Study Documents Institution-Wide Strategy for Treating Femoral Pseudoaneurysm

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Pseudoaneurysm that develops during femoral artery catheterization can be safely and effectively treated using an algorithm emphasizing the use of ultrasound-guided thrombin injection over manual compression when possible. The strategy is described in a paper published online April 1, 2014, ahead of print in Circulation: Cardiovascular Interventions.

Researchers led by Nicolas Langwieser, MD, of Klinikum rechts der Isar (Munich, Germany), tested the algorithm in 432 out of 29,091 patients (1.48%) who developed pseudoaneurysm while undergoing femoral artery catheterization at 2 German hospitals between 2007 and 2011. By default, cases were referred to ultrasound-guided thrombin injection (n = 287; 66.4%). When compressible, pseudoaneurysms that were small (< 20 mm), lacking clearly definable necks, directly adjacent to vessels, or with concomitant arteriovenous fistula were referred to manual compression (n = 145; 33.6%).

Follow-up duplex scans, available for 428 patients, were performed within 4 to 6 hours after thrombin injection and within 12 to 14 hours after manual compression.

High Success, Few Complications

The success rate of the institution-wide therapeutic approach was 97.2% in the entire cohort and 96.3% when assuming that pseudoaneurysms were not closed in the 4 patients lost to follow-up. These results were achieved during a total of 535 treatment attempts (178 manual compression and 357 thrombin injection), amounting to a procedural success rate of 77.8%.

In the ultrasound-guided thrombin injection group, the pseudoaneurysms of 212 patients (74.4%) were successfully occluded with only 1 attempt, while 42 patients (14.7%) required multiple procedures (maximum 3). In the manual compression group, pseudoaneurysms were successfully treated on the first try in 111 patients, though 11 patients (7.7%) required more than 1 attempt (maximum 4).

Twelve patients whose thrombin-injection therapy failed switched over to manual compression, and 20 patients whose manual compression failed crossed over to thrombin injection.

Periprocedural complications were rare at an overall rate of 1.5% (table 1).

Table 1. Periprocedural Complications

 

Manual Compression

Ultrasound-Guided Thrombin Injection

Peripheral Embolization

0

0.8%

Deep Vein Thrombosis

0.6%

0.3%

Pseudoaneurysm Infection

0.6%

0.3%

Pseudoaneurysm Rupture

0.6%

0


Alternative treatments were required for 12 of the 428 evaluable patients (2.8%). Two of these patients (0.5%) had their pseudoaneurysms closed by implantation of a covered stent with no additional complications. The remaining 10 patients (2.3%) underwent surgical repair; one experienced intensive bleeding during surgery that required transfusion, another developed wound infection requiring further revisions, and a third had persistent postoperative neuralgia.

Thrombin Injection the Default Approach

“Based on the individual [pseudoaneurysm] morphology, our algorithm should support the physician in finding the best treatment option,” the study authors write, adding that ultrasound-guided thrombin injection “was installed as the primary option” because of manual compression’s known disadvantages.

Manual compression should be performed when possible in all aneurysms with features suggesting that they might be at high risk of complications from thrombin injection, Dr. Langwieser and colleagues advise. They report that manual compression is performed at their institution without ultrasound guidance and as such “is cost effective and can be performed on any ward and at any time.” However, they note, the treatment “has considerable drawbacks” including long compression time, need for extended bed rest, and pretreatment with narcotic analgesics.

Study Details

More than two-thirds of cases arose from the common femoral artery, nearly one-third from the superficial artery, and the rest from the deep femoral artery and the external iliac artery. Sheath size in patients developing pseudoaneurysm averaged 6.3 ± 0.7 Fr. Eighty percent of cases were cardiac catheterizations, and the remainder were peripheral interventions or electrophysiology studies.

Patients in the manual compression group were younger and less likely to be smokers or have peripheral artery disease compared with those in the thrombin injection group.

 


Source:
Dzijan-Horn M, Langwieser N, Groha P, et al. Safety and efficacy of a potential treatment algorithm by using manual compression repair and ultrasound-guided thrombin injection for the management of iatrogenic femoral artery pseudoaneurysm in a large patient cohort. Circ Cardiovasc Interv. 2014;Epub ahead of print.

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Disclosures
  • Dr. Langwieser reports no relevant conflicts of interest.

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