Incidence of pseudoaneurysm after diagnostic and therapeutic angiography

Ultrasound-guided thrombin injection for cardiac catheterization pseudoaneurysms: efficacy, safety, and predictors

BACKGROUND

Percutaneous ultrasound-guided thrombin injection has become the gold standard treatment for pseudoaneurysms caused by cardiac catheterization. However, failure can occur in up to 25% of the procedures and little is known about its causes.

PURPOSE

To study the efficacy and safety of the technique and to determine possible risk factors responsible for the unsuccess.

MATERIAL AND METHODS

A cohort study was carried out based on data from medical records collected between December 2012 and June 2020 of 110 patients with the diagnosis of pseudoaneurysm, femoral or radial, secondary to cardiac catheterization. Clinical data, pseudoaneurysm morphological parameters, and technical factors related to catheterization were reviewed.

RESULTS

Primary and global technical success rates were 85.5% and 100%, respectively. Age, neck, and anteroposterior diameter variables were predictors of primary failure on multivariate analysis. The odds ratio (OR) for age was 0.960 (95% confidence interval [CI]=0.927-0.995; P = 0.025), for anteroposterior diameter, OR was 2.023 (95% CI=1.144-3.578; P = 0.015), and for neck diameter, it was 4.625 (95% CI=1.023-20.904; P = 0.047). The receiver operating characteristic (ROC) curve was performed for the multivariate analysis model and the three predictors of failure. The area under the curve for the multivariate analysis model was 0.695, for age it was 0.675, for anteroposterior diameter it was 0.679, and for neck diameter it was 0.676. No complications were observed.

CONCLUSIONS

Percutaneous ultrasound-guided thrombin injection is safe and effective for the treatment of pseudoaneurysms after cardiac catheterization. Largest anteroposterior diameter, largest neck diameter, and a younger age were independent predictors of primary failure with the technique.

Managing Femoral Artery Pseudoaneurysm Using Snare-Guided Through-and-Through Access With Perclose ProGlide

Iatrogenic femoral artery pseudoaneurysm (IFAP) is a common complication following endovascular procedures. Treatment options include manual compression, ultrasound-guided compression, thrombin injection, and surgical repair, each with its own limitations. Recent case reports have described successful IFAP treatment using the Perclose ProGlide/ProStyle (Abbott Vascular, Lake Bluff, USA) suture-mediated closure device by directly puncturing the pseudoaneurysm sac and advancing a guidewire into the native artery. Herein, we present a novel through-and-through wire technique using the same device for treating IFAP. The technique involves advancing a microcatheter into the pseudoaneurysm from the contralateral femoral artery, deploying a snare through it, and then puncturing through the center of the deployed snare to establish through-and-through wire access for Perclose deployment. We successfully treated a 60-year-old woman who developed a femoral artery pseudoaneurysm following angiography. Compared to previously reported direct puncture techniques using Perclose, this approach allows real-time angiographic confirmation of device deployment and may reduce radiation exposure to operators compared with direct puncture techniques. While further experience is needed to determine its optimal role in clinical practice, this technique may serve as an effective alternative in the endovascular treatment of IFAP.

Surgical Strategies in Reoperation of the Proximal Aorta and Arch for Patients with Previous Frozen Elephant Trunk

Background: The frozen elephant trunk (FET) technique is increasingly utilized for aortic arch replacement in cases of aortic dissections and aneurysms. This rise in usage has led to more patients needing redo aortic surgeries due to progression of existing conditions, FET-related complications, or new valvular/coronary diseases. This article aims to evaluate surgical techniques to minimize risks during these reoperations, including a case study of a complex redo surgery. Methods: A comprehensive examination of surgical strategies was conducted, focusing on preoperative preparation, cannulation site identification, cerebral and cardiac protective measures, and pitfalls to avoid. The importance of adapting to the modified anatomical landscape post-FET is emphasized. A detailed case study of a patient undergoing complex redo FET surgery is included. Results: The article identified key surgical strategies for reoperation in patients with prior FET, highlighting the importance of meticulous preoperative planning and execution. Techniques to minimize risks include detailed imaging for planning, strategic cannulation for optimal perfusion, multidisciplinary approaches as well as careful fail-safe measures. The case study demonstrates the practical application of these strategies in a high-risk scenario. The evidence underscores the necessity for individualized patient management and the development of standardized protocols. Conclusions: The FET technique, while effective for initial aortic arch repairs, often necessitates complex reoperations. Adopting advanced surgical strategies and multidisciplinary planning can significantly mitigate risks associated with these procedures. Future research should focus on refining these techniques and establishing standardized protocols to improve patient outcomes.

Accuracy and feasibility in building a personalized 3D printed femoral pseudoaneurysm model for endovascular training

BACKGROUND

The use of three-dimensional(3D) printing is broadly across many medical specialties. It is an innovative, and rapidly growing technology to produce custom anatomical models and medical conditions models for medical teaching, surgical planning, and patient education. This study aimed to evaluate the accuracy and feasibility of 3D printing in creating a superficial femoral artery pseudoaneurysm model based on CT scans for endovascular training.

METHODS

A case of a left superficial femoral artery pseudoaneurysm was selected, and the 3D model was created using DICOM files imported into Materialise Mimics 22.0 and Materialise 3-Matic software, then printed using vat polymerization technology. Two 3D-printed models were created, and a series of comparisons were conducted between the 3D segmented images from CT scans and these two 3D-printed models. Ten comparisons involving internal diameters and angles of the specific anatomical location were measured.

RESULTS

The study found that the absolute mean difference in diameter between the 3D segmented images and the 3D printed models was 0.179±0.145 mm and 0.216±0.143mm, respectively, with no significant difference between the two sets of models. Additionally, the absolute mean difference in angle was 0.99±0.65° and 1.00±0.91°, respectively, and the absolute mean difference in angle between the two sets of data was not significant. Bland-Altman analysis confirmed a high correlation in dimension measurements between the 3D-printed models and segmented images. Furthermore, the accuracy of a 3D-printed femoral pseudoaneurysm model was further tested through the simulation of a superficial femoral artery pseudoaneurysm coiling procedure using the Philips Azurion7 in the angiography room.

