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A. Al-Nowfal and I. Ahmed
Example of Re-entry
A 66-year-old male with critical limb ischaemia.
Angiogram demonstrates short SFA stump with complete
occlusion of the remaining SFA.There is reconstitution
of the P1 segment of popliteal artery (Image 1). After
reaching a hard distal cap, difcult to re-enter the true
lumen. Therefore, an Outback-assisted re- entry at the P1/
P2 junction. Wire position conrmed re-entry. This was
treated with 5 mm PTA and DCB then stented with a
Biomimics 6mm × 150mm deployed from the P1 POP
back to the SFA origins. Post-stent ballooning with 6mm
PTA.
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Tack Endovascular System
Severe ow-limiting post-angioplasty dissections occur in
42% of femoropopliteal angioplasties. These can negatively
affect both short- and long-term patency. Acutely, dissection
can reduce or obstruct ow, requiring additional therapeutic
intervention. Moreover, within the rst 2 years, the severe
ow limiting dissection signicantly lower patency rate and
four times higher rates of target lesion revascularization
compared to the non-severe group, with increased risk of
restenosis [35].
Dissections can be treated by either prolonged ballooning
or stenting. By scaffolding the vessel wall with high radial
outward force, stents treat the dissection as well as residual
stenosis improving patient outcomes. However, the aggressive radial force combined with an extensive amount of nitinol can cause vessel wall inammation and lead to intimal
hyperplasia formation and in-stent restenosis. It is reported
up to 37% of restenosis occurs 1year post-stent treatment.
The unique dynamic forces exerted in the femoropopliteal
segment can also lead to additional shear stress, inammation, and occasional stent fracture [36].
The Phillips Tack endovascular system is a novel device
specically designed to address the limitations of stents
while providing durable repair of post-PTA dissections in
the SFPA.To reduce the metal surface area in contact with
the luminal wall, Tack implants are short (6mm), with an
open- cell design resulting in lower chronic outward force
compared with similar-sized stents. This allows focal dissection treatment and scaffolding while limiting the amount
of biological injury and neo-intimal hyperplasia. The TOBA
(Tack Optimized Balloon Angioplasty) II study states that
92.1% post angioplasty dissections resolved completely
with only one bailout stent was required. At 12months,
there were no device fractures or clinically signicant
migrations, and signicant improvements were noted in
Rutherford category, ankle-brachial index, and quality of
life [36].
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Example of TACK Endovascular System
A. Al-Nowfal and I. Ahmed
A 70-year-old female with diabetes mellitus II presented with gangrenous right third and forth toes. Angiogram
demonstrates patent CFA and PFA.The SFA proximally contains a signicant stenosis of around 80% and nearocclusive stenosis at the adductor canal. No signicant popliteal or crura disease (Image 1). After crossing with a
0.14″ wire, IVUS was used to conrm luminal crossing. After treatment with atherectomy, POBA and DCB, there
was a ow- limiting dissection in the proximal SFA (Image 2). This was initially treated with prolonged angioplasty with a 6mm POBA, with limited success. Therefore, an INTACT 4.8mm × 8mm was used to treat the
dissection (Image 3). Post-treatment angiogram demonstrates there is now a patent angiogram demonstrate a now
widely patent SFA and popliteal artery (Image 4).
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205
Intravascular Ultrasound
Intravascular ultrasound (IVUS) has emerged as a useful
adjunctive tool to DSA in the evaluation of the vasculature.
It may provide a more precise visualization to what happens
into the blood vessel and play an increasing role in peripheral arterial occlusive procedures. IVUS catheters offer
accurate cross-sectional imaging of arterial vessels with
high dimensional accuracy and provide accurate information about lesion morphology. It enables assessment of the
plaque morphology, vessel diameter, and the presence of
arterial dissections. In a systematic review conducted by
Makris etal. (2017), 13 clinical studies evaluated IVUS as
an adjunct tool to DSA during endovascular interventions in
patients with PAD in iliac, femoral or popliteal arteries. It
was identied IVUS offered better outcomes in appropriate
vessel size and prep for PTA and stenting, more accurate
true-lumen re- entry and appropriate luminal crossing prior
to atherectomy [37].
