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Interact CardioVasc Thorac Surg 2009;8:353-357. doi:10.1510/icvts.2008.188623
© 2009 European Association of Cardio-Thoracic Surgery
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ESCVS article - Vascular general

Femoral pseudoaneurysms post-cardiac catheterization surgically treated: evolution and prognosis{star}

Enrique M. San Norberto García*, José-Antonio González-Fajardo, Vicente Gutiérrez, Santiago Carrera and Carlos Vaquero

Division of Vascular Surgery, Valladolid University Hospital, Valladolid, Spain

Received 29 July 2008; received in revised form 13 October 2008; accepted 14 October 2008

{star} Presented at the 57th International Congress of the European Society for Cardiovascular Surgery, Barcelona, Spain, April 24–27, 2008.

*Corresponding author. C/Ramón y Cajal n°3, 47005, Valladolid, Spain. Tel.: +34-686754618; fax: +34-983420000.

E-mail address: esannorberto{at}hotmail.com (EM. San Norberto García).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objectives: To analyze the postoperative complications of patients who have undergone surgical repair of femoral pseudoaneurysm after cardiac catheterization. Design: Prospective study. Materials: Cardiovascular risk factors, related to surgery and cardiac catheterization were collected prospectively in 79 patients from 2003 to 2006 in Valladolid University Hospital. The indications of surgery included necrosis of adjacent soft tissue, rapid growth, infection, bleeding, hemodynamic instability or failure of the percutaneous treatment (US-guided compression and US-guided percutaneous thrombin injection). Methods: Patient and management related predictors for 30-day outcome were analyzed. Results: Fifty-six patients (56/79, 71%) experienced some type of postoperative complication, the most frequent being the need for a transfusion. Infection (15/79, 19%) and dehiscence of the surgical wound (10/79, 12.7%) were the other two most common complications. The mortality related to the intervention was 3.8% (3/79). The mean hospital stay was 32.5 days (±28.4 days). Significant risk factors in logistic regression model were gender (P=0.023, OR=9.66), 70 years old (P=0.049, OR=0.15) and the concurrent use of anticoagulation or antiplatelet therapy after the cardiac catheterization (P=0.005, OR=0.03). Conclusion: Patients who undergo surgical treatment of femoral pseudoaneurysm post-cardiac catheterization experience a high postoperative morbidity and hospital stay. Factors such as female gender, age over 70 years and treatment with anticoagulants or antiplatelets increase the postoperative morbidity. A seasonal influence was appreciated, with a higher frequency during the summer period.

Key Words: Pseudoaneurysm; Cardiac catheterization; Surgical risk


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Vascular Interventional and Interventional Cardiology Laboratory have experienced remarkable advances in endovascular techniques during the last few decades. The use of an entry to the vascular tree constitutes an essential part of the procedure. The commonly used arterial and venous approach is the femoral route. The most important group of technical complications is those related to the site of puncture, femoral pseudoaneurysms are the most frequent complication [1].

The role of the surgery in the treatment of femoral pseudoaneurysms has diminished since the development of less invasive therapeutic methods like echo-guided compression, echo-guided thrombin injection or endovascular repair [2–4]. This avoids the need for general or locoregional anesthesia in a group of patients with a significant morbidity and who do not tolerate vascular reconstruction and bleeding. However, there still remain a subset of cases in which open surgical repair is necessary.

The majority of studies about the surgical treatment of this pathology [5–8] were performed in the early 1990s. After more than ten years, these patients have not been studied, in spite of the great advances which have taken place, both in the technique of cardiac catheterization and in the treatment of critical patients. This article constitutes an update on the evolution of patients submitted to a surgical repair of femoral pseudoaneurysms following cardiac catheterization.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
Between January 2003 and December 2006 we prospectively recorded the data from every patient who experienced femoral pseudoaneurysm following cardiac catheterization surgery in a database at the Angiology and Vascular Surgery Division of the University Hospital of Valladolid. The diagnosis is usually straightforward and is made on the combination of physical examination and duplex ultrasound findings. Ultrasound diagnostic criteria were: an echolucent cavity on B-mode ultrasound examination, pulsatile expansion and contraction of the suspected echolucent area and bidirectional flow at the neck of the pseudoaneurysm in systole and diastole. Intraarterial angiography was reserved for patients who experienced associated lower extremity ischemia.