CONCLUSIONS

3D printing is a reliable technique for producing a high accuracy 3D anatomical model that closely resemble a patient's anatomy based on CT images. Additionally, 3D printing is a feasible and viable option for use in endovascular training and medical education. In general, 3D printing is an encouraging technology with diverse possibilities in medicine, including surgical planning, medical education, and medical device advancement.

Influence of anatomical factors on the efficacy of treating femoral pseudoaneurysms with ultrasound-guided compression technique: A prospective cohort study

BACKGROUND

Femoral pseudoaneursysm treatment is still controversial.

AIMS

The aim of this study was to evaluate the anatomic features related to femoral pseudoaneurysm (FPA) closure failure for ultrasound-guided compression (USGC).

METHODS

This was a single-center, prospective, cohort study. FPA patients admitted to the radiology department for USGC were included in the study. Age, sex, duration of FPA, thrombosis, ratio of thrombosis to FPA diameter, feeding artery, tortiosity, connection properties, length and width of the neck, volume, and fistula-to-common femoral artery (CFA) speed ratio were reported during color Doppler ultrasonography (CDUS) scanning.

RESULTS

The study was completed with 192 patients. FPA compression therapy was successful in 155 patients and failed in 37 patients. FPA without a narrow connection (p < 0.001), FPA without existing thrombosis (p < 0.001), a lower thrombosis ratio (p < 0.001), a longer duration of FPA (p = 0.035), a shorter neck length, a wider neck width (p < 0.001), and a higher fistula-to-CFA speed rate (p < 0.001) were related to FPA closure failure with USGC. ROC analysis of the fistula-to-CFA speed ratio showed that a ratio of 1.01 had 47% sensitivity and 63% specificity for USGC treatment failure (AUC, 0.72; p < 0.05).

CONCLUSIONS

Failure of FPA closure with USGC is closely related to anatomic features of FPA. Evaluating the anatomical features of FPA before deciding the treatment method can be beneficial for patients and clinicians.

Incidence, risk factors, and management following cardiac catheterization via carotid and axillary artery approaches: A single-center experience on pseudoaneurysms in young infants

BACKGROUND

Use of alternate access for complex neonatal interventions has gained acceptance with carotid and axillary artery access being used for ductal and aortic interventions.

METHODS

This study was a retrospective, single-center study at Cincinnati Children's Hospital Medical Center. The study included infants, aged ≤90 days, who underwent cardiac catheterization with either carotid or axillary artery access between 2013 and 2022. Data encompassing demographics, clinical information, catheterization data, and the incidence of pseudoaneurysm as a procedural complication were collected.

RESULTS

Among 29 young infants (20 males, 69%), 4 out of 15 patients (27%) who underwent the carotid approach developed pseudoaneurysms, while 1 out of 14 patients (7.1%) who underwent the axillary approach developed one. Two patients required transcatheter intervention due to enlargement of pseudoaneurysms, involving the placement of transarterial flow-diverting stent and occlusion of left common carotid artery. Longer sheath in-to-out time (135 vs. 77 min, p = 0.001), and higher closing activated clotting times (ACT) (268 vs. 197 s, p = 0.021) were observed among patients with pseudoaneurysms compared to those without.

CONCLUSIONS

Young infants with alternative access via the carotid and axillary arteries may be at risk of pseudoaneurysm formation during longer procedures and with higher ACTs for closure. Ultrasound-guided compression can be employed to prevent the progression and in resolution of these lesions.

Balloon-Assisted Thrombin Injection of a Profunda Femoral Pseudoaneurysm Using Radial Access

The profunda femoral artery is an uncommon location for a pseudoaneurysm and is technically challenging to resolve with traditional techniques, such as ultrasound-guided compression or thrombin injection, owing to its deep anatomical location. Balloon-assisted thrombin injection (BATI) is a technique that has been shown to be effective using contralateral access for technically difficult pseudoaneurysms in high-risk surgical patients. We report a case of BATI using radial access in a patient with a profunda femoral artery pseudoaneurysm.

Use of veno-venous extracorporeal membrane oxygenation for stabilization prior to redo sternotomy for aortic pseudoaneurysm repair

Background: Aortic pseudoaneurysms are particularly dangerous because of the risk of rupture and compression of mediastinal structures, including the trachea, and resultant respiratory distress. If respiratory distress progresses to respiratory failure, extracorporeal membrane oxygenation may be used to provide oxygenation prior to or during pseudoaneurysm repair. Case presentation: A 62-year-old male with a history of emergent aortic ascending and arch replacement for Stanford Type A dissection 10 months prior presented to his primary care physician with dyspnea. Chest radiography revealed a widened mediastinum, and subsequent computed tomography angiogram revealed a pseudoaneurysm at the distal suture line of the aortic arch replacement. Due to the location of the pseudoaneurysm, the patient's trachea was compressed, and he was emergently placed on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) following unsuccessful intubation for respiratory distress. Two days later, the patient underwent a redo sternotomy and repair of a 2-3 mm defect in the anterior aspect of the distal suture line of the prior aortic arch replacement. The patient progressed well and was discharged on postoperative day 13. What we learned: Using a combination of peripheral bypass, hypothermic circulatory arrest, delayed closure, and respiratory support, this case demonstrates how even complex patients can be successfully treated with multiple strategies.

Pseudoaneurysms: Different ultrasound patterns, aetiologies and locations

Pseudoaneurysms are frequent vascular anomalies. This review article aims to describe the unique specific aspect of pseudoaneurysm (PSA) that allows to make the diagnosis using different modalities: colour Doppler ultrasound, computed tomographic angiography, magnetic resonance angiography and conventional angiography. It is essential to know the various aetiologies of PSA: iatrogenic, traumatic, dissecting and anastomotic; different locations and the possible complications, information to help clinicians choose the best treatment. Our review is supported by illustrated series of cases.

