Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3609_Библиотеки_им_академика_М_И_Перельмана
.pdf
362
https://t.me/medicina_free
Fig. 34.3 Completion angiography post deployment of endograft
Fig. 34.4 Completion angiography of run-off vessels post deployment
of endograft
M. Eslami and O. Abdul-Malak
References
1. Leake AE, Avgerinos ED, Chaer RA, Singh MJ, Makaroun MS,
Marone LK. Contemporary outcomes of open and endovascular
popliteal artery aneurysm repair. J Vasc Surg. 2016;63:70.
2. Dawson I, Sie R, van Baalen JM, Van Bockel JH.Asymptomatic
popliteal aneurysm: elective operation versus conservative follow up. Br J Surg. 1994;81(10):1504.
3. Lowell RC, Gloviczki P, Hallett JW, Naessens JM, Maus TP, Cherry
KJ, etal. Popliteal artery aneurysms: the risk of nonoperative management. Ann Vasc Surg. 1994;8(1):14.
4. Whitehouse WM, Wakeeld TW, Graham LM, Kazmers A,
Zelenock GB, Cronenwett JL, etal. Limb-threatening potential of
arteriosclerotic popliteal artery aneurysms. Surgery. 1983;93(5).
5. Marin ML, Veith FJ, Panetta TF, Cynamon J, Bakal CW, Suggs
WD, etal. Transfemoral endoluminal stented graft repair of a popliteal artery aneurysm. J Vasc Surg. 1994;19(4):754.
6. Cervin A, Tjärnström J, Ravn H, Acosta S, Hultgren R, Welander
M, etal. Treatment of popliteal aneurysm by open and endovascular
surgery: a contemporary study of 592 procedures in Sweden. Eur J
Vasc Endovasc Surg. 2015;50(3):342.
7. Eslami MH, Rybin D, Doros G, Farber A.Open repair of asymptomatic popliteal artery aneurysm is associated with better outcomes than endovascular repair. J Vasc Surg. 2015;61:663.
8. Golchehr B, Zeebregts CJ, Reijnen MMPJ, Tielliu IFJ.Long-term
outcome of endovascular popliteal artery aneurysm repair. J Vasc
Surg. 2018;67(6):1797.
9. Leake AE, Segal MA, Chaer RA, Eslami MH, Al-Khoury G,
Makaroun MS, etal. Meta-analysis of open and endovascular repair
of popliteal artery aneurysms. J Vasc Surg. 2017;65:246.
10. Serrano Hernando FJ, Martínez López I, Hernández Mateo MM,
Hernando Rydings M, Sánchez Hervás L, Rial Horcajo R, etal.
Comparison of popliteal artery aneurysm therapies. J Vasc Surg.
2015;61(3):655.
11. Antonello M, Frigatti P, Battocchio P, Lepidi S, Cognolato D,
DALL’ANTONIA A, etal. Open repair versus endovascular treatment for asymptomatic popliteal artery aneurysm: results of a prospective randomized study. J Vasc Surg. 2005;42(2):185.
12. Antonello M, Frigatti P, Battocchio P, Lepidi S, Dall’Antonia A,
Deriu GP, et al. Endovascular treatment of asymptomatic popliteal aneurysms: 8-year concurrent comparison with open repair. J
Cardiovasc Surg. 2007;48(3):267.
13. Zaghloul MS, Andraska EA, Leake A, Chaer R, Avgerinos ED,
Hager ES, etal. Poor runoff and distal coverage below the knee are
associated with poor long-term outcomes following endovascular
popliteal aneurysm repair. J Vasc Surg. 2021;74:153.
14. Baril DT, Rhee RY, Kim J, Makaroun MS, Chaer RA, Marone
LK. Duplex criteria for determination of in-stent stenosis after
angioplasty and stenting of the supercial femoral artery. J Vasc
Surg. 2009;49(1):133.
15. Willmann JK, Mayer D, Banyai M, Desbiolles LM, Verdun FR,
Seifert B, et al. Evaluation of peripheral arterial bypass grafts
with multi-detector row CT angiography: comparison with
duplex US and digital subtraction angiography. Radiology.
2003;229(2):465.
16. Wolf YG, Kobzantsev Z, Zelmanovich L.Size of normal and aneurysmal popliteal arteries: a duplex ultrasound study. J Vasc Surg.
