Ipsilateral femoral vein compression: a contraindication to thrombin injection of femoral pseudoaneurysms

Development of a femoral artery pseudoaneurysm occurs in 0.6% to 3.2% of interventional procedures. Nonsurgical treatment has consisted of ultrasound scan-directed compression and, more recently, direct thrombin injection into the pseudoaneurysm cavity to achieve thrombosis. Reported complications after thrombin injection are rare. We report two cases of femoral venous compression associated with pseudoaneurysm injection and review the literature. A 76-year-old man and an 86-year-old man both underwent thrombin injection of pseudoaneurysms compressing the ipsilateral common femoral vein. Both patients were diagnosed with deep venous thrombosis and subsequently needed surgical exploration for repair of the pseudoaneurysm and release of the venous compression. At exploration, both were found to have significant inflammation surrounding the femoral vessels, which made vessel exposure challenging. Because of the venous outflow obstruction involved in femoral pseudoaneurysms with secondary venous compression and the surgical difficulty caused by surrounding inflammation, avoidance of thrombin injection in favor of early surgical intervention is suggested.     

Percutaneous ultrasound guided thrombin injection: A new method for treating postcatheterization femoral pseudoaneurysms

Purpose: Since its introduction in 1991, ultrasound guided compression repair of postcatheterization femoral artery pseudoaneurysms has been shown to be effective. Disadvantages of ultrasound guided compression repair include patient discomfort during compression, inability to treat noncompressible pseudoaneurysms, prolonged use of ultrasound equipment and personnel, limited success with patients being treated with anticoagulants, and some early recurrences. We conducted a prospective study to evaluate a new method of treating femoral pseudoaneurysms, percutaneous ultrasound guided thrombin injection. Methods: Under duplex ultrasound guidance, a 22- or 25-gauge needle was percutaneously positioned within the pseudoaneurysm. Without compressing the pseudoaneurysm, 0.5 to 1 ml thrombin solution (1000 U/ml) was injected to induce thrombosis. Early in the study, the procedure was modified to allow more than one injection. After successful thrombosis, the patients were kept at rest in bed for at least 1 hour. Duplex ultrasound examination was repeated in 1 to 4 days. Distal pulses and ankle-brachial indexes were measured before and after the procedure. Results: Twenty of 21 consecutive pseudoaneurysms were successfully treated with thrombin injection. Fifteen pseudoaneurysms thrombosed immediately (<20 seconds) after one injection. The other five had partial thrombosis after one injection and complete thrombosis immediately after a second injection. The one failure occurred in a patient who had only one injection and then underwent subsequent ultrasound guided compression repair, which failed. No patient required sedation or analgesia during thrombin injection. There were no procedure-related complications and no recurrences. Conclusions: Percutaneous ultrasound guided thrombin injection appears to be a safe and expeditious method for treating postcatheterization femoral pseudoaneurysms. It has significant advantages with respect to ultrasound guided compression repair or surgical repair. (J Vasc Surg 1998;27:1032-8.)     

Ultrasound-guided thrombin injection is the treatment of choice for femoral pseudoaneurysms

HYPOTHESIS: Ultrasound-guided injection of thrombin is the treatment of choice for femoral pseudoaneurysms. DESIGN: A prospective study of patients undergoing a single form of treatment for femoral pseudoaneurysms. SETTING: Patients were treated at 2 tertiary care, university-affiliated hospitals. PATIENTS: Forty consecutive patients with femoral pseudoaneurysms resulting from diagnostic and therapeutic catheterizations for peripheral arterial, coronary arterial, and cerebrovascular diseases were evaluated. INTERVENTION: Thrombin was injected directly into the pseudoaneurysms under ultrasonographic guidance. MAIN OUTCOME MEASURE: Thrombosis of the pseudoaneurysm following thrombin injection was the goal of treatment. RESULTS: All 40 patients had initial complete thrombosis of their femoral pseudoaneurysms. In each case, except for one, the aneurysm was noted to have thrombosed on follow-up duplex ultrasonogram. There was one complication. CONCLUSION: Ultrasound-guided thrombin injection is the treatment of choice for femoral pseudoaneurysms.     

