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False Aneurysm in the Groin Following Coronary Angioplasty 89
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Heparin was discontinued and ultrasound-guided compression repair
(UGCR) was attempted.
Question 4
Which are the disadvantages of UGCR?
A. Thrombosis of the underlying artery is a frequent complication.
B. Most patients find it painful.
C. It is less successful in patients who are anticoagulated.
D. Approximately 30 percent of successfully thrombosed false aneurysms recur.
Due to patient discomfort, intravenous morphine and midazolam were administered. After 60 min of compression, the false aneurysm still had flow. It was decided
not to persist. The hospital did not have any experience with ultrasound-guided
thrombin injection. After discussion with our vascular surgery service, the patient
was transferred to our hospital for thrombin injection.
Question 5
Which of the following statements regarding ultrasound-guided thrombin injection
is/are true?
A. It requires direct injection of thrombin into the neck of the false aneurysm.
B. It involves simultaneous compression of the false aneurysm.
C. It is less painful but less effective than UGCR.
D. It works well in anticoagulated patients.
E. It is appropriate only for femoral false aneurysms.
Thrombin solution (1000 units/ml) was loaded into a small syringe and a
22-gauge spinal needle was attached. Under ultrasound guidance, the needle was
placed into the center of the false aneurysm (Fig. 9b.2) and 0.3 ml thrombin was
injected slowly. Within 15 s, the false aneurysm was thrombosed completely (Fig.
9b.3). The procedure was tolerated well. Flow in the underlying artery was preserved and pedal pulses were intact. As the patient was otherwise stable, she was
discharged soon afterwards.
Question 6
What are the reported complications of thrombin injection?
A. Anaphylaxis.
B. Intra-arterial thrombosis.
90 Vascular Surgery
Fig. 9b.2. The tip of the needle is visible within the false aneurysm cavity.
Fig. 9b.3
. The aneurysm is completely thrombosed 15 seconds after thrombin injection.
False Aneurysm in the Groin Following Coronary Angioplasty 91
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C. Prolonged urticaria.
D. Mad cow disease.
Commentary
A false aneurysm after catheterization is suspected when there is a hematoma, especially an enlarging one, at the puncture site hours or days after the procedure. There
is often significant ecchymosis of the overlying skin. There may be a bruit, but a
continuous bruit is usually associated with an arteriovenous fistula. There may be
pain or neuralgia, and the site is often tender. A pulsatile mass is usually palpable,
but a simple hematoma overlying the artery may give the same impression. Only a
minority of false aneurysms are diagnosed unequivocally by physical examination.
The diagnosis of a femoral false aneurysm has become very easy with duplex
ultrasound. [Q1: B]
The incidence of postcatheterization femoral false aneurysms varies from less
than 0.5 percent to more than 5 percent [1]. Some of the factors that increase the
likelihood of false aneurysm formation include larger sheaths, longer procedure
times, multiple catheter exchanges, and peri- and postprocedure anticoagulation.
Puncture of the superficial femoral or deep femoral artery instead of the CFA is
found to be associated with higher rates of false aneurysm formation. Direct manual
compression after catheter removal is better than compression devices, such as the
FemoStop or C-clamp. Patient characteristics that may increase the likelihood of
false aneurysm formation include atherosclerosis of the punctured artery, obesity
and hypertension. [Q2: B, C, D]
The potential complications of untreated false aneurysms are well known.
Rupture is the most dramatic and life-threatening complication. Compression of
surrounding tissues can cause pain, neuropathy, venous thrombosis, and necrosis
of the overlying skin. Thrombosis of, or embolization into, the femoral artery may
occur. Infection of these false aneurysms is less common. Because of these potential
outcomes, early surgical repair had been advocated in the past. However, in the
1990s, several series showed that the majority of small false aneurysms will develop
spontaneous thrombosis [2–4]. It is less likely to occur with larger false aneurysms
or in patients who are on anticoagulants. [Q3: C, D] Thrombosis may occur within
days, or it may take weeks. Once thrombosis occurs, the false aneurysm is then a
simple hematoma that gets resorbed slowly over time. The defect in the artery heals
uneventfully in most cases.
In 1991, Fellmeth et al. [5] described the method of UGCR of postcatheterization femoral false aneurysms and arteriovenous fistulas. The ultrasound transducer is used to apply downward pressure on the neck of the false aneurysm to
arrest flow. Pressure is maintained until the blood in the aneurysm becomes
thrombosed. After the introduction of UGCR, numerous reports were published
verifying the efficacy and overall safety of this procedure [6–9]. The typical
success rate was between 60 and 90 percent. There were only a few published
complications, including thrombosis of the underlying artery or the femoral
vein from the compression, rupture during compression, rupture after successful compression, skin necrosis caused by prolonged pressure on the skin, and
vasovagal reactions. Therefore, UGCR was shown to be a good alternative to
92 Vascular Surgery
surgical repair or observation, and most centers made it the initial treatment
method.