2006;43(3):488.
17. https://evtoday.com/device- guide/us/self- expanding- stent- grafts.
18. Garg K, Rockman CB, Kim BJ, Jacobowitz GR, Maldonado TS,
Adelman MA, etal. Outcome of endovascular repair of popliteal
artery aneurysm using the Viabahn endoprosthesis. J Vasc Surg.
2012;55(6):1647.
19. Farber A, Angle N, Avgerinos E, Dubois L, Eslami M, Geraghty P,
etal. The Society for Vascular Surgery clinical practice guidelines
on popliteal artery aneurysms. J Vasc Surg. 2022;75(1):109S.
20. Kalish J, Eslami M, Gillespie D, Schermerhorn M, Rybin D, Doros
G, et al. Routine use of ultrasound guidance in femoral arterial
34 Endovascular Repair ofPopliteal Artery Aneurysms
https://t.me/medicina_free
363
access for peripheral vascular intervention decreases groin hematoma rates. J Vasc Surg. 2015;61(5):1231.
21. Cho S, Lee YJ, Ko YG, Kang TS, Lim SH, Hong SJ, etal. Optimal
strategy for antiplatelet therapy after endovascular revascularization
for lower extremity peripheral artery disease. JACC Cardiovasc
Interv. 2019;12(23):2359.
22. Stone PA, Armstrong PA, Bandyk DF, Keeling WB, Flaherty
SK, Shames ML, et al. The value of duplex surveillance after
open and endovascular popliteal aneurysm repair. J Vasc Surg.
2005;41(6):936.
23. Tielliu IFJ, Zeebregts CJ, Vourliotakis G, Bekkema F, van den
Dungen JJAM, Prins TR, etal. Stent fractures in the Hemobahn/
Viabahn stent graft after endovascular popliteal aneurysm repair. J
Vasc Surg. 2010;51(6):1413.
Peripheral Pseudoaneurysms
https://t.me/medicina_free
OrnellaMoschovaki-Zeiger, NikolaosAchilleasArkoudis,
StavrosSpiliopoulos, KonstantinosPalialexis,
andEliasBrountzos
35
Case Presentation
A 69-year-old female patient had recently undergone a
right femur fracture xation with an intramedullary rod
after a fall. She developed swelling of the ipsilateral thigh
within 12 h post-op, and necessity for multiple transfusions due to inability to preserve normal hematocrit and
hemoglobin levels was suspicious of active bleeding. The
patient was transferred for an emergency CT angiography,
where a large hematoma was observed at the incision site
Fig. 35.1 Axial CT
angiography depicting the
pseudoaneurysm originating
from the right deep femoral
artery and the
pseudoaneurysm neck (blue
arrow)
and in the vastus lateralis muscle. In addition, a pseudoaneurysm was demonstrated on the lateral aspect of the thigh,
with a diameter of 2.6cm and a depth of 7.5cm from the
skin, which originated from the deep femoral artery
(Fig.35.1).
The patient turned unstable, with blood pressure drop and
tachycardia, and was immediately transferred to the angiography suite for further intervention.
Continued at page 380
O. Moschovaki-Zeiger (*) · N. A. Arkoudis · S. Spiliopoulos ·
K. Palialexis · E. Brountzos
2nd Department of Radiology, National and Kapodistrian University,
“ATTIKON” University General Hospital, Athens, Greece
e-mail: omoschovaki@med.uoa.gr; narkoudis@med.uoa.gr;
stavspiliop@med.uoa.gr
© 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_35
365
366
https://t.me/medicina_free
O. Moschovaki-Zeiger et al.
Introduction
False aneurysms, also known as pseudoaneurysms, are
formed due to damage to the arterial wall that can induce a
locally conned hematoma with the presence of turbulent
ow within it due to the inability of hemostasis. A pseudoaneurysm, unlike a true aneurysm, lacks the three vascular
wall layers, as they are conned by the tunica media, adventitia, or solely the hematoma they are embedded in and the
surrounding soft tissue. Real aneurysms are in majority of
the cases caused by deterioration of the arterial wall due to
atherosclerosis, whereas false aneurysms are caused due to
arterial damage (mostly after endovascular interventions) or
disruption of an anastomotic connection. The pseudoaneurysm that develops is made up of a sac that is constantly
being perfused with blood, which is connected to the donor
vessel via a neck. It may form in any vessel that has been
compromised, but it has only been described to originate
from veins so seldom.