US-guided percutaneous management of femoral artery pseudoaneurysms by thrombin injection: personal experience and review of the literature

Treatment of femoral artery pseudoaneurysms includes US-guided compression, endovascular coil embolisation or stenting, thrombin injection and open surgical repair. Thrombin injection is currently the standard approach to all non-complicated pseudoaneurysms of the peripheral arteries. Between January 2001 and December 2004, 59 pseudoaneurysms of the femoral artery were submitted to percutaneous US-guided thrombin injection in our surgery division. Complicated pseudoaneurysms, patients in whom percutaneous treatment failed, and chronic pseudoaneurysms with large necks were excluded from this kind of treatment and underwent surgical repair. Eighteen patients were on therapeutic anticoagulation (30.5%) and none of the pseudoaneurysms had an associated arteriovenous fistula. All patients were submitted to clinical and ultrasound follow-up at 24 hours and at 1, 6 and 12 months, and thereafter at yearly intervals for evaluation of recurrences. The thrombin injection was successful in 57/59 patients (96.6%) while two patients (3.4%) were submitted to surgical treatment after failure of the procedure. In 1 patient (1.7%) an additional injection was necessary to achieve complete thrombosis of the pseudoaneurysm. No complications occurred; none of the patients reported discomfort and there was no request for sedation. No recurrences were seen at follow-up. Nowadays US-guided percutaneous thrombin injection is the treatment of choice for femoral artery pseudoaneurysms. Surgical treatment is reserved to rare selected cases. More studies are necessary to evaluate further indications for treatment of visceral or small distal artery pseudoaneurysms.     

A prospective study of ultrasound scan-guided thrombin injection of femoral pseudoaneurysm: a trend toward minimal medication

BACKGROUND: Catheterizations and endovascular procedures in which the femoral artery is cannulated are sometimes complicated by iatrogenic pseudoaneuryms. Surgical repair of pseudoaneurysms was the treatment of choice until 1991 when compression was used in those that were small. A less uncomfortable technique involving the ultrasound scan-guided injection of thrombin (UGTI) has been used more recently. The purpose of this study was to prospectively evaluate the effectiveness of ultrasound scan-guided thrombin injection (UGTI) as a treatment of iatrogenic femoral pseudoaneurysms. METHODS: From December 1998 to December 2000, 3734 femoral artery catheterizations were performed, and from those, 32 consecutive patients with 33 femoral pseudoaneurysms (0.88%) of less than 8 cm were prospectively enrolled for UGTI. With sterile technique, a 21-gauge or 22-gauge spinal needle was used to access the pseudoaneurysm and thrombin (100 to 6000 international units [IU]) was slowly injected until thrombosis occurred. RESULTS: The initial success rate was 100%. Thirty-one cases (93.9%) remained successfully thrombosed with a single injection at day 30. Recurrence of two pseudoaneurysms (6.1%) was seen at day 1 and day 8. One patient had groin cellulitis develop, and the other had a bleed into the thigh after discharge; both were treated with open surgical repair. Fifteen patients underwent UGTI on an outpatient basis with 100% successful ablation. More than half of the patients were on an inpatient basis (53.1%). Hospital stay was 1 to 9 days, with 88.2% of the patients released on day 1 or 2. However, two patients had a prolonged stay: one from open repair (day 9) and the other from a gastrointestinal bleed (day 8). Pseudoaneurysms ranged from 1.7 to 7.5 cm and lasted 1 to 17 days before UGTI. Twenty-one of the patients (65.7%) continued undergoing anticoagulant therapy at the time of injection. Ten of the last 11 cases needed less than 800 IU, and nearly half of the pseudoaneurysms (49%) successfully thrombosed with less than 600 IU. No procedural complications or mortality were noted. No statistical significance was found between occurrence of the pseudoaneurysm and sheath size (with chi(2) test, P value =.05) or between the size of the pseudoaneurysm and successful thrombosis (with chi(2) test: degrees of freedom, 6 - 1 = 5; P value =.227426). A mean follow-up period of 11.8 months was documented (range, 71 to 24 months). Seven patients were lost to follow-up at less than 30 days. CONCLUSION: Percutaneous thrombin injection of iatrogenic pseudoaneurysms is an effective treatment. Not only is it minimally painful, but it can be done as an outpatient procedure and anticoagulation therapy does not hinder the success. Minimal thrombin seems necessary to successfully treat pseudoaneurysms that may further limit procedure-related complications.     

