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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3823_Библиотеки_им_академика_М_И_Перельмана
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however, in patients on anticoagulation a failure rate as
high as 30–40% has been documented [26].
Ultrasound‐Guided Compression Repair
Step 1. Using a 5 or 7 MHz linear or curvilinear
probe, the neck of the PSA is identified using color
flow Doppler.
Step 2. Manual compression is applied to the neck
via the transducer, in order to prevent flow into the
PSA sac on color Doppler.
Step 3. Continuous pressure is applied while
monitoring flow into the aneurysm sac for
approximately 10 minutes.
Step 4. Pressure is slowly released and flow into the
PSA sac is assessed (see Figure 13.2a,b).
The steps are repeated until either the patient can no
longer tolerate the discomfort, the operator can no
longer continue due to fatigue, or the PSA thromboses.
Compression times of up to 300 minutes can be
required, though the average compression time is about
30 minutes. Analgesia and/or sedation may be required
for the patient to tolerate the procedure. Although
effective and noninvasive, patient discomfort and
significant labor/time intensiveness have limited this
technique’s widespread adoption in the modern era.
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Figure 13.2 Pseudoaneurysm arising from the CFA as
demonstrated by color duplex ultrasonography (a).
Successful thrombosis of PSA after UGCR with cessation
of flow into the PSA sac (b).
Ultrasound‐Guided Thrombin Injection
An increasingly attractive option to treat PSA is the US‐
guided injection of thrombin to elicit thrombosis of the
aneurysm sac. Technical ease, minimal patient
discomfort, and high procedural success rates have made
this the favored primary approach for the treatment of
PSAs in many institutions, including ours. The procedure
can be safely performed at the bedside or in the
catheterization laboratory, and requires only an assistant
and standard US equipment and needles. Technical
success rates are high, and have been reported in the
range of 90–100% [27–30]. We prefer human thrombin
as opposed to bovine in order to minimize the risk of
allergic reaction.
Step 1. 1000 IU human thrombin in 1 ml of normal
saline is suspended to yield a concentration of 1000
IU/ml.
Step 2. A three‐way stopcock is prepared with an
appropriate needle (most PSAs can be treated with a
1.5 in. 22‐gauge needle), and two 1 cc syringes, one
with thrombin and the other with normal saline.
Step 3. Under US guidance, the tip of the needle is
slowly advanced into the PSA sac, directed toward the
base of the sac and away from the neck of the PSA.
Step 4. Ensuring the saline syringe is “on” and the
thrombin syringe is “off” on the three‐way stopcock, 5
ml of saline are injected while monitoring the color
Doppler signal to ensure the tip of the needle is in the
desired location.
Step 5. After satisfactory position is confirmed, the
three‐way stopcock is turned so the thrombin syringe
is “on” and 300 IU (0.3 ml) of thrombin are injected
into the PSA sac.
Step 6. Monitor for thrombus formation and
cessation flow in the PSA. If flow remains after 10
minutes, repeat the process as needed.
Most PSAs can be thrombosed with 1000 IU thrombin,
but rarely more may be required. Bed rest is generally
advised for 6–12 hours after the procedure. A repeat
duplex US should be performed 24 hours after thrombin
injection, and again in one to two weeks to ensure
resolution of the PSA.
Embolization of thrombin into the native arterial tree is a
rare but real complication of this method, and may result
in distal thrombosis which may require emergent
angiography using contralateral retrograde femoral
access, mechanical thrombectomy, and/or intraarterial
thrombolysis. In PSAs with absent or short, wide necks
(>5 mm), balloon occlusion of the parent vessel over the
mouth of the PSA during thrombin injection has been
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suggested as a way to reduce the risk for thrombin
embolization; however, data is lacking to support this.