Given the increased ow within the pseudoaneurysm, a
rupture might result in major hemorrhage that could be lifethreatening, which makes the rapid diagnosis and management crucial.
Pseudoaneurysms, hematomas, arteriovenous stulas,
and retroperitoneal hemorrhages are the most prevalent complications of femoral artery access interventions, while the
use of antiplatelet and anticoagulation therapy is a cofactor.
Surgery has always been considered the recommended
approach, but that has changed in the past few years, as pseudoaneurysms may now be treated using less invasive procedures. This chapter discusses the percutaneous and
endovascular techniques available to date, as well as the possible tips and tricks for the safe management of peripheral
pseudoaneurysms.
often discovered at the site of percutaneous arterial puncture
for a broad variety of interventional procedures including
diagnostic angiograms and angioplasties. This is because the
artery wall fails to seal adequately following the removal of
the sheath or the catheter, which is one of the most prevalent
causes of iatrogenic false aneurysms. With the use of largebore sheaths and periprocedural anticoagulation and antiplatelet treatment, the incidence of pseudoaneurysm
development is as high as 7.7% in minimally invasive procedures [2, 3]. Insufcient pressure or limited pressure time
post-procedurally might also be a factor, as could laceration
of an artery or one of its branches by the access needle.
Despite the growing popularity of the radial artery for
percutaneous procedures, the femoral artery continues to be
the most frequent access point for diagnostic and therapeutic
procedures alike. The reduction in the size of sheaths is a
factor that contributes to the overall lower complication rates
for femoral artery procedures.
Anastomotic Failure
At the conuence of a synthetic/autogenous graft and an
artery, anastomotic false aneurysms are discovered. Suture
failure or infection of the graft material may also cause arterial graft anastomoses to fail over time. However, infection
of the graft material is likely to be the more prevalent cause.
There is a wide range of time intervals between the time of
surgery and the onset of pseudoaneurysms, with those
appearing at a very early stage after the original surgery
being most likely due to infection.
Failure ofClosure Device
Failure of hemostasis may result from improper deployment
of a closure device owing to a highly atheromatic vessel or a
lack of expertise.
Etiology andPathophysiology
False aneurysms may be divided into two primary categories: iatrogenic and non-iatrogenic and further into three
groups in order of occurrence: traumatic, anastomotic, and
mycotic.
Iatrogenic
Arterial Access forEndovascular Procedure
Iatrogenic injury to the femoral or brachial artery accounts
for the great majority of false aneurysms that are seen in
practice today [1]. These types of false aneurysms are most
Non-iatrogenic
Trauma
Penetrating trauma, such as those caused by stab wounds or
gunshot wounds, may result in the development of traumatic
false aneurysms that are not caused by medical
intervention.
Infection
Mycotic pseudoaneurysm is a condition that may develop as
a consequence of arterial damage and infection that are
brought on by the repeated use of injectable intravenous
drugs. This condition can put a person at risk for bleeding,
distal septic emboli, limb loss, and even death [4].
35 Peripheral Pseudoaneurysms
https://t.me/medicina_free
367
Complications
Post-catheterization pseudoaneurysms may lead to a number
of complications, including discomfort and swelling around
the aficted location, pseudoaneurysm rupture, the development of neuropathy, distal embolization, infection, local skin
ischemia and necrosis, and compression of the surrounding
vasculature or nerves [3]. Pseudoaneurysms have a propensity to enlarge, and in the most severe instances, they are
capable of rupturing as a consequence of the pulsatile inow
and outow of blood via their necks. Femoral pseudoaneurysms have the potential to rupture into the retroperitoneal
space, which may result in substantial bleeding that may or
may not be immediately apparent and ultimately result in
death. Epidemiology of Site and Risk Factors.
In most cases, femoral pseudoaneurysms are the consequence of accessing the femoral artery for catheter-based
procedures. The great majority of arterial catheterizations
employ the femoral artery, whereas the radial artery access
site is utilized less often [5]. They may, however, exist in any
location where arterial access is exploited. Following a diagnostic procedure, the frequency is reported to be between
0.06 and 0.18%; however, following interventional operations, the frequency ranges between 0.7 and 6.25% [6].