Ultrasound-guided thrombin injection is a safe and durable treatment for femoral pseudoaneurysms

Ultrasound-guided percutaneous thrombin injection has recently been described as a treatment for postcatheterization femoral pseudoaneurysms. Although ultrasound guided compression offers another nonoperative treatment option, thrombin injection has shown superior initial success rates. Reports of follow-up for thrombin injection longer than 30 days are currently lacking. The authors reviewed their initial experience with thrombin injection and prospectively evaluated patients for occult late recurrences of pseudoaneurysm and for distal circulatory complications. Records and vascular laboratory data for all patients treated with ultrasound-guided thrombin injection were reviewed for an 18-month period. Tibial vessel Doppler waveforms and ankle/brachial indices were routinely obtained before and after thrombin injection. Follow-up duplex examinations were performed within 24 hours of initial treatment. In the prospective portion of the study, successfully treated patients underwent a repeat femoral duplex scan and lower extremity arterial examination for comparison with the pretreatment studies. Forty-nine of 52 femoral pseudoaneurysms (94%) were successfully treated with ultrasound guided thrombin injection. One immediate failure and 2 early recurrences were treated surgically. There was 1 thrombotic complication of the native circulation identified at the time of injection. Follow-up studies were obtained in 32 of 46 available patients with a mean length of follow-up of 9 months (range 3-17 months). No late recurrences of the pseudoaneurysms or arterial-venous fistulas were observed. No distal circulatory complications were detected by arterial waveform analysis. Three deaths occurred in the interim (cardiac related). Two patients were lost to follow-up. The remaining 12 patients reported no additional limb complications but declined to be restudied. Ultrasound-guided thrombin injection is a safe, effective, and durable treatment for iatrogenic pseudoaneurysms. Thrombin injection should be the therapy of choice for catheter-related femoral false aneurysms.     

Thrombin injection versus compression of femoral artery pseudoaneurysms

OBJECTIVE: The compression of femoral artery pseudoaneurysms is a time consuming, painful, and sometimes unsuccessful procedure. Thrombin injection has been advocated as a superior alternative. In this study, we compare our experiences with both techniques. METHODS: All the records of femoral artery false aneurysms that were treated in the vascular laboratory from January 1996 to April 1999 were retrospectively reviewed. Treatment with ultrasound scan-guided compression was compared with treatment with dilute thrombin injection (100 U/mL). RESULTS: Both groups had similar demographics and aneurysm sizes (P >.2). Of the pseudoaneursyms, 88% were caused by cardiac catheterization and the others were the results of femoral artery access for cardiac surgery (6%), arteriography (5%), and renal dialysis (1%). Compression was successful in 25 of 40 patients (63%). Nine persistent aneurysms necessitated operation, and six were treated successfully with thrombin injection. Primary thrombin injection successfully obliterated 21 pseudoaneurysms in 23 patients. Overall, 27 of 29 pseudoaneurysms were treated successfully with thrombin injection (93%). Thrombosis occurred within seconds of the thrombin injection and required, on average, 300 units of thrombin (100 to 600 units). The patients who underwent successful compression required an average of 37 minutes of compression (range, 5 to 70 minutes) and required analgesia on several occasions. No patients in the thrombin group required analgesia or sedation. Neither group had complications. A cost analysis shows that thrombin treatment results in considerable savings in vascular laboratory resource use but not in overall hospital expenditures. CONCLUSION: Ultrasound scan-guided thrombin injection is a safe, fast, and painless procedure that completely obliterates femoral artery pseudoaneurysms. The shift from compressive therapy to thrombin injection reduces vascular laboratory use and is less expensive, although it does not significantly impact hospital costs.     