IVUS catheters are currently provided by two companies, Philips and Boston Scientic. The catheter sizes range
from 2- to 4-French (Fr) and can be easily guided through a
5- or 6-Fr sheath. Larger IVUS catheters are also used for
larger peripheral vessel applications and require larger
sheaths. The larger IVUS catheters come over 0.035-inch
guidewires, and the smaller ones that are more often used
for requiring 0.018- inch or 0.014-inch guidewires. The
length of IVUS catheters ranges from 90 to 150cm, allowing imaging of infra- popliteal arteries via contralateral
approach.
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A. Al-Nowfal and I. Ahmed
Example of Intravascular Ultrasound
A 67-year-old female with critical limb ischaemia with
right second metatarsophalangeal neuroischemic ulcer.
Angiogram demonstrates short SFA stump with complete occlusion of the remaining SFA.There is reconstitution of the P1 segment of popliteal artery (Image 1).
After crossing with a 0.14″ wire, IVUS was used to conrm luminal crossing. It was also used to conrm the
SFA/P1 popliteal diameter of 4.6–4.9 mm (Image 2).
After treatment with atherectomy, POBA and DCB,
IVUS was used to conrm patency of vessel (Image 3). It
was also used to identify signicant residual disease in
the distal SFA, which required stenting (Image 4). Post
treatment angiogram demonstrate there is now a patent
angiogram demonstrate a now widely patent SFA and
popliteal artery (Image 5).
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Case Study
Continued from page 193
Post open endarterectomy an 11 cm 6 Fr sheath was
inserted in the CFA patch. After crossing with a 0.14″ wire.
IVUS was used to conrm luminal crossing. After treatment
with 2.2 mm Philips Phoenix atherectomy system, POBA
and DCB (Selution), there was a ow-limiting dissection in
the proximal SFA.This was initially treated with prolonged
angioplasty with a 6 mm POBA, with limited success.
Therefore, an INTACT 4.8mm×8mm was used to treat the
dissection. Post-treatment angiogram demonstrates there is
now a patent angiogram demonstrate a now widely patent
SFA and popliteal artery. Sheath was removed and closure of
the patch was performed surgically.
Patient was commenced on dual antiplatelet on
discharge.
Conclusion
As the population ages, it is anticipated that the prevalence of
peripheral vascular disease will increase. Within the past few
decades there has been an unprecedented evolution of the
endovascular technologies and vital improvements are
expected in the next decade. Percutaneous procedures will
continue to replace open surgery. New technologies will
pave the way for improved patient outcomes.
References
1. Gerhard-Herman MD, Gornik HL, Barrett C, Barshes NR,
Corriere MA, Drachman DE, Fleisher LA, Fowkes FG, Hamburg
NM, Kinlay S, Lookstein R, Misra S, Mureebe L, Olin JW, Patel
RA, Regensteiner JG, Schanzer A, Shishehbor MH, Stewart KJ,
Treat-Jacobson D, Walsh ME. 2016 AHA/ACC guideline on the
management of patients with lower extremity peripheral artery
disease: executive summary: a report of the American College of
Cardiology/American Heart Association task force on clinical practice guidelines. Circulation. 2017;135(12):e686–725.
2. Katsanos K, Tepe G, Tsetis D, Fanelli F.Standards of practice for
supercial femoral and popliteal artery angioplasty and stenting.
Cardiovasc Intervent Radiol. 2014;37(3):592–603.
3. Antonopoulos CN, Mylonas SN, Moulakakis KG, Sergentanis TN,
Sfyroeras GS, Lazaris AM, Kakisis JD, Vasdekis SN.A network
meta-analysis of randomized controlled trials comparing treatment
modalities for de novo supercial femoral artery occlusive lesions.
J Vasc Surg. 2017;65(1):234–245.e11.
