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

Abstract

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.