There are several disadvantages to the procedure. It is time-consuming, requiring
an average of 30–60 min of compression. In most hands, the results are significantly
poorer for patients on anticoagulants [10]. The recurrence rate is about 4–11
percent, but it is as high as 20 percent for anticoagulated patients [6]. About 10
percent of patients cannot be treated with UGCR because they have false aneurysms
that are not compressible or cannot be compressed without also collapsing the
underlying artery, which would increase the chance of arterial thrombosis. For most
patients, the compression is painful, and intravenous sedation or analgesia is often
necessary. Some patients have required epidural or general anesthesia to allow compression. Applying compression is also very uncomfortable for the operator. [Q4: B, C]
Various endovascular treatments have been described for false aneurysms that
have failed compression. They usually require catheterization of the feeding artery
or false aneurysm from a remote access site. Embolization coils can be used to
occlude the neck or to fill the cavity of the false aneurysm [11, 12]. Stent grafts can
be placed in the femoral artery to exclude the false aneurysm, but late occlusion of
the grafts is not uncommon [13]. They certainly should not be the initial method of
treatment. However, for false aneurysms arising from other, less easily accessible
arteries, these techniques may have a role.
Because of the shortcomings of UGCR, we developed a new method of treating
false aneurysms with ultrasound-guided thrombin injection [14, 15]. Thrombin
causes the cleavage of fibrinogen into fibrin, which then polymerizes into a solid. It
is the final product of the coagulation cascade, and this reaction occurs naturally
whenever blood clots. Thrombin has been used topically for many years to control
surface bleeding in the operating room. Our technique is as follows: The ultrasound transducer is centered over the false aneurysm. Thrombin at a concentration of 1000 U/ml is placed into a small syringe, and a 22-gauge spinal needle is
attached. The needle is inserted at an angle into the false aneurysm along the same
plane as the transducer, and the tip is positioned near the center of the false
aneurysm. About 0.5 ml thrombin solution is injected slowly into the false
aneurysm. Within seconds, thrombosis of the false aneurysm is seen. The procedure is not painful, and patients do not require any analgesia or sedation. We allow
patients to get out of bed immediately after treatment, and outpatients are sent
home soon after the procedure.
So far, we have had great success with this procedure. We have treated 165 false
aneurysms. Most (149) developed after groin puncture. There were also false
aneurysms in six brachial, three subclavian, two radial, two tibial, one distal SFA,
and one superficial temporal arteries, and in one arm arteriovenous fistula. Fortyseven patients were anticoagulated at the time of thrombin injection. It was initially
successful in 161 of 165 patients. The other four (all femoral) had partial thrombosis. One of these had complete thrombosis 3 days later when brought back for
repeat injection. Three had surgical repair. There were early recurrences in 12
patients who had initial successful thrombin injection. Seven were reinjected successfully at the time the recurrence was diagnosed. One had spontaneous thrombosis several days after recurrence was identified. Four had surgical repair. Overall,
only 7 of 165 required surgical repair. There were three complications. A brachial
artery false aneurysm had injection of thrombin directly into its neck, which caused
thrombosis of the brachial artery. A femoral false aneurysm had a relatively large
volume of thrombin injected and developed a thrombus in the posterior tibial
False Aneurysm in the Groin Following Coronary Angioplasty 93
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Table 9b.1. Results of ultrasound-guided thrombin injection
Cases Successes (percent) Complications
Current 165 158 (96) 3
Khoury [18] 131 126 (96) 3
Paulson [19] 114 110 (96) 4
Maleux [20] 101 99 (98) 0
Mohler [21] 91 89 (98) 1
La Perna [22] 70 66 (94) 0
TOTAL 672 648 (96) 11 (1.6)
artery. Both of these thromboses resolved after intravenous heparin. A femoral false
aneurysm with a short neck that was about 10 mm wide had partial thrombosis of
the aneurysm. Further injection was not able to thrombose the remaining cavity but
instead caused a tail of thrombus to form in the SFA. The patient underwent surgical thrombectomy and repair of the aneurysm. [Q5: D]
Our results show that intra-arterial thrombosis after thrombin injection is
uncommon. The high concentration of thrombin results in almost immediate conversion of the solution into a solid (thrombus) when it mixes with relatively stagnant blood. Since the neck of the false aneurysm is usually much narrower than the
aneurysm cavity, the thrombus cannot enter the artery. As long as the volume of the
thrombin injected does not approach or exceed the volume of the false aneurysm,
which may result in forcing some of the solution out of the cavity, then the risk of
native artery thrombosis should be small. It is likely to be higher when the neck is
very wide. Other complications that have been reported include single cases of anaphylaxis [16] and prolonged urticaria [17]. Repeated exposure to bovine thrombin
can also lead to development of antibodies to bovine factor V, which may crossreact with autogenous factor V, causing hemorrhagic complications. [Q6: A, B, C]
Many others have also had good results with this procedure. In the largest series,
the success rate is around 96 percent and the complication rate less than 2 percent
(Table 9b.1). Given its simplicity, efficacy, and safety, ultrasound-guided thrombin
injection should be considered the initial treatment of choice for postcatheterization false aneurysms.
