In addition to the excerpts from today’s post please see Life-threatening Rupture of a Femoral Pseudoaneurysm after Cardiac Catheterization [PubMed Abstract] [Full Text HTML] [Full Text PDF]. Open Cardiovasc Med J. 2016; 10: 201–204.
Authors: Madia C.
The following are key points to remember about postcatheterization femoral artery pseudoaneurysms:
- Pseudoaneurysm is the most common femoral access complication following angiography; incidence ranges from 0.2% to 8%.
- Risk factors include antiplatelet agents, anticoagulants, larger sheath size, puncture site below common femoral artery, and emergency procedures. Patient risk factors include platelet count below 200,000 cells/mm3, obesity, female sex, hypertension, arterial calcification, and age >75 years.
- Symptoms may include groin swelling, unusual pain, bruising, skin changes, neuropathy from femoral nerve compression, and, rarely, limb ischemia or claudication from embolization or arterial compression. Rupture can be associated with severe pain and hemodynamic instability.
- Physical examination may reveal groin or limb swelling, tenderness, mass, bruising, skin necrosis, thrill, or bruit.
- Duplex ultrasound with B mode imaging, color flow imaging, and Doppler pulse wave analysis is the diagnostic test of choice.
- Management options include observation, ultrasound-guided compression, ultrasound-guided thrombin injection, or surgery. For small, stable pseudoaneurysms (<2 cm), observation with weekly duplex ultrasound until thrombosis occurs is appropriate. Anticoagulation should be held; patients should avoid lifting or bending.
- More aggressive treatment should be considered if a pseudoaneurysm is >2 cm, has a short (<4 mm) neck width, is enlarging, is associated with significant pain, or occurs within 7 days of femoral access, or if continued anticoagulation is required.
- Ultrasound-guided compression is now generally reserved for smaller pseudoaneurysms that fail to thrombose spontaneously after a period of observation. Compression is applied with the ultrasound probe in 10-minute cycles; an average of 37 minutes is required to achieve thrombosis. Patient discomfort may limit the procedure, and most patients require analgesia. The patient lies flat for 2-4 hours following compression. Repeat duplex ultrasound should be performed in 24-48 hours to verify that the pseudoaneurysm has not reopened. The success rate is 63-88%.
- Ultrasound-guided thrombin injection is currently preferred to ultrasound-guided compression in most practices. The procedure is performed under local anesthesia with a sterile field; dilute thrombin is slowly injected into the pseudoaneurysm under duplex imaging and observed for thrombosis. Following successful thrombosis, the patient remains on bedrest for ≤12 hours. The procedural success rate is 93-97%, and complications are rare (1.2%). The most common complication is distal embolization (0.5%).
- Surgical repair may be necessary for pseudoaneurysms that are rapidly expanding, infected, or associated with skin necrosis or compressive symptoms such as ischemia or neuropathy. Surgical repair carries a 20% complication rate.