Femoral pseudoaneurysms after percutaneous access
2014; Elsevier BV; Volume: 60; Issue: 5 Linguagem: Inglês
10.1016/j.jvs.2014.07.035
ISSN1097-6809
AutoresPatrick A. Stone, John E. Campbell, Ali F. AbuRahma,
Tópico(s)Venous Thromboembolism Diagnosis and Management
ResumoThe femoral artery has been the primary percutaneous-based arterial access site for coronary artery catheterizations for more than three decades. Noncardiac percutaneous-based procedures have also been performed primarily with femoral access and have increased in number exponentially by vascular specialists in past decades. Groin complications are infrequent in incidence after femoral arterial access for cardiac and peripheral diagnostic and interventional cases, with groin hematomas and pseudoaneurysms being the most common. Until ultrasound-based treatment modalities became the mainstay of treatment, vascular surgeons were the primary specialty managing pseudoaneurysms, but now other specialties also manage these cases. This review outlines the clinical implications and current issues relevant to understanding the ideal treatment strategy for this common complication. The femoral artery has been the primary percutaneous-based arterial access site for coronary artery catheterizations for more than three decades. Noncardiac percutaneous-based procedures have also been performed primarily with femoral access and have increased in number exponentially by vascular specialists in past decades. Groin complications are infrequent in incidence after femoral arterial access for cardiac and peripheral diagnostic and interventional cases, with groin hematomas and pseudoaneurysms being the most common. Until ultrasound-based treatment modalities became the mainstay of treatment, vascular surgeons were the primary specialty managing pseudoaneurysms, but now other specialties also manage these cases. This review outlines the clinical implications and current issues relevant to understanding the ideal treatment strategy for this common complication. Historically, the common femoral artery has been, by far, the most commonly used percutaneous arterial access site. The traditional method of entry into the femoral arterial system has been the modified Seldinger technique. There is debate over which technical method to use as a landmark for entry (“best pulse,” guidance with fluoroscopy, and most recently, ultrasound-guided puncture) to achieve successful arterial cannulation with sheath introduction. Many patients rate their interventional experience on the degree of access site discomfort encountered during and after the procedure. This is comparable to a patient undergoing an open reconstruction and judging the skill of the surgeon on the external appearance of the incision. With percutaneous-based procedures, patients are not aware of whether the operator achieved optimal luminal gain with stent placement or whether asymptomatic distal embolization occurred, but they are aware of access complications. Many access-related complications can occur, and although some are life- and limb-threatening, such as retroperitoneal hemorrhage or arterial occlusion, emergency surgery is rare, occurring in well below 1% of patients. Rapid and persistent hemostasis is essential for a return to the prepuncture state. Any loss of hemostasis at the entry site results in a spectrum of local hemorrhage, if located below the inguinal ligament. At the most urgent end of the spectrum is an expanding hematoma, secondary to ongoing hemorrhage within the soft tissue space that may require urgent endovascular or surgical intervention if pressure application to the site cannot resolve the problem. At the other end of the spectrum is a temporary hemorrhage that subsides, resulting in hematoma or somewhere in between. The fibrin shell prevents an expanding hematoma but lacks arterial wall sealing, which allows for ongoing blood extravasation from the artery into a contained area, a “false aneurysm sac,” which is described as a femoral artery pseudoaneurysm. This review focuses on this specific problem—iatrogenic femoral artery pseudoaneurysms—including incidence, risk factors, diagnostic approach, management, new techniques, and unresolved issues. The reported incidence of femoral artery pseudoaneurysms varies widely in the literature, with some society guidelines expecting an acceptable rate of 1000 patients demonstrated pseudoaneurysms in 3.8% of patients when routine duplex imaging was performed.2Moll R. Habscheid W. Landwehr P. The frequency of false aneurysms of the femoral artery following heart catheterization and PTA (percutaneous transluminal angioplasty).Rofo. 1991; 154: 23-27Crossref PubMed Google Scholar Although this study is >20 years old, a more recent study demonstrated similar results when routine ultrasound imaging was performed, with an incidence of 2.9% in >500 consecutive patients.3Hirano Y. Ikuta S. Uehara H. Nakamura H. Taniguchi M. Kimura A. et al.Diagnosis of vascular complications at the puncture site after cardiac catheterization.J Cardiol. 