Emerging techniques in management of post-catheterisation femoral artery psuedoaneurysms

Transcription

1 Emerging techniques in management of post-catheterisation femoral artery psuedoaneurysms Poster No.: R-0072 Congress: RANZCR ASM 2013 Type: Educational Exhibit Authors: S. Davis, J. Huang, G. Pavilion, K. Redmond, J. Harper; Brisbane/ AU Keywords: Interventional vascular, Ultrasound, Arterial access, Puncture, Hemorrhage DOI: /ranzcr2013/R-0072 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply RANZCR's endorsement, sponsorship or recommendation of the third party, information, product or service. RANZCR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold RANZCR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies,.ppt slideshows,.doc documents and any other multimedia files are not available in the pdf version of presentations. Page 1 of 10

2 Learning Objectives Outline the physiology and incidence of iatrogenic pseudoaneurysms following femoral artery catherisation. Discuss traditional management options for femoral artery pseudoaneurysm. Describe the technique of using saline / lignocaine injection around the aneurysm neck prior to manual compression. Review a case study in which femoral artery pseudoaneurysm was successfully thrombosed using saline / lignocaine injection and manual compression. Background Pseudoaneurysms are defined as a contained rupture involving all 3 layers of an arterial wall. The incidence of iatrogenic pseudoaneurysms post catheterization ranges from 0.05% - 2% (1). The incidence increases further with use of thrombolytics, anticoagulants, antiplatelets and increased sheath diameters such that an incidence of up to 8% have been reported in literature post coronary angioplasty and stenting (2). Many techniques have been developed to treat pseudoaneurysms. Sonographically guided compression is the traditional non-operative approach in managing pseudoaneurysms. However its success is limited by the strong pressure required, lengthy duration of compression and patient tolerance. In patients who receive anticoagulation, the success rate is 62-73% (3). Sonographically guided percutaneous injection of bovine or human thrombin into the pseudoaneurysm is quick, comfortable for the patient and induces thrombosis of the pseudoaneurysm in % of cases. The disadvantages of this approach is the high cost, risk of allergy with bovine thrombin (reduced with the use of human thrombin) and potential for distal arterial embolization which has been reported in 2% of cases (3). In refractory pseudoaneurysms, various endovascular repair and open surgical techniques have been described(4). A more recently described technique of treating pseudoaneurysms involves infusing a mixture of saline and lignocaine into the soft tissue surrounding the pseudoaneurysm (Figure 1). This is followed by a short sonographically guided compression of the pseudoaneurysm (5). Early studies have suggested this to be an effective, easy method of achieving pseudoaneurysm thrombosis whilst being better tolerated and with greater success than the traditional sonographically guided compression. At the same time, it is considered safe and not associated with potential complications seen with thrombin injection. Page 2 of 10

3 Images for this section: Fig. 1: Pseudoaneurysm closure with saline injection Page 3 of 10

4 Imaging Findings OR Procedure Details The following case documents closure of a femoral artery pseudo aneurysm using subcutaneous injection of saline and lignocaine via the method outlined by Periard et al (5) (Figure 1). The patient, a 78 year old male, sustained an iatrogenic femoral artery pseudoaneurysm following lower limb balloon angioplasty. The initial procedure involved ultrasound guided antegrade puncture (Figure 2) and a 6-french sheath. Postprocedurally the sheath was removed under manual compression and clinically there was concern that the patient had developed a femoral artery pseudoaneursym. Ultrasound and CT confirmed the diagnosis and demonstrated a femoral artery pseudoaneurysm measuring 1.2cm x 1.5cm with a neck length of 2.0cm (Figure 3 and 4). The patient was haemodynamically stable and following assessment of the size and morphology of the aneurysm the decision was made to proceed with ultrasound guided saline and lignocaine injection prior to manual compression. A solution of 40 ml saline and 10 ml lignocaine 1% was prepared in a 50 ml syringe, mounted with a 9 cm, 21 gauge needle. (Figure 5). Under sonographic control, the solution was injected into the soft tissues around the aneurysm neck until sufficient oedema of the soft tissue was present. Firm compression of the aneurysm neck was then performed under sonographic control, checking for thrombosis every 2 minutes. Thrombosis of the aneurysm was confirmed at 6 minutes with no residual flow on Doppler ultrasounde (image 6). Following the procedure the patient was restricted to bed for 12 hours. Repeat ultrasound the following day confirmed thrombosis of the aneurysm. Images for this section: Page 4 of 10

5 Fig. 1: Pseudoaneurysm closure with saline injection Page 5 of 10

6 Fig. 2: Antegrade percutaneous femoral artery puncture Page 6 of 10

7 Fig. 3: Ultrasound of femoral pseudoaneurysm Page 7 of 10

8 Fig. 4: CT of femoral pseudoaneurysm Page 8 of 10

9 Fig. 6: Ultrasound of femoral pseudoaneurysm post closure Fig. 5: Equipment for saline injection of pseudoaneurysm Page 9 of 10

10 Conclusion Femoral artery pseudoaneurysms occur at a rate of approximately 1 in 100 arterial punctures. Various techniques are available for management and have traditionally involved lengthy aneurysm compression with variable success or percutaneous thrombin injection which is invasive and carries the risk of distal embolization. Injection of saline and lignocaine into the soft tissues surrounding the pseudoaneurysm followed by brief sonographic compression offers a safe and effective management option which is well tolerated by the patient and can be readily performed in the radiology department. Personal Information References Webber, GW, Jang, J, Gustavson, S, Olin, JW. Contemporary Management of Postcatheterization pseudoaneurysms. Circulation Vol pp Paulson, EK, Nelson, RC, Mayes, CE, Sheafor, DH, Sketch, MH, Kliewer, MA. Sonographically Guided Thrombin Injection of Iatrogenic Femoral Pseudoaneurysms. American Journal of Roentgenology Vol. 177 (no. 2). pp Vazquez, V, Reus, M, Pinero, A, Abellan, D, Canteras, M, Rueda, M, Morales, D, Parrilla, P. Human Thrombin for Treatment of Pseudoaneurysms: Comparisons of Bovine and Human Thrombin Sonogram-Guided Injection. American Journal of Roentgenology Vol. 184 (no. 5). pp Reeder, SB, Widlus, DM, Lazinger, M. Low-Dose Thrombin Injection to Treat Iatrogenic Femoral Artery Pseudoaneurysms. American Journal of Roentgenology Vol. 177 (no. 3). pp Periard, D, Meyer, M, Hayoz, D, Cook, S. Sealing Pseudoaneurysms of the Femoral Artery with Saline Injection: A New Technique. Eurointervention Vol. 7 (no. 10). pp Page 10 of 10