4. Norgren L, Hiatt WR, Dormandy JA, TASC II Working Group,
et al. Inter-society consensus for the management of peripheral
arterial disease. Int Angiol. 2007;26(2):81–157.
5. Mewissen MW.Primary nitinol stenting for femoropopliteal disease. J Endovasc Ther. 2009;16(2 Suppl 2):II63–81.
6. Laird JR, Katzen BT, Scheinert D, Lammer J, Carpenter J,
Buchbinder M, Dave R, Ansel G, Lansky A, Cristea E, Collins TJ,
Goldstein J, Cao AY, Jaff MR, RESILIENT Investigators. Nitinol
stent implantation vs balloon angioplasty for lesions in the supercial femoral and proximal popliteal arteries of patients with claudi-
cation: 3-year follow-up from the RESILIENT randomized trial. J
Endovasc Ther. 2012;19(1):1–9.
7. Tepe G, Laird J, Schneider P, et al. Drug-coated balloon versus
standard percutaneous transluminal angioplasty for the treatment of supercial femoral and popliteal peripheral artery disease: 12-month results from the IN.PACT SFA randomized trial.
Circulation. 2015;131:495–502.
8. Schneider PA, Laird JR, Tepe G, etal. Treatment effect of drugcoated balloons is durable to 3 years in the femoropopliteal arteries: long-term results of the IN.PACT SFA randomized trial. Circ
Cardiovasc Interv. 2018;11:e005891.
9. Roseneld K, Jaff MR, White CJ, et al. Trial of a paclitaxelcoated balloon for femoropopliteal artery disease. N Engl J Med.
2015;373:145–53.
10. Iida O, Soga Y, Urasawa K, et al. Drug-coated balloon versus
uncoated percutaneous transluminal angioplasty for the treatment
of atherosclerotic lesions in the supercial femoral and proximal
popliteal artery: 2-year results of the MDT-2113 SFA Japan randomized trial. Catheter Cardiovasc Interv. 2019;93:664–72.
11. Schroeder H, Werner M, Meyer DR, etal. Low-dose paclitaxelcoated versus uncoated percutaneous transluminal balloon angioplasty for femoropopliteal peripheral artery disease: 1-year results
of the ILLUMENATE European randomized clinical trial (randomized trial of a novel paclitaxel-coated percutaneous angioplasty balloon). Circulation. 2017;135:2227–36.
12. Krishnan P, Faries P, Niazi K, etal. Stellarex drug-coated balloon
for treatment of femoropopliteal disease: 12-month outcomes from
the randomized ILLUMENATE pivotal and pharmacokinetic studies. Circulation. 2017;136:1102–13.
13. Steiner S, Willfort-Ehringer A, Sievert H, etal. 12-month results
from the rst-in-human randomized study of the ranger paclitaxelcoated balloon for femoropopliteal treatment. JACC Cardiovasc
Interv. 2018;11:934–41.
14. Tepe G, Gögebakan Ö, Redlich U, etal. Angiographic and clinical
outcomes after treatment of femoro-popliteal lesions with a novel
paclitaxel-matrix-coated balloon catheter. Cardiovasc Intervent
Radiol. 2017;40:1535–44.
15. Albrecht T, Waliszewski M, Roca C, etal. Two-year clinical outcomes of the consequent trial: can femoropopliteal lesions be
treated with sustainable clinical results that are economically
sound? Cardiovasc Intervent Radiol. 2018;41:1008–14.
16. Katsanos K, Spiliopoulos S, Kitrou P, Krokidis M, Karnabatidis
D. Risk of death following application of paclitaxel-coated balloons and stents in the femoropopliteal artery of the leg: a systematic review and meta-analysis of randomized controlled trials. J Am
Heart Assoc. 2018;7(24):e011245.
17. Carter AJ, Aggarwal M, Kopia GA, Tio F, Tsao PS, Kolata R, Yeung
AC, Llanos G, Dooley J, Falotico R.Long-term effects of polymerbased, slow-release, sirolimus-eluting stents in a porcine coronary
model. Cardiovasc Res. 2004;63(4):617–24.