2004; 43: 259-265PubMed Google Scholar Multiple patient-related and procedure-related factors have been identified in the increasing incidence of femoral artery pseudoaneurysms. Patient-specific factors include body mass index, gender, degree of arterial calcifications, and preprocedural platelet counts. Procedure-specific risk factors include the urgency of the procedure, diagnostic vs interventional procedures, the site of arterial cannulation, the size of the sheath, combined arterial and venous access, procedural antiplatelet medication use, and anticoagulation.4Mlekusch W. Haumer M. Mlekusch I. Dick P. Steiner-Boeker S. Bartok A. et al.Prediction of iatrogenic pseudoaneurysm after percutaneous endovascular procedures.Radiology. 2006; 240: 597-602Crossref PubMed Scopus (40) Google Scholar Postprocedural factors that have been associated with an increased risk of development of a femoral pseudoaneurysm include the need for continued anticoagulation and urgent percutaneous coronary intervention. In a study of >2000 patients undergoing emergency percutaneous coronary intervention who had duplex imaging of the groin, the incidence of pseudoaneurysms was 2.3% higher than what has been reported in most nonemergency series. Other statistically significant risk factors for pseudoaneurysms in this study included gender and age, with women and those aged >75 years at increased risk for pseudoaneurysms during their hospitalization.5Ayhan E. Isik T. Uyarel H. Ergelen R. Cicek G. Ghannadian B. et al.Femoral pseudoaneurysm in patients undergoing primary percutaneous coronary intervention for ST-elevation myocardial infarction: incidence, clinical course and risk factors.Int Angiol. 2012; 31: 579-585PubMed Google Scholar The Table lists the risk factors for the development of pseudoaneurysms.TableRisk factors for femoral pseudoaneurysmsPatient-related factorsAdvanced ageGender: Female > maleBody habitus: increased body mass indexPlatelet count: increased risk with decreasing platelet countProcedural-related factorsPuncture site: below the bifurcationSheath size: increasing sizeInterventional procedures higher risk than diagnostic proceduresUrgent vs elective proceduresFemoral artery and vein cannulationAnticoagulation and antiplatelet administration and continued administration postprocedure Open table in a new tab The initial step in the diagnosis of femoral artery pseudoaneurysms should always be the physical examination. Unfortunately, secondary to the painful nature of the adjacent hematoma and recent catheterization, the groin is extremely sensitive to palpation and examination. The limb may also become swollen secondary to underlying hematoma or pseudoaneurysm compression of the femoral vein that rarely results in sufficient compression to cause deep venous thrombosis. A prospective study by Mlekusch et al4Mlekusch W. Haumer M. Mlekusch I. Dick P. Steiner-Boeker S. Bartok A. et al.Prediction of iatrogenic pseudoaneurysm after percutaneous endovascular procedures.Radiology. 2006; 240: 597-602Crossref PubMed Scopus (40) Google Scholar evaluated clinical parameters in identifying femoral artery pseudoaneurysms. The presence of a pulsatile mass had a 100% positive and negative predictive value. Additional clinical parameters, including bruit, nonpulsatile mass, or superficial painful pulse palpation, were less accurate in a study of 23 patients with pseudoaneurysms.4Mlekusch W. Haumer M. Mlekusch I. Dick P. Steiner-Boeker S. Bartok A. et al.Prediction of iatrogenic pseudoaneurysm after percutaneous endovascular procedures.Radiology. 2006; 240: 597-602Crossref PubMed Scopus (40) Google Scholar In a larger prospective study, Kent et al6Kent K.C. McArdle C.R. Kennedy B. Baim D.S. Anninors E. Skillman J.J. Accuracy of clinical examination in the evaluation of femoral false aneurysm and arteriovenous fistula.Cardiovasc Surg. 1993; 1: 504-507PubMed Google Scholar reported that the physical examination was extremely accurate, with a sensitivity of 83% and a specificity of 100% in 53 patients who were examined by vascular surgeons before their duplex examinations. Although these series demonstrate impressive accuracy of physical examination, this depends to a large extent on observer acuity, particularly for small pseudoaneurysms. Therefore, the duplex examination has become the gold standard for the definitive diagnosis and development of a management strategy. Laboratory parameters may also aide in the diagnosis of pseudoaneurysms. A study by Mlekusch et al4Mlekusch W. Haumer M. Mlekusch I. Dick P. Steiner-Boeker S. Bartok A. et al.Prediction of iatrogenic pseudoaneurysm after percutaneous endovascular procedures.Radiology. 