Besides the common femoral artery, pseudoaneurysms are
more likely to arise at lower puncture points, such as those at
the supercial and deep femoral arteries. This is mainly due
to the femur head not providing support during compression
of the artery after the intervention. Some society recommendations state that the acceptable incidence of pseudoaneurysm
following percutaneous access should be less than 0.2% with
the growing use of ultrasonography for access [7].
viduals are engaged in the puncture site hemostasis, this
could sometimes lead to uncontrolled and other times dangerous circumstances.
The creation of pseudoaneurysms was thought to be at a
lower risk with the use of closure devices in the past; however, more recent studies reveal that there is no signicant
decrease in the occurrence of pseudoaneurysms with closure
devices or manual compression [5].
When determining whether a closure device may be utilized in a particular situation, it is imperative that the procedure be carried out by physicians who are well versed in the
technical details of the device. Choosing manual compression necessitates that the person doing the compression be
adequately trained and applies steady direct digital compression for at least 20min.
Closure devices are typically not suggested at the level of
the brachial artery because of their relatively small diameter,
and a tourniquet-type bandage should not be applied around
an access site since it might quickly lead to blockage of the
artery and ischemia in the distal portion of the vessel, all of
which could lead to insufcient pressure on the puncture
site.
Another factor that decreases the probability of vascular
complications is when the interventionalist employs ultrasonography or uoroscopy with femoral head localization to
puncture the femoral artery in the desired location and on the
rst attempt.
Heparin-treated patients need to have their activated clotting time (ACT) evaluated, which should be reduced to less
than 200s, for sheath removal.
Physical Examination andDiagnosis
Risk Factors
Inadequate hemostasis at the puncture site may lead to complications after endovascular procedures. Several variables
might contribute to an incomplete puncture site closure risk,
including anticoagulation, large sheath size (7-French and
above), incorrect puncture technique, inadequate manual
compression, obesity, synchronous catheterization of artery
and vein, puncture of the superior or deep femoral artery,
arterial hypertension, complex compression sites, and heavily calcied arteries. Complications at the access site are
exceedingly infrequent when the interventionalist acknowledges that maintaining hemostasis at the access site is just as
crucial as the intervention being carried out. After interventional procedures, access site closure is often entrusted to
younger residents/trainees/fellows, so when unskilled indi-
After an endovascular procedure, one should be suspicious
of the presence of a pseudoaneurysms if they present with
local signs and symptoms. The clinical manifestations of an
underlying pseudoaneurysm are pain and swelling, with or
without neurologic symptoms, which are secondary to the
mass effect on the surrounding structures. A palpable thrill,
an audible systolic bruit, or a pulsatile mass could be the
clinical ndings of a false aneurysm. Growing pseudoaneurysms have the ability to exert pressure on the overlying skin,
which may result in pain and, in the long run, ischemia,
necrosis, or hemorrhage. Thrombi that develop within the
sac have the potential to embolize distally. The development
of neurologic symptoms may occur as a consequence of
nerve compression or ischemia. When nearby veins are compressed, the result might be edema as well as deep vein
thrombosis. When comparing brachial artery pseudoaneu-
368
ab
https://t.me/medicina_free
O. Moschovaki-Zeiger et al.
Fig. 35.2 (a) Power Doppler lling of a pseudoaneurysm, (b) thrombosed pseudoaneurysm with no Doppler sign detected following
intervention
rysms to femoral artery pseudoaneurysms, it is vital to note
that hemodynamic instability is far less likely in the former,
a
but neurologic symptoms are much more common.
Numbness and tingling in the hand are potential symptoms
that might be brought on by compression of the median
nerve that is located nearby. Even a small amount of blood
tracking up into the axillary sheath from a high puncture in
the arm might cause signicant nerve compression. A comprehensive history and a physical exam are initially essential,
but a duplex ultrasound examination of the aficted region is
required to conrm the diagnosis (Fig.35.2). This may evaluate the existence of a pseudoaneurysm, its size, the vessel
from which the pseudoaneurysm originates and preferably
the size of the native vessel, the presence of blood ow or
thrombus inside the pseudoaneurysm, the length and width
of the neck, the integrity of the surrounding vessels, and the
presence of loculations. A femoral artery pseudoaneurysm
may be detected with 95–98% sensitivity and specicity
b
with duplex ultrasonography [3]. The presence of blood ow
characterized by a swirling motion, also known as the “yingyang” sign, is a common nding. A distinctive to-and-fro
(Fig.35.3) ow pattern in the neck of the pseudoaneurysm
has been characterized as early as 1988 using spectral waveforms and color Doppler imaging [8]. During systole, blood
enters the pseudoaneurysm (the “to” component), while
Fig. 35.3 (a) Spectral Doppler applied at the pseudoaneurysm neck,
(b) revealing the traditional “to-and-fro” waveform
blood exits the pseudoaneurysm during diastole (the “fro”
35 Peripheral Pseudoaneurysms
https://t.me/medicina_free
369
Table 35.1 Checklist for the imaging evaluation of a
pseudoaneurysm
Is there a presence of a pseudoaneurysm?
