Repair of femoral pseudoaneurysm after cardiac catheterization: utility of extraperitoneal iliac control

Femoral artery lesions may occur after cardiac catheterization or percutaneous transluminal coronary angioplasty (PTCA). The incidence of pseudoaneurysm following transfemoral catheterization ranges from 0.21 to 6.25%. Among 3162 cardiac catheterization procedures thirteen (0.41%) patients presented a femoral pseudoaneurysm requiring surgical repair. The Authors reported their technical consideration about the utility of extraperitoneal iliac control during surgical repair of femoral artery pseudoaneurysm due to cardiac catheterization.     

Spontaneous closure of selected iatrogenic pseudoaneurysms and arteriovenous fistulae

PURPOSE: We report our approach to the management of postcatheterization femoral artery pseudoaneurysms and arteriovenous fistulae in an attempt to determine the frequency of spontaneous resolution of selected lesions. METHODS: We studied 196 pseudoaneurysms, 81 arteriovenous fistulae, and 9 combined lesions that were identified by duplex scan. Indications for immediate surgical repair included pseudoaneurysm greater than 3 cm, enlarging hematoma, pain, groin infection, nerve compression, limb ischemia, concomitant surgical procedure, and patient refusal or inability to comply with follow-up. All other lesions were observed. RESULTS: One hundred thirty-nine patients underwent prompt surgical repair, and 147 patients were initially managed without operation. There were no limb-threatening complications associated with nonoperative management in this subset of patients. Eighty-six percent of the lesions being observed resolved spontaneously within a mean of 23 days, whereas 14% required surgical closure for a variety of reasons (at a mean of 111 days after the initial diagnosis). There was no statistically significant difference in the rate of spontaneous pseudoaneurysm closure (89%) as opposed to fistulae (81%) (p < 0.17). By life-table analysis, 90% of selected pseudoaneurysms had resolved by 2 months. Patients selected for observation underwent an average of 2.6 duplex scans per patient versus 1.4 scans per patient for those treated with immediate surgery (p < 0.01). CONCLUSION: The natural history of stable pseudoaneurysms and arteriovenous fistulae is benign and frequently results in spontaneous resolution, which allows properly selected patients to be managed without operation.     

Structural motif and characteristics of the extracellular domain of P2X receptors

OBJECTIVES: We attempted to evaluate nonsurgical methods of treating postcatheterization pseudoaneurysm. BACKGROUND: The value of reapplication of a compression bandage, ultrasound-guided compression repair (UGCR) and awaiting spontaneous thrombosis in the treatment of postcatheterization pseudoaneurysms is unsettled. METHODS: We followed a stepwise treatment strategy of primarily conservative management using 1) reapplication of a compression bandage, followed by 2) UGCR, if needed, and 3) observation of the natural course. Surgical repair was reserved for patients with a rapidly expanding or complicated lesion. RESULTS: Reapplication of a compression bandage was performed in 128 patients and was successful in 32%. The success rate correlated inversely with anticoagulant therapy and the size of the aneurysm. In case of failure this pretreatment with a compression bandage significantly enhanced the success rate of subsequent UGCR (p = 0.04). UGCR was performed in 124 cases with a success rate of 84%. In 54 patients with a stable lesion, refraining from any (further) active measures resulted in spontaneous thrombosis of the aneurysm in 50 patients (93%) after 1 to 180 days (median 40 days). The course of the remaining four femoral artery aneurysms was uneventful. Definitive repair by operation or collagen plug implantation was required in only 20 patients (9%). CONCLUSIONS: The first measure performed in the treatment of pseudoaneurysms should be reapplication of a compression bandage, followed, if necessary, by UGCR. After failure of UGCR, spontaneous healing occurs in the majority of patients. Operation can be reserved for progressive and complicated lesions.     

Expression of CD1a monocytes cultured with supernatants from periodontally diseased gingival epithelial cells

MATERIAL AND METHODS: We evaluated the role of color Doppler US-guided compression in the non-invasive treatment of femoral artery pseudoaneurysms after cardiac catheterization, including 22 PTCA procedures. The diagnosis of 32 pseudoaneurysms in 32 patients was accomplished by detection of the typical US-Doppler pattern consisting of the swirling color Doppler flow and the "to and fro" pulsed Doppler waveform at a mean 3.6 days (1 to 14) after the cardiac catheterization. Thirteen patients had multiple cavity pseudoaneurysms (2 to 4). All the patients immediately underwent compression therapy. RESULTS: Treatment was successful in 42/49 cavities (86%) and 25/32 patients (78%), usually after 1 to 3 compression cycles of 6 to 8 minutes duration. Only one recurrence was noted at the 24 hour US-Doppler follow-up. In all cases, pain relief during compression was an excellent clinical sign of hemostatic plug formation and conversion from pseudoaneurysm to simple hematoma. Failures occurred among patients under high dose anticoagulants in spite of 4 to 10 compression cycles. COMMENTARY: In conclusion, color Doppler US-guided compression of post-cardiac catheterization pseudoaneurysms should be the first line therapeutic modality, even in cases of multiple cavities and among patients under effective anticoagulation therapy.     