Covered Stent Placement
Covered stent placement may be used to exclude PSAs
from the circulation in cases not treatable by
percutaneous compression of thrombin injection, and
can be a good alternative to surgery. For example, PSAs
of the SFA or DFA can be treated with short covered
stents to avoid crossing into the CFA, maintaining a site
for possible future catheterization while preserving
vessel patency. Several small series have reported a high
success rate in treating PSAs using covered stents [31,
32]. As previously mentioned, care must be taken to
avoid deploying covered stent‐grafts near the CFA
bifurcation in order to avoid occlusion of the SFA or
DFA. Covered stent‐grafts should be used judiciously in
younger patients, as long‐term patency remains a
concern [32].
Other Techniques
Other percutaneous techniques for the treatment of PSAs
include transarterial thrombin injection, coil
embolization, and percutaneous collagen injection.
Transarterial thrombin injection may allow thrombin
delivery to sites not otherwise accessible percutaneously,
such as the DFA, but requires contralateral arterial
access. Coil embolization, either percutaneous or
transarterial, leads to thrombosis of the PSA; however, it
also risks increasing PSA pressure possibly leading to
rupture, as well as preventing shrinkage of the PSA after
occlusion, and may act as a nidus for infection [33]. The
percutaneous injection of a collagen paste or plug is an
alternative to percutaneous thrombin injection; however,
it requires a larger needle or even sheath for delivery,
and is generally not favored compared to thrombin.
Figure 13.3 Algorithm for the management of femoral
pseudoaneurysms.
Surgical treatment of PSAs should be considered in very
large (>5 cm) or rapidly expanding PSAs, symptoms
associated with local compression (neuropathy, local
ischemic changes, etc.), an infected PSA, or failure of
percutaneous therapies. An algorithm for the
management of femoral PSA is described in Figure 13.3.
Arteriovenous Fistulas
An arteriovenous fistula (AVF) refers to an abnormal
communication between an adjacent artery and vein.
This can occur when an access needle and introducer
sheath are inserted through both vessels, thus allowing
for shunting from artery to vein upon sheath removal.
The incidence of femoral AVF after cardiac
catheterization has been cited to be less than <1% [34,
35]. Factors associated with femoral AVF formation
include a low puncture (below the bifurcation of the
CFA), multiple puncture attempts, ipsilateral arterial and
venous cannulation, and prolonged clotting times during
the procedure [20].
Clinically, most patients with AVFs are asymptomatic,
and the shunt is usually discovered incidentally after
clinical examination reveals a palpable thrill and a “to
and fro” murmur on auscultation. The presence of
classical examination findings should prompt duplex
ultrasonography which confirms the diagnosis. Most
AVFs are of no significant clinical consequence and will
close spontaneously. Uncommonly, high output heart
failure, arterial insufficiency, or venous congestive
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symptoms may occur. In these rare instances,
percutaneous or surgical closure is indicated.
Some cases may respond to US‐guided compression;
however commonly, these patients are on antithrombotic
therapy for comorbid cardiovascular disease, and have
AVFs in less compressible areas below the femoral head,
both of which decrease the efficacy of this technique.
Covered stent placement on the arterial side of the AVF
has been associated with high success and patency rates
[31]. Balloon‐expandable covered stents such as the
Viabahn VBX (Gore Medical, Flagstaff, AZ, USA) allow
for precise placement and are available in shorter lengths
than their self‐expanding counterparts, making them
ideal for this application, especially in AVFs of the SFA
and DFA where stent deformation is of lower concern.
Surgical referral is indicated in cases where less invasive
techniques fail or are not feasible.
Vascular Closure Device Related
Complications
Vascular closure devices (VCD), first developed in the
mid‐1990s, have been a novel means to improve patient
comfort and allow for early ambulation after
endovascular procedures performed from the femoral
artery. VCDs may be categorized based on their
mechanism of action: active closure devices include
suture‐mediated devices (Perclose, Abbott Vascular,
Redwood City, CA, USA), bioresorbable intravascular
anchor/extravascular collagen implant (Angioseal,
Terumo Medical, Somerset, NJ, USA; MANTA, Teleflex,
Morrisville, NC, USA), and surgical staple/clip
technology (Starclose, Abbot Vascular, Redwood City,
CA, USA). Passive VCDs are a heterogenous group that is
often used in conjunction with manual compression to
achieve hemostasis, and include procoagulant patches,
compression devices, and soluble extravascular sealants
(Mynx, Cordis, Santa Clara, CA, USA). A list of the most
common VCDs, their mechanism, and sheath sizes is
detailed in Table 13.4.