2006; 240: 597-602Crossref PubMed Scopus (40) Google Scholar demonstrated that the clinical examination was very accurate and correlated with a positive ultrasound imaging for pseudoaneurysm. All patients with duplex confirmation of false aneurysms had a preoperative platelet count of 200,000/L.4Mlekusch W. Haumer M. Mlekusch I. Dick P. Steiner-Boeker S. Bartok A. et al.Prediction of iatrogenic pseudoaneurysm after percutaneous endovascular procedures.Radiology. 2006; 240: 597-602Crossref PubMed Scopus (40) Google Scholar The use of a D-dimer test after percutaneous-based access has also been evaluated. A study by Hoke et al7Hoke M. Koppensteiner R. Schillinger M. Haumer M. Minar E. Wiebauer F. et al.D-dimer testing in the diagnosis of transfemoral pseudoaneurysm after percutaneous transluminal procedures.J Vasc Surg. 2010; 52: 383-387Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar compared 72 controls with 48 patients with pseudoaneurysms. They demonstrated higher D-dimer values in patients with pseudoaneurysms compared with controls (1.9 vs 0.8 μg/mL; P < .001) and an increasing pseudoaneurysm size with increasing quartile of D-dimer values. They concluded that, with a negative predictive value of 90%, a D-dimer value of <0.67 μg/mL could be used as a screening laboratory assessment before duplex imaging. A noteworthy finding was that all patients with a pseudoaneurysm had preprocedural platelet counts 200,000/L had a pseudoaneurysm.7Hoke M. Koppensteiner R. Schillinger M. Haumer M. Minar E. Wiebauer F. et al.D-dimer testing in the diagnosis of transfemoral pseudoaneurysm after percutaneous transluminal procedures.J Vasc Surg. 2010; 52: 383-387Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar The potential benefit of these two laboratory values in selecting which patients need duplex examinations of groin hematomas for suspected or potential pseudoaneurysms is obvious. The scenario is similar to the emergency department D-dimer testing in patients with a swollen leg. With a high negative predictive value, patients with platelet counts >200,000/L and D-dimer levels within normal reference ranges could forego a duplex evaluation and reduce negative workups and, ultimately, health care dollars. The population of this study was small, and larger studies are needed to verify these results, and as stated earlier, the diagnosis is best made by duplex imaging for now. Duplex ultrasound remains the cornerstone of imaging for patients with groin complications after catheterization. Duplex is not only the initial imaging modality of choice but also the primary method of monitoring with observation and the modality for direct nonsurgical therapy (ie, compression/thrombin injection). Duplex imaging must differentiate a pseudoaneurysm from other pathology and accurately identify patients who need future imaging or an immediate intervention. Duplex imaging includes ultrasound for adequate assessment of groin pathology and B-mode imaging for measuring hypoechoic collections (ie, hematoma); however, B-mode alone cannot determine the presence of a persistent arterial defect. A 5- to 7-mHz linear transducer is used initially for evaluation, and a sector transducer is reserved for obese patients or those with a large groin hematoma. Color flow imaging is used to assess flow within the hypoechoic mass to differentiate a simple hematoma from a pseudoaneurysm. Confirmation that no connection is demonstrated with the adjacent venous system is imperative. Doppler waveform analysis with a low resistance pattern that implies an arteriovenous fistula would exclude management with thrombin injection. Color flow can aid in the anatomic characterization of the aneurysm, including neck diameter, length of the tract from the neck to the aneurysm sac(s), number of sacs, and size in millimeters. The flow volume and maximum aneurysm diameter should be recorded. Color flow will demonstrate the classic “yin-yang” shape as arterial blood leaves the arterial defect and reflects back within the artery. Doppler waveform analysis should also be performed to rule out the presence of concomitant arteriovenous fistulae, which have a characteristic low resistance pattern with a considerable diastolic flow component. As in true aneurysms of the peripheral arteries, observation plays an important role until a size threshold is