Iatrogenic Femoral Pseudoaneurysms Research Articles

Etiology and management of iatrogenic femoral pseudoaneurysm

Etiology and management of iatrogenic femoral pseudoaneurysm

Post-catheterization Common Femoral Artery Pseudoaneurysm in a Patient with a Mechanical Mitral Valve Requiring Anticoagulation: A Case Report

Iatrogenic femoral pseudoaneurysms are a rare complication of transfemoral vascular access. We present a case of a 65-year-old woman with a mechanical mitral valve requiring warfarin, who developed a femoral pseudoaneurysm four days after cardiac catheterization with femoral access. The patient developed a 17 x 10 x 17 cm rectus sheath hematoma and was treated with ultrasound-guided thrombin injection. Anticoagulation was held for three days while the patient was monitored for further bleeding and later restarted based on shared decision-making, given the risk of valve thrombosis. There are few guidelines regarding the re-initiation of anticoagulation in high-risk bleeding patients with mechanical mitral valves. Non-invasive coronary computed tomography angiography should be considered in patients on anticoagulation who require non-emergent cardiac ischemic evaluation.

Case Report of New Technique for the Repair of Iatrogenic Femoral Pseudoaneurysm

Femoral artery Pseudoaneurysm was caused at the puncture site of the right groin after diagnostic coronary angiography. Manual compression for 48 hours was administrated but failed then balloon tamponade was attempted for hemostasis at the aneurysmal site but hemostasis was not achieved. Next, using contralateral anterograde approach was use to cross the wire from the neck of the pseudoaneurysm and ipsilateral retrograde approach by direct puncture of the pseudoaneurysm was tried. A 0.014-inch guidewire was crossed from the neck of the pseudoaneurysm to the external iliac artery. The wire was replaced with a 0.035-inch guidewire. A star close device was inserted and was deployed at the neck of the pseudoaneurysm. Final angiography revealed completion of hemostasis.

Girişimsel işlemlere bağlı gelişen femoral psödoanevrizmanın primer onarımı

Objective: This study aimed to report our clinical experience with the treatment of iatrogenic femoral pseudoaneurysms with the primary suture technique. Materials-methods: Thirty patients treated with the diagnosis of femoral pseudoaneurysm in the femoral artery between September 2015 and August 2020 participated in the Non-iatrogenic pseudoaneurysms, iatrogenic aneurysms smaller than 4 cm, and thrombosed aneurysms were excluded. All pseudoaneurysms were diagnosed by ultrasonography and computed tomography. Results: Peripheral arterial thrombosis developed in 1 (4%) patients. All femoral pseudoaneurysms were repaired with primary suture without clamping. No early postoperative deaths occurred. Conclusion: Although cross-clamp surgical treatment modalities have been described as standard surgical treatment, surgical repair with primary suture technique without clamping is a good method for iatrogenic peripheral arterial pseudoaneurysms.

Effective treatment of iatrogenic femoral pseudoaneurysms by combined endovascular balloon inflation and percutaneous thrombin injection.

The increasing number of percutaneous endovascular procedures in highly anticoagulated patients has increased the possibility of iatrogenic femoral artery pseudoaneurysm (IFAP). Ultrasound (US)-guided percutaneous thrombin injection is one of the feasible treatments; however, there are concerns about complications such as peripheral embolization. This study was performed to examine the efficacy and safety of treatment of IFAPs using a combination of percutaneous thrombin injection and intravascular balloon inflation. In this retrospective, single-center study, we analyzed 11 patients who developed and were treated for IFAPs from January 2017 through April 2020. The patients were treated with endovascular therapy (EVT) with percutaneous thrombin injection. The technique utilized fluoroscopic guidance to place a balloon at the neck of the IFAP, and the balloon was then inflated to prevent the inflow of blood to the aneurysm. We then performed US-guided thrombin injection. The mean age was 72.36 ± 10.43years; mean body mass index (BMI) was 25.25 ± 3.18. All patients had hypertension, 72.7% were undergoing hemodialysis, and 54.5% used oral anticoagulant drugs. The mean aneurysm size was 24.34 ± 13.54mm. The approach was transfemoral in ten patients and transradial in one patient. All procedures were successful, and there were no complications. The mean thrombin dose was 677.3 ± 410.7IU; the total hemostatic time was 45.4 ± 24.9min. In conclusion, the combination of percutaneous thrombin injection and endovascular balloon inflation was feasible and safe for the treatment of IFAPs. This technique may contribute to the treatment of IFAPs.