What is its size and distance from the skin?
What is the vessel from which the pseudoaneurysm originates?
What is the size of the native vessel?
Is there presence of blood ow or thrombus within the
pseudoaneurysm?
What is the length and width of its neck?
Is there integrity of the surrounding vessels?
Are any loculations present?
component). In conclusion, ultrasound is an essential tool of
the follow-up of patients since it may determine whether or
not the false aneurysm is completely thrombosed or recurred
with ow in its lumen.
CT angiography may be used for further verication and
assessment of the region, revealing a contrast-lled sac adjacent to and related to the donor artery. When it comes to identifying pseudoaneurysms in the proximal extremities, CT
angiography exhibits a sensitivity of 95.1% and a specicity of
98.7% [9]. The wall of a pseudoaneurysm is typically smooth
and well dened, with the exception of the wall of a mycotic
pseudoaneurysm, which is thickened, irregular, and enhanced.
When compared with CT or US, MR angiography continues to be a time-consuming procedure, but it may be a suitable alternative for people who are allergic to iodine contrast
medium. Helpful checklist table for the assessment of the
morphology of pseudoaneurysms (Table 35.1).
Treatment/Management
Surgery was formerly the only option for treating arterial
pseudoaneurysms. But this approach has become less applicable in recent decades. The current treatments include observation, ultrasound-guided compression, ultrasound- guided
injection of thrombin or other brin adhesive agent, percutaneous embolization, endovascular stent-graft exclusion, transarterial embolization, and surgical repair (Table 35.2).
Table 35.2 Suggested endovascular toolkit for the endovascular management of a peripheral pseudoaneurysm. These are only a few suggested options based on the author’s experience and can cover the vast
majority of cases
Tools Size/length
Percutaneous methods
Needles
Percutaneous entry needle 18–22 gauge
Embolic material
Human thrombin Incremental doses (0.1–
0.2mL). Usually a total of
1mL (500IU) is sufcient
Macro- or micro-coils Pushable. 2–10mm diameter
Endovascular methods
Needles
Percutaneous entry needle 18–21 gauge
Sheaths
Any standard access sheath 4.0–6.0 Fr/11cm
Guidewires
Standard J guidewire
Micro-guidewire
Catheters
Standard angled angiocatheters
(VanSchie 1–3; Vertebral,
Headhunter, Cobra, etc.)
Coaxial microcatheter system 1.8–2.7 Fr
Balloons
Standard semi-compliant PTA
balloon catheters
Stent-grafts
Self-expandable covered stents 2–10mm diameter/20–40mm
Balloon-expandable covered stents 2–8mm diameter/20–40mm
Embolic material
Micro-coils
Pushable 2–12mm diameter
Detachable (preferably) 2–12mm diameter
Liquid embolics (N-butylcyanoacrylate with Lipiodol, Onyx®)
Diameter: 0.035′, lengths:
180–260cm
0.012″–0.021″
0.035″/5.0 Fr/40–110cm
Diameters: 2–8mm, length
20–40mm
length/75cm or 135cm shaft
length/75cm or 135cm shaft
Small amounts are usually
required (0.5–3mL)
lation/antiplatelet status, which is frequently necessary in
patients after cardiac procedures, are both factors that withhold spontaneous thrombosis.
Observation
Pseudoaneurysms of less than 2cm in diameter in individuals with no symptoms or anticoagulation may be treated by
observation because of the likelihood of spontaneous thrombosis, according to research [10]. A follow-up duplex ultrasound will be necessary in a week for this group of patients
in order to document a reduction in the size of the pseudoaneurysm or its complete elimination. Due to the extensive
hospital stay, most pseudoaneurysms are nowadays treated.