Vascular Access Management in Complex Percutaneous Coronary Interventions

Vascular access is a crucial step, which every interventional cardiologist needs to be skilled with to consistently achieve excellent periprocedural outcomes. Some operators argue that it is the most important aspect of the entire intervention. Hence, careful planning of vascular access in an individualized fashion - based on the patient's clinical status, anatomy, and technical requirements of the intervention - is the first step in securing optimal procedural safety and successful results. We briefly review multiple aspects of vascular access and management including site selection, ultrasound guidance, micro-puncture techniques, sheathless techniques, limb perfusion, clinical monitoring, large bore closure, and management of complications. Approaching every vascular access in a systematic way, even in emergent situations, allows operators to minimize the risk of complications, especially in an often severely ill patient population.

A rare complication after an interventional procedure using the common carotid: carotid pseudoaneurysm in an infant

The carotid artery is a valuable vascular access that can be used in patients who have undergone repetitive interventional and surgical procedures and premature babies. In the past, cut-down was used but nowadays, mostly the procedure is performed under ultrasonographic guidance. Complications such as bleeding, haematoma, and pseudoaneurysm may occur when the carotid artery is used as a vascular access for the procedures such as aortic balloon valvuloplasty, coarctation balloon angioplasty, or after interventional or surgical treatments to the carotid artery. Although pseudoaneurysm is very rare, prompt diagnosis and accurate treatment planning are life-saving. In this article, the diagnosis and treatment of pseudoaneurysm in the left common carotid after transcatheter coarctation balloon angioplasty in a 6-month-old infant will be presented.

Bullet Wound Blues: A Case Report on Brachial Artery Pseudoaneurysm

Pseudoaneurysms are typically iatrogenic due to the increasing use of the artery for arterial interventions such as invasive vascular radiological procedures, invasive coronary artery procedures, arterial punctures for an arteriogram, or catheterization. Other reasons for pseudoaneurysm formation are intravenous drug use and penetrating trauma. They are more commonly observed in the lower limbs than in the upper limbs. In this case report, we present the occurrence of a brachial artery pseudoaneurysm (BAP) in a 73-year-old male patient who suffered a gunshot wound (GSW) 25 years ago during the war and was admitted to the hospital because of a fall episode. This case represents one of the few documented instances of a pseudoaneurysm formation following a GSW in the United States. Along with that, we describe the subsequent medical care provided to the patient.

Lower extremity pseudoaneurysms and their interventional radiological management: a pictorial review

Lower extremity pseudoaneurysms (PsAs) are mostly developed after traumatic or iatrogenic injury to the arteries. Unless treated, they can be complicated by adjacent mass effects, distal embolism, secondary infection, and rupture. Imaging helps in the diagnosis and planning of therapeutic intervention. Ultrasonography (USG) is often diagnostic, while CT angiography aids in vascular mapping required for intervention. Image-guided therapy offers to manage these pseudoaneurysms in a minimally invasive approach, obviating the need for surgery. A smaller, superficial, and narrow-necked PsA can easily be managed with local USG-guided compression or thrombin injection. When the percutaneous approach is not a feasible option, PsA from expendable arteries can also be managed with coiling or glue injection. Wide-necked PsA from an unexpendable artery necessitates stent graft placement, although coiling of the neck may be a viable and cheaper alternative for a long- and narrow-necked PsA. Presently, vascular closure devices are also used to seal a small arterial rent through a direct percutaneous approach. This pictorial review entails various techniques to deal with lower extremity pseudoaneurysms. An idea about the various intervention radiological approaches will help in choosing appropriate methods to tackle lower extremity pseudoaneurysms.

Percutaneous access of an intraoperatively recanalized mid-superficial femoral artery for distal lower limb revascularization

A 61-year-old male patient presented with rest pain and ulceration in his left leg 1 week after a hybrid procedure with bilateral external iliac stenting, common femoral artery thromboendarterectomy, and left-sided femoral popliteal bypass with an in situ saphenous vein. The bypass had been stented intraoperatively but had again become occluded directly after surgery. In the present report, we demonstrate the usefulness of direct percutaneous access to the mid-superficial femoral artery that had been intraoperatively recanalized via brachial artery access during the same procedure. This innovative combination of approaches allows for proximal and distal lower limb revascularization with stenting when avoidance of femoral artery access is considered appropriate.

Percutaneous Thrombin Injection with Balloon Protection for a Large Iatrogenic Femoral Artery Pseudoaneurysm: A Case Report with Review of Literature

Iatrogenic femoral artery pseudoaneurysms (IFAPs) are not uncommon due to the increase in various minimally-invasive endovascular procedures. Percutaneous thrombin injection is an established technique for large pseudoaneurysms. When ultrasound-guided compression of an aneurysmal neck is not feasible, percutaneous thrombin injection can be combined with endovascular balloon occlusion to prevent leakage of thrombin into the parent artery. We describe a large IFAP following the removal of the femoral dialysis catheter after an inadvertent arterial puncture, which was managed with percutaneous ultrasound-guided (USG) thrombin injection with simultaneous balloon occlusion at the level of the aneurysmal neck without any complications. Follow-up imaging showed thrombosed IFAP without any recurrence.

Pseudoaneurysm Infection Ballooning Out of Control Following Sequential Cardiac Catheterizations: A Case Report

A femoral artery pseudoaneurysm (PSA) is a potential complication of vascular access procedures, such as cardiac catheterizations, that can have serious consequences if left untreated. Although the incidence of PSA formation has decreased due to the advent of improved surgical techniques, this case demonstrates that such complications should be considered in a clinical setting. This report presents a case of right femoral PSA, pacemaker infection, and high-grade methicillin-resistant Staphylococcus aureus (MRSA) bacteremia status post multiple cardiac catheterizations. Treatment included open repair of his femoral artery PSA, antibiotics tailored to culture sensitivities, and pacemaker removal. The potential complications, diagnosis, management, and alternative treatment options for PSAs are discussed in order to encourage clinical awareness of a rare complication.

Transaneurysmal Occlusion of Complicated Common Femoral Artery Pseudoaneurysms Using the Angio-Seal Closure Device-A Promising Technique

PURPOSE

Pseudoaneurysm (PSA) developing after catheter examinations is one of the most frequent vascular complications and a nonsurgical technique with utmost low risk of complications is warranted. Our aim was to investigate the technical feasibility, success, and safety of transaneurysmal occlusion of complicated post-interventional common femoral artery (CFA) PSA using the Angio-Seal Closure Device (ASCD) and a technique that we describe as the transaneurysmal (TA) maneuver.