References
1. Skillman JJ, Kim D, Baim DS. Vascular complications of percutaneous femoral cardiac interventions.
Incidence and operative repair. Arch Surg 1988;123:1207–12.
2. Kent KC, McArdle CR, Kennedy B, Baim DS, Anninos E, Skillman JJ. A prospective study of the clinical outcome of femoral pseudoaneurysms and arteriovenous fistulas induced by arterial puncture.
J Vasc Surg 1993;17:125–31.
3. Kresowik TF, Khoury MD, Miller BV, Winniford MD, Shamma AR, Sharp WJ, et al. A prospective
study of the incidence and natural history of femoral vascular complications after percutaneous
transluminal coronary angioplasty. J Vasc Surg 1991;13:328–33.
4. Toursarkissian B, Allen BT, Petrinec D, Thompson RW, Rubin BG, Reilly JM, et al. Spontaneous
closure of selected iatrogenic pseudoaneurysms and arteriovenous fistulae. J Vasc Surg
1997;25:803–8.
5. Fellmeth BD, Roberts AC, Bookstein JJ, Freischlag JA, Forsythe JR, Buckner NK, et al.
Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression.
Radiology 1991;178:671–5.
94 Vascular Surgery
6. Cox GS, Young JR, Gray BR, Grubb MW, Hertzer NR. Ultrasound-guided compression repair
of postcatheterization pseudoaneurysms: results of treatment in one hundred cases. J Vasc Surg
1994;19:683–6.
7. Hajarizadeh H, LaRosa CR, Cardullo P, Rohrer MJ, Cutler BS. Ultrasound-guided compression of
iatrogenic femoral pseudoaneurysm failure, recurrence, and long-term results. J Vasc Surg
1995;22:425–30.
8. Hertz SM, Brener BJ. Ultrasound-guided pseudoaneurysm compression: efficacy after coronary
stenting and angioplasty. J Vasc Surg 1997;26:913–16.
9. Hood DB, Mattos MA, Douglas MG, Barkmeier LD, Hodgson KJ, Ramsey DE, et al. Determinants of
success of color-flow duplex-guided compression repair of femoral pseudoaneurysms. Surgery
1996;120:585–8.
10. Hodgett DA, Kang SS, Baker WH. Ultrasound-guided compression repair of catheter-related femoral
artery pseudoaneurysms is impaired by anticoagulation. Vasc Surg 1997;31:639–44.
11. Jain SP, Roubin GS, Iyer SS, Saddekni S, Yadav JS. Closure of an iatrogenic femoral artery pseudoaneurysm by transcutaneous coil embolization. Catheter Cardiovasc Diagn 1996;39:317–19.
12. Pan M, Medina A, Suarez DL, Romero M, Hernandez E, Segura J, et al. Obliteration of femoral
pseudoaneurysm complicating coronary intervention by direct puncture and permanent or removable coil insertion. Am J Cardiol 1997;80:786–8.
13. Thalhammer C, Kirchherr AS, Uhlich F, Walgand J, Gross CM. Postcatheterization pseudoaneurysms
and arteriovenous fistulas: repair with percutaneous implantation of endovascular covered stents.
Radiology 2000;214:127–31.
14. Kang SS, Labropoulos N, Mansour MA, Baker WH. Percutaneous ultrasound guided thrombin injection: a new method for treating postcatheterization femoral pseudoaneurysms. J Vasc Surg
1998;27:1032–8.
15. Kang SS, Labropoulos N, Mansour MA, Michelini M, Filliung D, Baubly MP, et al. Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms. J Vasc Surg 2000;31:289–98.
