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A pseudoaneurysm refers to a defect in an arterial wall, which allows communication of

arterial blood with the adjacent extra-luminal space. Blood extravasates out of the artery,
which is contained by surrounding soft tissue forming the cavity or sac. There is often
a narrow tract from the arterial wall to the pseudoaneurysm sac, termed the neck. A
pseudoaneurysm is distinct from a true aneurysm, which results from dilation of all
layers of the arterial wall.

Groin complications related to the femoral arterial access site used for various invasive
cardiovascular procedures represent a significant problem. Among these, femoral artery
pseudoaneurysm (FPA) is one of the most troublesome. The FPA occurs in 0.1% to
0.2% of diagnostic angiograms and 3.5% to 5.5% after interventional procedures. The
incidence of the FPA has increased recently with the more frequent use of high doses of
antiplatelet and anticoagulant therapy and the use of larger-sized cannulas for various
interventional procedures.
Femoral pseudoaneurysm is the second most common complication after bleeding.
The most common site of pseudoaneurysm occurrence is the common femoral artery.
The incidence is 10 times greater after angioplasty than after diagnostic procedures owing
to the circumference of the catheters use. Angiology Volume 56, Number 5, 2005
Factors Associated With the Formation of FPA Antiplatelet agents (often aspirin and
clopidogrel) and Anticoagulation Large sheath size, 8F Age 65 years, Female.
Obesity Poor postprocedural compression Simultaneous artery and vein
catheterization Hypertension, diabetes mellitus. Peripheral arterial disease
Complex interventions Multiple punctures Low or high puncture sites, inadvertent
catheterisation of the superficial femoral artery or profunda femoris artery. Increased
number of cases performed in a day in same room. (avg. 17 cases in single room per day)
COMPLICATIONS
1. RUPUTURE The most catastrophic complication of FPA is rupture. Although the exact
rate is unknown, the risk of spontaneous rupture is related to -size > 3 cm. -presence of
symptoms. -large hematoma. -continued growth of the sac.

2. INFECTION Although most postcatheterization FPAs are sterile, infection of it


significantly increases the risk of rupture as well as septic emboli.
3. Pseudoaneurysms which persist may enlarge and lead to complications related to
compression of the adjacent femoral vein, nerve, and overlying skin. This can lead to leg
swelling, deep vein thrombosis, compressive neuropathy and skin necrosis. Circulation.
2007;115:2666-2674
How to diagnose FPA ? H/o of catheterization Gradually expanding pulsatile mass
Painful, tender. Extensive skin discoloration or ecchymosis Thrill or bruit.
8. Prediction of FPA after Percutaneous Procedures The presence of a palpable groin
mass is predictive. A platelet count of less than 200 x 109/L is strongly associated.
Radiology: Volume 240: Aug-2006 100 %
DIAGNOSIS Color Doppler flow mapping has been the mainstay in diagnosing FPA.
Criteria used to diagnose a pseudoaneurysm include: Swirling color flow seen in a
mass separate from the affected artery. Color flow within a tract leading from the artery
to the mass consistent with pseudoaneurysm neck. Typical to and fro Doppler
waveform in the pseudoaneurysm neck. Clin Med Res. 2003 July; 1(3): 243247
Doppler USG The sensitivity of doppler ultrasound to identify a FPA is 94% with a
specificity of 97%. Number, size, and depth of the chambers of the FPA, the depth,
width, and length of the tract that connects the artery to the FPA should be identified.
Feeding artery should be made clear.
TREATMENT A proportion of femoral pseudoaneurysms will resolve spontaneously
without any form of intervention. An accepted approach is to monitor small (less than
3cm), stable, asymptomatic pseudoaneurysms, as the majority of them will thrombose
within 4 weeks. In one large series of small (<3cm) pseudoaneurysms, reported a rate
of spontaneous thrombosis of ~90% at 60 days . Spontaneous thrombosis of the
pseudoaneurysm may be less likely in patients who are fully anticoagulated.
TREATMENT OPTIONS
1. ULTRASOUND GUIDED COMPRESSION REPAIR
2. THROMBIN INJECTION