Vascular complications of drug abuse: an Indian experience

Background: Vascular complications resulting from i.v. drug abuse constitute a range of clinical problems from simple to serious. In addition, patients who present with these complications frequently have viral infections, which are a hazard to health care workers. Patients and Methods: The present study is a retrospective review of 46 male drug addicts with 52 vascular complications (45 arterial, seven venous). Pseudoaneurysm of the femoral artery was the most common complication (n = 35). Fourteen of these patients underwent ligation of the common, superficial and deep femoral arteries above and below the pseudoaneurysm. Twenty‐one underwent bipolar ligation of the common femoral artery after complete excision of the pseudoaneurysm. The decision to revascularize was based on the presence or absence of postligation Doppler signal. Arterial reconstruction was performed in five patients. All eight brachial artery pseudoaneurysms were ligated and excised, and deep vein thrombosis was managed with anticoagulation. Results: There was no mortality but three patients had to undergo late amputations of the lower limb after successful salvage following the initial surgery. The median postoperative ankle‐brachial indices, after bipolar and triple ligations were 0.51 and 0.46, respectively. Positive blood cultures were present in 30% of patients and tissue cultures were positive in 72%, the most common organism isolated was methicillin‐sensitive Staphylococcus aureus. Six patients were positive for viral markers. The median hospital stay was 43 days. Conclusion: Ligation and excision of pseudoaneurysms without revascularization is safe for drug addicts provided it is based on the presence of a postligation Doppler signal.     

Treatment of Femoral Artery Pseudoaneurysms with Percutaneous Thrombin Injection

The objective of this study was to prospectively evaluate the efficacy of ultrasound-guided thrombin injection for the treatment of post-catheterization femoral artery pseudoaneurysms. Between August 1, 1998 and August 31, 1999, 38 patients underwent ultrasound-guided injection of thrombin into 39 femoral false aneurysms. Peripheral pulses and ankle/brachial indices were assessed before and after the injection. Patients were followed with a control duplex scan within 4 weeks. The good results from this study showed that ultrasound-guided thrombin injection is an effective method for the treatment of post-catheterization false aneurysms. In a minority of patients, signs consistent with arterial embolization or vasospasm were identified.     

Percutaneous Induced Thrombosis of Iatrogenic Femoral Pseudoaneurysms following Catheterization

Femoral pseudoaneurysms are one of the common iatrogenic complications following catheterization procedures done via the femoral approach. Their treatment has evolved over the last decade from operative repair to ultrasound-guided compression (USGC) and more recently to thrombin injection of the pseudoaneurysm. We report our experience with that technique and compare the results of thromboobliteration to those of the compression method. All consecutive iatrogenic femoral pseudoaneurysms diagnosed in the vascular laboratory of two large community hospitals were referred for the study. Under ultrasound guidance, percutaneous thromboobliteration (PTO) of the pseudoaneurysms was done by injecting thrombin solution (500-unit increments) into the pseudoaneurysm. Time to thrombosis, dose of thrombin, patient's discomfort, and ease of procedure were recorded and analyzed. Comparison with results of USGC reported in the literature was made. Percutaneous thromboobliteration may be a simple and very effective treatment of femoral pseudoaneurysms. The high success rate, ease of procedure, and cost benefit over USGC are noteworthy. A larger trial is currently under way. If results are duplicated, PTO will emerge as the preferred treatment for iatrogenic femoral pseudoaneurysms.     

