A prospective study of the clinical outcome of femoral pseudoaneurysma and arteriovenous fistuals induced by arterial puncture☆

Article Outline

• Abstract
• Material and methods
• Results
• Discussion
  • False aneurysms
  • Arteriovenous fistula
  • Ultrasound-guided compression repair
  • Hemorrhagic complications
  • Summary
• Discussion
• References
• Copyright

Abstract 

Purpose: Although spontaneous thrombosis of femoral false aneurysms (FAs) and arteriovenous fistulas (AVFs) has been reported, the frequency of this occurrence is unknown. This prospective study was designed to establish the natural history of FA and AVF and to evaluate factors that might predict eventual thrombosis of these lesions. Methods: Twenty-two patients with either femoral FAs (n = 16) or AVFs (n = 6) induced by percutaneous arterial punctures were evaluated prospectively. After an initial duplex scan, all patients were monitored with serial scans, either in hospital or weekly as outpatients, depending on the stability of the process. Operative repair was performed for the following indications: (1) a greater than 100% increase in size of a FA by duplex scan, (2) the development of symptoms, or (3) continued patency of the lesion after 2 months of observation. Results: Nine of 16 FAs and four of six AVFs closed spontaneously; FAs greater than 6 cm³ (1.8 cm in diameter) required repair more often (p = 0.065). However, size was not an absolute predictor of the need for repair because two small aneurysms (1.6 and 0.7 cm³) remained patent, although both patients were discharged safely from the hospital, and two large aneurysms (13.2 and 10.7 cm³) thrombosed spontaneously. Three of seven patients whose aneurysms required repair received anticoagulation continuously from the time of catheterization until repair became necessary. None of the patients whose FAs closed spontaneously were receiving anticoagulants at the time of thrombosis (p = 0.02). Neither length of the FA neck, velocity in the FA cavity, size of original arterial puncture, nor velocity in the AVF correlated with thrombosis. Conclusions: We conclude that (1) all FAs do not thrombose spontaneously and at least one third require surgical repair, (2) patients receiving continuous anticoagulation should undergo aneurysm repair, (3) discharge of patients with FAs less than 6 cm³ is safe (the majority of these FAs will eventually thrombose spontaneously), and (4) many AVFs close spontaneously and repair is not required unless symptoms or signs of progressive enlargement develop. (J VASC SURG 1993;17:125-33.)

The development of complex percutaneous vascular procedures, including angioplasty, atherectomy, stenting, and valvuloplasty has resulted in a rise in the incidence of arterial injury after femoral catheterization.¹ The larger sheaths that are necessary for these more complex interventions, and the more frequent use of anticoagulation, are two factors that contribute to the increased frequency of complications resulting from arterial puncture.², ³

Although uncontrollable hemorrhage and limb-threatening ischemia mandate urgent surgical intervention, controversy exists regarding the proper management of femoral false aneurysms (FAs) and arteriovenous fistulas (AVFs). Thought to be unstable lesions, FAs were traditionally repaired immediately after their discovery.⁴ Reports describing spontaneous thrombosis of FAs have appeared recently.⁵, ⁶, ⁷ Kresowik et al.⁵ monitored seven pseudoaneurysms prospectively and found that within 2 weeks of their discovery, all seven thrombosed spontaneously. In the same study three AVFs were observed for 4 weeks and all remained patent.

Although spontaneous thrombosis has been observed, FAs may also rapidly expand, rupture, produce a femoral neuralgia, or lead to femoral venous thrombosis. Considering the risk associated with each of these events, we were concerned that a nonoperative approach for all FAs would be associated with increased morbidity. Also, in contrast to the findings of Kresowik et al.,⁵ we and others⁶ have frequently observed spontaneous closure of femoral AVFs.

Thus a prospective study of the clinical outcome of FAs and AVFs was undertaken. Our study was designed to determine how often FAs and AVFs will thrombose spontaneously. We searched also for variables that might predict eventual thrombosis of FAs or AVFs. The ability to predict the fate of a FA or AVF would allow patients soon after the discovery of these lesions either to be safely discharged from the hospital or to undergo repair of their femoral artery injury.

