Treatment of arterial pseudoaneurysms with percutaneous ultrasound-guided thrombin injection

Background: The pseudoaneurysms or false aneurysms are one of the most common complications after arterial invasive manipulation. Different methods of treatment have been described, such as surgical repair, ultrasound-guided compression and endovascular procedures. Ultrasound-guided thrombin injection has shown efficacy, safety and low cost, and, in some cases, the procedure is considered the treatment of choice. Preliminary results are presented. Methods: Design: Case series. We studied adult patients with iatrogenic arterial pseudoaneurysms demonstrated clinically and corroborated with ultrasound. We describe the technique used for the management of the arterial pseudoaneurysms by ultrasound-guided thrombin application, as well as complications and follow-up. Results: Twelve patients were included with a mean age of 63 years (SD 12.4), 33% were male and 67% female. Associated comorbid states were hypertension 83%, 50% diabetes, obesity 66%. All pseudoaneurysms were located in the femoral artery (2:1 right/left ratio). The mean size of the pseudoaneurysm was 48.2 mm SD 11.9, (range of 30 to 65 mm) by 44.3 mm SD 9.3, (range 20 to 53 mm). The average neck diameter was 2.2 mm SD 0.54 (range of 1.5 to 3 mm). Eleven cases were unilobulated (87.5%), and one bilobulated (12.5%). All reported arterial integrity with complete occlusion after one thrombin application without recurrence and morbidity after 90 days of follow up. Conclusions: In our study we obtained a 100% of thrombosis without pseudoaneurysm recurrence or complications. However a longer follow-up time and more number of cases are required to confirm these results.     

Ultrasound-guided compression repair of postcatheterization pseudoaneurysms: Results of treatment in one hundred cases

Purpose: The purpose of this report is to describe the indications, technique, and results for ultrasound-guided compression repair (UGCR) of postcatheterization pseudoaneurysms at a large medical center in which catheter-based diagnostic and interventional procedures are frequently used.Methods: We reviewed the initial series of 100 consecutive patients who underwent UGCR in our noninvasive vascular laboratory from May 1991 through August 1992. Nearly all (n = 95) of these pseudoaneurysms involved the common femoral artery or its major branches, and each was manually compressed with a 5 MHz linear transducer for 10-minute intervals until the pseudoaneurysm was completely occluded or the procedure was considered to be a failure.Results: UCGR was immediately successful in 94 patients, including 30 (86%) of 35 patients who were receiving anticoagulants and 64 (98%) of the 65 who were not (p = 0.019). The average compression time to achieve occlusion was 33 minutes (range 10 to 120 minutes), but was nearly twice as long (51 minutes) for pseudoaneurysms that had been present for more than 14 days. There were no related complications, but recurrent pseudoaneurysms occurred in six (20%) of 30 patients who continued to receive formal anticoagulation, compared with only four (6%) of 64 who did not (p = 0.074). Eight of the 10 recurrences were discovered within 24 hours after primary UGCR, but two others presented at 16 and 35 days, respectively. Eight recurrent lesions were corrected by repeat UGCR, whereas the remaining two required surgical repair.Conclusions: UGCR provides a reliable alternative to surgical treatment for postcatheterization pseudoaneurysms. Adequate follow-up is important, however, especially in patients for whom continued anticoagulation is necessary. (J VASC SURG 1994;19:683-6.)     

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.     

