Treatment of iatrogenic false aneurysms.

Abstract

The incidence of iatrogenic false aneurysms has risen exponentially in recent years. Although this growth in peripheral vascular injuries likely is multifactorial in origin, the increasing complexity of percutaneous techniques combined with public demand for minimally invasive procedures has probably contributed. Periprocedural complications secondary to vascular interventions include false aneurysms, hematomas, thromboemboli, AV fistulae, and lacerations. False aneurysms, or pseudoaneurysms, account for more than 60% of these iatrogenic complications. Historically, the incidence of procedure-related vascular injury has been estimated as 0.05% to 0.1%. Today the incidence is estimated to range from 0.2% to 9.0%. Although percutaneous vascular access was once primarily used for diagnostic purposes, a transfemoral approach is now used for a wide variety of both diagnostic and therapeutic modalities. The femoral route is generally preferred for ease and reliability of access to the arterial and venous systems. Consequently, iatrogenic vascular injuries and false aneurysms are frequently located in the groin. The terms false aneurysm, pseudoaneurysm, and pulsatile or communicating hematoma are synonymous and may be used interchangeably. True aneurysms are defined as a circumscribed dilation of the artery; pseudoaneurysms involve dilation of an artery with actual disruption of one or more layers of its walls. The etiology of true and false aneurysms also differs: true aneurysms are typically caused by degenerative factors and false aneurysms are generally traumatic in origin. Iatrogenic pseudoaneurysms are most commonly produced by cardiac catherization, and these diagnostic and interventional procedures account for 70% to 80% of the incidence. Peripheral angiography or angioplasty, or both, are responsible for 10% to 15% of pseudoaneurysms. Additional causes of iatrogenic false aneurysms include percutaneous hemodialysis access, percutaneous intraaortic balloon pump placement, and other interventional techniques. Risk factors for the development of iatrogenic pseudoaneurysms include age greater than 60 years, female gender, catheter size greater than 8F, cannulation of both artery and vein, and concurrent anticoagulation. Operator inexperience, catherization of an artery other than the common femoral artery, and underlying peripheral vascular disease are also positively correlated with increased risk of false aneurysm formation. The natural history of peripheral vascular injuries is uncertain and surgical dictum previously mandated prompt operative repair. Recently, the focus has shifted from open surgical repair to a vast array of management options, including observation, compression therapies, thrombin injection, and embolization procedures. The remainder of this review focuses on the diagnosis, natural history, and treatment options for iatrogenic false aneurysms.