Back to Article Outline

Material and methods 

From May 1, 1991, to January 1, 1992, all patients undergoing femoral artery catheterization at the Beth Israel Hospital were eligible for study. Patients were routinely examined by the medical or surgical staff after catheterization for the presence of a new femoral bruit or a widened pulse. A vascular surgery consultation and duplex scan were obtained in all patients suspected of having a FA or AVF. After verification of the presence of either of these two lesions, informed consent was obtained and the patient was entered into the study.

Patients were excluded from the study if they had progressive hemorrhage from the femoral artery after catheterization (n = 2). Femoral artery repair was performed urgently in these patients. Several patients were found to have a pulsatile groin mass that expanded rapidly over a period of hours (n = 6). Although these lesions could be considered to be FAs, we included in our prospective study only those lesions that appeared to be stable for at least 24 hours.

All duplex scans were performed by one ultrasonographer (B.K.) and reviewed by one radiologist (C.M.). An Acuson 128 XP with color-flow Doppler (Acuson, Inc., Mountain View, Calif.) was used for the duplex scans. The following information was derived from the initial duplex scan: FAs—three-dimensional size of FA cavity, velocity of flow within the FA, and length of FA neck; and AVF—velocity of flow in the AVF.

Patients remained in the hospital for at least 2 days after initial discovery of a FA; patients with AVFs were discharged without delay. Daily in-hospital inspections were made by a vascular surgeon (J.J.S. or K.C.K.), and all patients with FAs underwent repeat duplex scanning at 48 hours. Patients with stable FAs were then discharged and followed at weekly intervals by a vascular surgeon. Ultrasound examinations were performed at 1-week intervals.

False aneurysms were repaired for the following reasons: (1) development of symptoms, (2) expansion greater than 100%, or (3) failure to thrombose after 2 months of observation. Arteriovenous fistulas were repaired if they did not close after 2 months of observation.

Femoral artery repair, when required, was performed under local anesthesia with anesthesia standby.

Back to Article Outline

Results 

During the 8-month period of the study, 1838 femoral catheterizations were performed at this institution (1454 cardiac and 384 other). Twenty-four patients were discovered to have either a FA (n = 18) or AVF (n = 6) (incidence 1.3%). Two patients with FAs were not studied prospectively because appropriate arrangements for follow-up could not be made. Both of these FAs were repaired. Sixteen FAs and six AVFs were monitored prospectively. The average age of all patients was 71 years. Nine patients were female and 13 were male.

Femoral artery puncture was performed in these patients for a variety of reasons, including diagnostic cardiac catheterization (n = 8), percutaneous transluminal coronary angioplasty (PTCA) (n = 7), PTCA with stent (n = 4), aortic valvuloplasty (n = 1), coronary atherectomy (n = 1), and placement of a dialysis line (n = 1). Sheath sizes were standard for each procedure: diagnostic catheterization, 7F; PTCA, 8F; PTCA with stent, 8F; and valvuloplasty, 12F.

Nine FAs thrombosed spontaneously, and seven required repair. The average interval from catheterization to spontaneous closure of FAs was 22 days, with a range of 3 to 34 days. All seven FAs that required repair expanded during the period of in-hospital observation. Reasons for repair included expansion greater than 100% (n = 4), severe femoral pain (n = 2), and femoral neuralgia (n = 1). It was necessary for the five patients with large FAs who eventually required repair to remain in the hospital for a mean of 6 ± 2 days. The patients with smaller aneurysms were discharged from the hospital. One patient returned at 7 days with femoral neuralgia prompting repair, and a second patient underwent elective repair 51 days after catheterization.

Table I shows the profile of each patient with a FA.

Table I. Data in 16 patients with FAs

Diag cath, Diagnostic catheterization; aortic valve, aortic valvuloplasty.

Aneurysms less than 6 cm³ (1.8 cm in diameter) had a greater tendency to thrombose spontaneously compared with aneurysms greater than 6 cm³ (p = 0.065, Fisher's exact test). However, as the p value reflects, size was not an absolute predictor of aneurysm closure. Two of seven large aneurysms thrombosed and two of nine FAs less than 6 cm³ remained patent.