3. FIBRIN INJECTION
4. COLLAGEN
5. ENDOVASCULAR TECHNIQUES
6. OPEN SURGICAL REPAIR.
Treatment
ULTRASOUND GUIDED COMPRESSION REPAIR The treatment is ultrasound
probe compression of the neck of the pseudoaneurysm. The "neck" of the
pseudoaneurysm is the narrow path of blood flow between the artery, through the arterial
wall, and into the pseudoaneurysm cavity. The artery, neck, and pseudoaneurysm are seen
on ultrasound. Ultrasonographic guided compression repair is a safe, cost-effective first
approach to treatment for many femoral artery pseudoaneurysms and does not affect
possible surgical intervention if the ultrasonographic guided compression repair attempt
fails. .
CONTRAINDICATIONS FOR UGCR Inaccessible site. Limb ischemia. Infection.
Large hematomas with overlying skin ischemia. Compartment syndrome
UGCR- PROCEDURE IV line in place Oral diazepam or analgesics. Discontinue
heparin 2hrs before and 4 hrs after compression. Baseline ankle brachial index and look
of peripheral pulses also as to confirm after the procedure. The pseudoaneurysm and
the underlying artery were localized, the communicating tract was centered on the colorflow image. Direct vertical pressure was manually applied with the ultrasound probe
just sufficient to impede arterial flow into the pseudoaneurysm. Journal of Vascular
Surgery, 425-433, October 1995
UGCR - PROCEDURE Start compressing the neck with transducer and after 30
minutes, pressure was temporarily released every 20 minutes to check whether the lesion
was cured; release for every 1 min for distal perfusion. Sometimes if necessity for
femoral artery compression decrease the compression interval to 10 min, UGCR was
stopped as soon as this was the case. Approximately every 15 minutes, a change of
operators was undertaken, without releasing the pressure or altering the position of the
transducer. The procedure was also terminated when success could not be obtained within

120 minutes. Flow was then reassessed, and, if the pseudoaneurysm was still present,
repeat compression was undertaken, with the same time increments, until successful
pseudoaneurysm thrombosis was achieved. Circulation. 1994;90:1861-1865
The artery and vein were also restudied after compression to exclude subsequent
thrombosis. All successfully treated patients were confined to bed for 24 to 48 hours
with a compression dressing over the affected site. The arteries were reexamined with
doppler at 24 hours after the initial UGCC to assure closure. If clinically warranted,
additional scans were ordered.
PRINCIPLE OF COMPRESSION REPAIR Transducer- start compress-30min-then
visusalise every 20 min intervals-release for 1 min-again compress-max. compress for
120 minutes. Repeat after 24 hrs Success-bed rest for 24 hrs If not-other methods.
Factors Affecting Success by UGCR Ability to compress Anticoagulation status
Pseudoaneurysm size Age of the pseudoaneurysm (epithelialization of the tract and
more fibrous capsule) Neck width, length of communicating tract.
UGCR Less successful if the patient is obese and if the neck of the pseudoaneurysm is
wider. Finally, it is also much less successful if the patient is taking aspirin, warfarin or
another anticoagulant, since these would prevent clotting of blood within the
pseudoaneurysm. Advantages are that this is the least invasive method of stopping
arterial blood flow into a pseudoaneurysm.
UGCR Ultrasound-guided compression is now increasingly used as a therapeutic tool,
to avoid the need for surgery. Patients will require effective analgesia or sedation, or both,
in order to tolerate the procedure. Success rates of 63% to 88% have been reported.
Care must be taken to avoid compromising flow within the underlying femoral artery.
Ultrasound guided thrombin injection Another minimally-invasive technique used
today is ultrasound-guided thrombin injection. Thrombin (factor IIa in the coagulation
cascade) is a clotting factor that converts fibrinogen into fibrin, which then polymerizes to

form a blood clot. Under ultrasound guidance, thrombin can be injected directly into a
pseudoaneurysm, causing it to clot. Advantages are that the technique is relatively easy to
perform, is successful, and is minimally invasive. One contraindication to this
procedure is if there is an arteriovenous fistula (communication between an artery and
vein), in addition to the pseudoaneurysm. This occurs with about 10% of
pseudoaneurysms. If this is present, thrombin injected into the pseudoaneurysm could
then enter the venous circulation and possibly lead to distant thrombosis
Thrombin injection An average dose of 1100 U of thrombin was used. Time to
coagulation ranged from 10 to 60 seconds. A new study shows the average dose of 192
U thrombin will act on FPA.. Bovine Thrombin comes in strengths of 5000 or 20,000
units, in a powder form with 0.9% sodium chloride as diluent. It is reconstituted at a
concentration of 1000 U/mL and then diluted to a concentration of 100 U/mL with sterile
saline. With sonographic guidance, a 22 gauge needle is introduced into the
pseudoaneurysm.
Dose of thrombin The needle tip is visualized and positioned at a site distant from the
neck of the pseudoaneurysm. Increments of 0.5-1.0 mL (50-100 U) of thrombin were
slowly injected at a rate of approximately 1 mL/10 sec. A period of 5-10 sec is allowed
to elapse before additional thrombin is injected. Results are monitored continuously with
color-flow Doppler sonography. Injection is stopped when no further flow is identified in
the pseudoaneurysm. When possible, the neck of the pseudoaneurysm must be occluded
manually or with the sonographic probe during the injection procedure.
25. Adv. and disadv. of thrombin The success rate of thrombin injection reported in the
literature has been consistently high, at an average of 97%, even with patients treated with
therapeutic levels of anticoagulants. Treatment can usually be completed within several
minutes. Topical bovine thrombin has been used extensively for hemostasis for more
than 20 years. Recent descriptions of antibody responses show high titers against
endogenous coagulation factors, with resulting bleeding complications. Prior exposure
to bovine thrombin is considered a contraindication to treatment of pseudoaneurysms
with thrombin.