Ultrasound-guided percutaneous thrombin injection for femoral artery pseudoaneurysms

We reviewed 13 cases of ultrasound-guided thrombin injection of femoral pseudoaneurysms. All cases occurred within a 17-month period from January 1998 through May 1999 and were complications of femoral artery puncture. Immediate total thrombosis occurred in nine of 13 patients. Twenty-four-hour follow-up ultrasound in seven patients revealed no recurrence of pseudoaneurysm. Two of 13 patients required operative repair. One pseudoaneurysm thrombosed with 15 minutes of compression after injection and one case required a second injection. No cases of arterial thrombosis were noted. Ultrasound-guided thrombin injection for femoral artery pseudoaneurysm represents a safe and effective alternative to operative repair.     

Behandlung des persistierenden Aneurysma spurium aus gef??chirurgischer Perspektive

Purpose

This retrospective study evaluated experiences with ultrasound-guided thrombin injection and open surgical repair for the treatment of arterial pseudoaneurysms.

Method

Between January 2006 and December 2010, 51 patients (26 male, 25 female, mean age 70.5±?11.9 years) were treated for pseudoaneurysms of the femoral artery.

Results

Out of 51 patients 33 underwent surgical repair of pseudoaneurysms, 18 were treated by ultrasound-guided percutaneous thrombin injection and 48 (94.1%) patients received anticoagulation therapy (36 patients with platelet inhibitors, 6 patients with anticoagulation, such as cumarine and 6 patients with low molecular weight heparin). One patient suffered from mild hemophilia A. The mean operation time was 58.6±?36.4?min and mean postoperative hospital stay was 9.8±?6.3 days. Major complications (defined as needed surgical revision) occurred in three patients of the surgical group (9.1%) and two patients of the thrombin group (11.1%). Indications of surgical revision included postoperative hematoma (n=3), unsuccessful thrombin injection (n=1) and compression of the femoral vein (n=1). Minor complications were only observed in nine patients in the surgical group (27.3%), two patients developed postoperative pneumonia and seven patients had wound healing disorders. No mortalities were observed in either group.

Conclusions

The endovascular orientation and interdisciplinary assignment of vascular surgery have created a new perception for the treatment of arterial pseudoaneurysms. Ultrasound-guided thrombin injection is considered to be a safe alternative to surgical intervention for selected patients.     

Iatrogenic femoral artery pseudoaneurysm: Studies relating to the current treatment strategies including observation,ultrasound-guided compression,and duplex-directed thrombin injection

These articles demonstrate 3 “conservative” management strategies for postcatheterization femoral artery pseudoaneurysms. The continuum of watchful waiting in selected patients to ultrasound-guided compression, to ultrasound-guided thrombin injection mirrors many of the changes in the surgical treatment of myriad disease states. Operative repair of these lesions, such as open cholecystectomy, is not going to be of historical importance because many of these lesions will still require open repair. However, with the ever-increasing use of catheter-based therapies, minimally invasive techniques that demonstrate similar efficacy and safety are needed.The most frequent complication of femoral artery catheterization is the development of a femoral artery pseudoaneurysm. Approximately 500,000 interventional cardiologic procedures are performed in the United States every year. This does not take into account the interventional radiologic and other (femoral arterial line placement) procedures used to gain access to the central arterial system via the femoral artery. The reported incidence of complications after femoral artery catheterization ranges from 0.2%–9%. Pseudoaneurysm formation has been reported as a complication in 0.05%–5% of all femoral artery catheterizations.Obviously, with the large number of procedures being performed each year, femoral artery pseudoaneurysm formation is not an uncommon lesion referred to general and vascular surgeons.The first article reviewed explores the conservative management of femoral artery pseudoaneurysms. This article is important in that it documents the benign natural history of a large number of these lesions. Although the conservatively managed patients were a relatively select group, they were not so select that the findings of the study become uninterpretable. This study demonstrates that many of these lesions can in fact be observed with frequent spontaneous resolution.The second article discusses another “conservative” management strategy for the treatment of femoral artery pseudoaneurysms, involving ultrasound-guided compression of the lesion. Ultrasound-guided compression has been adopted in many centers and has shown very good results. Success rates of 70%–100% have been reported. Unfortunately, a recurrence rate of 20% is still seen, especially in patients undergoing anticoagulant therapy. Also, a large number of patients fail this therapeutic method secondary to intolerance of the pain associated with compression. Still, it is clear that ultrasound-guided compression is a highly effective choice in many patients.The third article addresses duplex-directed thrombin injection, a novel technique that is being employed in certain centers. This technique appears to be quite effective and safe. Although this study included only 11 patients, this paper is one of a series of papers that have documented the efficacy and safety of the technique. Duplex-directed thrombin injection is also very expeditious with thrombosis, occurring in only 30 seconds in most patients.Surgical repair of femoral artery pseudoaneurysms will always be necessary for a number of these lesions. However, many can be observed with spontaneous thrombosis. Other techniques have been and are being designed to treat this common condition. With the economic pressure for decreased in-patient treatment, the conservative strategies that have been reviewed will continue to occupy a central role in the management of these lesions.     