The connection between the native femoral artery and the FA was identified by ultrasonography in all cases. In those aneurysms that closed, the average length of this neck was 8 mm, compared with 9 mm in aneurysms that required repair (p > 0.4, t test). The velocity of flow in the FA cavity was determined in 13 of the 16 patients. The average velocity in the aneurysms that closed was 90 cm/sec versus 123 cm/sec in patients whose aneurysms remained patent (p > 0.1, t test). Thus neither the length of the neck nor the velocity of flow could be used to predict the propensity for closure of an aneurysm. Also, neither the type of procedure nor the sheath size was useful in predicting thrombosis of FAs or AVFs (p = 0.9).

All patients but one received heparin at the time of femoral artery puncture. In 10 patients, heparin was continued for 24 hours after the procedure. Anticoagulation (heparin, Coumadin, or both) was continued for greater than 24 hours in only four patients. None of the nine patients whose aneurysms closed were receiving anticoagulants at the time that closure occurred. Three of seven patients requiring repair were receiving anticoagulants continuously from the time of catheterization until expansion or the development of symptoms necessitated operative repair (p = 0.02, Fisher's exact test).

Table II shows the data of six patients with AVFs.

Table II. Data in six patients with AVFs

Diag cath, Diagnostic catheterization; coron ather, coronary atherectomy.

A fistulous tract could not be identified by ultrasonography in two patients, and the diagnosis was made by auscultation of a systolic/diastolic bruit in the groin and a duplex scan demonstrating turbulence in the femoral vein. Four AVFs closed spontaneously and two required repair. One of the two repairs was performed at 4 weeks in conjunction with a coronary bypass. The second AVF was repaired 4 months after the cardiac catheterization. The average interval between catheterization and spontaneous closure of the AVF was 37 days.

During the course of this prospective study, eight additional patients underwent urgent operation for femoral artery hemorrhage. Two additional patients were found to have FAs related to catheterizations that had been performed 6 weeks and 3 years earlier. Both of these lesions were repaired.

Back to Article Outline

Discussion 

False aneurysms 

A study of the natural history of femoral pseudoaneurysms requires a reproducible and accurate method for evaluating FA size. Previous studies⁵ have used the greatest diameter of an aneurysm as an estimate of size. However, FAs are often oblong, irregular, or even multilobed (Fig. 1).

• 
  • View Large Image
  • Download to PowerPoint

• Fig. 1. 

  Femoral false aneurysms are usually irregular in shape and determination of true size requires measurement of three dimensions. A, Transverse image demonstrates aneurysm that is 4.8 cm in width and 2.4 cm in depth. B, Longitudinal projection shows aneurysm to be 2.7 cm in length.

In this study all three dimensions were measured precisely, and the size was reported as the product of these dimensions. In calculating the volume of an aneurysm, it is important to separate the cavity containing flow from the surrounding hematoma. This is accomplished most accurately with a duplex scan.⁸, ⁹, ¹⁰ The use of color enhances further the ability of the duplex scan to define the region of flow.¹¹

Fifty-six percent of the FAs that we studied thrombosed spontaneously (Fig. 2).

• 
  • View Large Image
  • Download to PowerPoint

• Fig. 2. 

  A, A 2.7 cm³ FA was noted immediately after diagnostic catheterization. B, Duplex scan 3 days later shows no flow in previous aneurysm cavity, indicating that closure has occurred.

Of those FAs that required repair, progressive enlargement was noted in all and symptoms developed in three patients (Fig. 3).

• 
  • View Large Image
  • Download to PowerPoint

• Fig. 3. 

  A, After femoral artery puncture for coronary angioplasty, duplex scan shows false aneurysm 1.7 cm in length and 1.0 cm in depth. B, Six days later, FA has increased in size and now measures 3.0 cm in length and is 1.3 cm deep.

Our criteria for repair were defined prospectively. We assumed that most vascular surgeons would consider the development of symptoms or expansion of more than 100% as appropriate indications for repair. There was no morbidity associated with the observation of patients with FAs when these criteria were used.