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.

Comparison of the Efficacy and Safety of Two Dosing Protocols for Ultrasound Guided Thrombin Injection in Patients with Iatrogenic Femoral Pseudoaneurysms

Ultrasound guided thrombin injection (UGTI) is a minimally invasive method of treatment for iatrogenic post-catheterisation femoral pseudoaneurysms (psAs). The optimal dosing protocol for UGTI has not been established. The aim of the study was to compare the success and complication rates between two different dosing protocols (the most commonly used “standard dose protocol” and the “low dose protocol,” which is the fractionated administration of smaller thrombin doses of up to 40 IU every 15 s) in patients with a psA with sac volume of ≥1 mL. This was a retrospective cohort study, and the analysis was performed using a case matching approach based on propensity score. From June 2004 to August 2018, 384 patients who underwent femoral puncture for transcatheter procedures were diagnosed with femoral psA with a sac volume of ≥1 mL and qualified for UGTI. The patients’ mean age was 68 (±10.6) years and there were 217 (56.5%) women. To compare protocols, 124 patients treated according to the low dose protocol were nearest neighbour matched according to their propensity score to 124 patients treated according to the standard dose protocol. The overall success rate (99.2% vs. 98.4%; p = 1) and success rate of the first UGTI attempt (87.1% vs. 86.3%; p = .85) did not differ between the low dose and standard dose groups. Complications were less common in the low dose group (7.3% vs. 16.1%; p = .03) and the median total amount of thrombin used for procedures was smaller in the low dose group (120 IU vs. 195 IU; p = .01). In patients with femoral psA with sac volume of ≥1 mL, the use of the low dose protocol seemed to be equally effective as the standard dose protocol and was associated with a lower complication rate and reduced thrombin dose.

Comparison of the Efficacy and Safety of Two Dosing Protocols for Ultrasound Guided Thrombin Injection in Patients with Iatrogenic Femoral Pseudoaneurysms

Ultrasound guided thrombin injection (UGTI) is a minimally invasive method of treatment for iatrogenic post-catheterisation femoral pseudoaneurysms (psAs). The optimal dosing protocol for UGTI has not been established. The aim of the study was to compare the success and complication rates between two different dosing protocols (the most commonly used "standard dose protocol" and the "low dose protocol," which is the fractionated administration of smaller thrombin doses of up to 40 IU every 15s) in patients with a psA with sac volume of ≥1mL. This was a retrospective cohort study, and the analysis was performed using a case matching approach based on propensity score. From June 2004 to August 2018, 384 patients who underwent femoral puncture for transcatheter procedures were diagnosed with femoral psA with a sac volume of ≥1mL and qualified for UGTI. The patients' mean age was 68 (±10.6) years and there were 217 (56.5%) women. To compare protocols, 124 patients treated according to the low dose protocol were nearest neighbour matched according to their propensity score to 124 patients treated according to the standard dose protocol. The overall success rate (99.2% vs. 98.4%; p=1) and success rate of the first UGTI attempt (87.1% vs. 86.3%; p=.85) did not differ between the low dose and standard dose groups. Complications were less common in the low dose group (7.3% vs. 16.1%; p=.03) and the median total amount of thrombin used for procedures was smaller in the low dose group (120 IU vs. 195 IU; p=.01). In patients with femoral psA with sac volume of ≥1mL, the use of the low dose protocol seemed to be equally effective as the standard dose protocol and was associated with a lower complication rate and reduced thrombin dose.

Sometimes Less May Be More: Thoughts About a Low Dose Protocol for Iatrogenic Femoral Pseudoaneurysm

Sometimes Less May Be More: Thoughts About a Low Dose Protocol for Iatrogenic Femoral Pseudoaneurysm

Safety and Effectiveness of Percutaneous Low-Dose Thrombin Injection for Femoral Puncture Site Pseudoaneurysms in Neurointervention: Single-Center Experience.