18. Ali RM, Abdul Kader MASK, Wan Ahmad WA, Ong TK, Liew
HB, etal. Treatment of coronary drug-eluting stent restenosis by
a sirolimus- or paclitaxel-coated balloon. JACC Cardiovasc Interv.
2019;12(6):558–66.
19. Lemos PA, Farooq V, Takimura CK, Gutierrez PS, Virmani R,
et al. Emerging technologies: polymer-free phospholipid encapsulated sirolimus nanocarriers for the controlled release of drug
from a stent-plus-balloon or a stand-alone balloon catheter.
EuroIntervention. 2013;9(1):148–56.
20. Duda SH, Bosiers M, Lammer J, etal. Drug-eluting and bare nitinol stents for the treatment of atherosclerotic lesions in the supercial femoral artery: long-term results from the SIROCCO trial. J
Endovasc Ther. 2006;13:701–10.
21. Med Alliance’s SELUTION FIM study achieves primary endpoint. 2018. https://evtoday.com/2018/01/31/
med-alliances-selution-m-study-achieves-primary-endpoint.
208
https://t.me/medicina_free
A. Al-Nowfal and I. Ahmed
22. Vroegindeweij D, Tielbeek AV, Buth J, Schol FP, Hop WC,
Landman GH.Directional atherectomy versus balloon angioplasty
in segmental femoropopliteal artery disease: 2-year follow-up with
color-ow duplex scanning. J Vasc Surg. 1995;21(2):255–68.
23. Gray WA, Garcia LA, Amin A, Shammas NW, JET Registry
Investigators. Jetstream atherectomy system treatment of femoropopliteal arteries: results of the post-market JET Registry.
Cardiovasc Revasc Med. 2018;19(5 Pt A):506–11.
24. Davis T, Ramaiah V, Niazi K, Martin Gissler H, Crabtree T.Safety
and effectiveness of the Phoenix Atherectomy system in lower
extremity arteries: early and midterm outcomes from the prospective multicenter EASE study. Vascular. 2017;25(6):563–75.
25. Rocha-Singh KJ, Zeller T, Jaff MR.Peripheral arterial calcication: prevalence, mechanism, detection, and clinical implications.
Catheter Cardiovasc Interv. 2014;83(6):E212–20.
26. Chowdhury MM, Makris GC, Tarkin JM, Joshi FR, Hayes PD,
Rudd JHF, Coughlin PA.Lower limb arterial calcication (LLAC)
scores in patients with symptomatic peripheral arterial disease are
associated with increased cardiac mortality and morbidity. PLoS
One. 2017;12(9):e0182952.
27. Tepe G, Brodmann M, Werner M, Bachinsky W, Holden A,
Zeller T, Mangalmurti S, Nolte-Ernsting C, Bertolet B, Scheinert
D, Gray WA, Disrupt PAD III, Investigators. Intravascular lithotripsy for peripheral artery calcication: 30-day outcomes from
the randomized Disrupt PAD III trial. JACC Cardiovasc Interv.
2021;14(12):1352–61.
28. Wong CP, Chan LP, Au DM, Chan HWC, Chan YC.Efcacy and
safety of intravascular lithotripsy in lower extremity peripheral
artery disease: a systematic review and meta-analysis. Eur J Vasc
Endovasc Surg. 2022;63(3):446–56.
29. Tepe G, Brodmann M, Werner M, Bachinsky W, Holden A,
Zeller T, Mangalmurti S, Nolte-Ernsting C, Virmani R, Parikh
SA, Gray WA, Disrupt PAD III Investigators. Intravascular lithotripsy for peripheral artery calcication: mid-term outcomes from
the randomized Disrupt PAD III trial. JACC Cardiovasc Interv.
2022;1(04):100–341.
30. Bolia A, Miles KA, Brennan J, Bell PR. Percutaneous transluminal angioplasty of occlusions of the femoral and popliteal
arteries by subintimal dissection. Cardiovasc Intervent Radiol.