Patients were more likely to require repair of a FA if they were receiving anticoagulant drugs continuously. Three of seven patients with aneurysms that required repair were treated with anticoagulants from the time of catheterization until repair. None of the nine patients whose aneurysms thrombosed spontaneously were receiving anticoagulants at the time the aneurysm closed.

Size of the aneurysm on the initial duplex scan was not a statistically significant predictor of closure. A size of 6 cm³ allowed the best statistical division between large and small aneurysms (p = 0.065). Two of seven FAs greater than 6 cm³ thrombosed spontaneously, and two of nine FAs less than 6 cm³ required repair. All patients with FAs less than 6 cm³ were discharged safely and monitored as outpatients. We felt that discharge of patients with larger FAs could be potentially hazardous.

Although many of the FAs in this study were related to complex cardiologic procedures requiring large sheaths, the type of procedure or sheath size could not be used to predict whether an FA would close. It might be expected that aneurysms with longer necks would have a greater propensity to occlude. However, there was no correlation between the length of the neck and spontaneous closure. Velocity of flow in the aneurysm cavity was also not a useful predictor of closure. Because velocity varies throughout the cavity, it was difficult to know which value to choose. The swirling nature of blood flow within the cavity made an accurate estimation of the Doppler angle of the interrogating beam difficult.

Based on these findings, we recommend that aneurysms be repaired in patients who are receiving continuous anticoagulation. Patients with aneurysms that are less than 6 cm³ can be discharged safely from the hospital. The majority of these FAs will thrombose spontaneously (seven of nine did so), and outpatient monitoring of these patients appears to be safe. For the remaining patients with FAs greater than 6 cm³ who are not receiving continuous anticoagulation, a period of in-hospital observation allowed 50% (two of four) to thrombose spontaneously.

Arteriovenous fistula 

Although iatrogenic femoral AVFs pose no immediate risk for the patient, occasionally high-output congestive heart failure, lower extremity edema, or even arterial insufficiency may develop if the fistula remains patent.¹², ¹³ The long-term fate of these lesions is unknown, and the proportion of patients who will eventually have complications has not been determined. Most patients with AVFs have underlying coronary artery disease. The insidious onset of congestive heart failure could be potentially dangerous. It seems prudent to be certain that all AVFs eventually close.

Four of six AVFs in this study closed spontaneously. One of the remaining two was repaired 4 weeks after its recognition in conjunction with a coronary artery bypass. The bruit in this patient had been gradually increasing in intensity during the 4-week period. It seemed unlikely that spontaneous closure would occur. The second AVF was repaired 4 months after the initial catheterization.

Velocity of flow through the aneurysm neck could be measured only in four of the six AVFs.¹⁴ Velocities ranged from 30 to 150 cm/sec, but unfortunately velocity did not predict closure or continued patency of the AVF. Anticoagulation was also not a useful predictor of whether these lesions would close.

Because two thirds of these lesions developed thrombosis spontaneously, we recommend that AVFs not be repaired immediately. Repair can be performed later if the AVF becomes symptomatic or shows signs of progressive enlargement.

Ultrasound-guided compression repair 

It has been proposed that all femoral FAs and AVFs should be treated with ultrasound-guided compression repair.¹⁵ Ultrasonography is used to identify the neck of the pseudoaneurysm or AF. A downward force is applied with the transducer until flow in the FA or through the AVF is eliminated. Fellmeth et al.¹⁵ were able to treat successfully 27 of 33 patients in whom ultrasound-guided compression repair was attempted. Drawbacks of this technique include discomfort associated with compression and the potential for femoral artery thrombosis. The utility of this procedure is uncertain in patients receiving anticoagulation.¹⁶ It would seem that the spontaneous resolution of an FA or AVF would be preferable to any type of intervention, whether this be ultrasound-guided compression or surgery. Spontaneous closure of FAs occurred in 59% of our patients.

However, the excellent results reported by Fellmeth et al.¹⁵ are encouraging. Our most recent protocol includes an initial attempt to close pseudoaneurysms by ultrasound-guided compression in patients who are receiving continuous anticoagulation or in patients whose FAs are large.