The most common complications associated with VCD
use include bleeding due to device failure, infection, and
acute vessel closure; the last of which requires the most
urgent recognition and treatment to prevent ischemic
complications.
Suture‐mediated or collagen plug VCDs have an
intravascular component which can lead to vascular
stenosis or occlusion by various mechanisms, including
suturing of the posterior femoral arterial wall [36]. In the
case of collagen plug devices, vessel closure can occur by
interaction of the intravascular footplate with small or
severely diseased vessels [37] or embolization of the
footplate to the distal vascular bed [38].
Treatment of these occlusions is typically carried by
contralateral femoral arterial access with the crossover
technique as previously described. Balloon angioplasty is
usually sufficient to restore flow. A balloon sized 1 : 1 to
the vessel should be used, though a smaller balloon with
a better crossing profile may initially be required to
traverse the occlusion. A stent is rarely required in cases
of CFA injury due to VCDs (see Figure 13.4).
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Table 13.4 Common vascular closure devices (VCDs),
their mechanism of action, and sheath sizes appropriate
for their use.
Device Mechanism Sheath size
Perclose Suture with
intravascular
component
5–8 Fr
Larger sizes possible
with preclose
technique
Angioseal Collagen and suture
with intravascular
component
6 and 8 Fr
Starclose Extravascular nitinol
clip
5 and 6 Fr
Mynx Extravascular PEG
hydrogel plug
5–7 Fr
MANTA Collagen and suture
with intravascular
component
14 Fr (10–14 Fr)
18 Fr (15–22 Fr)
It should be noted that in these cases early referral to a
vascular surgical specialist is particularly important.
Heroic measures and aggressive escalation of a difficult
percutaneous rescue attempt could lead to further
complications that can significantly increase patient
morbidity. Access site complications are usually easily
accessible by surgery and repair can be relatively
uncomplicated; therefore, early surgical consultation and
a team approach in the treatment of VCD‐related
complications are essential in treating these patients.
Radial Artery Related Complications
Transradial access (TRA) for PCI has seen a rapid growth
in the last 15 years in the United States. National
Cardiovascular Data Registry (NCDR) data shows that
the number of PCIs performed via the radial artery has
increased from 1.2% in 2007 to nearly 50% in 2020. TRA
is also being increasingly used in peripheral vascular
interventions, with several observational and feasibility
studies demonstrating safety and efficacy in carotid,
renal, subclavian, common femoral, and iliac artery
procedures [39–43]. Its increasing adoption is credited
to a lower incidence of access site complications with
similar procedural success across the spectrum of
coronary disease presentations, collateral blood flow
from the ulnar artery which mitigates ischemic
complications, and improved patient satisfaction due to
early ambulation [44].
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Figure 13.4 (a) Femoral angiography via contralateral
access demonstrating acute occlusion of the left CFA
(white arrow) after VCD deployment. (b) Through a
sheath advanced from the contralateral side (outlined
arrow), an angioplasty balloon was advanced across the
obstruction over a wire and inflated (black arrow). (c)
Angiography with the balloon inflated confirms 1 : 1
sizing. (d) Final angiography demonstrates resolution of
obstruction and brisk distal flow.
Radial Artery Spasm
Radial artery spasm (RAS) occurs in about 10% of TRA
procedures [45], and contributes to patient discomfort or
even procedural failure leading to access site crossover.
Prevention of spasm is of utmost importance: measures
include administration of spasmolytic “cocktails” and
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