1990;13(6):357–63.
31. London NJ, Srinivasan R, Naylor AR, Hartshorne T, Ratliff
DA, Bell PR, Bolia A. Subintimal angioplasty of femoropopliteal artery occlusions: the long-term results. Eur J Vasc Surg.
1994;8(2):148–55.
32. Lipsitz EC, Ohki T, Veith FJ, Suggs WD, Wain RA, Cynamon J,
Mehta M, Cayne N, Gargiulo N.Does subintimal angioplasty have
a role in the treatment of severe lower extremity ischemia? J Vasc
Surg. 2003;37(2):386–91.
33. Met R, Van Lienden KP, Koelemay MJ, Bipat S, Legemate DA,
Reekers JA.Subintimal angioplasty for peripheral arterial occlusive disease: a systematic review. Cardiovasc Intervent Radiol.
2008;31(4):687–97.
34. Shin SH, Baril D, Chaer R, Rhee R, Makaroun M, Marone
L.Limitations of the Outback LTD re-entry device in femoropopliteal chronic total occlusions. J Vasc Surg. 2011;53(5):1260–4.
35. Fujihara M, Takahara M, Sasaki S, Nanto K, Utsunomiya M, Iida
O, Yokoi Y.Angiographic dissection patterns and patency outcomes
after balloon angioplasty for supercial femoral artery disease. J
Endovasc Ther. 2017;24(3):367–75.
36. Gray WA, Cardenas JA, Brodmann M, Werner M, Bernardo NI,
George JC, Lansky A. Treating post-angioplasty dissection in
the femoropopliteal arteries using the tack endovascular system:
12-month results from the TOBA II Study. JACC Cardiovasc Interv.
2019;12(23):2375–84.
37. Makris GC, Chrysa P, Little M, Patel R, Bratby M, Wigham A,
Anthony S, Uberoi R.The role of intravascular ultrasound in lower
limb revascularization in patients with peripheral arterial disease.
Int Angiol. 2017;36(6):505–16.
Complications andTheir Management
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inPeripheral Interventions
AthanasiosDiamantopoulos andIakovosTheodoulou
21
Case Presentation
A 67-year-old male with a history of hyperlipidaemia, hypertension and signicant smoking history was under investigation for a possible abdominal aortic aneurysm (AAA) after
reporting symptoms of ill-dened back pain as well as a pulsating mass in the abdomen. Following an ultrasound examination, an aneurysmal abdominal aorta was conrmed, after
which he was referred to a tertiary centre for consideration
for an elective endovascular aneurysm repair (EVAR). He
was eventually admitted for an EVAR for which a right femoral access was performed. The procedure had no immediate
operative complications; however, over the course of the
next 2days he complained of swelling and bruising in the
groin, pain and overlying tingling sensation. Following clinical examination, there was suspicion for the formation of a
femoral artery pseudoaneurysm, and this was conrmed with
an ultrasound examination.
Continued at page 214
Background
With peripheral arterial disease (PAD) representing a spectrum of disease, chronic or critical limb ischaemia (CLI)
constitutes a more severe form of PAD, whereby symptoms
occur at rest and can lead to permanent complications such
as ischaemic tissue necrosis [1]. Recent reviews conclude
that the latest calculated prevalence of PAD globally is
5.6%, the equivalent of 236 million adults worldwide [2].
Given the high prevalence, utilisation of peripheral vascular
interventions (PVI) for treatment of PAD is on the rise with
a tenfold increase since 1995 [3], with interventional radiology maintaining a steady market share for provision of such
services in the United States (US) [4]. In fact, PVI has
largely replaced bypass surgery, now becoming the main
choice of revascularisation for PAD patients [5]. With a rise
in PVI, associated complications remain prevalent, therefore their recognition and management are critically important. It is critical that interventional practitioners remain
cognisant of such complications, both for early recognition
and timely management. In addition, with a lot of endovascular treatments rendering patients ready for discharge from
hospitals quicker than open repairs, it is crucial that patients
are aware of signs and symptoms that come with each complication such that recognition happens promptly and relevant care is sought accordingly. In this chapter, complications
are classied into ‘puncture site’, ‘angioplasty site’ and
‘systemic complications’ (Fig.21.1) and management algorithms described for each.