Because two thirds of AVFs thrombose spontaneously and the majority do not become symptomatic, we do not see a role for this method in the treatment of AVFs.

Hemorrhagic complications 

During the course of this prospective study, eight additional patients underwent femoral artery exploration for hemorrhage. The usual indication for operation was an expanding hematoma, which in several patients was associated with hemodynamic instability. Although these patients were not included in the analysis of FAs, they serve to demonstrate the risks associated with continued patency of a laceration after FA puncture.

Summary 

We make the following conclusions and recommendations: (1) All false aneurysms do not thrombose spontaneously; at least one third will require surgical repair. (2) Patients receiving continuous anticoagulation should undergo repair of the aneurysms. (3) Patients with aneurysms less than 6 cm³ can be discharged safely from the hospital if close follow-up is maintained. The majority of these FAs will thrombose spontaneously. (4) Many AVFs close spontaneously. Repair is not required unless symptoms or signs of progressive enlargement develop.

All FA and AVF repairs are performed under local anesthesia. Morbidity and mortality rates of the procedure are low, particularly in patients who are hemodynamically stable at the time of operation.³ Of the seven patients who underwent repair during the course of this study, there were no deaths or morbidity, although three of seven patients required transfusion. We believe that the potential risks associated with symptomatic or expanding FAs far outweigh the small risk that is associated with repair. Spontaneous thrombosis of an FA or AVF is preferable to any interventional procedure. Ultrasound-guided compression repair may be useful in the treatment of those FAs that are unlikely to thrombose spontaneously, and we await further studies to verify the efficacy of this technique.

Back to Article Outline

Discussion 

Dr. Malcolm O. Perry (Lubbock, Texas). Why did you decide on 6 cm³, and how did you determine those dimensions? I must have missed that in the early part.

Dr. K. Craig Kent. For each FA, width, length, and depth were determined. The volume was calculated by taking the product of these three dimensions.

Dr. Perry. Because there is laminated clot and you could not visualize all that with the duplex scan, was it a combination of tactile work as well?

Dr. Kent. Color-flow duplex scanning is able to differentiate between a central area of flow and outer laminated clot. When determining the volumes of these FAs, we measured only the portion of the cavity where flow was present.

We observed that smaller FAs were more likely to thrombose spontaneously and larger FAs were more likely to remain patent. The value that provided the best statistical separation between large and small was 6 cm³ (p = 0.065). Although not statistically significant, this was practically useful; we were able to send all of the patients with FAs less than 6 cm³ home, and most of the FAs (seven of nine) thrombosed spontaneously.

Dr. Perry. So we are talking about 1.5 cm in diameter?

Dr. Kent. Yes, the cube root is approximately 1.8 cm.

Dr. Robert B. Smith (Atlanta, Ga.). Your 1.7% local vascular complication rate, after a variety of transfemoral procedures, compares favorably with reports from other centers and emphasizes that pseudoaneurysms and arterial venous fistulas are infrequent complications of very common procedures. When they do occur, the vascular surgeon must recommend a course of action.

All would agree that large or symptomatic false aneurysms should be repaired immediately, but what about those 2 cm in diameter or less? Can they be observed safely on an outpatient basis provided the patient lives locally, is reliable to return for frequent office visits, and has sufficient financial resources to comply in such a program of care? Obviously, a conservative treatment plana is not appropriate for regional referral centers where patients live at considerable distance from the hospital and the local physician may be intolerant of being asked to follow complications created at the tertiary facility. Our own experience, and that of Dr. Kent's group, suggests that anticoagulation therapy may further reduce the likelihood of spontaneous thrombosis of false aneurysms.

To these considerations should be added the acknowledgement that repair of a pseudoaneurysm under local anesthesia is safe and effective and the patient is usually discharged from the hospital the following day. The relatively small number of cases that meet the criteria for nonoperative care, the definitiveness of surgical treatment, and the inability to guarantee successful outcome with conservative management argue against a wait-and-see approach for most false aneurysms, in our opinion. We tend to repair them when they are diagnosed.