Comparison of outcomes for balloon angioplasty,atherectomy, and stenting in the treatment of infrapopliteal disease for chronic limb-threatening ischemia

ObjectiveWe evaluated limb salvage (LS), amputation-free survival (AFS), and target extremity reintervention (TER) after plain old balloon angioplasty (POBA), stenting, and atherectomy for treatment of infrapopliteal disease (IPD) with chronic limb-threatening ischemia (CLTI).MethodsAll index peripheral vascular interventions for IPD and CLTI were identified from the Vascular Quality Initiative registry. Of the multilevel procedures, the peripheral vascular intervention type was indexed to the infrapopliteal segment. Propensity score matching was used to control for baseline differences between groups. Kaplan-Meier and Cox regression were used to calculate and compare LS and AFS.ResultsThe 3-year LS for stenting vs POBA was 87.6% vs 81.9% (P = .006) but was not significant on Cox regression analysis (hazard ratio [HR], 0.91; 95% confidence interval [CI], 0.56-0.76; P = .08). AFS was superior for stenting vs POBA (78.1% vs 69.5%; P = .001; HR, 0.73; 95% CI, 0.60-0.90; P = .003). LS was similar for POBA and atherectomy (81.9% vs 84.8%; P = .11) and for stenting and atherectomy (87.6% vs 84.8%; P = .23). The LS rate after propensity score matching for POBA vs stenting was 83.4% vs 88.2% (P = .07; HR, 0.71; 95% CI, 0.50-1.017; P = .062). The AFS rate for stenting vs POBA was 78.8% vs 69.4% (P = .005; HR, 0.69; 95% CI, 0.54-0.89; P = .005). No significant differences were found between stenting and atherectomy (P = .21 for atherectomy; and P = .34 for POBA). The need for TER did not differ across the groups but the interval to TER was significantly longer for stenting than for POBA or atherectomy (stenting vs POBA, 12.8 months vs 7.7 months; P = .001; stenting vs atherectomy, 13.5 months vs 6.8 months; P < .001).ConclusionsStenting and atherectomy had comparable LS and AFS for patients with IPD and CLTI. However, stenting conferred significant benefits for AFS compared with POBA but atherectomy did not. Furthermore, the interval to TER was nearly double for stenting compared with POBA or atherectomy. These factors should be considered when determining the treatment strategy for this challenging anatomic segment.     

Color duplex-guided compression therapy for postcatheterization pseudoaneurysms in a community hospital

Diagnostic or therapeutic arterial catheterization may be complicated by postcatheterization pseudoaneurysm. Pseudoaneurysms have generally been treated surgically, but more recently, encouraging results with duplex-guided compression therapy (DGCT) of pseudoaneurysms have been reported from university hospitals. We reviewed our experience with DGCT to assess the applicability of DGCT in a community hospital setting. Sixty-two patients presented with 63 symptomatic postcatheterization pseudoaneurysms between January 1, 1990, and December 31, 1993. Prior to October 28, 1991, all pseudoaneurysms were treated surgically. Subsequently we initiated DGCT as primary treatment for pseudoaneurysms, reserving surgery for DGCT failures and unstable patients. DGCT patients were indistinguishable from primary surgery patients, and the number of pseudoaneurysms treated did not appear to increase during the study period. DGCT was initially successful in 27 (75%) of 36 patients. Three pseudoaneurysms recurred, yielding cumulative success in 24 (67%) of 36 patients. Three of 12 DGCT failures were due to patient intolerance. DGCT was unsuccesful in three of four intra-aortic balloon pump (IABP)-associated pseudoaneurysms. There was some variation in pseudoaneurysm volume between the successful and failed groups, and a trend toward failure with larger pseudoaneurysms was not significant (13 vs. 6 cm³,p0.25). DGCT failure appears more likely in post-IABP pseudoaneurysms and possibly with larger pseudoaneurysms. Anticoagulation, type of procedure (exclusive of IABP), obesity, and other patient characteristics examined did not appear to predict success or failure of DGCT. Treatment was reserved for symptomatic patients throughout the period of study and there was no evidence that patients were more likely to be treated for pseudoaneurysms after DGCT was initiated. We conclude that DGCT is usually successful and is appropriate primary treatment for all symptomatic postcatheterization pseudoaneurysms in stable patients.Presented at the Eighteenth Annual Meeting of the Mid-western Vascular Surgical Society, Cincinnati, Ohio, September 24, 1994.     