The size of the pseudoaneurysm and the patient’s anticoagu-
Percutaneous Treatment
Ultrasound-Guided Compression
Using duplex ultrasound, the location of the pseudoaneurysms and the neck may be determined. An estimation is also
made on the direction in which pressure must be applied in
order to disrupt circulation into the sac, and downward pressure is applied across the neck, leading to ow interruption
(Fig. 35.9a). It is important to avoid exerting excessive pressure, since this might lead to the surrounding vessels being
370
https://t.me/medicina_free
O. Moschovaki-Zeiger et al.
constricted or to decreased blood ow in the distal arteries;
however, there are often no negative aftereffects associated
with the momentary blockage of blood ow. An intravenous
line must be set up, the skin is disinfected, and local anesthetic is administered to alleviate discomfort prior to compression, as it is a particularly unpleasant procedure for the
patient. The rst few seconds of pressure usually bring on
the most immense pain, but while the pressure is held constant, a tolerance for the pain will develop; however, it is not
uncommon to miss the position over the neck, which
demands further modication of the position of the ultrasound probe in order to proceed with the procedure, which
causes disruption of constant pressure that is being applied to
the neck, increases the risk of blood owing in the pseudoaneurysm, and decreases the likelihood of technical success.
The process is repeated as many times as necessary if the
false lumen and neck remain patent with 10–15min compression intervals. In clinical settings, the process is often
terminated if the pseudoaneurysm has not thrombosed by the
end of the rst hour [11].
Until the introduction of thrombin embolization therapy,
this method, initially reported in 1991 by Fellmeth et al.
[12], was the treatment of choice for pseudoaneurysms.
Patient discomfort, time demands, and the sonologist’s ability to maintain enough pressure are major limitations [13].
Contraindications to ultrasound-guided compression
include substantial hematomas, limb or skin ischemia, signicant patient discomfort, infection, and anatomical
incompatibilities (e.g., if the pseudoaneurysm neck is not
easily approachable, above the inguinal ligament) [3]. The
use of anticoagulants lowers the probability of the procedure being successful; hence, anticoagulation therapy has to
be withheld if medically safe [3]. Anticoagulation, pseudoaneurysm size, the number of locations, the age of the pseudoaneurysm, neck length, and width have all been studied to
evaluate whether these have any effect on the efcacy of
US-guided compression. This method has been shown to
achieve hemostasis in a secure and cost-effective manner,
with success rates ranging from 74 to 86%, as reported [14].
It has been described that the rate of failed success of this
approach ranges between 15 and 38% and that the incidence
of recurrence after initial success is as high as 20–30% in
patients who have taken anticoagulants [3, 15–17]. As a
result, 24-h follow-up is indicated to verify that the pseudoaneurysm remains thrombosed. Patients are instructed to
avoid intense activities for a minimum of 1day after the
procedure.
Complications from compression under ultrasound guidance are quite infrequent. Increasing pseudoaneurysm size
that could lead to rupture (1% risk), distal embolization, and
vein thrombosis are possible complications of the method,
with an overall complication rate of 3.6%, that are quite signicant if they occur [11, 14, 18].
The US-guided compression method has various alterations. Pressure may be applied on the pseudoaneurysm, with
the force of the hand, while the probe is positioned and used
to visualize the pseudoaneurysm, which makes it easier if
pressure needs to be exerted for an extended time or if the
patient is overweight [19]. Occluding the aneurysm sac’s
ow using a freehand mechanical compression device, such
as a FemoStop device, is another option. As a result of the
discomfort reported by patients, this treatment option has
been less popular in recent years, in addition to being more
time consuming.
Ultrasound-Guided Thrombin Injection
The use of ultrasound-guided thrombin injection for the
treatment of pseudoaneurysms that are percutaneously
accessible is a commonly used minimally invasive technique. Even though patients may be taking anticoagulants
and/or antiplatelet medication, a single treatment for femoral
pseudoaneurysms has been reported to have a very high success rate, ranging from 97 to 100%, in a number of studies
[20]. Blood stasis, as seen in pseudoaneurysms, makes it
easier for activated clotting factors, including thrombin, to
remain in the bloodstream and produce thrombi, which, in
addition to injection of exogenous thrombin, induces further
development of the thrombus [21], a mechanism that is independent of the usage of anticoagulants [22]. The use of percutaneous thrombin injection for false aneurysms at locations
other than the femoral artery has also been shown to be
successful, like the radial or brachial artery, at the sites of
hemodialysis stulas [1, 23, 24].
