- Interventional Ultrasound Unit, Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
| | - Song-Yuan Yu
- Interventional Ultrasound Unit, Department of Medical Ultrasound, Shanghai Tenth People's Hospital, Ultrasound Research and Education Institute, Tongji University Cancer Center, Shanghai Engineering Research Center of Ultrasound Diagnosis and Treatment, Tongji University School of Medicine, Shanghai, China
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Delf J, Ramachandran S, Mustafa S, Saeed A, Kandiyil N. Factors associated with pseudoaneurysm development and necessity for reintervention: a single centre study. Br J Radiol 2019; 92:20180893. [PMID: 30982331 DOI: 10.1259/bjr.20180893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Evaluate the factors associated with pseudoaneurysm development and morphology. Measure ultrasound-guided thrombin injection (UGTI) and surgical treatment outcomes for pseudoaneurysms, and the necessity for post-primary intervention (reintervention). METHODS Retrospective analysis of ultrasound scans and CT angiography of peripheral pseudoaneurysm interventions from February 2011 to April 2017. 99 patients (61.6% female) were identified; median age 72 years (range 12-89). Multivariate analysis of patient demographics, including pre-intervention anticoagulant and antiplatelet medication was performed. RESULTS Primary intervention for peripheral pseudoaneurysms (62.6% common femoral artery) included 93 UGTI and 6 surgical repairs; with 12 reinterventions (9 UGTI and 3 surgical). Pseudoaneurysm incidence for vascular interventional radiology (VIR) was 0.48% (31/6451) and cardiology was 0.24% (60/25,229). Rates for primary success, immediate complications, 30-day mortality and reintervention were measured respectively for UGTI (98.9%, 3.0%, 2.0%, and 11.8%) and surgical repair (100%, 0.0%, 22.2% and 16.7%). Reintervention risk factors included pre-intervention thrombocytopaenia (<150 × 109/L) ( p = 0.025) and pseudoaneurysms following vascular surgery (p = 0.033). Other positive associations for reintervention (non-significant) included use of a sheath size > 6 Fr ( p = 0.108) or arterial closure device ( p = 0.111) during the pseudoaneurysm causative procedure. The pre-intervention warfarin subgroup developed a larger mean pseudoaneurysm sac size (4.21 cm, range 0.9-7.6), compared to no treatment (p = 0.003), aspirin (p = 0.005) and clopidogrel (p = 0.026) subgroups. UGTI dosage for thrombosis had a positive correlation with incremental sac size increase (p < 0.001). CONCLUSION The main reintervention risk factor was pre-intervention thrombocytopaenia, with additional positive associations including pseudoaneurysms caused by surgery, increased sheath size and arterial closure devices. Warfarinized patients developed larger sac-sized pseudoaneurysms compared with other pre-intervention regimens, with positive correlation of higher UGTI dosage required for thrombosis. ADVANCES IN KNOWLEDGE Patients with pre-intervention thrombocytopaenia and pseudoaneurysms attributed to vascular surgery are subgroups that may benefit from post-intervention imaging surveillance due to significant reintervention risk.
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Affiliation(s)
- Jonathan Delf
- 1 University Hospitals of Leicester NHS Trust and University of Leicester , Leicestershire, United Kingdom
| | - Sanjeev Ramachandran
- 1 University Hospitals of Leicester NHS Trust and University of Leicester , Leicestershire, United Kingdom
| | - Syed Mustafa
- 2 Vascular radiology department, University Hospitals of Leicester NHS Trust and University of Leicester , Leicestershire, United Kingdom
| | - Abdullah Saeed
- 2 Vascular radiology department, University Hospitals of Leicester NHS Trust and University of Leicester , Leicestershire, United Kingdom
| | - Neghal Kandiyil
- 2 Vascular radiology department, University Hospitals of Leicester NHS Trust and University of Leicester , Leicestershire, United Kingdom
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Abstract
Peripheral arterial pseudoaneurysm, while relatively rare, are encountered by most vascular specialists. This review evaluates the epidemiology, diagnosis, natural history, and treatment of pseudoaneurysm in the peripheral arteries. Most of this review concentrates on iatrogenic peripheral pseudoaneurysms, but pseudoaneurysms of other etiologies will also be discussed.