Minimally invasive salvage therapy for transplanted renal allografts

Abstract

Purpose: To evaluate the effectiveness of interventional therapy for complications of transplanted renal allografts. Materials and methods: Between January 2009 and March 2014, 14 patients underwent interventional therapy for complications of renal allografts. Complications included transplant renal artery stenosis (TRAS), TRAS combined with pseudoaneurysms, transplant renal venous kinking and ureteral obstruction (UO). Serum creatinine (S.Cr) levels were evaluated before and after procedure. The characteristics and procedure outcomes of these patients with vascular and nonvascular complications were also analyzed. Results: All primary procedures were successfully performed, which included percutaneous transluminal angioplasty (PTA) for TRAS (n?=?4), stenting and coil embolization for TRAS combined with pseudoaneurysms (n?=?1), stenting for renal vein kinking (n?=?2), and percutaneous nephrostomy (PCN) for UO (n?=?7) and secondary antegrade stent placement in six UO patients after 1 week of PCN. No major procedure related complications occurred. S.Cr level subsequently improved from 6.0?±?3.6 to 2.6?±?2.1?mg/dL (p?<?0.001), as well as patients’ clinical features within 1 week after procedure. In our study, the onset time of vascular complications was earlier (<6 months) than nonvascular complications with significant difference (p?<?0.001). During follow-up, the patient with TRAS and pseudoaneurysms suffered acute rejection 1 month after treatment and received transplant renal artery embolization. One patient with TRAS showed restenosis 4 months after procedure, and was retreated successfully with stenting. Thirteen cases reserved their transplanted renal allografts. Conclusion: Interventional therapy could be prior considered for transplanted renal allograft complications as its effectiveness and minimal invasiveness in saving the transplanted renal grafts.     

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.     

Independent predictors of restenosis after percutaneous coronary revascularization in haemodialysis patients.

BACKGROUND: Percutaneous balloon angioplasty has become a well-established and routine procedure for coronary revascularization of haemodialysis patients with coronary artery disease. However, the incidence of restenosis after balloon angioplasty is significantly higher in haemodialysis patients than in the general population. We performed a retrospective study comparing balloon angioplasty with coronary stenting in haemodialysis patients. We evaluated the long-term clinical and angiographic outcome after successful percutaneous coronary revascularization in haemodialysis patients. METHODS: A total of 103 consecutive haemodialysis patients (123 lesions) underwent procedurally and clinically successful percutaneous revascularization. Patients were treated with three different strategies: (i) balloon angioplasty in 55 patients (69 lesions); (ii) coronary stenting with balloon angioplasty in 23 patients (25 lesions); and (iii) coronary stenting with rotational atherectomy in 25 patients (29 lesions) who had severely calcified stenotic coronaries. RESULTS: The rates of in-hospital mortality were similar in the three groups. The 1-year incidence of overall events and major adverse cardiac events (MACE) were significantly higher in the balloon group than in the stent with/without rotational atherectomy groups (75% vs 36 and 28%, P<0.01; 71% vs 32 and 28%, P<0.01). Use of coronary stenting (relative risk=0.006, P<0.001) and the presence of calcified coronary lesion (relative risk=68.2, P<0.001) were independent predictors of the 1-year MACE-free survival after percutaneous revascularization. The 3-year MACE-free survival rate was significantly lower in the balloon group than in the stent with/without rotational atherectomy groups (11% vs 33 and 47%, P<0.005 and P<0.001). CONCLUSIONS: This study shows that coronary stenting reduces the incidence of MACE in haemodialysis patients with/without calcified coronary lesions. Moreover, coronary stenting reduces the restenosis rate of both complex and restenotic lesions, and rotational atherectomy prior to coronary stenting reduces the restenosis rate of the severely calcified coronary lesions. These results suggest that coronary stenting with/without rotational atherectomy has led to an improved long-term outcome in the haemodialysis patients with coronary artery disease.     

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.     

Profunda femoral artery pseudoaneurysm after percutaneous transluminal procedures manifested by neuropathy.