MATERIAL AND METHODS

We used the Angio-Seal (Terumo, Tokyo, Japan) Closure System to manage complicated PSAs in patients who would otherwise have needed surgery after failure of all conservative therapies. The TA maneuver was performed in 14 consecutive patients from July 2021 to July 2022. After ultrasound-guided puncture of the PSA close to its neck, the CFA was entered radiographically with micro-guidewires, and the neck of the PSA was closed with the ASCD after changing the sheaths and wires. All patient had to wear a pressure dressing until the next day, when successful closure was verified by sonography.

RESULTS

All procedures were performed with technical success and without any complications. No patient had to undergo surgery. All sonographies on the next day confirmed complete absence of perfusion within the PSA and normal flow conditions of the CFA and vessels below.

CONCLUSION

The TA maneuver a promising minimally invasive procedure for closing complicated PSA of the CFA after catheter examination.

US-guided percutaneous thrombin injection to treat non-femoral artery pseudoaneurysms: preliminary experience and review of the literature

PURPOSE

To evaluate the clinical outcome of US-guided percutaneous thrombin injection in the treatment of non-femoral artery pseudoaneurysms (NFAP).

MATERIALS AND METHODS

Among all pseudoaneurysms treated in our institution, we retrospectively collected NFAP embolized with percutaneous thrombin injections from January 1, 2015, to December 31, 2021. The embolization was prompted for an ongoing antiaggregating/anticoagulation therapy, NFAP optimal US visibility, or high surgery-related risks. Causes, location, size and neck of NFAP, complications, number of repeated treatments, clinical success and patients clinical conditions at discharge were annotated. The endpoint for clinical success was the resolution of NFAP at postprocedural imaging, with no resort to surgery.

RESULTS

Eight consecutive patients (5 females, median age 73 years, range 46-84) underwent 16 procedures. Arterial damage was due to catheterization (3), CVC mispositioning (2), trauma, hemorrhagic diathesis and endoprosthesis endoleak. We treated humeral (2), subclavian (2), thyrocervical, anterior tibial, radial and pancreaticoduodenal arteries. Median pseudoaneurysm size was 530 mm² (range 32-2400 mm²), with a thin (7/8) or non-visible (1/8) neck. No complications occurred. Clinical success was obtained in 7/8 patients (88%), with a single treatment in 4, multiple in 3 cases (4 embolizations, 3 and 2, respectively). One patient underwent surgical suture after the second failed attempt of percutaneous embolization. Seven patients were discharged in good clinical conditions; one died during hospitalization, due to the worsening of the underlying cardiac disease.

CONCLUSIONS

Percutaneous US-guided thrombin injection to treat NFAP is feasible in selected cases, with rare complications. Clinical success is often reached, also by repeated injections.

Successful endovascular repair of complicated pseudoaneurysm using Perclose ProGlide: A novel concept

Iatrogenic pseudoaneurysm is common vascular complications of angiographic procedures. Patients with uncomplicated pseudoaneurysms can be managed with ultrasound-guided techniques. However, for complicated pseudoaneurysms, surgical repair of the artery is mandatory. We report a case of successful repair of complicated pseudoaneurysm using an access-site closure device, Perclose ProGlide™ without a surgical approach.

Imaging-Guided Percutaneous Puncture and Embolization of Visceral Pseudoaneurysms: Feasibility and Outcomes

Visceral artery pseudoaneurysms (VAPAs) are the most frequently diagnosed pseudoaneurysms (PSAs). PSAs can be asymptomatic or symptomatic. The aim of our study was to evaluate the safety and effectiveness of percutaneous embolization of VAPAs performed on patients with an unfeasible trans-arterial approach. Fifteen patients with fifteen visceral PSAs, with a median dimension of 21 mm (IQR 20–24 mm), were retrospectively analyzed. No patients were suitable for trans-arterial catheterization and therefore a percutaneous approach was chosen. During percutaneous treatments, two embolic agents were used, either N-butyl cyanoacrylate (NBCA) (Glubran II, GEM Milan, Italy) mixed with Lipiodol (Lipiodol, Guerbet, France) or thrombin. The outcomes of this study were technical success, primary clinical success, and secondary clinical success. In our population the 15 PSA were located as follows: 2 in the left gastric artery, 1 in the right gastric artery, 3 in the right hepatic artery, 2 in a jejunal artery, 1 in left colic artery branch, 1 in a right colic artery branch, 1 in the gastroepiploic artery, 1 in the dorsal pancreatic artery, 1 in an ileocolic artery branch, 1 in an iliac artery branch, and 1 in a sigmoid artery branch. 80% of PSAs (12/15) were treated with a NBCA:lipiodol mixture and 20% of PSAs (3/15) were treated with thrombin. Technical, primary, and secondary clinical successes were obtained in 100% of the cases. No harmful or life-threatening complications were observed. Minor complications were registered in 26.6% (4/15) of the patients. Percutaneous embolization of visceral PSA is a safe and effective treatment and should be considered as an option when the endovascular approach is unsuccessful or unfeasible.

Interventional radiology management of extremity pseudoaneurysms: a pictorial essay

Pseudoaneurysms are vascular abnormalities caused by a damaging force on an arterial wall, resulting in a persistent extravasation of blood into the surrounding tissue, which can be the result of infection, inflammation, trauma or any iatrogenic procedure. The incidence of extremity artery pseudoaneurysms is rising because of increased number of endovascular procedures. As a number of complications are associated with these false aneurysms, it is important to know the treatment modalities available. Ultrasound is the most common method of diagnosing extremity pseudoaneurysm because of their superficial location. Computed tomographic angiography is the next investigation of choice as it has three-dimensional capability and can help evaluate the vascular bed. Digital subtraction angiography is rarely used for diagnosis alone, and is used only when a therapeutic procedure is planned. Treatment of these pseudoaneurysms has shifted from open surgical procedures to minimally invasive treatment in recent years. The different techniques for tackling these lesions include ultrasound-guided compression, percutaneous thrombin or glue embolisation and endovascular coil or stent graft placement. In this pictorial essay, we review the different treatment modalities so that an interventional radiologist is aware of all the treatments he can offer when confronted with these lesions.