Although we seem more aggressive than you in our approach to false aneurysms, we are more conservative in our management of iatrogenic arteriovenous fistulas. Our experience suggests that many small arteriovenous communications resolve over time and few are responsible for serious problems. Accordingly, we simply observe most femoral arteriovenous fistulas not associated with false aneurysms, delaying repair for up to 6 months. At that time, elective surgical repair is recommended for persistent fistulas, not out of concern about imminent consequences of the fistula but from apprehension about eventual loss of control of the patient with the possibility of a remote complication resulting in criticism of our cardiology associates. Clearly, an extended multicenter study is needed to define better treatment alternatives in such cases.

Would it be cost-effective or clinically useful to search for iatrogenic vascular complications by routine duplex scanning of all patients undergoing transfemoral procedures before their release from care?

Dr. Kent. I do not believe it would be efficacious to perform routine duplex scanning of all patients who undergo femoral artery catheterization. In a center where attending and house staff are attuned to these complications and reliably examine patients after catheterization, it would be remote that a “missed” lesion would lead to any eventual harm.

In the past we were very aggressive about repairing all FAs. At the meeting of the International Society for Cardiovascular Surgery, North American Chapter, 2 years ago, Dr. Kresowik reported that all of the FAs in his series thrombosed spontaneously. Unfortunately, about 2 weeks later an FA that we were monitoring ruptured. In our experience some FAs thrombose spontaneously and some do not. We hoped, with this study, to establish criteria that would help determine which ones we should monitor and which ones should be repaired. Six cubic centimeters turns out to be a very practical value. We were able to discharge patients with aneurysms smaller than 6 cm³, and most of these aneurysms thrombosed. As you mentioned, we also found that aneurysms in patients who received anticoagulant medication were less likely to thrombose.

Dr. Geoffrey S. Cox (Cleveland, Ohio). You have partly answered my question, which was going to be what your experience with ultrasound-guided compression repair has been. Instead, I will answer in part your question and give you our experience.

During the last 12 months at the Cleveland Clinic, we have seen 79 patients with postcatheterization pseudoaneurysms, including 22 who were given anticoagulants and an additional who were about to undergo open-heart surgery. Although, as you have clearly demonstrated, many pseudoaneurysms thrombose spontaneously, some will and do develop symptomatic enlargement. We now prefer to treat all these lesions with ultrasound-guided compression repair. Of 74 pseudoaneurysms treated in this way, we have successfully occluded 93%, including 98% of patients who are not given anticoagulants and 82% of those receiving heparin or Coumadin. There have been no complications, and all patients treated successfully were able to be discharged the following day if their other conditions permitted.

We believe that this method of treatment is safe and reliable and reduces the need for the close follow-up that you have recommended, especially in patients taking anticoagulants and for those traveling long distances. Furthermore, with a conservative approach, the mean time to occlusion is 32 minutes overall. For those patients with aneurysms present for greater than 30 days, this rises to 75 minutes. In our experience the size of the aneurysms did not influence our ability to occlude the aneurysms. Therefore we prefer to see them acutely and thrombose them, rather than have to follow up on them.

Dr. Richard L. McCann (Durham, N.C.). I also support the concept of compression therapy. We were quite interested in this problem until about 1 ½ years ago when we instituted a similar program with compression therapy, and in our last 40 cases we have failed to occlude the false aneurysm in only two cases.

We use a slightly different system. We do use ultrasound color-flow guidance but also the C clamp and find that is more comfortable and more reproducible in the patients. On the other hand, we have found that this therapy has not been helpful in resolving arteriovenous fistulas, but, like Dr. Smith, we find that these cause very few problems in the long term. Our only question is, what are the long-term implications and indications for repair of arteriovenous fistulas? We think that very few of these do become hemodynamically significant and we have seen several of them that have been present for 5 and 6 years, without increasing in size.