Peripheral arterial pseudoaneurysm treated by ultrasound-guided compression

Ultrasound-guided compression repair of a pseudoaneurysm is a simple, safe and effective therapy, and has been proposed as a first-line treatment for pseudoaneurysms caused by catheterization. Herein, we report a case of a pseudoaneurysm arising from a sport injury which was treated by this method. Obliteration of the track of the pseudoaneurysm induced manual thrombosis and successfully converted the pseudoaneurysm to haematoma. Understanding the mechanism and the procedure is the basis of success in the use of this treatment.     

Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective, randomized study of one hundred patients

One hundred elderly patients who had an intertrochanteric femoral fracture were randomized to treatment with a compression hip-screw with a plate (fifty patients) or a new intramedullary device, the intramedullary hip-screw (fifty patients). All patients were followed prospectively for one year or until death. A detailed assessment of the functional status and the plain radiographs of the hip was performed one, three, six, and twelve months postoperatively. The two treatment groups were strictly comparable. The operative time needed to insert the intramedullary hip-screw was significantly greater than that needed to insert the compression hip-screw with the plate (p = 0.02), but use of the intramedullary hip-screw was associated with less estimated intraoperative blood loss (p = 0.011). The prevalence of perioperative complications, such as bronchopneumonia, cardiac failure, and urinary tract infection, was comparable in the two treatment groups. There were one intraoperative fracture of the femoral shaft and two intraoperative fractures of the greater trochanter in the group managed with the intramedullary hip-screw. One patient had pulling-out of the compression hip-screw on the seventh postoperative day. Four patients had a trochanteric wound hematoma, without infection, after insertion of an intramedullary hip-screw. All but one of the fractures healed. The one non-union, which was in a patient who had a compression hip-screw, was treated with a hemiarthroplasty. The mortality rate was similar in the two treatment groups. The patients who had an intramedullary hip-screw had, on the average, significantly better mobility at one (p < 0.0001) and three months (p = 0.0013) postoperatively. This difference was no longer seen at six and twelve months, although the patients who had an intramedullary hip-screw still had significantly better walking ability outside the home at those time-periods (p = 0.05). The compression hip-screw was removed from two patients because of pain in the mid-portion of the thigh, which had begun after consolidation of the fracture. Fourteen patients who had an intramedullary hip-screw had cortical hypertrophy at the level of the tip of the nail at twelve months postoperatively. Cortical hypertrophy was significantly related to the use of two interlocking screws (p = 0.02). Six of these patients also had pain in the mid-portion of the thigh, and the nail had been locked with two screws in five of them. Three of the six patients had the hardware removed because of the pain, and the symptoms resolved. A seventh patient had pain without cortical hypertrophy. The intramedullary hip-screw device was associated with significantly less sliding of the lag-screw and subsequent shortening of the limb in the region of the thigh (p = 0.012 and 0.019, respectively); these differences were more pronounced when the unstable fractures in the two treatment groups were compared (p < 0.001).     

Percutaneous suture closure of the femoral artery access after diagnostic heart catheter examination or coronary intervention

BACKGROUND AND OBJECTIVE: Alternative methods to the conventional one of external compression with a pressure bandage over the site of arterial puncture after percutaneous catheter introduction for coronary angiography or transluminal balloon coronary angioplasty have failed to reduce the rate of vascular complications. This study was undertaken to assess the complication rate of a percutaneously introduced suturing device (Techstar, Perclose). PATIENTS AND METHODS: To achieve immediate haemostasis and thus shorten post-interventional immobilisation the technique of percutaneous suturing of the femoral artery was used in 1030 consecutive patients (793 men, 237 women; mean age 58.6 years) without obstructive vascular disease or local vascular complications. RESULTS: Percutaneous suture closure with primary haemostasis was successful after 137 of 153 coronary angioplasties (89.5%) and after 786 of 977 left heart catheterisations (89.6%). Early mobilisation, after at most 4 hours, was possible in 923 patients with successful suture closure (89.6%). The overall complication rate was 0.78%. CONCLUSION: Percutaneous suture repair of the femoral artery after cardiac catheterisation is a safe and effective method to achieve immediate haemostasis. However, controlled studies are needed to demonstrate harmlessness of early mobilisation.     