A. Diamantopoulos (*)
Guy’s and St Thomas’ NHS Foundation Trust, London, UK
e-mail: athanasios.diamantopoulos@gstt.nhs.uk
I. Theodoulou (*)
Barts NHS Health Trust, The Royal Hospital, London, UK
e-mail: iakovos.theodoulou@gstt.nhs.uk
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
G. Geroulakos et al. (eds.), Mastering Endovascular Techniques, https://doi.org/10.1007/978-3-031-42735-0_21
209
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Fig. 21.1 Summary of
peripheral vascular
intervention-associated
complications
A. Diamantopoulos and I. Theodoulou
Puncture Site Complications
Puncture site complications are variably reported in literature ranging between 3.5% [6] and 7.0% [7, 8]. Furthermore,
only a fraction of these require active treatment with latest
studies reporting a gure of 0.9% [6].
Haematoma
This is a relatively common (1.0–11.0%) and minor complication, often resolving with conservative management. It
requires careful monitoring post-procedurally, including
assessing for any changes in the size, extent, and location of
the haematoma. A haematoma normally arises due to persistent bleeding post sheath removal, often due to difcult initial access or an over-anticoagulated patient. Expansion and
worsening severity can manifest as new onset neuralgias
with symptoms varying according to anatomical location.
Radial puncture site haematomas may interfere with distal
neurology to the hand whilst femoral haematomas can present with acute limb ischaemia or femoral neuropathy. In
upper extremities, haematomas can be further classied
based on (a) extent of inltration in muscle compartments,
(b) the proximal extension of haematoma to the elbow joint
and (c) any impending threat for compartment syndrome [9].
Retroperitoneal haematoma can be a signicant source of
ongoing bleeding and culprit in haemodynamically deteriorating patients with a new ipsilateral ank pain. It has been
associated to high femoral puncture or access at the external
iliac artery superior to the inguinal ligament, requiring stent
placement or open repair if the former fails to control
bleeding.
Management
Management of non-expanding and stable subcutaneous
haematomas is straight forward with manual compression
followed by loose compression dressings and elevation (if
upper limb) often proving sufcient. Growing haematomas
require more urgent attention, especially if compartment
syndrome is suspected; however, these are much rarer. In
such cases, proximal compression with blood pressure cuff
is necessary, addition of pressure dressing and discussion
with the vascular surgery team. Reversal of anticoagulation
is also worth considering.
Suspicion of retroperitoneal haematomas should be conrmed with urgent non-contrast CT.Management is guided
by the size of the haematoma and the presence or absence
of active bleeding. Conservative approaches rely on bed
rest, consideration for anticoagulation reversal and, depending on haemoglobin (Hb), supportive blood transfusions. A
radiographic indication for active management includes
active extravasation on CT.Emergency rst line approaches
include endovascular covered stents over the culprit arterial
segment or balloon ination proximal to the lesion.
Ongoing bleeders with refractory Hb drops despite blood
transfusions require urgent surgical exploration for source
control.
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211
Pseudoaneurysm
In the femoral region, these are often associated with low
puncture sites (e.g. inferior to common femoral artery) which
render post-procedural manual compression more challenging and can lead to insufcient haemostasis. Pseudoaneurysm
is dened as contained arterial rupture where bleeding is
suppressed by adjacent structures, depending on anatomical
location, including chiey, the tunica adventitia of the artery,
subcutaneous fat and adjacent muscle tissue. Clinically, iatrogenic pseudoaneurysm (IPA) generally occurs in less than
1% of cases and manifests as increased local pain, skin bruising, palpable pulsatile mass, or regional neuropathies. In the
past, their management was often guided by their size, with
conservative approach reserved for smaller aneurysms (usual
cut-off of 3cm) and ultrasound-guided thrombin injection
for those exceeding the 3cm cut-off. Opting for a conservative management, necessitates 2-weekly duplex ultrasound
scans for a minimum of 6weeks. These patients should be
re-considered for intervention in the presence of an expanding IPA or non-compliance with surveillance scans.