Dr. Timothy F. Kresowik (Iowa City, Iowa). I am the author of the report on this subject presented at these meetings 2 years ago. I do not think that there is a large discrepancy between our results and yours. The differences that do exist can probably be explained by differences in our patient populations. Our study was a series of unselected patients who underwent transfemoral coronary angioplasty and routine color duplex scanning irrespective of any clinical suspicion of puncture-related complications. Your patients were specifically referred for evaluation because a puncture complication was suspected. I would assume that a common cause of this suspicion was the presence of a large hematoma. We have observed that the presence of a large surrounding hematoma may indicate a less stable pseudoaneurysm. Was this in fact the case with your patients? Because three of your seven patients who required repair were operated on for symptoms, I wonder whether the symptoms were caused by a large hematoma rather than the pseudoaneurysm itself. You also mentioned that three of your seven patients who required repair were receiving continuous anticoagulation. Was there a relationship between continuous anticoagulation and the pseudoaneurysm expansion that you described? In your pseudoaneurysms that did expand did this enlargement occur in one specific dimension or was it generalized?

With respect to arteriovenous fistulas, we had observed a relationship between a puncture site distal to the femoral bifurcation and arteriovenous fistula formation. Specifically a common cause appeared to be a puncture into the superficial artery and the circumflex femoral vein, which passes between the superficial and deep femoral arteries. Did this site of fistula formation occur in your experience?

Dr. Robert J. Hye (San Diego, Calif.). I just wanted to echo the comments of the previous discussants. We have been using ultrasound-guided compression at the University of California, San Diego, for the past 3 years and have treated well over 70 patients, with a success rate of greater than 90%. You alluded to cost and discomfort of the procedure as being potential problems. Although there is a cost associated with the compression procedure itself, we believe it is more cost-effective than performing serial ultrasound examinations or seeing the patient repeatedly in the clinic to evaluate the pseudoaneurysm. The discomfort of the procedure is occasionally a problem but can generally be managed with small doses of intravenous sedatives or narcotics.

We also believe that it is important to treat these lesions early to optimize the opportunity for successful ultrasound-guided compression. Our experience has been that the more long-standing pseudoaneurysms are much more difficult to obliterate with this method.

Finally, we have had one incidence of femoral arterial thrombosis with embolization to the popliteal artery. This occurred in a patient with a 6-week-old pseudoaneurysm in whom the required compression resulted in cessation of flow in the femoral artery. This resulted in thrombosis and embolization. This was managed successfully; however, because of the consequence of this experience we do believe it is important to monitor femoral artery blood flow and be certain that it is not interrupted during the compressive maneuver.

Dr. Kent. I do not want anyone to think that we are against ultrasound-guided compression repair. We are presently using this technique at our institution. I still believe that spontaneous resolution of a FA is preferable to any interventional procedure, particularly if this procedure uses resources and has the potential to produce complications. We have identified a group of patients (those patients with FAs less than 6 cm³) in whom spontaneous thrombosis is very likely to occur. I do not believe ultrasound-guided compression repair should be used as the initial treatment in these patients. Our present protocol includes an initial attempt to compress FAs that are greater than 6 cm³, as well as FAs in patients who are given anticoagulant medication.

We have attempted to compress four very large aneurysms. We were unsuccessful in three out of the four. All of these patients had very large aneurysms, and they all had large hematomas. In two of the patients we were not able to achieve adequate compression because of patient discomfort; and in the third patient, every time we occluded the neck of the aneurysm, we occluded the femoral artery. I am certain there is a learning curve. I hope that we and other institutions can duplicate your results, particularly in the patients that have these very large, painful aneurysms.

Dr. McCann asked me about the long-term fate of an AVF. Unfortunately, we do not know in how many late complications will eventually develop in patients with AVF. One of the late complications that can develop is congestive heart failure. Because these patients usually have myocardial disease, the insidious onset of congestive heart failure could be harmful. If an AVF does not close after several months of observation, repair of the fistula may be indicated, particularly if long-term follow-up cannot be assured.

As Dr. Kresowik outlined, the FAs in his study were derived from a group of patients who were screened by use of duplex scanning. The FAs in our study were discovered in patients who had symptoms. These are two different populations, and I am sure this, at least in part, explains why his rate of spontaneous thrombosis was greater than ours. We did not specifically examine the relationship between hematoma size and the potential for FA thrombosis. FAs expanded in every direction. We have noted that both FAs and AVFs are more often associated with puncture below the femoral bifurcation.