PurposeWe present ultrasound-guided percutaneous low-dose thrombin (200–250 IU) injection for the treatment of iatrogenic femoral pseudoaneurysms. Second, we compared patient and procedure factors between subcutaneous hematoma and pseudoaneurysm groups.Materials and MethodsFrom April 2012 to May 2018, 8,425 patients underwent neurointervention. Among these patients, 18 had small subcutaneous hematomas and 6 had pseudoaneurysms. Pseudoaneurysms in the neck and entire sac were visualized, and low-dose thrombins were injected while visualizing a “whirlpool” hyperechoic core in the pseudoaneurysm sac. Subcutaneous hematomas were treated with simple compression. We compared the following parameters between the subcutaneous hematoma group and pseudoaneurysm group: sex, age, body mass index (BMI), type of procedure, heparin usage, sheath size, procedure time, and number of previous neurointervention procedures with the Mann-Whitney U test.ResultsMost of the pseudoaneurysms were successfully occluded with 200 IU of thrombin (n=5). Only 1 pseudoaneurysm required a slightly higher thrombin concentration (250 IU, n=1). During the short-term follow-up, no residual sac was observed and no surgical repair was necessary. Pain in the groin region was alleviated. During the 1-month follow-up, no evidence of pseudoaneurysm recurrence nor subcutaneous hematoma was noted. Patient factors (sex, age, and BMI) and procedure factors (heparin usage, sheath size, procedure time, number of previous procedures) were not statistically different between the subcutaneous hematoma and pseudoaneurysm groups.ConclusionUltrasound-guided percutaneous low-dose thrombin injection (200–250 IU) is safe, effective, and less invasive for treating iatrogenic femoral pseudoaneurysm in neurointervention.

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

BackgroundIatrogenic 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. MethodsA 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. ResultsA 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. ConclusionsUltrasound-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.

Percutaneous closure of iatrogenic femoral pseudoaneurysms with thrombin injection

Iatrogenic femoral artery pseudoaneurysm (IFP) is a tedious complication of percutanous coronary and peripheral interventions which prolong the in-hospital stay. It's overall incidence may increases to 8% in the therapeutic complex procedures. Surgical correction is a traditional approach which is still preferred as a first resort in the many cardiovascular centers in the Turkey. Herein, we aimed to demonstrate the feasibility of percutaneous closure of IFP with thrombin injection.

Ultrasound Guided Percutaneous Injection of Thrombin: Effective Technique for Treatment of Iatrogenic Femoral Pseudoaneurysms.

Arterial pseudoaneurysms are well known iatrogenic complication of percutaneous angiographic or interventional vascular procedures. In the past, the definitive treatment option was open surgical repair which is a relatively invasive procedure. In the last few years, Ultrasound (US) guided percutaneous thrombin injection has been gaining popularity as definitive treatment of pseudoaneurysms. To evaluate efficacy and safety of US guided percutaneous injection of thrombin for treatment of iatrogenic femoral pseudoanurysms at a tertiary care interventional radiological and cardiology centre. A retrospective analysis was conducted on 38 consecutive patients, diagnosed to have iatrogenic femoral artery pseudoaneurysms by Doppler study, in the period from Jan 2013 to Jun 2016. All these patients were treated by US guided percutaneous injection of thrombin solution inside the pseudoaneurysm sac till contents became echogenic and flow inside the pseudoaneurysm stopped completely. One month further follow up in all these patients was done. The dose of thrombin injected varied from 200-1000 IU (mean 300 IU). Immediate thrombosis was seen in all the pseusdoaneurysms. Follow up at 24-48 hours showed complete thrombosis and regression of pseudoaneurysm in all the patients except one in whom a small residual sac was seen which thrombosed completely on second thrombin injection. Further follow up at one month showed regression of aneurysms in all the cases. No significant post procedural clinically significant complications were seen in any of the patients. US guided percutaneous thrombin injection is a highly successful and safe procedure for the treatment of iatrogenic femoral pseudoaneurysms.

Determinants of iatrogenic femoral pseudoaneurysm after cardiac catheterization or percutaneous coronary intervention via the femoral artery.

