Echo-guided pin-point compression can effectively repair pseudoaneurysms associated with catheter procedure ()
1. INTRODUCTION
A pseudoaneurysm is a rare complication of a catheter examination or intervention. It is a hematoma that forms as the result of a leaking hole at the puncture site of the artery and is covered by surrounding connective tissues [1]. Because of the communication to the artery, the pseudoaneurysm often grows rapidly, resulting in rupture in some cases [2]. Proper management of a pseudoaneurysm remains an important clinical issue.
Surgery is the gold-standard treatment, but most patients hope for a less invasive treatment. One of the less invasive options is ultrasound-guided compression (Figure 1). This procedure, however, is not always successful despite long compression. In this procedure, we have tried to drain as much of the blood from the pseudoaneurysm as possible by compressing it with an ultrasound probe. However, this can result in insufficient blood within the residual space to make a clot stopper at the communication point. We therefore consider that it is important to have sufficient blood in the residual space to make a clot and to stop the blood flow through the communication in order to enhance clot formation over the communication. For these requirements, we have developed a simple approach for compression guided by echography (Figure 1(c)). Pin-point compression with a finger is used to effectively close the communication. This procedure can effectively close the communication with enhancement of the coagulation cascade of blood in the residual space of the pseudoaneurysm (Figure 1(c)). We monitored the success of this procedure and clot formation with echography to improve its clinical efficacy. In this study, we performed this revised procedure
(a) (b) (c)
Figure 1. Pseudoaneurysm at puncture site (a) and methods to treat it (b, c). (a) A pseudoaneurysm forms outside the arterial wall. It is surrounded by connective tissues; (b) Ultrasound-guided compression: A pseudoaneurysm is compressed by an echo-probe. The lumen of the pseudoaneurysm apparently disappears during the compression because the compression procedure drains intra-cavity blood into the artery. There is insufficient blood to make a clot over the communication; (c) Pin-point compression: One-finger compression on the communication point may effectively close the communication. Flow stagnation within the pseudoaneurysm may accelerate the coagulation cascade of blood to effectively make a clot stopper.
in consecutive patients with post-procedural arterial pseudoaneuryms to study its safety and clinical efficacy.
2. METHODS
2.1. Study Population
In the period from April 2006 to July 2010, 4347 patients underwent catheter examination or intervention in our hospital using the radial artery approach in 2800 patients, brachial artery approach in 356 patients and femoral artery approach in 1191 patients. Ten patients (0.2%) suffered from pseudoaneurysms and underwent the revised procedure.
Diagnosis of pseudoaneurysm was made with an echo apparatus equipped with a high-frequency linear probe (3 - 13 MHz) and a color Doppler imaging technique (Figure 2(a)). The entry point, which is the communication to the artery, was identified on the echo images.
2.2. Procedure for Pin-Point Compression
Antiplatelet and/or anticoagulant therapies were continued. After identifying the communication to the artery by echography, the right index finger was placed on the pseudoaneurysm just above the communication point (Figure 2(b)), and compression was applied until the flow through the communication stopped, which was confirmed by echography. At that moment, the lumen of pseudoaneurysm had not completely disappeared. The goal of pin-point compression is complete obliteration of flow in the pseudoaneurysm as confirmed by echography. We monitored clot formation within the pseudoaneurysm. After about 5 minutes, the compression was stopped and closure of the communication was confirmed by echography. Flow thorough the communication was reassessed with echography after the procedure. If the flow was still found, pin-point compression was repeated, with the same time increments, until successful pseudoaneurysm thrombosis was achieved as confirmed by echography. We defined clot formation on an echo image as emergence of a heterogeneously echogenic mass together with disappearance of Doppler signal from the sac (Figure 2(c)). Echography was performed 24 hours later to examine the success of the procedure.
3. RESULTS
3.1. Baseline Characteristics
Table 1 summarizes the clinical data for patients with a pseudoaneurysm undergoing one-finger pin-point compression. Mean age of the patients was 71.4 years (range: 61 - 86 years), and 4 patients were female. Nine patients had hypertension, 6 had dislipidemia, 2 had diabetes, and 2 were undergoing hemodialysis. Nine patients were receiving dual anti-platelet therapy, but none of the patients were receiving anticoagulant therapy. The catheterization procedures included percutaneous coronary intervention in 8 patients, percutaneous trans-arterial angioplasty in one patient, and diagnostic coronary angiography in one patient. Sizes of sheeths used were 5F in one patient, 6F in 6 patients and 7F in 3 patients. After the catheterization procedures, 7 patients underwent astriction and 3 patients underwent an angioseal procedure. Duration of astriction ranged from 15 to 40 minutes (mean, 27.8 minutes). Six patients had a pseudoaneurysm on the femoral artery and 4 patients had a pseudoaneurysm on the