Ultrasound-guided thrombin injection of iatrogenic femoral pseudoaneurysms: a prospective analysis

An adverse consequence of the use of the femoral artery for the endovascular evaluation and treatment of arterial disease is the increased incidence of iatrogenic femoral pseudoaneurysms. Although surgical repair has traditionally been used to treat such aneurysms, less invasive modalities have emerged. The purpose of this study is to prospectively evaluate ultrasound-guided thrombin injection (UGTI) for the treatment of iatrogenic femoral pseudoaneurysms. A treatment protocol was approved and 30 stable patients (21 female; age range 43-85 years; mean 67 years) were prospectively enrolled from December 1997 through June 1999 to undergo UGTI on 30 iatrogenic femoral pseudoaneurysms. Pseudoaneurysms occurred after cardiac intervention (n = 22, 73%), peripheral intervention (n = 7, 23%), and after a femoral line placement (n = 1, 3%). They ranged in size from one to 5 cm with a time interval from intervention until UGTI of one to 132 days (median 3 days). Eleven patients (37%) were systematically anticoagulated at the time of UGTI. All pseudoaneurysms were treated using sterile technique and local anesthesia with ultrasound-guided injection via a 20-gauge spinal needle of 0.1 to 2 cm3 (median 0.6 cm3) of 1000 units/cm3 topical thrombin solution administered by one of six physicians. A period of bedrest for 4 to 6 hours after injection was followed by repeat groin duplex scan at 24 hours and a clinical follow-up at 30 days. There were no procedural deaths or nonvascular complications. Twenty-seven (90%) UGTIs resulted in successful pseudoaneurysm ablation with no recurrences at 24 hours or 30 days. Two (7%) UGTIs failed and one (3%) femoral artery embolic complication occurred; all were successfully treated with surgery. Success appeared to be independent of anticoagulation status, pseudoaneurysm age, size, or operator experience. We conclude that UGTI is a safe, easy, well-tolerated and effective noninvasive method for treatment of iatrogenic femoral pseudoaneurysms and should be considered in all stable patients before operative repair.     

Femoral artery thrombosis after percutaneous thrombin injection of an external iliac artery pseudoaneurysm

Ultrasound-guided percutaneous thrombin injection has been developed as a less invasive and highly successful treatment of iatrogenic femoral pseudoaneurysms. Most of these lesions have been the result of catheterization procedures. This method has proved to be highly effective, and few complications have been reported. Specifically, native arterial thrombosis, although recognized as a severe complication, has been mentioned only briefly in the literature. We present a case of the successful management of native arterial thrombosis after attempted percutaneous thrombin injection of a chronic external iliac artery pseudoaneurysm. This case serves to illustrate the risk factors for this complication and the treatment options once it occurs. The success of this treatment with acute iatrogenic femoral pseudoaneurysms may not necessarily translate into similar success in other anatomic locations and clinical situations.     