The incidence of arterial complications following femoral artery cannulation is low; however, with the increasing number of cardiac diagnostic and interventional procedures, vascular surgeons are being confronted with an increasing number of pseudoaneurysms and arteriovenous fistulas. Swelling and a painful pulsating groin masse are the most frequent presenting symptoms of a common femoral artery false aneurysm. We present the cases of 4 patients who had the unusual finding of a profunda femoral artery pseudoaneurysm after they had undergone cardiac catheterization or percutaneous transluminal coronary angioplasty. The only clinical sign of these patients was femoral neuropathy or neuropalsy caused by femoral nerve compression. Surgical repair of the pseudoaneurysm was successful in all patients. We discuss the reasons for this unusual finding and rare location for a pseudoaneurysm.     

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.     

Giant iatrogenic pseudoaneurysm of the brachial artery: A case report

IntroductionPseudoaneurysms are a pulsatile hematoma caused by hemorrhage on soft tissues. It is an uncommon condition with many different etiologies. We report a case of a giant pseudoaneurysm caused by iatrogenic injury on the brachial artery.Presentation of caseA 42 year-old male was submitted to our Vascular Surgery service with an enlargement of the right upper limb and a history of myocardial infarction. 60 days before the patient reached our service, he was submitted to a cardiac catheterization performed by another medical team, since the catheter was placed on the right brachial artery near the cubital fossa, we suspected an iatrogenic pseudoaneurysm, which was confirmed by his clinical history and physical exam. It was opted to treat the pseudoaneurysm with an implant of polytetrafluoroethylene prosthesis. There were no complications whatsoever and the patient was discharged.DiscussionPseudoaneurysms are more common after interventional procedures than diagnostic procedures, although brachial artery pseudoaneurysms are rare. Complications of pseudoaneurysms can cause serious threat to the afflicted limb and the patient’s life. The management of any pseudoaneurysm is dependent on its size, location and pathogenesis.ConclusionPseudoaneurysms develop slowly and should be diagnosed as early as possible in order to avoid complications and a better outcome. Due to an increase in recent endovascular procedures and the fact that brachial artery puncture is being performed more routinely, incidence of brachial artery pseudoaneurysms among overall population may rise.     

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.     

Treatment of iatrogenic femoral artery injuries with ultrasound-guided compression.

Iatrogenic injuries of the groin are becoming more common after increasingly sophisticated vascular intervention. These injuries are accurately detected by duplex and color Doppler ultrasonography. Recent treatment of these lesions by ultrasound-guided compression repair (UGCR) has been described. During a 1-year period we identified 18 femoral artery injuries, including 17 pseudoaneurysms and one arteriovenous fistula. Three of the pseudoaneurysms thrombosed spontaneously before attempted treatment. The remaining 15 lesions underwent a trial of UGCR. Successful closure was accomplished in 10 patients (56%). Seven of these lesions were successfully treated during the initial session, and thrombosis was accomplished after repeat compression in three additional lesions. Three patients who were given anticoagulants had a failed UGCR, but their pseudoaneurysms thrombosed after administration of anticoagulants was discontinued. Two patients had failed UGCR and required operation. Seven (88%) of eight patients who were not given anticoagulants were successfully treated. In contrast only two (29%) of seven patients given therapeutic doses of anticoagulant medication were successfully treated by the technique. There was no statistical difference between mean pseudoaneurysm diameter, mean width and length of pseudoaneurysm neck, or depth of pseudoaneurysm neck from skin surface in patients in whom successful initial closure was achieved when compared with those patients in whom the initial attempt failed. UGCR is a safe, simple, noninvasive technique that can be used to treat many femoral artery injuries that traditionally were treated with surgery. The technique can be applied by any laboratory that has the necessary ultrasonography equipment and is currently the method of choice for treating uncomplicated iatrogenic femoral artery injuries at our institution.     

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.     