Thermal expansion modular femoral head extractor for revision total hip arthroplasty

Removal of a prosthetic modular femoral head is sometimes desirable during revision hip arthroplasty. A femoral head extractor was designed to heat and expand the prosthetic femoral head, apply a gentle distraction load, and remove the femoral head without injury to the femoral neck, taper, or bone-prosthesis interface. The device was used clinically in six hip revision cases. In five hips with cobalt-chrome heads and titanium alloy tapers, femoral heads were removed successfully; femoral fixation was maintained and femoral components were not visibly damaged. In the sixth case, the female portion of the taper junction was contained in a long femoral head sleeve. Heating the ball did not adequately expand the sleeve to allow easy ball removal.     

Formation, therapy and prevention of false aneurysm of the femoral artery following diagnostic and interventional heart catheterization

OBJECTIVE: As pseudoaneurysm of the femoral artery after catheter introduction is a frequent complication, its causes and therapeutic options were investigated in a large patient collective. PATIENTS AND METHODS: In a prospective study with colour-Doppler duplex sonography of 6928 patients after diagnostic and of 3764 after interventional cardiac catheterisation, pseudoaneurysms were diagnosed in 80 patients (0.75%), 46 after diagnostic (0.66%) and 34 after interventional (0.9%) catheterisation. RESULTS: The incidence was higher in women than men (1.33% vs 0.58%; P < 0.05). Anticoagulation after sheath removal was the leading risk factor (n = 55, 68.8%), especially after interventional coronary intervention 85.3 vs 56.5%, P < 0.05). Local compression under duplex sonography monitoring was undertaken in 69 patients (86.3%), achieving aneurysmal obliteration in 53 (76.8%). Spontaneous thrombosis occurred in 15 of the remaining 27 patients, and surgical closure became necessary in 12. CONCLUSIONS: These data indicate a risk profile for the occurrence of pseudoaneurysm after cardiac catheterisation which can be dealt with by preventive measures. Local compression under duplex sonographic monitoring was the treatment of choice with a high success rate and low incidence of complications.     

Comparison of the compression hip screw with the Medoff sliding plate for intertrochanteric fractures

The Medoff sliding plate was designed to achieve compression along the femoral neck and the longitudinal axis of the femoral shaft theoretically to improve the treatment of intertrochanteric hip fractures. The Medoff sliding plate was compared with a standard compression hip screw in a randomized, prospective study for the fixation of 160 stable and unstable intertrochanteric fractures with an average followup of 9.5 months (range, 6-26 months). Overall, 91 fractures were treated using the compression hip screw and 69 were treated with the Medoff sliding plate. Stable fracture patterns (46) united without complication in both treatment groups. Unstable fractures (114) had an overall failure rate of 9.6%, 14% (nine patients) with the compression hip screw and 3% (two patients) with the Medoff plate; this difference was significantly different. The time to union for the 114 unstable fractures was not significantly different between the two devices. For all patients, no differences in lengths of hospitalization, return to ambulatory status before fracture, postoperative living status, or postoperative pain was observed between the two device groups. Use of the Medoff plate for all fracture types was associated with a significantly higher amount of blood loss and operating time.     

Endovascular repair of peripheral aneurysms, pseudoaneurysms, and arteriovenous fistulas

Endovascular repair of peripheral arterial lesions was performed in 10 patients including two iliac aneurysms, two iliac anastomotic pseudoaneurysms, one subclavian pseudoaneurysm, one axillary anastomotic disruption, two prosthetic pseudoaneurysms, and two posttraumatic arteriovenous (AV) fistulas. The indications for repair were aneurysm size in five cases, massive hematoma in one, threatened prosthetic dialysis graft in two, venous hypertension with non-healing ulcer in one, and arm pain in one. Vascular access was obtained through surgical cutdown in all cases, via the femoral artery in five patients, the proximal brachial artery in three and a prosthetic graft in two. Stented prosthetic grafts were used in five cases (1 polyester and polytetrafluoroethylene 4 [PTFE]), and PTFE-covered stents in five cases. Concomitant procedures were done in four patients including two open repairs of a common femoral artery aneurysm, a transluminal dilatation of a proximal aortic anastomotic stenosis, and an iliac artery transluminal angioplasty. Eight of 10 cases were technically successful. Completion arteriography revealed complete exclusion of all lesions, except for one minimal proximal stented graft leak in a pseudoaneurysm, and an incomplete obliteration of an AV fistula. No complications occurred. Operative time ranged from 45 min to 5 hours. Postoperative hospital stay was 1 day in five patients, 2 days in three patients, and 4 days in two patients. Follow-up contrast CT scan, arteriography, or duplex scanning demonstrated complete exclusion of all lesions except an AV fistula, and decrease in size in three aneurysms. The proximal leak initially present in a stented graft resolved. All grafts and covered stents remained patent at 2-19 months of followup. Endovascular exclusion of peripheral arterial aneurysms, pseudoaneurysms, and AV fistulas can be done with a high degree of technical success, low morbidity, and short hospital stay. Short-term follow up is encouraging, however, long term follow up of these procedures is warranted to assess durability of the repair and absence of complications.     