The management of mycotic femoral pseudoaneurysms in intravenous drug abusers

Mycotic femoral pseudoaneurysms, particularly in the drug-abusing population, pose a difficult problem to the vascular surgeon. Management ranges from ligation with debridement to extra-anatomical bypass. This study reviewed the management of mycotic femoral pseudoaneurysms presenting in intravenous drug abusers to an inner city tertiary referral center. Between 2001 and 2006, 11 cases presenting in nine patients were treated. The mean age was 30.7 years with a male-to-female ratio of 1:2. Eight patients had a positive viral status for the human immunodeficiency virus and/or hepatitis C. Two patients re-presented with a contralateral pseudoaneurysm. A combination of groin pain and swelling was the most common presentation. Two patients presented with significant hemorrhage. The diagnosis was confirmed by ultrasound in the majority of cases. Nine cases were managed with arterial ligation and debridement of the necrotic tissue. The two remaining cases were managed with ultrasound-guided thrombin injection and arterial puncture closure. On follow-up, one patient required a below-knee amputation following reinjection into the postoperative wound site. One further patient underwent a fifth metatarsal amputation due to ischemia. Ligation and debridement are well tolerated in the majority of drug-abusing patients diagnosed with mycotic femoral pseudoaneurysms.     

Postarteriographic femoral pseudoaneurysms: Treatment with ultrasound-guided compression

Pseudoaneurysms following femoral arterial catheterization are increasingly common and are related to factors such as catheter size, periprocedural anticoagulation, hypertension, and improper technique. Ultrasound-guided compression as a noninvasive technique for repair of these lesions was prospectively evaluated in 16 patients whose mean age was 61 years. Nine patients were on anticoagulants and six had hypertension. All patients presented with an enlarging groin hematoma, a pulsatile mass, and/or a bruit following femoral catheterization. Seventeen femoral artery pseudoaneurysms, including one with an associated arteriovenous fistula, were detected using color-flow Doppler imaging. Three pseudoaneurysms thrombosed spontaneously. The remaining 14 were managed with compressive therapy lasting from 20 to 100 minutes. No complications were encountered during the compressions and 10 false aneurysms (71%) responded completely (mean time to thrombosis of 38 minutes). Two lesions responded partially to compression and there were two failures, the latter associated with excessive anticoagulation in one patient and a well-established pseudoaneurysm in the second patient. Only one pseudoaneurysm (6%) in the series required surgical correction. Ultrasound-guided compression of acute pseudoaneurysms in the groin is a safe, inexpensive, and effective method of treatment.We thank Brenda Scott, Tammy Kovacs, Lisa Ungar, and Alison Grzywnowicz in the ultrasound department at Victoria Hospital for the time and enthusiasm they devoted to this project.     

True and false aneurysms of the femoral artery

True aneurysms of the femoral artery are uncommon. They are most often identified in elderly males and are frequently associated with aneurysms at other locations. Femoral artery aneurysms that are symptomatic or larger than 2.5 cm should be repaired in order to prevent limb-threatening complications, such as rupture, thrombosis, or embolization. Open repair is the standard method of treatment and should be preceded by evaluation for coexisting aortoiliac or popliteal aneurysms, assessment of superficial femoral artery patency, and determination of the point of origin of the deep femoral artery relative to the aneurysm sac. Femoral artery pseudoaneurysms are most often seen in the setting of previous femoral artery catheterization but may also be associated with trauma, anastomotic leakage, or infection. The majority of femoral pseudoaneurysms less than 3 cm in diameter will spontaneously thrombose and may be observed with serial duplex ultrasound exams in asymptomatic patients. Symptomatic pseudoaneurysms, pseudoaneurysms with a diameter greater than 3 cm, and those found in patients who are anticoagulated should usually be treated. Ultrasound-guided thrombin injection is our preferred method for treating femoral pseudoaneurysm because of its low risk, high success rate, and efficacy in the setting of anticoagulation. Ultrasound-guided compression is an alternative method that may be considered when thrombin products are contraindicated. Open pseudoaneurysm repair should be undertaken in the setting of infection, rapid expansion, or if less-invasive methods are not technically feasible.     