Successful treatment of a femoral pseudoaneurysm by ultrasonographically-guided application of a suture-mediated closure device

We treated successfully a man with a femoral artery pseudoaneurysm by ultrasonography-guided application of a suture-mediated closure device. Radiography was not needed, as a guide wire was placed into the femoral artery along the rupture under ultrasonographic guidance alone, and the femoral artery was then sutured with the vascular closure device. The pseudoaneurysm was then completely resolved. This novel approach, which minimizes risks and costs, may be a safe and acceptable option to control iatrogenic pseudoaneurysms, especially when thrombin injection is not feasible.

Non-neoplastic Soft Tissue Tumors and Tumor-like Lesions

Clinicians are commonly faced with patients presenting with a solitary palpable soft tissue mass. Most soft tissue lesions are benign, and not every mass is due to a neoplastic process. Many pathologies can mimic a malignant tumor. Despite appropriate clinicoradiologic assessment, these lesions can be mistaken for a soft tissue sarcoma and can lead to multiple investigations or an intervention, inconveniencing patients and leading to an increased health care cost. With the relevant clinical history, clinical examination, and specific imaging characteristics, the diagnosis can be narrowed. We present a pictorial review of soft tissue sarcoma mimics with guidance on appropriate differential diagnoses.

Safety and Efficacy of Arterial Closure Devices Following Antegrade Femoral Access: A Case-Control Study

PURPOSE

Vascular closure device (VCD) use following antegrade femoral access may present unique challenges relative to retrograde access. We retrospectively compared safety and efficacy of these devices between antegrade and retrograde patient cohorts undergoing percutaneous intervention.

MATERIALS AND METHODS

Over a 5-year period, a consecutive series of 107 limbs in 84 patients underwent VCD arteriotomy closure following percutaneous revascularization using an antegrade approach (VCD-A). Device deployment success rates, time to ambulation, and complication rates were compared to a contemporaneous control group of 401 limbs in 305 patients who underwent closure following retrograde access (VCD-R) during revascularization or embolization procedures.

RESULTS

Closure was attempted in VCD-A using 53 StarClose, 35 Perclose, and 19 Angio-Seal devices. Hemostasis (without supplemental manual compression) was achieved in 86/107 (80.4%) limbs. Closure was attempted in VCD-R using 215 StarClose, 119 Perclose, and 67 Angio-Seal devices with hemostasis in 357/401 (89.0%) limbs. Device deployment failure occurred in 7/107 (6.5%) of VCD-A and 20/401 (5.0%) of VCD-R (P = .52), independent of specific device type. Femoral pseudoaneurysm developed in 1/107 and 1/401 of VCD-A and VCD-R (P = .31), and minor hematoma developed in 3/107 and 8/401 of the VCD-A and VCD-R (P = .61). Mean time to ambulation was 204.1 minutes in VCD-A and 204.8 minutes in VCD-R (P = .97).

CONCLUSION

Antegrade femoral closure was associated with high rates of technical success and low complications, similar to retrograde closure. Time to ambulation was the same in both groups despite higher heparin doses in the antegrade patients.

Balloon-assisted Transcatheter arterial embolization using N-butyl cyanoacrylate for iatrogenic arterial bleeding by groin puncture: a new technology

Background

Balloon-assisted transcatheter arterial embolization (TAE) using n-butyl cyanoacrylate (NBCA) and lipiodol (Lp) mixture is a new endovascular treatment technique for iatrogenic arterial bleeding by groin puncture. It is less invasive compared to surgical repair, and NBCA migration into the circulation can be prevented by temporary balloon occlusion of the parent artery without ultrasound-guidance. This study aimed to report on the technical aspects and evaluate the efficacy and safety of fluoroscopically guided balloon-assisted transcatheter arterial embolization using NBCA for iatrogenic arterial bleeding by groin puncture.

Materials and methods

The study included five patients (mean age 54.6 years; 3 male and 2 female) with iatrogenic arterial bleeding by groin puncture. We performed transcatheter arterial embolization using NBCA while occluding the responsible artery with a balloon catheter during the embolization to prevent NBCA migration. Two sheaths were inserted into the common femoral artery. A microcatheter was advanced into the pseudoaneurysm or extravasation via the contralateral sheath. A balloon catheter was advanced into the responsible artery until the balloon portion covered the leakage site via another sheath. After balloon inflation, the NBCA and Lip mixture was slowly injected until the pseudoaneurysm, or the extravasation was filled without touching the balloon. The microcatheter was removed immediately after the filling. We assessed technical success, overall success, and complications.

Results

The injured arteries were the external iliac artery (n = 1), the common femoral artery (n = 2), and the proximal portion of the superficial femoral artery (n = 2). NBCA was injected once in four cases and twice in one case where complete hemostasis could not be achieved with one injection. The technical and overall success rate was 100% with no complications, including distal embolization of NBCA.

Conclusions

Balloon-assisted TAE using NBCA is a feasible, effective, and safe treatment for iatrogenic arterial bleeding by groin puncture. It may also be applicable in other arterial bleeding situations where the potential risk of distal embolization can be decreased by applying the balloon-assisted technique.

Ultrasound-guided thrombin injection versus ultrasound-guided compression therapy of iatrogenic femoral false aneurysms: Single center experience

Background

Iatrogenic femoral pseudoaneurysm (false aneurysm) due to arterial access following cardiovascular procedures is becoming common because of the increase in number and complexity of the procedures. Recently, percutaneous thrombin injection is becoming a popular treatment of these false aneurysms.The aim of this study was to assess the efficacy and safety of femoral pseudoaneurysm closure using ultrasound-guided thrombin injection in comparison to ultrasound-guided compression.

Methods

A retrospective analysis was undertaken of 65 patients who presented to our vascular department with iatrogenic femoral pseudoaneurysm between January 2015 and March 2019. Twenty-five patients underwent ultrasound-guided thrombin injection, and 40 were treated using ultrasound-guided compression therapy. The primary outcome measured was efficacy, while other outcomes examined were safety, procedure duration, and cost.