Back to Article Outline

References 

1. Oweida SW, Roubin GS, Smith RB, Salam AA. Postcatheterization vascular complications associated with percutaneous transluminal coronary angioplasty. J Vasc Surg. 1990;12:310–315
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (613 KB)
   • CrossRef
2. Wyman RM, Safian RD, Portway V, Skillman JJ, McKay RG, Baim DS. Current complications of diagnostic and therapeutic cardiac catheterization. J Am Coll Cardiol. 1988;12:1400–1406
   • View In Article
   • Abstract
   • Full-Text PDF (842 KB)
   • CrossRef
3. Skillman JJ, Kim D, Baim DS. Vascular complications of percutaneous femoral cardiac interventions. Arch Surg. 1988;123:1207–1212
   • View In Article
   • MEDLINE
4. Mills JL, Wiedeman JE, Robison JG, Hallett JW. Minimizing mortality and morbidity from iatrogenic arterial injuries: the need for early recognition and prompt repair. J Vasc Surg. 1986;4:22–27
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (1203 KB)
   • CrossRef
5. Kresowik TE, Khoury MD, Miller BV, et al.  A prospective study of the incidence and natural history of femoral vascular complications after percutaneous transluminal coronary angioplasty. J Vasc Surg. 1991;13:328–336
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (2862 KB)
   • CrossRef
6. McCann RL, Schwartz LB, Pieper KS. Vascular complications of cardiac catheterization. J Vasc Surg. 1991;14:375–381
   • View In Article
   • Abstract
   • Full Text
   • Full-Text PDF (2681 KB)
   • CrossRef
7. Kotval RS, Khoury A, Sha PM, Babu SC. Doppler sonographic demonstration of the progressive spontaneous thrombosis of pseudoaneurysms. J Ultrasound Med. 1990;9:185–190
   • View In Article
   • MEDLINE
8. Sacks D, Robinson ML, Perlmutter GS. Femoral arterial injury following catheterization: duplex evaluation. J Ultrasound Med. 1989;8:241–246
   • View In Article
   • MEDLINE
9. Coughlin BF, Paushter DM. Peripheral pseudoaneurysms: evaluation with duplex US. Radiology. 1988;168:339–342
   • View In Article
   • MEDLINE
10. Helvie MA, Rubin JM, Silver TM, Kresowik TF. The distinction between femoral artery pseudoaneurysms and other causes of groin masses: value of duplex doppler sonography. AJR. 1988;150:1177–1180
    • View In Article
11. Sheikh KH, Adams DB, McCann R, Lyerly HK, Sabiston DC, Kisslo J. Utility of Doppler color flow imaging for identification of femoral arterial complications of cardiac catheterization. Am Heart J. 1989;117:623–628
    • View In Article
    • MEDLINE
    • CrossRef
12. Glaser RL, McKellar D, Scher KS. Arteriovenous fistulas after cardiac catheterization. Arch Surg. 1989;124:1313–1315
    • View In Article
    • MEDLINE
13. Kron J, Sutherland D, Rosch J, Morton MJ, McAnulty JH. Arteriovenous fistula: a rare complication of arterial puncture for cardiac catheterization. Am J Cardiol. 1985;55:1445–1446
    • View In Article
    • MEDLINE
    • CrossRef
14. Igidbashian VN, Mitchell DG, Middleton WD, Schwartz RA, Goldberg BB. Iatrogenic femoral arteriovenous fistula: diagnosis with color Doppler imaging. Radiology. 1989;170:749–752
    • View In Article
    • MEDLINE
15. Fellmeth BD, Roberts AC, Bookstein JJ, et al.  Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression. Radiology. 1991;178:671–675
    • View In Article
    • MEDLINE
16. Dorfman GS, Cronan JJ. Postcatheterization femoral artery injuries: is there a role for nonsurgical treatment?. Radiology. 1991;178:629–630
    • View In Article
    • MEDLINE