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Affiliation(s)
- Jon C Henry
- Division of Vascular Surgery, Grant Medical Center, OhioHealth Heart and Vascular Institute, Columbus, Ohio
| | - Randall W Franz
- Division of Vascular Surgery, Grant Medical Center, OhioHealth Heart and Vascular Institute, Columbus, Ohio
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Bode K, Ueberham L, Gawlik S, Hindricks G, Bollmann A. Inguinal vascular complications after ablation of atrial fibrillation: an economic impact assessment. Europace 2019; 21:91-98. [PMID: 29901719 DOI: 10.1093/europace/euy132] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Accepted: 05/17/2018] [Indexed: 11/13/2022] Open
Abstract
Aims Ablation of atrial fibrillation (AF) is recommended in the guidelines as a Class Ia/IIa indication. However, associated complications should not be dismissed; specifically, inguinal vascular complications (IVC). Although IVCs are generally considered trivial, they represent an economic burden for the procedure-performing hospital and the patient. Therefore, the ability to monitor and ultimately minimize potential complications is of considerable interest. Methods and results An economic model was developed to calculate the economic impact for certain IVC-types from a large German single-centre perspective in 2015 and 2016. Twenty-nine of 1040 (2.79%) and 48 of 1152 (4.17%) AF-ablation patients had documented IVC in 2015 and 2016 (P = 0.08), respectively. Inguinal vascular complications that required invasive treatment (thrombin, intervention, surgery) occurred in 0.58% of the 2015 and in 0.87% of the 2016 AF-ablation cases. The expected excess costs (incorporating direct costs, benefit lost adjusted for reimbursement) per patient treated with AF-ablation were 139.54€ and 153.31€ in 2015 and 2016, respectively. This was mostly driven by opportunity costs, which could reach 15 544.71€ for certain IVC. Sensitivity analysis revealed the probability of occurrence, length of stay of certain IVC types, and the revenue per day influenced the expected costs per AF-ablation patient. Conclusion Even relatively benign complications such as IVC can result in considerable cost increases. Therefore, measures to reduce them should be established and implemented.
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Affiliation(s)
- Kerstin Bode
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig, Germany
| | - Laura Ueberham
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig, Germany
| | - Susan Gawlik
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig, Germany
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig, Germany
| | - Andreas Bollmann
- Department of Electrophysiology, Heart Center Leipzig, University of Leipzig, Struempellstrasse 39, Leipzig, Germany
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Stone PA, Thompson SN, Hanson B, Masinter D. Management of Iatrogenic Pseudoaneurysms in Patients Undergoing Coronary Artery Bypass Grafting. Vasc Endovascular Surg 2016; 50:217-20. [DOI: 10.1177/1538574416637448] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: A plethora of papers have been written regarding postcatheterization femoral pseudoaneurysms. However, literature is lacking on pseudoaneurysmal management in patients undergoing coronary artery bypass grafting (CABG). Thus, we examined if pseudoaneurysms with subsequent CABG can be managed with the same strategies as those not exposed to the intense anticoagulation accompanying CABGs. Methods: During a 14-year study period, we retrospectively examined femoral iatrogenic pseudoaneurysms (IPSAs) diagnosed postheart catheterization in patients having a subsequent CABG. Patient information was obtained from electronic medical records and included pseudoaneurysm characteristics, treatment, and resolution. Outcomes of interest included the occurrence of IPSA treatment failures and complications. Results: In the 66 patients (mean age, 66 ± 11 years, 46% male) meeting inclusion criteria, mean dose of heparin received during the CABG procedure was 34 000 ± 23 000 units. The IPSA size distribution was the following: 17% of IPSAs measured <1 cm, 55% between 1 and 3 cm, and 21% measured >3 cm. Pseudoaneurysms were managed with compression, duplex-guided thrombin injection, and surgical repair (1%, 27%, and 26% of cases, respectively). Thrombin injection and surgical repair were 100% effective at treating pseudoaneurysms, with 1 patient experiencing a surgical site infection postsurgical repair. Observation-only management was employed in 30 (45%) patients. Nine of 30 patients with no intervention beyond observation had duplex documented resolution/thrombosis during follow-up. One patient initially managed by observation required readmission and surgical repair of an enlarging pseudoaneurysm (6 cm growth) following CABG. Conclusion: Management of pseudoaneurysms in patients prior to CABG should be similar to those patients not undergoing intense anticoagulation. In appropriate cases, small aneurysms can be safely observed, while thrombin injections are effective and safe as well. Thus, routine open surgical repair is not routinely required in patients with femoral pseudoaneurysms at time of CABG.