A total of 79 patients were included in this analysis, 5371 cardiac catheterizations were performed during the same period (incidence 1.47%), 57 (1.06%) were treated successfully by ultrasound-guided compression and 21 (0.39%) by thrombin injection. Their mean diameter was 3.2 cm (range 1.4–7.3 cm). The indications for surgical repair were: rapidly expanding pseudoaneurysm, infected pseudoaneurysm (this diagnosis was supported by fever, leukocytosis or positive blood cultures), distal ischemia caused by local pressure of the pseudoaneurysm on the femoral artery, neuropathy caused by local pressure on the femoral nerve, jeopardized viability of soft tissues and the superadjacent skin, failure of percutaneous treatment (US-guided compression and US-guided percutaneous thrombin injection), previous history of allergic reaction to thrombin or bovine products, bleeding or hemodynamic instability.

Demographic data such as age and gender were gathered in the registry. The presence of accompanying cardiovascular co-morbidity (chronic coronary artery disease, arterial hypertension, diabetes mellitus, hyperlipidemia) or of another type (respiratory insufficiency, renal insufficiency, auricular fibrillation, peripheral arterial disease) was also obtained. Data related to the nature of cardiac catheterization (diagnostic vs. therapeutic) as well as post-catheterization anticoagulation or antiplatelet therapy were also incorporated into our analysis. Postoperative surgical and medical 30-day complications were also recorded. The sheath size of the devices used in the diagnostic interventions was 5F and in therapeutics 6F and 7F. Arterial closure devices (Prostar®, Perclose Peripheral Vascular Surgery, Menlo Park, USA) were used in all the therapeutic procedures.

The surgical approach to the femoral arteries for a pseudoaneurysm was direct and gentle. A longitudinal groin incision over the femoral pulse was elected. Instead of entering the hematoma, the surgeon carried the dissection directly to the inguinal ligament, where the femoral artery or distal external iliac artery can be exposed and controlled. If femoral artery thrombosis had occurred or if arterial repair with a graft or patch angioplasty was deemed necessary, a low dose of intravenous heparin (2000–3000 U) was administered. After the femoral artery was clamped at the inguinal ligament, the hematoma could be incised and evacuated. The puncture site could be identified and controlled with finger pressure. Usually a simple suture was sufficient. Large hematoma cavities were drained with a closed suction catheter. A separate suprainguinal external iliac approach was necessary for control in patients because of proximal injury, massive pseudoaneurysm, morbid obesity, or extensive groin scarring (n=11). Most pseudoaneuryms could be repaired by simple suture of the arterial puncture. A patch angioplasty was necessary if it appears that closure of the defect in the arterial wall would compromise the lumen. General anesthesia was used in 42 cases (53.2%) and regional anesthesia in 37 (46.8%).

Statistical analysis was carried out using the SPSS 14.0 for Windows program (SPSS Inc., Chicago, IL, USA). The correlation between potential factors cardiovascular or surgical risk factors and 30-day overall complications and death rate was assessed by univariate analysis using the {chi}2 and the Fisher exact test. The variables that positively associated with postoperative outcome at P<0.05 were selected for a multivariate analysis using forward stepwise logistic regression. Odds ratios (OR) and 95% confidence interval (CI) were calculated. A risk factor was considered statiscally significant when P<0.05.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
Of the 79 patients treated, 32 were women and 47 men. The mean age was 70 years (47–87). The diagnosis of femoral pseudoaneurysm after cardiac catheterization was made by duplex ultrasound in 88.6% of the cases, requiring arteriography study only in the remaining 11.4%. Arterio-venous fistula accompanied the pseudoaneurysm in 13.9% of the cases. Indications of surgical treatment collected were: necrosis of soft tissues and skin adjacent to the pseudoaneurysm 32.9%, rapid growth 25.3%, infection 22.8% or failure of the percutaneous treatment 10.1%, shock 6.3% and femoral neuropathy 2.5%. Baseline characteristics and catheterization details are summarized in Table 1.