Results

A total of 65 patients (45 males, 20 female) were identified with a mean age of 62 years. Out of the 65, 40 patients (28 males, 12 female) underwent ultrasound-guided compression therapy (group A) with a mean aneurysm size of 2.9 cm, and 25 (17 male, 8 female) underwent ultrasound-guided thrombin injection (group B) with a mean pseudoaneurysm sac size of 3.7 cm. The success rate of thrombosis in group A was 70% and in group B was 92%. No significant complications were reported in both groups.

Conclusions

Ultrasound-guided thrombin injection should be considered as the first line of treatment for uncomplicated femoral pseudoaneurysms because it has a higher thrombosis and lower recurrence rates, when compared with ultrasound-guided compression treatment.

Radial artery pseudoaneurysm as a rare very late complication of transradial cardiac catheterization

AIMS

Here, we report a case of very late (70+ days) development of pseudoaneurysm on the site of sheath insertion in a 60- year old woman.

METHODS

The patient underwent cardiac catheterization using transradial approach.

RESULTS

Despite the transradial approach, which is generally considered as a suitable prevention of this problem, and despite absence of any periprocedural complications, the patient developed a pseudoaneurysm after more than 70 days from the procedure.

CONCLUSIONS

In some cases, a pseudoaneurysm may develop extremely late after cardiac catheterization. Such an extremely late development of pseudoaneurysm has not been described in literature so far.

Management of Aortic Pseudoaneurysms: Evolving Concepts and Controversies

Background  Techniques to repair aortic pseudoaneurysms have been rapidly evolving. We present our results following open and endovascular repair of aortic pseudoaneurysms from 2009 to 2013.

Methods  A total of nine patients underwent pseudoaneurysm repair from April 2009 to February 2013. Of them, five underwent open repair and four underwent endovascular repair. The median age was 58 years (range, 40–72 years) and two (22%) were females. Preoperative, operative, and postoperative data are presented along with operative modality.

Results  Two patients died during the period of study. Patient 1 died from massive hemorrhage at the site of prior stenting. Patient 7 died from postoperative cardiac arrest and respiratory failure. A single patient required hemorrhage-related reexploration. None of the patients experienced stroke or acute renal failure following repair. Median hospital and intensive care unit length of stays were 7.1 (range, 1–20) and 2.0 (range, 1–5), respectively.

Conclusions  Pseudoaneurysm repair can be effectively achieved through open or percutaneous repair but only after careful consideration of anatomical constraints, as well as patient comorbidities.

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 treatment of vascular access-site complications: a ten years' experience in two centres

Background

The spread of percutaneous arterial catheterization in diagnostic and therapeutic procedures has led to a parallel increase of vascular access site complications. The incidence of these events is between 0.2–1%. A detailed analysis of injuries by type of procedure shows a higher incidence of injuries after therapeutic procedures (3%) than those observed for diagnostic ones (1%), due to the greater size of the vascular devices used and the necessity to frequently administer anticoagulant and antiplatelet therapy during procedures. The iatrogenic arterial injuries requiring treatment are the pseudoaneurysm, arteriovenous fistula, arterial rupture and dissection. Less frequent complications include distal embolization of the limbs, nerve damage, abscess and lymphocele.

Moreover, the use of percutaneous vascular closure devices (VCD) has further expanded the types of complications, with an increased risk of stenosis, thrombosis, distal embolism and infection. Our work aims to bring the personal 10 years’ experience in the percutaneous treatment of vascular access-site complications.

Results

Ninety-two pseudoaneurysms (PSA), 12 arteriovenous fistulas (AVF), 15 retrograde dissections (RD) and 11 retroperitoneal bleedings (RB) have been selected and treated. In 120/130 cases there were no periprocedural complications with immediate technical success (92.3%). Nine femoral PSA, treated with percutaneous ultrasound-guided thrombin injection, showed a failure to close the sac and therefore they were treated by PTA balloon inflation with a contralateral approach and cross-over technique. Only one case of brachial dissection, in which the prolonged inflation of the balloon has not led to a full reimbursement of the dissection flap, was then surgically repaired. At the 7 days follow-up, complications were two abscesses in retroperitoneal bleedings, treated by percutaneous drainage. At 3 months, acute occlusion of 3 covered femoral stents occurred, then treated by loco-regional thrombolysis and PTA. A total of 18 major complications was recorded at 2 years, with a complication rate at 2 years of 13.8%.

Conclusions

The percutaneous treatment of vascular access-site complications is the first-choice treatment. It represents a safe and effective option, validated by a high technical success rate and a low long-term complication rate, that allows avoiding the surgical approach in most cases.

Ultrasound-guided thrombin injection for treatment of iatrogenic femoral artery pseudoaneurysms compared with open surgery: first experiences from a single institution

Purpose

The frequency of iatrogenic femoral artery pseudoaneurysm (FAP) diagnoses has recently increased due to the growing use of diagnostic and interventional procedures involving large diameter sheaths, as well as more potent anticoagulation procedures. In this study, we aimed to present our experience with ultrasound-guided thrombin injection (UGTI) in patients with iatrogenic FAP.

Methods

We studied patients with FAP who were under anticoagulant or antiplatelet therapies preoperatively, or who had received a loading dose during an interventional procedure. The outcomes of patients with FAP treated with UGTI were compared with those of patients who underwent open surgical repair for pseudoaneurysms.

Results

Among the 55 patients included in this study, 24 had UGTI while 31 had open surgery. The success rate was 95.8% when taking into consideration primary and secondary attempts. The mean duration of the procedure was shorter in patients with UGTI (10.1 ± 3.54 minutes) when compared with those who underwent open surgery (76.55 ± 26.74 minutes, P ≤ 0.001). In addition, the total complication frequency was significantly higher in the open surgery group (P = 0.005), as was their length of hospital stay (P < 0.001). Cost analysis showed significant differences between UGTI ($227.50 ± $82.90) and open surgery ($471.20 ± $437.60, P = 0.01).

Conclusion

We have found that UGTI is the safer and more effective choice of treatment in appropriate patients with FAP, as opposed to surgery.