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Affiliation(s)
- Patrick A. Stone
- Division of Vascular and Endovascular Surgery, Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
| | - Stephanie N. Thompson
- Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
| | - Brent Hanson
- Division of Vascular and Endovascular Surgery, Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
| | - David Masinter
- Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA
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Stone PA, Martinez M, Thompson SN, Masinter D, Campbell JE, Campbell Ii JR, AbuRahma AF. Ten-Year Experience of Vascular Surgeon Management of Iatrogenic Pseudoaneurysms: Do Anticoagulant and/or Antiplatelet Medications Matter? Ann Vasc Surg 2015; 30:45-51. [PMID: 26256702 DOI: 10.1016/j.avsg.2015.06.068] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 05/06/2015] [Accepted: 06/02/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Previous studies examining the natural history of femoral pseudoaneurysms (PSAs) were performed before the current era of anticoagulant and/or antiplatelet therapy. The purpose of our study was to elucidate in a vascular surgeon directed approach to PSAs, the association between medication use and the failure of conservative, observation-only management. METHODS We retrospectively examined 308 femoral iatrogenic PSAs diagnosed via duplex imaging at our institution during a 10-year time period (2004-2013). Information on PSA characteristics, treatment, and antiplatelet and/or anticoagulant medication usage was obtained. We identified patients who failed observation-only conservation management, with failure defined as the need for delayed treatment because of PSAs triggered by either expansion (≥ 1 cm increase or size enlarging to ≥ 3 cm) and/or persistence (≥ 15 days). RESULTS Immediate and/or acute treatments of PSAs included 1 ultrasound-guided compression, 14 surgical repairs, and 126 thrombin injections. Of the 167 PSAs initially managed by observation only, 70 (42%) were found by ultrasound imaging to thrombosis spontaneously. An additional 70 (42%) patients had the diagnosis of PSA <3 cm and were managed conservatively with only clinical follow-up. Twenty-seven PSAs (16%) originally managed conservatively required additional treatment because of expansion and/or persistence. Patients receiving dual-antiplatelet therapy had higher rates of failed conservative management (44%) than patients not on dual therapy (9%, P < 0.01). The number of antiplatelet and/or anticoagulant medications used during observation was larger in patients failing conservative management (2.0 ± 0.7) versus patients not requiring additional intervention (1.5 ± 0.7, P < 0.01). CONCLUSIONS Most of the PSAs initially managed with observation-only did not require additional intervention. However, anticoagulant and/or antiplatelet agents use associated with PSAs required further intervention after failing observation-only management. When observation is the chosen strategy for PSA management, especially in the setting of aggressive antithrombotic and dual-antiplatelet therapy, surveillance is required to ensure proper resolution.
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Affiliation(s)
- Patrick A Stone
- Division of Vascular and Endovascular Surgery, West Virginia University, Charleston, WV.
| | - Maria Martinez
- Division of Vascular and Endovascular Surgery, West Virginia University, Charleston, WV
| | - Stephanie N Thompson
- Charleston Area Medical Center Health Education and Research Institute, Charleston, WV
| | - David Masinter
- Charleston Area Medical Center Health Education and Research Institute, Charleston, WV
| | - John E Campbell
- Division of Vascular and Endovascular Surgery, West Virginia University, Charleston, WV
| | - James R Campbell Ii
- Division of Vascular and Endovascular Surgery, West Virginia University, Charleston, WV
| | - Ali F AbuRahma
- Division of Vascular and Endovascular Surgery, West Virginia University, Charleston, WV
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Stone PA, Campbell JE, AbuRahma AF. Femoral pseudoaneurysms after percutaneous access. J Vasc Surg 2014; 60:1359-1366. [PMID: 25175631 DOI: 10.1016/j.jvs.2014.07.035] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Accepted: 07/16/2014] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Patrick A Stone
- Department of Surgery, West Virginia University, Charleston, WV.
| | - John E Campbell
- Department of Surgery, West Virginia University, Charleston, WV
| | - Ali F AbuRahma
- Department of Surgery, West Virginia University, Charleston, WV
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Stone PA, Campbell JE. Complications Related to Femoral Artery Access for Transcatheter Procedures. Vasc Endovascular Surg 2012; 46:617-23. [DOI: 10.1177/1538574412457475] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Percutaneous-based procedures continue to increase as endovascular techniques improve and provide a less morbid approach than the open vascular procedures. The most common complications associated with either cardiac interventions or peripheral interventions involve the access point of the procedure. The retrograde femoral access has and is currently the most frequently used arterial access. Vascular surgeons have been responsible for management of complications following femoral-based procedures and now are a significant contributor to catheter-based diagnostic and interventional procedures. This review provides in-depth review of the literature on specific complications encountered during percutaneous femoral artery puncture. This review includes access complications related to the method of obtaining access (ie, best pulse fluoroscopic guided), direction of access either retrograde or antegrade, risk factors and incidence of complications based on best literature sources, and management strategies for specific complications.
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Affiliation(s)
- Patrick A. Stone
- Division of Vascular & Endovascular Surgery, WVU, Charleston, WV, USA
| | - John E. Campbell
- Division of Vascular & Endovascular Surgery, WVU, Charleston, WV, USA
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Dregelid E, Jenssen G, Jonung T, Braaten A. Pseudoaneurysm of the abdominal aorta due to a needle-like osteophyte on the first lumbar vertebra. J Vasc Surg 2007; 45:1059-61. [DOI: 10.1016/j.jvs.2006.12.070] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2006] [Accepted: 12/28/2006] [Indexed: 12/01/2022]
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