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  		Table 1 Baseline characteristics of patients and catheterization technique

 
The postinterventional treatment included antiplatelet therapy in 37 patients (56.7%, 22.4% aspirin and 34.3% aspirin plus clopidogrel), anticoagulation and antiplatelet therapy in 19.2% (15/79) of the subjects and double anticoagulant and antiplatelet therapy in six patients. In four patients (5.5%), the IIb/IIIa receptor antagonist was used.

Seventy-nine patients underwent 98 surgical procedures. Fig. 1 shows the various surgical techniques that were utilized. The most frequently performed procedure was direct closure and resection of the sac 84 (79.7%), followed by patch angioplasty 9 (11.4%), bypass grafting 5 (6.3%) or vein angioplasty 2 (2.5%). The operation was performed on the same day of the diagnosis in 40.6% (32/79) of the cases and within the following day in 12.5% (10/79). One case required the substitution of the arterial suture material to a vein angioplasty following the initial repair and it was necessary to carry out 18 postoperative surgical resections of devitalized skin limits (22.8%). No amputations were required.


Figure 1
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  		Fig. 1. Surgical techniques.

 
Seventy-one percent of the subjects underwent some type of 30-day perioperative complication. Necessity for blood transfusion was the most frequent non-lethal complication 42 (53%), with a maximum of 10 red blood cell concentrates and an average of more than one red blood cell concentrate per patient affected. Infection without 16 (20.3%) and with dehiscence of the surgical wound 10 (12.7%) were the other two most common complications (Table 2). The cultures taken from the infected wounds were primarily polymicrobial infections 18 (22.8%) in comparison with monomicrobial 8 (10.1%). The most frequently isolated microorganisms were E. coli, S. epidermidis and S. aureus. Patients with infected wounds were treated with 10 days of intravenous antibiotics. The infection rate was not correlated with the employment of percutaneous closure devices (P=0.836).


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  		Table 2 Postoperative complications

 
Three postoperative intervention related deaths occurred (mortality: 3.8%). Of the expired patients, the cause of death was attributed to cardiac failure in a 59-year-old patient, and another two of 67 and 68-year-olds expired due to septic shock related infected pseudoaneurysms. The mean hospital stay of this series was 32.5 days (±28.4 days).

Statistically significant differences were found in relation to the length of hospital stay (P=0.027) and the age of the patients (P=0.031) who underwent a perioperative complication and those who did not (Table 3). No other demographic differences were found between patients with or without complications after surgical repair. Higher rates of adverse outcome were found in patients with hypertension (5.7 vs. 2.9%, P=0.072); however, the difference did not reach statistical significance. Univariate and multivariate logistic regression models of risk factors predicting 30-day complication rates are shown in Table 4. Strong independent predictors were female gender (P=0.023, OR=9.66), age over 70 years (P=0.049, OR=0.15) and anticoagulation or antiplatelet therapy after cardiac catheterization (P=0.005, OR=0.03).


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  		Table 3 Age and hospital stay of patients with complications and no complications

 

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  		Table 4 Risk factors as independent factor for perioperative overall morbidity

 
A histogram of frequencies during the study period showed a seasonal influence, around the summer months, focused on May and August, correlates with a higher incidence of femoral pseudoaneurysm at the same period, without a higher overall catheterization techniques volume during this interval (Fig. 2).


Figure 2
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  		Fig. 2. Seasonal distribution of femoral pseudoaneurysm post-cardiac catheterization surgically treated.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
This is the first study to report a prospective review of patients submitted to surgical repair of femoral pseudoaneurysm after cardiac catheterization. This study aims to contribute new knowledge to this literature.

Oweida et al. [5] in 1990, analyzed patients with any vascular complication after cardiac catheterization, including arterial thrombosis or embolization and even a case of mesenteric ischemia. In our opinion, the patients examined in this study constitute groups with very different pathologies and prognoses. Hence an exclusive study of the patients with pseudoaneurysm is required.