Effect of high fat corn oil, olive oil and fish oil on phospholipid fatty acid composition in male F344 rats

Venous stasis associated with prolonged bed rest can enhance the risk of deep venous thrombosis (DVT). Pneumatic compression of the lower extremities can reduce this risk by preventing venous stasis. When selecting a method of leg compression for their patients, physicians must chose between two distinctly different types of compression devices. One device applies pressure with a single-chambered sleeve to the below knee region while the other applies pressure in a sequential gradient fashion from the ankle to the thigh. The current prospective study was designed to evaluated the ability of two such devices to increase blood flow in the profunda femoral vein. Venous blood flow velocity, compression time, and vein diameter were measured in nine normal experimental subjects using an Accuson duplex-Doppler before, during and after leg compression. Compression with the single-chambered device produced a significant rise in venous blood flow velocity; however, this could not be maintained and our results indicate a higher average velocity was achieved with the sequential gradient device. The sequential gradient device also moved a greater volume of blood and achieved a higher average blood flow rate. The time between deflation of the sleeve and return of a phasic respiratory signal was greater after compression with the sequential gradient device. These results suggest that sequential gradient compression produces the type of hemodynamic alterations needed to reduce the risk of DVT by achieving a sustained increase in venous blood flow and more completely emptying of the veins in the leg.     

Short-course intravenous prophylaxis for paclitaxel-related hypersensitivity reactions

A previously well 35-year-old female was referred to hospital with a four-week history of intermittent chest pain. She had a history of Marfan syndrome when she presented 11 years previously with aortic insufficiency and underwent replacement of the aortic root with a composite graft. Magnetic resonance examination of the chest and coronary angiography revealed an area of extraluminal flow posteromedially at the base of the aortic graft with no evidence of dissection. Transesophageal echocardiography clearly demonstrated the presence of a pseudoaneurysm that resulted from detachment of the left coronary artery from the graft, with intermittent compression of the aortic graft during systole. The patient underwent uneventful resection and replacement of the false aneurysm and patch repair of the left coronary artery. This unusual case illustrates the presence of a pseudoaneurysm as a result of detachment of the left coronary artery from a Dacron graft 11 years after a composite graft replacement.     

The effect of intermittent pneumatic compression devices on intraoperative blood loss during radical prostatectomy and radical cystectomy

Intermittent pneumatic compression devices are a widely used, effective and presumed risk-free method of deep venous thrombosis prophylaxis, presumably by increasing peak venous blood velocity, and stimulating local and systemic fibrinolysis. We investigated whether intermittent pneumatic compression devices had any effect on intraoperative blood loss or transfusion during radical pelvic urological surgery. To our knowledge no previous study has addressed these issues. Records were reviewed for patients undergoing radical retropubic prostatectomy or radical cystectomy with diversion from 1985 to 1990. A total of 91 cases was reviewed: 38 radical retropubic prostatectomies and 53 radical cystectomies with diversion (34 male and 19 female patients). There were 59 patients with intermittent pneumatic compression devices (29 radical retropubic prostatectomies and 30 radical cystectomies with diversion) and 32 without intermittent pneumatic compression devices (9 radical retropubic prostatectomies and 23 radical cystectomies with diversion). Intraoperative blood loss and transfusions were calculated for each group with and without intermittent pneumatic compression devices. No clinically apparent lower extremity deep venous thrombosis or pulmonary embolus was diagnosed in any patient. For the group with intermittent pneumatic compression devices mean intraoperative blood loss was 2,541 ml. (range 700 to 8,850) versus 1,807 ml. (range 450 to 5,100) without a device, for a statistically significant difference of 734 ml. (p = 0.005). When 5 patients with excessive intraoperative blood loss (more than 5,000 ml.) were excluded the statistically significant difference was maintained. When comparing radical retropubic prostatectomy and radical cystectomy with diversion, with and without intermittent pneumatic compression devices, blood loss was greater for the group with a device for each procedure. Differences in intraoperative blood loss were independent of sex or tumor stage. Intraoperative transfusions were increased by approximately 0.6 units per patient with the device. Our study suggests that intermittent pneumatic compression devices may increase blood loss during a radical pelvic operation.     