医源性股动脉假性动脉瘤的治疗方法

目的 评估超声引导下局部压迫和手术治疗医源性股动脉假性动脉瘤的疗效并介绍治疗经验.方法 1995年4月至2008年4月对197例医源性股动脉假性动脉瘤病人进行治疗,其中171例首选超声引导下局部压迫治疗(假性动脉瘤稳定者),26例(假性动脉瘤破裂或瘤腔直径≥40 mm者)直接手术治疗.结果 压迫治疗的171例中137例压迫成功,有效率80%,34例失败者改行手术治疗.直接手术治疗的26例及上述改行手术的34例中,47例行股动脉假性动脉瘤切除、动脉壁破口修补术,6例行自体大隐静脉补片成形术,7例行人工血管转流术.围手术期所有手术病例无出血、神经痛、淋巴瘘、动静脉瘘等严重并发症和死亡.随访1个月至5年,均未见假性动脉瘤复发或肢体缺血症状.随访期间无死亡.结论 局部压迫疗法治疗医源性股动脉假性动脉瘤安全、有效、经济,可作为大部分稳定病人的首选治疗方法.不适合压迫治疗者及压迫治疗失败的病人可手术治疗,疗效确切.     

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)     

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.)     

经导管动脉栓塞术治疗重症急性胰腺炎并发假性动脉瘤破裂出血

目的探讨经导管动脉栓塞术(TAE)在重症急性胰腺炎(SAP)并发假性动脉瘤破裂出血中的应用价值。方法对13例SAP并发假性动脉瘤破裂出血患者行TAE,分析假性动脉瘤DSA表现及栓塞情况。结果 13例SAP患者共并发15个假性动脉瘤,包括感染性假性动脉瘤13个、腐蚀性假性动脉瘤2个。6个(6/15,40.00%)假性动脉瘤的责任动脉为脾动脉,5个(5/15,33.33%)为肠系膜上动脉,2个(2/15,13.33%)为胃十二指肠动脉,1个(1/15,6.67%)为肠系膜下动脉,1个(1/15,6.67%)为胃网膜右动脉(1/15,6.67%)。TAE治疗技术成功率为93.33%(14/15)。1例(1个假性动脉瘤)TAE术后出现脾脓肿,经穿刺引流及抗感染好转。感染性假性动脉瘤患者死亡率为45.45%(5/11),腐蚀性假性动脉瘤无死亡患者。TAE术后复发出血率为15.38%(2/13)。结论 TAE是治疗SAP并发假性动脉瘤破裂出血的有效方法。     

False Aneurysm of the Hepatic Artery after Laparoscopic Cholecystectomy

Purpose: A rare complication of laparoscopic cholecystectomy is defined: iatrogenic injuries to hepatic artery system which may evolve to pseudoaneurysms in the late postoperative period. This rare phenomenon may be overlooked and pose a challenge to surgeons.

Material and methods: We will describe three cases with iatrogenic pseudoaneurysms after laparoscopic cholecystectomy.

The onset of symptoms and the course of the disease was not uniform. Diagnosis was made after a considerable delay. In the first case, a small, uncomplicated extrahepatic pseudoaneurysm was successfully treated with coil embolization. The second patient who had an intrahepatic pseudoaneurysm with multiple injuries to the common bile duct and portal vein, did not survive despite surgical and endovascular interventions. In the latter, surgical treatment for a large pseudoa-neurysm that had ruptured into the liver parenchyma was successfully conducted.

Review of the literature reveals fifty-four more cholecystectomy-related pseudoaneurysms. The site of injury was the right hepatic artery in 61% of the cases and the presenting symptom was upper gastrointestinal bleeding (haemobilia) in two-third of the patients. Embolization was performed in 82% of the cases, and surgery was undertaken in the remaining 18%.

Conclusion: Pseudoaneurysm is an uncommon complication of laparoscopic cholecystectomy. Prompt attention is necessary since the lesion has a high risk of rupture. Embolization is the first line of treatment and surgery is reserved for more complex injuries and cases with life-threatening rupture of the aneurysm.