Patients with vascular complications or pseudoaneurysms related to the use of an intraaortic balloon pump have also been excluded from this study in light of their severely depressed cardiac function and grim prognosis, making it impossible to objectively and clearly differentiate surgical morbidity from the patient's underlying pathology [9].

The published literature has identified several variables that are responsible for a greater risk of peripheral vascular complications after cardiac catheterization. Such risks include increasing age, female gender, fibrinolytic therapy, postprocedural anticoagulation [5] or the procedure being diagnostic or interventional [6, 10–12]. Other variables have been studied with heretofore unjustified validity, including hypertension, diabetes, catheter size, peripheral vascular arteriopathy, hemodialysis or a previous history of another percutaneous procedure through the same vascular entry [11]. All these risk factors, in the development of complications after surgical repair of femoral pseudoaneurysm after a cardiac catheterization, were evaluated in our study.

The morbidity experienced by patients in our study is greater than in the morbidity reported in other publications. In our study the need for transfusion has been considered a perioperative complication which increases our incidence of perioperative morbidity to 71%. The most noteworthy postoperative complication of surgical repair is its requirement of blood transfusion. If we excluded the need for transfusion as a complication the percentage, however, remains high, reaching 46%. The morbidities published in prior studies range from 7.4 to 31.7% [5, 10, 13]. This large disparity is explained by the lack of unanimity in criteria for the registration of any complications. A complication that has been commented on in these articles has been the need for amputation of the affected member in some cases. In the study by Messina et al. there were up to three amputations. Unlike our study, the Messina study analyzed all vascular complications after cardiac catheterization, not only those with pseudoaneurysms, and in these patients, although it is not detailed, the responsible pathology is likely ischemia of the member in question. The mortality observed in our study reached 3.8% of the subjects. Mortalities of 7.9% have been reported in prior studies amongst patients who have undergone therapeutic catheterizations [10].

The only publication that established clear difference among patient groups was that of Messina et al. [6] published in 1991, in which 64 patients are considered intervened after a diagnostic catheterization and 37 after a therapeutic procedure. In their analysis, morbidity differences (27% as opposed to 19%) and mortality differences (2.7 and 7.9%, respectively), were observed between both groups. No statistical study between both groups was carried out. Technical advances during the last years have developed therapeutic sheaths with smaller diameters, closer to the size of diagnostic devices.

Results demonstrate that female patients, age over 70 years and treatment with anticoagulants or antiplatelets are at higher risk for adverse outcomes following surgical repair of femoral pseudoaneurysm after cardiac catheterization. The explanation for the increased risk in most elderly patients may be related to age related changes in the arterial wall associated, mediated by increasing calcification and loss of elastin [14]. Careful monitoring of physical findings and ultrasound examination is recommended in these patients to offer early non-invasive treatment procedures as ultrasound-guided compression or thrombin injection. The radial approach offers a safer alternative to femoral access in selected patients.

Our study has several limitations. One limitation is the fact that this study is a post-hoc analysis on a prospectively compiled database. Another limitation is the use of different surgical techniques in this study. Additionally, our study has a relatively low prevalence of diabetes (13%) and follow-up time is low (30 days). Furthermore, the population constitutes a selective group of patients who could not undergo percutaneous repair of the pseudoaneurysms and were therefore relegated to surgery. In spite of these limitations, our findings, which were obtained in a large number of consecutive, unselected patients, provide sufficient support for our conclusions.

The technical procedure of cardiac catheterization by femoral route takes time, in accordance with a learning curve to attain a pre-defined level of proficiency [15, 16]. The finding of a maximum incidence of pseudoaneurysms postcatheterization in the summer vacation period, urges thoughtful search of possible justifications. A possible reason for this finding is the fact that it is a specialized multidisciplinary technique. Previous to the puncture, norms of asepsis and antisepsis are required to maintain to prevent infection; especially when devices for percutaneous suture are implanted. Post-procedurally, an adequate compression as well as of the patient are important factors. In our opinion, these multiple factors that affect the integrity of the femoral vessels after a catheterization exist, making this procedure a multidisciplinary technique with a steep learning curve. Periodic review of these complications may help identify additional factors that can be modified to reduce them.