Impulsive aggression: a behavior in search of clinical definition

During a 10-year period, 110 patients underwent mitral valve replacement (MVR). We experienced three left ventricular ruptures among these patients. Two had a type I immediate rupture, and one had a type III delayed rupture. Two patients (type I, III) survived after repair of the rupture. It was possible to control bleeding by manual compression with oxidized cellulose, collagen mat and fibrin glue with or without external mattress sutures. Following the repair, an intra-aortic balloon pump and sedative agents were used in both patients. In the other patient with a type I early rupture, control of bleeding was attempted by external direct suture using Teflon felt. The bleeding was controlled by this repair and the use of a left ventricular assist device, but the patient died of a brain infarction 5 days after the operation. The manual compression technique using oxidized cellulose, collagen mat and fibrin glue may be useful for minor lacerations, and for reinforcing repairs. The intra-aortic balloon pump and continuous sedation are useful for unloading the ventricle and reducing the tension on repairs.     

Closure of an iatrogenic femoral artery pseudoaneurysm by transcutaneous coil embolization

Pseudo-aneurysm following diagnostic or interventional procedures is a well-recognized complication. Ultrasound guided compression repair is routinely used to close an uncomplicated pseudo-aneurysm. We describe a patient with a femoral artery pseudo-aneurysm following iliac angioplasty and stenting in which ultrasound guided compression repair failed. Pseudoaneurysm was successfully closed by transcutaneous coil embolization technique.     

Vasoseal hemostasis following coronary interventions with Abciximab

Femoral arteriotomy management using a collagen vascular hemostasis device (VasoSeal) was studied in 50 consecutive patients following interventional coronary procedures performed with Abciximab (ReoPro). Low dose weight adjusted or no heparin was employed. The first 25 patients were permitted to sit up after 6 hours with ambulation the following day. The second 25 patients were allowed to sit up after 1 hour and ambulate after 6 hours. Despite early activity and ambulation, there were no hemorrhagic complications including hematoma, pseudoaneurysm, blood transfusion, or surgical repair. Hemoglobin and platelet counts remained stable overnight prior to discharge. This pilot study demonstrates the potential efficacy of VasoSeal in achieving early sheath removal and ambulation in patients undergoing interventional procedures using ReoPro.     

Novel vascular sealing device for closure of percutaneous vascular access sites

To investigate the hemostatic capabilities of a novel vascular sealing device consisting of a balloon catheter and procoagulant, vascular sheaths were placed percutaneously in the femoral arteries of dogs. The sealing device was evaluated using the balloon catheter alone in six femoral arteries and with the addition of a procoagulant, in 21 femoral arteries. The balloon catheter alone was successfully deployed in six of six femoral arteries achieving immediate hemostasis. In a second study in which the procoagulant was delivered following balloon placement, the sealing device was successfully deployed and hemostasis was achieved in 20 of 21 attempts (95%) despite removal of the balloon catheter. In a subset of fully anticoagulated animals, hemostasis was achieved in the sealing device-treated arteries at 6.5+/-3.4 minutes, but in none of the controls (P < 0.001). This novel vascular sealing device successfully achieves rapid hemostasis in normal and anticoagulated dogs following percutaneous vascular procedures.     

Transforming growth factor-beta1 in hemangioma of the ovary

OBJECTIVE: Anastomotic pseudoaneurysms continue to be a late complication of vascular surgery, particulary following prosthetic graft procedures. The purpose of this study was to investigate if a previously reported increase in interval between the original operation and the development of pseudoaneurysm was related to a change in incidence. DESIGN: Retrospective study. METHODS: We reviewed the records of 76 patients who presented with 90 femoral pseudo-aneurysms and underwent reconstructive procedures from January 1989 to June 1994. The median age was 69 years (range: 39-83). In the same time period all femoral artery anastomosis operations were recorded. RESULTS: The incidence of femoral pseudo-aneurysms in Copenhagen was approximately 4.3%. CONCLUSIONS: A previously reported increase in interval between primary operation and aneurysms formation was not related to a change in incidence during the same time period.     

Clinical study day on oral cancer

An H-shaped device was invented to facilitate placement of the distal interlocking screws during closed femoral nailing. Eleven sound cadaveric femurs were experimentally nailed before the application of the device in 15 patients with a femoral shaft fracture. In all experimental cases the insertion of the distal screws proved to be easy. In 11 of 15 patients with a femoral fracture, distal locking was achieved using the H-device. These primary results should stimulate further clinical application of the device.