26. Disadv. of thrombin injection The first attempts to close a FPA with ultrasoundguided thrombin injections were not without complications. Distal migration of the
thrombin have been described may be these complications due to the nature of the
injected thrombin . Because thrombin is used in liquid form, it can easily diffuse from
the cavity through the neck of the FPA toward the lumen of the artery. It is also possible
that if the thrombin is injected in a too diluted concentration, it does not remain in the
cavity of the FPA long enough to form a clot. Furthermore, it has been described that
patients receiving thrombin are at risk for hypersensitivty reaction.
27. 3. Percutaneous injection of fibrin This technique involves percutaneous injection
of the adhesive components using ultrasound and screening control following successful
occlusion of the aneurysm neck by angioplasty balloon. The fibrin adhesive mimics the
final stage of coagulation cascade. Thrombin is used to convert fibrinogen to fibrin, and
the fibrin is then crosslinked in the presence of calcium to create a mechanically stable
network filling the aneurysm. The technique has several advantages-the balloon
virtually eliminates the chance of distal embolization. The tissue adhesive does not rely
on the patient's own clotting factors. Therefore it is more likely to work in anticoagulated
patients . Br J Radiol. 1998;71:12551259
28. 4. FEMORAL COLLAGEN INJECTION. When collagen comes in contact with
blood, platelets aggregate on the collagen and release coagulation factors that, together
with plasma factors, result in the formation of a fibrin matrix. Initially, the collagen was
applied guided by selective angiography using the contralateral access site with a 4F
sheath. After puncture of the contralateral femoral artery, the 4F catheter is introduced
through the sheath and positioned across the iliac bifurcation in the affected proximal
common femoral artery over a guide wire. The injection of the contrast medium allows
one to locate the FPA exactly and correctly, together with its tract and connections.
29. Procedure of collagen injection After applying routine local anesthesia with 1%
lignocaine, the pseudoaneurysm cavity is then directly punctured, leading to highpressure backflow of blood ensuring correct access to the pseudoaneurysm. The initial
application of the collagen plugs required a larger 11F sheath. After puncture of the
pseudoaneurysm, a guidewire was introduced through the needle to the pseudoaneurysm.
The needle is then removed, leaving the guidewire in place. A sheath-dilatator is passed
over the guidewire into the pseudoaneurysm cavity, and the guidewire and the dilatator

are removed, leaving only the sheath through which collagen plug could be inserted.
The application of the collagen paste allows use of a thinner needle. The pseudoaneurysm
cavity is directly punctured percutaneously using a 9F needle. Then the collagen paste is
applied directly through this 9F needle into the center of the FPA. This produces a very
rapid filling and thrombosis of the pseudoaneurysm. After 1 to 2 min, a repeat angiogram
is performed through the 4F sheath of the opposite access, to confirm aneurysm occlusion
.
30. Procedure
31. Success of collagen injection This results in a final success rate of 98.2%.
Injection of collagen is easily accepted by the patients, and during the procedure there
was no need for systemic analgesic medication . Not bothered whether or not the
patient is receiving anticoagulant therapy as it would not appear to impair the results.
32. Inj. of collagen Complete obliteration was usually achieved within some 10 s,
which is comparable to thrombin closure. The advantages of collagen lie in its
physical-chemical properties. The fact that it consists of long paste fibers allows the
collagen to remain within the FPA cavity, which putatively reduces the risk of migration
through the neck of the FPA.
33. 5. Open surgical repair INDICATIONS Rapid expansion of the FPA. There may not
be time to wait for noninvasive treatments. Concomitant distal ischemia or neurological
deficit due to local pressure from the FPA, or distal embolization. Mycotic infection of
FPA. Failure of percutaneous intervention. Compromised soft tissue viability.
34. Open surgical repair (OSR) Gold standard treatment for iatrogenic femoral
pseudoaneurysms, as the arterial defect is repaired definitively. Principle steps of OSR
involve obtaining proximal and distal control of the affected artery, evacuating the
aneurysm sac and repairing the defect in the arterial wall (either by primary or patch
closure). Complications of OSR include blood loss and infection. Other major
adverse events such as myocardial infarction or death are recognised. Recovery time
and inpatient stay may be prolonged following OSR.
35. 6. Other Options Placement of covered stents. Percutaneous coil placement to
occlude the FPA. In some cases the coil was placed in the neck, while in other patients the
coil was placed inside the pseudoaneurysm in order to achieve closure and local
thrombosis.