In conclusion, female gender, increasing age and anticoagulant or antiplatelet therapy, have an adverse influence on the 30-day morbidity and complications of patients submitted to surgical repair of femoral pseudoaneurysms after cardiac catheterization. Additional studies will be needed to expand the existing literature and thus improve the perioperative management of the affected population.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

  1. Skillman JJ, Kim D, Baim DS. Vascular complications of percutaneous femoral cardiac interventions. Arch Surg 1988;123:1207–1212.[Abstract/Free Full Text]
  2. Coley BD, Roberts AC, Fellmeth BD, Valji K, Bookstein JJ, Hye RJ. Postangiographic femoral artery pseudoaneurysms: further experience with US guided compression repair. Radiology 1995;194:307–311.[Abstract/Free Full Text]
  3. Krueger K, Zaehringer M, Store D, Stuetzer H, Boecker J, Lackner K. Postcatheterization pseudoaneurysm: results of US-guided percutaneous thrombin injection in 240 patients. Radiology 2005;236:1104–1110.[Abstract/Free Full Text]
  4. Kobeiter H, Lapeyre M, Becquemin JP, Mathieu D, Melliere D, Desgranges P. Percutaneous coil embolization of postcatheterization arterial femoral pseudoaneurysms. J Vasc Surg 2002;36:127–131.[CrossRef][Medline]
  5. Oweida SW, Roubin GS, Smith RB 3rd, Salam AA. Poscatheterization vascular complications associated with percutaneous transluminal coronary angioplasty. J Vasc Surg 1990;12:310–315.[CrossRef][Medline]
  6. Kresowik TF, Khoury MD, Miller BV, Winniford MD, Shamma AR, Sharp WJ, Blecha MB, Corson JD. A prospective study of the incidence and natural history of femoral vascular complications after percutaneous transluminal coronary angioplasty. J Vasc Surg 1991;13:328–333.[CrossRef][Medline]
  7. Lumsden AB, Miller JM, Kosinski AS, Allen RC, Dodson TF, Salam AA, Smith RB 3rd. A prospective evaluation of surgically treated groin complications following percutaneous cardiac procedures. Am Surg 1994;60:132–137.[Medline]
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  12. Khoury M, Rebecca A, Greene K, Rama K, Colaiuta E, Flynn L, Berg R. Duplex scanning-guided thrombin injection for the treatment of iatrogenic pseudoaneurysms. J Vasc Surg 2002;35:517–521.[CrossRef][Medline]
  13. Ricci MA, Trevisani GT, Pilcher DB. Vascular complications of cardiac catheterization. Am J Surg 1994;167:375–378.[CrossRef][Medline]
  14. Wixon CL. Hemodynamics. In: Hallett JW, Jr, Mills JL, Earnshaw JJ, Reekers JA, Comprehensive vascular and endovascular surgery. Edinburgh: Mosby; 2004:9–15.
  15. Wyman RM, Safian RD, Portway V, Skillman JJ, McKay RG, Baim DS. Current complications of diagnostic and therapeutic cardiac catheterization. J Am Coll Cardiol 1988;12:1400–1406.[Abstract]
  16. Schaub F, Theiss W, Busch R, Heinz M, Paschalidis M, Schömig A. Management of 219 consecutive cases of postcatheterization pseudoaneurysm. J Am Coll Cardiol 1997;30:670–675.[Abstract]

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eComment: Follow-up for femoral pseudoaneurysms
Narcis Hudorovic
Interactive CardioVascular and Thoracic Surgery 2009 8: 357-358. [Full Text] [PDF]



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eComment: Follow-up for femoral pseudoaneurysms
Interactive CardioVascular and Thoracic Surgery, March 1, 2009; 8(3): 357 - 358.
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