Nowadays, even pseudoaneurysms smaller than 3cm can be
treated ultrasound guided injection of thrombin. Indications
for active treatment include haemodynamic instability, active
bleeding, or infected access site. Relative contraindications
include large pseudoaneurysm necks due to an associated
risk for arterial thrombosis.
Management Options
1. Ultrasound-guided compression (UGC) used to be the
rst line treatment but has now largely been replaced by
Ultrasound-guided thrombin injection described in (2).
UGC technique is reserved for smaller pseudoaneurysms
(<3mm) in non-anticoagulated patients. Following sufcient local anaesthesia, using a linear probe with frequency >7MHz, pressure is applied through the probe on
the pseudoaneurysm beck while maintaining real time
colour Doppler sonographic guidance. Pressure and
positioning of the probe is adjusted such that ow into the
pseudoaneurysm is obliterated while ensuring good
patency and ow across the parent artery. Pressure across
the probe is gradually eased at 10-min intervals to assess
for complete elimination of ow and hence thrombosis.
Pressure and positioning are adjusted until pseudoaneurysm thrombosis is conrmed in the absence of ow.
Despite ongoing controversy, concomitant arteriovenous
stula (AVF) has previously been considered a relative
contraindication for this management option; therefore,
careful selection of patients is necessary while assessing
for this possibility.
2. Ultrasound-guided thrombin injection is today in
many centres the rst line treatment for pseudoaneu-
rysms. The operator should rst gather adequate imaging,
ideally using an ultrasound. Computer tomographic or
magnetic resonance angiographic imaging are acceptable
alternatives. Discernible pseudoaneurysm characteristics
should include the size of the sac as well as the width and
length of the neck; if multilobular, the number of lobes
should also be recorded. Using sterile technique, proceed
with adequate local anaesthesia followed by preparation
of the thrombin solution. Thrombin normally comes in
‘Thrombin kits’ with the appropriate reconstitution volumes to make up a Thrombin solution of 100units per
1mL. Using a 22-gauge needle under ultrasound guidance, thrombin is injected into the pseudoaneurysm sac
closest to the artery wall defect in increments of 10units
until limitation of ow and cessation of colour Doppler
ow is achieved. A colour Doppler assessment is repeated
10–20min later to conrm complete ow resolution and
assess need for further rounds of thrombin injections.
Bovine-derived thrombin preparations increase the risk
for allergic reactions, therefore operator should remain
vigilant if any signs of allergy arise and should proceed
with anaphylaxis treatment algorithms as needed.
In both instances, post-procedural instructions should
include bed rest for the patient and avoiding lifting, regular
neurovascular assessment of the ipsilateral limb and repeat
ultrasound Doppler within 24h. Regular and PRN analgesia
are likely to be benecial to treat tenderness around the
treated area. Groin pain, reperfusion of pseudoaneurysm and
distal embolism are some of the commonest complications
in the treatment of pseudoaneurysm.
3. Surgical repair is reserved for a fraction of pseudoaneu-
rysm cases which present with more sinister features,
including quickly expanding pseudoaneurysm which has
been refractory to approaches (1) and (2) and/or presents
with signs of skin necrosis or impending compartment
syndrome.
Arteriovenous Fistulae
AVF display abnormal connection between an artery and a
vein and are traditionally classied as congenital or acquired.
Traumatically acquired AVF are pertinent to PVI and carry
an incidence of up to 0.88% [10, 11]. The natural anatomical
proximity of arteries and veins, often travelling together as a
triplet of artery and a pair of veins, renders them vulnerable
to unduly simultaneous trauma as a needle traversing both
vessels during needle placement for access. Almost all
acquired AVF are initially clinically silent with symptom
onset ranging from 48 h to months after the procedure.
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