36. CONCLUSION In conclusion, as vascular interventional procedures are on a rise,


there are more possibilities for occurrence of Iatrogenic Pseudoaneurysms. Initially
Ultrasound Guided Compression Repair was the preferred treatment as it was non
invasive. But due to its failure in 25% of patients on studies conducted, increased pain
experienced by the patient, long procedure time and recent development of other
minimally invasive treatments which are more effective, UGCR is less preferred
nowadays. Percutaneous injection of thrombin, fibrin, collagen can be completed in
several minutes, has the advantage of avoiding surgical intervention or the pain associated
with ultrasound- guided compression, and can be performed effectively in patients who
have received anticoagulation.
37. PREVENTION Vascular complications are less common when the fluoroscopy is
used for localization of the femoral head to puncture the femoral artery in the correct
location and with the first attempt. Always need effective compression after sheath
removal. Monitor before the patient is discharged. If in doubt kindly review with
doppler and needs follow up. Attention to puncture under fluoroscopic guidance is
strongly recommended.

Veins
Veins Blood vessels which carry blood from tissues to heart Valves Venules
Veins of Lower Limb Superficial Deep Perforating Anterior Profunda Femoris &Greater
Saphenous Small Saphenous Femoral Vein Poplietal Vein Peroneal Vein Vein Posterior Tibial
Vein
Anterior tibial vein In human anatomy, the anterior tibial vein of the lower limb carries
blood from theanterior compartment of the leg to the popliteal vein which is formed when it
joins with the posterior tibial vein. Like most deep veins, the anterior tibial vein is
accompanied by an artery of the same name, the anterior tibial artery, along its course.

Posterior Tibial vein In anatomy, the posterior tibial vein of the lower limb carries blood
from the posterior compartment and plantar surface of the foot to the popliteal vein which it
forms when it joins with the anterior tibial vein. Like most deep veins, the posterior tibial
vein is accompanied by an artery of the same name, the posterior tibial artery, along its
course.
Peroneal Vein In anatomy, the fibular veins (also known as the peroneal veins) are
accompanying veins of the fibular artery. The fibular veins are deep veins that help carry
blood from the lateral compartment of the leg. They drain into the posterior tibial veins,
which will in turn drain into the popliteal vein. The fibular veins accompany the fibular
artery.
Popliteal vein The popliteal vein is located behind the knee. Its course runs alongside the
popliteal artery, but carries the blood from the knee joint and muscles in the thigh and calf
back to the heart. Its origin is defined by the junction of the posterior tibial vein and anterior
tibial vein. It drains the peroneal vein before reaching the knee joint and turns into the
femoral veinwhen leaving the adductor canal (also known as Hunters canal). The popliteal
artery extends from the femoral artery behind the popliteal fossa which is the space behind
the knee.
Profunda femoris vein Profunda femoris vein (or deep femoral vein) is a large deep vein in
the thigh. It receives blood from the inner thigh and proceeds superiorly and medially running
alongside the profunda femoris artery to join with the femoral vein approximately at the level
of the inferior-most portion of the ischial tuberosity.
Femoral Vein In the human body, the femoral vein is a blood vessel that accompanies the
femoral artery in the femoral sheath. It begins at the adductor canal (also known as Hunters
canal) and is a continuation of the popliteal vein. It ends at the inferior margin of theinguinal
ligament, where it becomes the external iliac vein.DrainageSeveral large veins drain into the
femoral vein: popliteal vein profunda femoris vein great saphenous vein

Great Saphenous Vein GSV The GSV originates from where the dorsal vein of the first
digit (the large toe) merges with the dorsal venous arch of the foot. After passing anterior to
the medial malleolus (where it often can be visualized andpalpated), it runs up the medial side
of the leg. At the knee, it runs over the posterior border of the medial epicondyle of the
femur bone. The great saphenous vein then courses laterally to lie on the anterior surface of
the thigh before entering an opening in the fascia lata called the saphenous opening. It joins
with the femoral vein in the region of the femoral triangle at the saphenofemoral junction.
Small Saphenous Vein The small saphenous vein (also short saphenous vein), is a relatively
large vein of the superficial posterior leg. Its origin is where the dorsal vein from the fifth
digit (smallest toe) merges with the dorsal venous arch of the foot , which attaches to the
great saphenous vein. It is a considered a superficial vein and is subcutaneous (just under the
skin). From its origin, it courses around the lateral aspect of the foot (inferior and posterior
to thelateral malleolus) and runs along the posterior aspect of the leg (with the sural nerve),
passes between the heads of the gastrocnemius muscle, and drains into the popliteal vein,
approximately at or above the level of the knee joint.
Communicating vein Communicating veins (or perforator veins ) are veins that directly
connect superficial veins to deep veins. Communicating veins have valves that only allow
blood to flow from superficial to deep veins