Interventional treatment options in pseudoaneurysms: different techniques in different localizations

Pseudoaneurysms are commonly experienced vascular abnormalities. The increase in the number of surgical and arteriographic procedures has caused a higher prevalence of pseudoaneurysms. Conventional angiography is still the gold standard method for diagnosis, but other imaging modalities such as duplex Doppler ultrasonography, magnetic resonance angiography and computed tomographic angiography are useful in noninvasive detection. Over the past few years, interventional radiological treatment has evolved and taken the place of surgery in management. There are different kinds of percutaneous and endovascular treatment methods in pseudoaneurysm management. Treatment options depend on certain conditions. We used a case-based approach to discuss pseudoaneurysms and their appropriate treatment by interventional radiological methods in this article.

Pulsatile Mass: Ruptured Common Femoral Artery Pseudoaneurysm with Active Extravasation

Delayed rupture of a pseudoaneurysm represents an extremely rare and life-threatening complication of endovascular, radiographic, and cardiac procedures. We discuss a case of a 69-year-old man with delayed rupture of a known left common femoral artery pseudoaneurysm, highlighting the importance of rapid recognition, to include the use of point of care ultrasound, if available. Computed tomographic angiography allows for better anatomic characterization and aids in operative planning, which is the mainstay of treatment. However, surgical repair in ruptured pseudoaneurysms remains a high-risk procedure.

'Enemy within': an interesting cause for anemia during warfarin therapy for atrial fibrillation

The oral anticoagulant warfarin is a vitamin K antagonist and is considered the first line anticoagulant in valvular atrial fibrillation. However prothrombin time should be closely monitored, drug interactions checked and compliance regarding diet ensured when the patient is on warfarin therapy. Anaemia should be looked for, evaluated for the cause and corrected since it is an independent predictor of bleeding and thrombotic episodes during warfarin therapy for atrial fibrillation We present an interesting case of anaemia which developed during warfarin therapy for atrial fibrillation. The patient was on amiodarone and was consuming leafy vegetables resulting in frequent raise in prothrombin time during which time she developed bleeding into the right femoral pseudoaneurysm which had developed following catheterisation for thrombectomy. Surgical correction of pseudoaneurysm was done, comedication was changed and diet compliance ensured which resulted in the subsequent maintenance of prothrombin time in the therapeutic range and steady haemoglobin levels.

Risk factors attributed to failure of ultrasound-guided compression for post-cardiac catheterization femoral artery pseudoaneurysms

Background:

Femoral pseudoaneurysm is the most important access site complication following cardiac catheterization. Ultrasound-guided compression repair is a safe and effective therapeutic modality with variable failure rates and risk factors. The aim of this study was to investigate which factors were associated with a higher incidence of ultrasound-guided compression repair failure for post-cardiac catheterization femoral pseudoaneurysm.

Methods:

Data were retrospectively collected from medical records at King Abdullah University Hospital during the period from January 2011 to December 2016. A total of 42 patients with post-cardiac catheterization femoral pseudoaneurysm had attempted ultrasound-guided compression repair. Data regarding patients, procedure and aneurysm-related factors were evaluated by univariate analysis and multivariate logistic regression.

Results:

Ultrasound-guided compression repair failed in 31% of the patients. Patients with body mass index of ⩾28 kg/m², platelet count of ⩽180,000/L, time lag (age of aneurysm) of >48 h following puncture time, aneurysmal neck diameter of ⩾4 mm and communicating tract length of <8 mm were associated with higher rate of ultrasound-guided compression repair failure in the univariate analysis. In the multivariate analysis, time lag (age of aneurysm) > 48 h (odds ratio = 5.7), body mass index ⩾ 28 kg/m² (odds ratio = 7.8), neck diameter > 4 mm (odds ratio = 14.4) and tract length < 8 mm (odds ratio = 18.6) were significantly associated with ultrasound-guided compression repair failure.

Conclusion:

Ultrasound-guided compression repair for patients with post-cardiac catheterization femoral pseudoaneurysm was successful in 69% of the patients. Risk factors for failed ultrasound-guided compression repair were as follows: delayed ultrasound-guided compression repair of >48 h, body mass index ⩾ 28 kg/m², wide neck diameter > 4 mm and short aneurysmal communication tract < 8 mm.

Factors associated with pseudoaneurysm development and necessity for reintervention: a single centre study

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.

Imaging-guided percutaneous thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms

PURPOSE

To evaluate factors that may affect successful ultrasound-guided percutaneous thrombin injection of iatrogenic femoral artery pseudoaneurysms (PSA).

MATERIALS AND METHODS

This was an IRB-approved, HIPAA-compliant retrospective study of 326 consecutive subjects (138 males, 188 females; mean age 68 years, range 18-95) who underwent thrombin injection for treatment of femoral PSA; follow-up ultrasound was available in 145 subjects. The number of PSA lobes and dimensions, pre-procedure laboratory values (international normalized ratio [INR], activated partial thromboplastin time [aPTT], platelet count), and concomitant anticoagulation therapy were recorded.

RESULTS

Technical success was achieved in 98.2% (320/326) of subjects. Primary effectiveness (complete thrombosis at 24 h) was achieved in 74.5% (108/145). Twenty-five subjects underwent repeat thrombin injection, successful in 21 subjects, for a total effectiveness rate of 97.0% (129/133). No imaging factor was associated with technique failure, including number of lobes (p = 0.898), largest dimension (p = 0.344), or volume (p = 0.697). No statistically significant difference in pre-procedure INR, aPTT, or platelet count was found between subjects with CT and those with IT (p > 0.138). Anticoagulation therapy was associated with incomplete thrombosis (35.5% [38/107] for CT vs. 63.9% [23/26] for IT; p = 0.002).

CONCLUSION

Imaging-guided percutaneous thrombin injection has high technical success and effectiveness rates for the treatment of iatrogenic femoral artery PSA. Anticoagulation therapy was the only factor associated with incomplete thrombosis.