Cope and Zeit originally documented the exclusion of
false aneurysms using percutaneous embolization with
thrombin in the year 1986 [25]. Thrombin injection was used
to treat 114 individuals who had iatrogenic pseudoaneurysms, according to Paulson etal., with a 90% success rate
with a single injection. A second successful injection a day
later was obtained in 7 out of 11 patients with residual ow,
equivalent to an overall 96% technical success rate [26]. In
131 patients, Khoury etal. had 96% technical success, with
complete pseudoaneurysmal thrombosis in 117 individuals
with the rst attempt, and the rest 9 were successfully embolized the day after on the second attempt [27]. US-guided
thrombin injection was recently reported in a multicenter
registry, where 91 patients were injected with thrombin, with
the initial technical success after a single injection being
96% [28].
Thrombin converts inactive brinogen into active brin,
which is a direct contributor in the formation of thrombus. It
may be found in a wide range of pharmacological formulations, derived from bovines or humans. The usage of bovine
thrombin was commonly used in the past, but due to possible
IgE-mediated anaphylactic reaction, from previous exposure
and questions regarding possible transmission of human
ab
35 Peripheral Pseudoaneurysms
https://t.me/medicina_free
371
form of bovine spongiform encephalopathy, it is avoided
nowadays. A sterile powder is the most common form of
bovine thrombin, which is diluted with normal saline solution to a concentration of 1000U/mL commonly, although a
lower concentration of thrombin could theoretically have a
lower risk of an allergic reaction [29]. Human thrombin is
often obtained from the Tisseel Fibrin Sealant Kit (Baxter
US), which is a dual syringe with brinogen that has been
approved for use as tissue glue in surgeries. It is used as an
independent component or in combination directly in the
pseudoaneurysmal sac, although sequential usage is sufcient for achieving thrombosis. It is also possible to utilize
human thrombin that has been extracted from the blood of
patients. About 30–60 mL of blood sampling is required,
which is processed, and then the thrombin component is
reinjected in the pseudoaneurysm sac. The use of autologous
thrombin provides the benets of a safe procedure, lower
risk of allergic responses, as well as lower cost [30].
After local sterility of the area, a linear 5–7.5MHz ultrasound transducer is used to visualize the pseudoaneurysm,
and 1–2% lidocaine is inltrated in the skin and subcutaneous tissue. A 19–22 gauge entry needle is guided in parallel
with the probe to puncture the pseudoaneurysmal sac under
constant ultrasound visualization, as supercially and far
from the neck as feasible. The tip of the needle should be
depicted and ensured to be as distant as possible from the
native vessel (Figs. 35.4 and 35.9b). Thrombin is slowly
administered over a period of 10s, until color Doppler ultrasonography reveals that blood ow has ceased, usually
within a few seconds. The quantity of thrombin needed for
each patient has not been estimated yet, but usually 0.1–
0.5mL of thrombin is sufcient for complete thrombosis.
Larger or multilocular pseudoaneurysms might require
higher doses of thrombin injection or a second administration if
ow persists (Fig. 35.5) [29]. Residual ow in the neck should
not be treated due to the increased risk of distal embolism. Final
ultrasound documentation should depict a patent native vessel,
and distal pulses should be assessed. A second duplex examination is required after 24h to prove that the pseudoaneurysm has
been successfully thrombosed, and a 4–6-h bedrest restriction is
imposed on all patients after the intervention.
Distal embolization and acute ischemia are possible complications of percutaneous thrombin injection in up to 2% of
patients [3], with a short pseudoaneurysm neck (less than
2mm) having an increased risk. Distal embolization into the
native circulation has been observed in three individuals by
Paulson et al., which required no surgery or endovascular
intervention [26]. An embolization to the distal brachial
artery was spontaneously lysed, as described by Kang etal.