This study aimed to define the prevalence and predictors for pseudoaneurysm after coronary angiography, cardiac catheterization and percutaneous coronary interventions (PCIs) performed via the femoral artery. The study included 8469 patients enrolled between January 2007 and December 2009 on whom cardiac catheterization, coronary and/or peripheral angiography and PCIs via the femoral artery were performed. All data, including clinical characteristics and complications, were obtained retrospectively from patient chart records. Pseudoaneurysm was detected in 65 (0.76%) patients. Pseudoaneurysm was ascertained more frequently in patients with a history of coronary artery disease (0.9% vs. 0.4%; p=0.012), in females than in males (1.4% vs. 0.5%; p<0.001), in patients older than 65 years (1.2% vs. 0.6%; p=0.002), in patients with a history of femoral artery intervention (1.2% vs. 0.6%; p=0.01), in hypertensives than in normotensives (1.3% vs. 0.5%; p<0.001), in patients taking low molecular weight heparin (1.0% vs. 0.2%; p<0.001), in patients taking clopidogrel (1.0% vs. 0.4%; p=0.007), and in patients with chronic renal disease (3.8% vs. 0.7%; p<0.001). There was no statistically significant trend (1.2% vs. 0.7%; p=0.053) towards more pseudoaneurysm formation in emergent interventions than in elective procedures. Patients with a higher risk of pseudoaneurysm development following intervention via the femoral artery should be specified and extra attention given during the intervention. These patients should be informed of the increased risk of this complication and its results, and should be under close follow-up concerning development of iatrogenic femoral pseudoaneurysm.

Incidence and Correlates in the Development of Iatrogenic Femoral Pseudoaneurysm after Percutaneous Coronary Interventions

We aimed to identify the correlates in the development of post-percutaneous coronary intervention (PCI) iatrogenic femoral pseudoaneurysm (IFP). IFP is one of the more common vascular complications of PCI. From February 2008 to June 2012, 10,169 consecutive patients who underwent PCI were retrospectively studied. Patients who developed postprocedural IFP were identified at a single, large tertiary PCI center. One hundred thirty-nine patients developed IFP (1.38%) and were compared to the cohort that did not. Baseline characteristics were comparable, although patients in the IFP group were older and had a higher incidence of insulin-requiring diabetes mellitus and chronic renal insufficiency (68.4 ± 12.9 vs. 65.4 ± 12.3 years, P = 0.004; 23.9% vs. 14.6%, P = 0.002; and 26.6% vs. 17.3%, P = 0.004, respectively). The non-IFP group had more men and a higher use of vascular closure devices, respectively (64.7% vs. 49.6%, P < 0.001; and 54.1% vs. 26.5%, P < 0.001). There was no significant difference in the use of dual antiplatelet or anticoagulation therapies between the 2 cohorts. Univariable correlates for the development of IFP were female gender, insulin-requiring diabetes mellitus, chronic renal insufficiency, and use of manual compression to achieve hemostasis. On multivariable analysis, the successful deployment of vascular closure device for hemostasis reduced the occurrence of IFP (odds ratio 0.31, 95% confidence interval 0.21-0.46, P < 0.0001). The development of IFP following PCI is not uncommon and the appropriate use of vascular closure devices to achieve hemostasis should be encouraged to minimize this vascular complication.

Ultrasound-guided thrombin injection for treatment of iatrogenic femoral pseudo-aneurysm: A nursing protocol

Femoral pseudo-aneurysm (FPA) is a pulsatile hematoma (false aneurysm) of the femoral artery that communicates with an artery through a disruption in the arterial wall. Most often, FPA develops after an injury or angiographic access to the femoral artery with bleeding into the adjacent tissue. FPA is an uncommon complication, but a very significant one, that can have serious consequences. FPA can initially present as a new thrill or bruit, a pulsatile hematoma, or marked pain and tenderness near the site of arterial puncture. Doppler flow imaging has been the mainstay of diagnosis. Ultrasound (US)-guided compression was the treatment of choice. However, it carries drawbacks including length of time to compress for adequate closure of the artery, discomfort to patients, high recurrence rate in patients receiving anticoagulation, femoral artery thrombosis, and a success rate of only 75% overall. An alternative to compression is US-guided thrombin injection (UGTI) of the FPA. This is a safe procedure that can be done as an outpatient or in an office setting. This paper will provide nursing guidelines and rationale as well as a nursing protocol for the management of patients who undergo UGTI for FPA.

An alternative noninvasive technique for treatment of iatrogenic femoral pseudoaneurysms: stethoscope guided compression