met. More than half dozen studies in the 1990s reported pseudoaneurysm observations. One of the first series, by Kresowik et al,8Kresowik T.F. Khoury M.D. Miller B.V. Winniford M.D. Shamma A.R. Sharp W.J. et al.A prospective study of the incidence and natural history of femoral vascular complications after percutaneous transluminal coronary angioplasty.J Vasc Surg. 1991; 13: 328-333Abstract Full Text Full Text PDF PubMed Scopus (340) Google Scholar studied seven pseudoaneurysms, ranging in size from 1.3 to 3.5 cm, that were monitored weekly with serial duplex examinations. All pseudoaneurysms successfully spontaneously thrombosed ≤4 weeks of the initial diagnosis.8Kresowik T.F. Khoury M.D. Miller B.V. Winniford M.D. Shamma A.R. Sharp W.J. et al.A prospective study of the incidence and natural history of femoral vascular complications after percutaneous transluminal coronary angioplasty.J Vasc Surg. 1991; 13: 328-333Abstract Full Text Full Text PDF PubMed Scopus (340) Google Scholar A larger series was published in 1992 by Paulson et al,9Paulson E.K. Hertzberg B.S. Paine S.S. Carroll B.A. Femoral artery pseudoaneurysms: Value of color Doppler sonography in predicting which ones will thrombose without treatment.AJR Am J Roentgenol. 1992; 159: 1077-1081Crossref PubMed Scopus (60) Google Scholar which included 24 pseudoaneurysms that were studied serially with color Doppler ultrasound imaging. Detailed duplex characteristics were evaluated to determine which patients had successful thrombosis with observation compared with those who eventually underwent intervention. This included the volume of flow, ratio of forward to reverse flow, duration of diastolic flow, and neck length. Only the volume of flow in the lumen was statistically different, with smaller flow volumes associated with spontaneous closure (1.8 mL vs 4.4 mL; P = .02). Unlike the previous series by Kresowik et al,8Kresowik T.F. Khoury M.D. Miller B.V. Winniford M.D. Shamma A.R. Sharp W.J. et al.A prospective study of the incidence and natural history of femoral vascular complications after percutaneous transluminal coronary angioplasty.J Vasc Surg. 1991; 13: 328-333Abstract Full Text Full Text PDF PubMed Scopus (340) Google Scholar only 58% had spontaneous thrombosis without intervention. Unfortunately, this series did not report the indications for intervention.9Paulson E.K. Hertzberg B.S. Paine S.S. Carroll B.A. Femoral artery pseudoaneurysms: Value of color Doppler sonography in predicting which ones will thrombose without treatment.AJR Am J Roentgenol. 1992; 159: 1077-1081Crossref PubMed Scopus (60) Google Scholar Also, contrary to the success with observation by Kresowik et al,8Kresowik T.F. Khoury M.D. Miller B.V. Winniford M.D. Shamma A.R. Sharp W.J. et al.A prospective study of the incidence and natural history of femoral vascular complications after percutaneous transluminal coronary angioplasty.J Vasc Surg. 1991; 13: 328-333Abstract Full Text Full Text PDF PubMed Scopus (340) Google Scholar Kent et al10Kent K.C. McArdle C.R. Kennedy B. Baim D.S. Anninos E. Skillman J.J. A prospective study of the clinical outcome of femoral pseudoaneurysms and arteriovenous fistulas induced by arterial puncture.J Vasc Surg. 1993; 17: 125-131Abstract Full Text Full Text PDF PubMed Scopus (194) Google Scholar reported that one-third of observed femoral pseudoaneurysms required repair. Only nine of 16 pseudoaneurysms spontaneously thrombosed, and the size did not necessarily correlate with who would require repair. Of note, three of the seven patients who required repair needed ongoing anticoagulation from the time of diagnosis until surgical intervention. The results from this study led the authors to recommend repair in patients who require anticoagulation and raised caution in using duplex parameters to predict which patients can be treated conservatively.10Kent K.C. McArdle C.R. Kennedy B. Baim D.S. Anninos E. Skillman J.J. A prospective study of the clinical outcome of femoral pseudoaneurysms and arteriovenous fistulas induced by arterial puncture.J Vasc Surg. 1993; 17: 125-131Abstract Full Text Full Text PDF PubMed Scopus (194) Google Scholar In a small study by Samuels et al11Samuels D. Orron D.E. Kessler A. Weiss J. Kaufman B. Miller H. et al.Femoral artery pseudoaneurysm: Doppler sonographic features predictive for spontaneous thrombosis.J Clin Ultrasound. 1997; 25: 497-500Crossref PubMed Scopus (18) Google Scholar in 1997, 11 patients were evaluated with duplex parameters to detect successful thrombosis. The length of the neck predicted earlier successful thrombosis, with those with a neck length >0.9 cm undergoing spontaneous thrombosis at a mean of 9 days vs 52 days for those with shorter neck lengths.11Samuels D. Orron D.E. Kessler A. Weiss J. Kaufman B. Miller H. et al.Femoral artery pseudoaneurysm: Doppler sonographic features predictive for spontaneous thrombosis.J Clin Ultrasound. 