16. Pope M, Johnston KW. Anaphylaxis after thrombin injection of a femoral pseudoaneurysm: recommendations for prevention. J Vasc Surg 2000;32:190–1.
17. Sheldon PJ, Oglevie SB, Kaplan LA. Prolonged generalized urticarial reaction after percutaneous
thrombin injection for treatment of a femoral artery pseudoaneurysm. J Vasc Interv Radiol
2000;11:759–61.
18. Khoury M, Rebecca A, Greene K, Rama K, Colaiuta E, Flynn L, et al. Duplex scanning-guided thrombin injection for the treatment of iatrogenic pseudoaneurysms. J Vasc Surg 2002;35:517–21.
19. Paulson EK, Nelson RC, Mayes CE, Sheafor DH, Sketch MH, Jr, Kliewer MA. Sonographically guided
thrombin injection of iatrogenic femoral pseudoaneurysms: further experience of a single institution. AJR Am J Roentgenol. 2001;177:309–16.
20. Maleux G, Hendrickx S, Vaninbroukx J, Lacroix H, Thijs M, Desmet W, et al. Percutaneous injection
of human thrombin to treat iatrogenic femoral pseudoaneurysms: short- and midterm ultrasound
follow-up. Eur Radiol 2003;13:209–12.
21. Mohler ER 3rd, Mitchell ME, Carpenter JP, Strandness DE, Jr, Jaff MR, Beckman JA, et al.
Therapeutic thrombin injection of pseudoaneurysms: a multicenter experience. Vasc Med.
2001;6:241–4.
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10. Acute Thrombosis
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Vikram S. Kashyap and Kenneth Ouriel
A 60-year-old retired nurse presents to the emergency department with a cold
and painful right foot. She has an extensive history of peripheral vascular disease
including bilateral iliac stenting for atherosclerotic occlusive disease. Prior to the
onset of symptoms, she could walk at least a quarter of a mile without pain. Her
past history includes a stroke years ago that she has recovered from, hyperlipidemia, coronary artery disease, and smoking. She has not been recently hospitalized or undergone any invasive procedure or operation.
On examination, her pulse is 90 bpm, and her blood pressure is 115/65. Her
heart sounds reveal a regular rhythm. She has a normal left femoral pulse and the
left foot is warm and well perfused. The right limb has no palpable pulses and the
right foot is pale and cool. She can move the foot, but the toes are insensate.
There is a venous Doppler signal in the right foot, but no arterial signal.
Question 1
Native arterial or graft thrombosis can be differentiated from embolic occlusion by
the following:
A. The presence of palpable pulses in the contralateral extremity.
B. A history of cardiac arrhythmias.
C. The degree of profound ischemia in the affected extremity.
D. The location of the occlusion.
E. All of the above.
Question 2
What is the SVS/ISCVS category of limb ischemia in this patient?
A. Category I.
97
98 Vascular Surgery
B. Category IIa.
C. Category IIb.
D. Category III.
Question 3
In acute embolism, the sequence of events is:
A. Paralysis, pain, paresthesia, pulselessness, pallor.
B. Pulselessness, pain, pallor, paresthesia, paralysis.
C. Pulselessness, pain, pallor, paralysis, paresthesia.
The patient is taken to the endovascular suite and an angiogram is performed via a
contralateral femoral approach. This reveals an occluded right iliac stent (Fig. 10.1)
Fig. 10.1.
Aortography via a left femoral approach documents a right iliac thrombosis in the setting of prior iliac
stenting.
Acute Thrombosis 99
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Fig. 10.2.
Arteriography of the right leg documents reconstitution of the common femoral artery with a normal
run-off via both anterior and posterior tibial arteries (not shown).
with reconstitution of the femoral bifurcation (Fig. 10.2) and normal outflow to the
foot.
Question 4
Treatment options for this patient include:
A. Anticoagulation with heparin and coumadin.
B. Operative thrombectomy.
C. Extra-anatomic bypass.
D. Aortofemoral bypass.
E. Mechanical thrombectomy, thrombolysis, and endovascular intervention.
F. Intravenous thrombolysis.
100 Vascular Surgery
Question 5
After thrombolysis, long-term outcome is predicated on:
A. The thrombolytic agent used.
B. Unmasking a “culprit lesion” that is treated via either endovascular or surgical
means.
C. The length of thrombolysis.
Fig. 10.3.
catheter placement in the native circulation distal to the iliac thrombosis.
A hydrophilic wire is used to safely cross the thrombosed segment and this arteriogram confirms
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