Purpose: In this study, we aimed to evaluate efficiency and safety of stethoscope guided compression as a novel noninvasive technique in the femoral pseudoaneurysm treatment. Methods and results: We prospectively included 29 consecutive patients with diagnosis of femoral pseudoaneurysm who underwent coronary angiography. Patients with clinical suspicion of femoral pseudoaneurysm were referred to color Doppler ultrasound evaluation. Adult side of the stethoscope was used to determine location of bruit. Then, compression with pediatric side of stethoscope was applied until bruit could not be heard and compression was maintained for at least two sessions. Once bruit disappeared, 12- hour bed rest with external elastic compression was advised, in order to prevent disintegration of newly formed thrombosis. Mean pseudoaneurysm size was 1.7±0.4 cm × 3.0±0.9 cm and mean duration of compression was 36.2±8.5 minutes. Twenty-six (89.6%) of these 29 patients were successfully treated with stethoscope guided compression. In 18 patients (62%), pseuodoaneurysms were successfully closed after 2 sessions of 15-minute compression. Only one patient experienced mild vagal reaction. ![Figure][1] Figure 1 Conclusion: Stethoscope guided compression of femoral pseudoaneurysms is a safe and effective novel technique which require less equipment and expertise than other contemporary methods. [1]: pending:yes

An alternative noninvasive technique for the treatment of iatrogenic femoral pseudoaneurysms: stethoscope-guided compression

Objective Iatrogenic femoral pseudoaneurysm is a well-known vascular access site complication. Many invasive and noninvasive techniques have been proposed for the management of this relatively common complication. In this study, we aimed to evaluate effi ciency and safety of stethoscopeguided compression as a novel noninvasive technique in the femoral pseudoaneurysm treatment.Methods and results We prospectively included 29 consecutive patients with the diagnosis of femoral pseudoaneurysm who underwent coronary angiography. Patients with a clinical suspicion of femoral pseudoaneurysm were referred to colour Doppler ultrasound evaluation. The adult (large) side of the stethoscope was used to determine the location where the bruit was best heard. Then compression with the paediatric (small) side of the stethoscope was applied until the bruit could no longer be heard and compression was maintained for at least two sessions. Once the bruit disappeared, a 12-hour bed rest with external elastic compression was advised to the patients, in order to prevent disintegration of newly formed thrombosis. Mean pseudoaneurysm size was 1.7 ± 0.4 cm × 3.0 ± 0.9 cm and the mean duration of compression was 36.2 ± 8.5 minutes. Twenty-six (89.6%) of these 29 patients were successfully treated with stethoscope-guided compression. In 18 patients (62%), the pseuodoaneurysms were successfully closed after 2 sessions of 15-minute compression. No severe complication was observed.Conclusion Stethoscope-guided compression of femoral pseudoaneurysms is a safe and eff ective novel technique which requires less equipment and expertise than other contemporary methods.

TCT-403 Percutaneous Ultrasound-Guided Thrombin Injection as a Safe and Efficacious Primary Treatment of Iatrogenic Femoral Pseudoaneurysms for the Interventional Cardiologist

TCT-403 Percutaneous Ultrasound-Guided Thrombin Injection as a Safe and Efficacious Primary Treatment of Iatrogenic Femoral Pseudoaneurysms for the Interventional Cardiologist

Percutaneous fluoroscopically guided n-butyl cyanoacrylate (NBCA) injection for iatrogenic femoral arterial pseudoaneurysm under temporary balloon occlusion of arterial blood flow

To evaluate the safety and efficacy of n-butyl cyanoacrylate (NBCA) injection under fluoroscopy for iatrogenic femoral artery pseudoaneurysms under temporary balloon occlusion. This treatment was approved by the Ethics Committee of our institute, and informed consent was obtained from the patients. Three male patients aged 82, 77, and 51 years developed femoral arterial pseudoaneurysms after catheterization. The pseudoaneurysms (diameter: 30, 12, and 15 mm; neck diameter: 1.8, 5.2, and 1.4 mm) were treated with percutaneous NBCA injection under fluoroscopy after failed ultrasound (US)-guided compression. First, a 4-Fr balloon catheter was inserted into the responsible femoral artery via the contralateral approach. An 18-gauge needle was placed in the pseudoaneurysm under US guidance, and a test injection of contrast medium was performed under fluoroscopic guidance to evaluate the extent of the pseudoaneurysm. NBCA-lipiodol (Lp) (ratio, 1:3) was then injected under balloon inflation. The balloon catheter was deflated and withdrawn after treatment. The total volume of the injected NBCA-Lp was 0.4-1.5 ml. In each case, angiography immediately after NBCA-Lp injection showed eradication of the pseudoaneurysm, and color Doppler US revealed no blood flow signal. No complications were observed. Color Doppler US showed no recurrence in the three patients at their last follow-ups at 6, 12, and 12 months. Percutaneous NBCA injection under fluoroscopy with the support of balloon inflation was safe, feasible, and useful for eradicating iatrogenic femoral artery pseudoaneurysms in three cases following failed US compression.