Pharmacology of Peripheral Arterial Disease in the Angio Suite: What Every Interventionalist Should Know

Safe and effective treatment of peripheral arterial disease (PAD) and critical limb ischemia can be routinely performed in the angiography suite. A systematic understanding of the medications commonly used during these procedures is essential. This review discusses the traditional roles of the medications used in PAD procedures, the existing evidence basis for those roles, potential alternatives, and evolving techniques. Developing a familiarity with these medications can help improve outcomes and safety for the patients being treated.

Off-label use of Angio-Seal vascular closure device for the repair of femoral pseudoaneurysm after transfemoral coronary intervention

Pseudoaneurysm was caused at the puncture site of the left groin after percutaneous coronary intervention. Balloon tamponade was attempted for hemostasis at the aneurysmal site. However, hemostasis was not achieved. Next, direct puncture of the pseudoaneurysm was tried. A 0.014-inch guidewire was crossed from the neck of the pseudoaneurysm to the left common femoral artery. The wire was replaced with a 0.035-inch guidewire. An 8F Angio-Seal (Terumo Interventional Systems, Somerset, NJ) was inserted, and a collagen plug was deployed at the neck of the pseudoaneurysm. Final angiography revealed completion of hemostasis. Three-dimensional computed tomography angiography after 8 months revealed no evidence of recurrence.

Pseudoaneurysm

Pseudoaneurysms (PSAs) are commonly known as complications associated with invasive interventions. Because of the pulsatile in- and outflow of blood through the neck of PSAs, they tend to grow and, in the worse cases, can rupture. Therapeutic options are compression therapy, using a compression bandage and ultrasound-guided compression, and thrombin injection. Manual ultrasound-guided compression is widely performed and is successful in most cases. In general, it is combined with a subsequently applied compression bandage. Thrombin injection is a more difficult technique, but it has a higher success rate. This article gives an overview of the characteristics of PSAs, their diagnostic characteristics and the therapeutic methods used to treat them. Complications associated with compression or thrombin injection are also explained in detail.

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.

A novel interventional method for treating femoral pseudoaneurysms: results from a monocentric experience

AIMS

Iatrogenic pseudoaneurysms of the femoral artery lead to increased morbidity and mortality, especially when surgical treatment is necessary. Manual compression and thrombin injection are commonly used to occlude the pseudoaneurysms. However, in some cases these treatment options are inapplicable or unsuccessful. The aim of the present study was to examine the feasibility, effectiveness and safety of a novel approach with the use of suture-based closure devices to treat pseudoaneurysms.

METHODS AND RESULTS

Between January 2014 and May 2016, a total of eight iatrogenic pseudoaneurysms of the femoral artery were treated by the interventional closure technique after at least one ineffective attempt at manual compression. After puncture of the cavity, a PTCA guidewire was used to pass the neck of the pseudoaneurysm and a sheath was inserted in the femoral artery. Afterwards, a suture-based closure system (ProGlide) was used to occlude the neck. All eight pseudoaneurysms were successfully obliterated. No complications occurred during the procedure.

CONCLUSIONS

The new interventional technique presented in this study fills the gap in successfully treating pseudoaneurysms that cannot be obturated with conventional techniques. By implementing this new technique in clinical practice, a significant number of open surgical repairs could be prevented.

Selective use of Duplex Ultrasound after Successful Thrombin Injection of Pseudoaneurysms

Introduction

Duplex-guided thrombin injection (DGTI) has been shown to be a safe and efficacious initial treatment of iatrogenic arterial pseudoaneurysms. Postinjection follow-up duplex ultrasound examination has become the accepted standard of care despite 1) the use of intraprocedural ultrasonography to monitor successful thrombosis, 2) a low post-DGTI recurrence rate, and 3) the relatively high cost of ultrasonography. A retrospective study of DGTI at our institution was conducted to examine the necessity of routine duplex ultrasound after successful DGTI, along with a review of the relevant literature.

Patient Population/Methods

A retrospective review was conducted of 82 patients with iatrogenic arterial pseudoaneurysms (12 complex; 25.6%) treated with DGTI after initial diagnostic duplex ultrasonography. Immediate routine follow-up duplex ultrasound was performed on 71 of 82 cases (86.6%), whereas 11 patients received only clinical follow-up at the surgeon's discretion. Patient demographics, pseudoaneurysm anatomy, procedural details, outcomes, and complications were retrospectively documented and analyzed.

Results

From January 2002 to November 2003, 82 patients (59.8% women) underwent DGTI for pseudoaneurysm, with the majority located in the common femoral artery (48 of 82; 58.5%). Eighty pseudoaneurysms (97.6%) were treated with DGTI, with 78 (95.1%) being initially successful. Four of 78 (5%) follow-up examinations were judged to be of clinical significance: 2 of 78 patients (2.6%) became symptomatic and experienced pseudoaneurysm recurrence, whereas 2 of 78 patients were found to have an additional, previously undocumented, pseudoaneurysm. Three of these four resolved with a second injection, whereas one resolved without additional treatment. No thromboembolic, allergic, or infectious complications related to DGTI occurred.

Conclusions

In concert with the available literature, this cohort confirms that DGTI is a safe and effective treatment of iatrogenic arterial pseudoaneurysms with a low rate of recurrence, complication, and need for conversion to surgical intervention. DGTI should undoubtedly be the initial treatment of choice for pseudoaneurysms; however, follow-up duplex ultrasonography can be reserved for the clinically symptomatic patient.

Ruptured Pseudoaneurysm of the Dorsalis Pedis Artery Following Ankle Arthroscopy: A Case Report

CASE

We describe the case of a pseudoaneurysm of the dorsalis pedis artery that developed following a repeat ankle arthroscopy for persistent osseous impingement. The patient underwent attempted fluid aspiration for a presumed effusion, and ultimately experienced rupture of the pseudoaneurysm with substantial blood loss, which required emergency vascular repair.

CONCLUSION

Anterior tibial artery and dorsalis pedis artery pseudoaneurysms are relatively rare, but they are well-documented complications of ankle arthroscopy; however, their clinical importance is poorly understood. To our knowledge, this is the first reported case of a ruptured pseudoaneurysm of the dorsalis pedis artery following ankle surgery, and it highlights the need for timely diagnosis.