[1]. Thrombin-induced distal embolism in one patient was
treated with endovascular tissue plasminogen activator and
heparin administration, according to Friedman etal. [31] and
similarly by Sadie and Ibrahim [32]. In the series of Khoury
et al., two patients developed limb ischemia necessitating
surgical thrombectomy [27]. Asymptomatic thrombi lyse
spontaneously due to natural circulating lytic agents,
although the administration of a tissue plasminogen activator
can assist by causing brinolysis through the conversion of
plasminogen to plasmin in clinically substantial distal embolization [31]. Studies on the security and effectiveness of this
process have been conducted by multiple independent
research groups, despite the fact that it is an unapproved
application of thrombin, as the label on the packaging points
out that it is for topical use only and not for injection. This
technique may also be used to treat vessels above the inguinal ligament, which is not recommended when using
ultrasound- guided compression due to the increased risk of
pseudoaneurysmal rupture [33].
Fig. 35.4 (a) Swirling of blood within the pseudoaneurysm on color Doppler—“Ying-yang” sign, (b) needle tip (blue arrow) visualized within
the pseudoaneurysm for thrombin injection
372
https://t.me/medicina_free
O. Moschovaki-Zeiger et al.
a
Fig. 35.5 Multiloculated pseudoaneurysm. (a) Percutaneously inserted needle (blue arrow), (b) thrombosed multiloculated pseudoaneurysm
(absence of Doppler signal)
With Endovascular Balloon Protection
One of the main risk factors of percutaneous thrombin injection for the treatment of pseudoaneurysms is leakage into the
peripheral arterial tree, so prevention is possible with the use
of a balloon catheter. Under uoroscopic guidance, a catheter
is inserted across the aortic bifurcation to the contralateral
femoral artery. Following angiographic conrmation of the
pseudoaneurysm’s location, a balloon catheter sized appropriately for the vessel is positioned across the pseudoaneurysm’s point of origin, and a 19–22-gauge needle is inserted
percutaneously into the pseudoaneurysm once it has been
identied by ultrasound. The balloon is properly positioned
and adequately inated until pulsatile ow through the percutaneous needle is ceased and thrombin is administered. The
balloon may be kept inated for 10min, and angiography and
ultrasound are performed to evaluate the pseudoaneurysm
thrombosis. There is currently no data to suggest that the use
of this approach results in fewer complications in comparison
b
pseudoaneurysms lack an actual wall, some interventionalists
may object to performing coil embolization, as it might raise
cavity pressure and trigger a rupture of the sac in addition to
prevention of natural absorption of the thrombus/hematoma
due to the lling space with coils. In addition, a nest of coils
may serve as a target for pathogens, being a foreign body. This
method has only been described in case reports and has never
been used as standard therapy for pseudoaneurysms. It is critical to rule out any AV connections on the affected limb to avoid
material embolization in the venous system and eventually the
heart and pulmonary artery. One more important thing to note
is that there should be no coil migration noticed in the native
artery. Manual compression after coil deployment is possible in
the case of persistent ow within the pseudoaneurysmal sac
[37]. Coils of all sizes can be used (micro-coils or macro-coils)
without the neck morphology being a restriction. Thrombin
injection is a less costly alternative that does not include the
usage of synthetic materials and is generally preferred.
to thrombin injection alone, despite the fact that it is theoretically a safer procedure. Due to the invasiveness of the contralateral puncture, data don’t support its use in routine practice.
This approach was recommended for use by Elford etal. in
situations in which the neck is short or wider than 3mm [34].
Use ofaClosure Device
There have been reports in the literature that state the use of
closure devices for the management of pseudoaneurysms. A
pseudoaneurysm is punctured with either a 22-gauge needle
or a micropuncture needle under uoroscopy assistance, and
Percutaneous Coil Embolization
Puncturing the pseudoaneurysmal cavity percutaneously and
deploying coils directly in the sac is an alternative approach.
This can be performed in addition with or instead of thrombin
injection [3]. It has been suggested that an angioplasty balloon
should be used to protect the false aneurysm neck [35]; however other researchers have successfully embolized the pseudoaneurysm with no need for balloon protection [36]. Because
then a Glidewire is advanced into the proximal femoral or
external iliac artery. An Angioseal/StarClose device sheath is
inserted over the wire, and the closure device is deployed,
with the anchor/clip placed at the orice of the neck of the
pseudoaneurysm (Fig. 35.9c) [38, 39]. The main signicant
concern is the procedure failure because of a wide pseudoaneurysm neck. The safety and efcacy of this method must
be evaluated in a wider study.
Соседние файлы в папке Библиотека им академика М.И. Перельмана