Obliteration of femoral artery pseudoaneurysm by thrombin injection

BACKGROUND: Femoral artery pseudyoaneurysms are a common complication after femoral access for transcatheter procedures, frequently requiring operative repair. We review the safety and efficacy of a novel nonsurgical method of pseudoaneurysm treatment METHODS: From June 1998 to November 2001, a total of 47 femoral artery pseudoaneurysms in 46 patients were treated by bedside ultrasound-guided injection of dilute topical thrombin. All pseudoaneurysms occurred after femoral access for transcatheter procedures, and were diagnosed clinically and confirmed with ultrasound imaging. Clinical follow-up was performed and included ultrasound (2 hours to 1 month) in 64.4% of patients, including any patient with a symptomatic or clinical change. RESULTS: Pseudoaneurysms ranged in size from 1.5 to 4.5 cm. Of 47 pseudoaneurysms, 45 were successfully obliterated on the initial injection. After successful obliteration of pseudoaneurysm, 1 patient sustained thrombosis of the tibioperoneal trunk that required surgical embolectomy, yielding a complication rate of 2%. Four pseudoaneurysms recurred after initially successful obliteration. In 1 of these cases, the patient was taken directly to surgery, and 3 were successfully treated with repeat injection, for an overall success rate of 93.6%. CONCLUSIONS: Obliteration of femoral artery pseudoaneurysm by injection is safe and effective, and may be associated with decreased morbidity. Recurrent pseudoaneurysms may be safely reinjected, with a high success rate.     

Selective non-operative management of pseudoaneurysms and arteriovenous fistulae complicating femoral artery catheterization.

Femoral arterial pseudoaneurysms or arteriovenous fistulae may sometimes complicate percutaneous femoral artery catheterization procedures. Most surgeons recommend prompt operative repair because of the unfavorable natural history of pseudoaneurysms or arteriovenous fistulae secondary to violent or accidental arterial trauma. However, the natural history of catheterization-induced pseudoaneurysms and arteriovenous fistulae has not been well documented. Accordingly, we prospectively studied the natural history of 22 pseudoaneurysms, 8 arteriovenous fistulae, and 3 combined lesions, identified by duplex scan in 32 patients following trans-femoral cardiac, peripheral vascular, or vascular access arterial catheterization procedures. Angiographic procedures were performed with the use of 5-8F introducer sheaths. A femoral artery complication was significantly more likely to result from coronary balloon angioplasty (9/304; 3.0%) than from diagnostic cardiac catheterization (21/2476; 0.8%) (p less than 0.003; chi square). Fourteen patients (13 pseudoaneurysms, 1 combined pseudoaneurysm/fistulae) underwent surgical repair. Pain and/or enlarging hematoma resulted in repair within two days of the diagnosis in 8 patients. The need for chronic anticoagulation prompted elective repair in 2 patients. A pseudoaneurysm was repaired in one patient five days following catheterization when it became painful. In three stable patients, asymptomatic pseudoaneurysms were repaired electively during another surgical procedure. There were no operative deaths. One patients (7%) developed a wound infection postoperatively. Eighteen patients (19 arterial lesions: 9 pseudoaneurysms, 8 arteriovenous fistulae, 2 combined pseudoaneurysms/arteriovenous fistulae) with improving symptoms and stable physical signs were followed by serial clinical evaluation and duplex scans. Seventeen of 19 (89%) of these lesions resolved spontaneously within 5-90 days (mean 30.7 days).(ABSTRACT TRUNCATED AT 250 WORDS)