1997; 25: 497-500Crossref PubMed Scopus (18) Google Scholar The largest series in the literature on observation of pseudoaneurysms, and likely the most widely quoted, is the work by Toursarkissian et al12Toursarkissian B. Allen B.T. Petrinec D. Thompson R.W. Rubin B.G. Reilly J.M. et al.Spontaneous closure of selected iatrogenic pseudoaneurysms and arteriovenous fistulae.J Vasc Surg. 1997; 25: 803-808Abstract Full Text Full Text PDF PubMed Scopus (218) Google Scholar during the same year. Their study included 147 patients with pseudoaneurysms with a maximum diameter 90% success with ultrasound-assisted compression, encouraging a nonsurgical approach as the first line of management. Throughout the 1990s, procedures were done in radiology suites under direct physician supervision with ultrasound-directed compression, which dramatically reduced the number of surgical interventions. The technique involves placement of the ultrasound probe on the groin with direct visualization of the neck of the aneurysm. Pressure is applied to the probe to eliminate flow through the aneurysm neck to the aneurysm, with maintenance of arterial flow within the native femoral artery. Continued evaluation at 5- to 10-minute intervals to assess arrest of flow into the aneurysm sac is typical. This technique is continued until patient discomfort does not permit further compression, operator fatigue is too great, or successful aneurysm thrombosis is achieved. Most of large series report an average compression time of nearly 30 minutes. Limitations of this technique include patient discomfort, frequent need for sedative administration for patient comfort, and failure rates higher than those achieved with duplex-guided thrombin injection (DGTI). The factors most commonly associated with failure of compression included the ongoing need for anticoagulation and increasing size of the aneurysm sac.14Schaub F. Theiss W. Busch R. Heinz M. Paschalidis M. Schomig A. Management of 219 consecutive cases of postcatheterization pseudoaneurysm.J Am Coll Cardiol. 1997; 30: 670-675Crossref PubMed Scopus (79) Google Scholar In a series by Schaub et al14Schaub F. Theiss W. Busch R. Heinz M. Paschalidis M. Schomig A. Management of 219 consecutive cases of postcatheterization pseudoaneurysm.J Am Coll Cardiol. 1997; 30: 670-675Crossref PubMed Scopus (79) Google Scholar of 219 pseudoaneurysms, the highly statistically significant predictors of failure of ultrasound-guided compression were ongoing anticoagulation and length of aneurysm neck ( 93%, respectively, for both subgroups. The aneurysm volume was statistically significant in the compression bandage cohort only in this large series but not with ultrasound-guided compression.14Schaub F. Theiss W. Busch R. Heinz M. Paschalidis M. Schomig A. Management of 219 consecutive cases of postcatheterization pseudoaneurysm.J Am Coll Cardiol. 1997; 30: 670-675Crossref PubMed Scopus (79) Google Scholar The initial technique was described 25 years ago by Cope and Zeit,15Cope C. Zeit R. Coagulation of aneurysms by direct percutaneous thrombin injection.AJR Am J Roentgenol. 1986; 147: 383-387Crossref PubMed Scopus (305) Google Scholar before the widespread use of ultrasound-guided compression instead of operative therapy. DGTI has supplanted ultrasound-guided compression as the initial therapy of choice, secondary to the speed of thrombosis, reduction in pain associated with the procedure, and the improved success in most series. In most centers, the radiology department offers this therapy; however, at our institution, the vascular surgery section has been the primary service responsible for evaluation and management of our own groin-related complications or those from our cardiology colleagues for more than a decade. The procedure consists of the following steps:•Complete examination of arterial anatomy of affected femoral artery○Site of origin of the aneurysm: common femoral or femoral/deep femoral○Waveform pattern of outflow arterial tree○Size of the aneurysm, including the number of lobes and the dimensions of flow lumen○Length and diameter of the aneurysm neck (Fig 1)•Prepare the groin site with antiseptic and use a sterile probe cover•Local anesthetic should be considered at skin entry site•Needle size: 19- to 25-gauge spinal needle with tuberculin 1-mL syringe•Under B-mode imaging, identify the sac most adjacent to the artery and direct the needle tip to the periphery of the aneurysm sac “away from the neck”•Inject 0.1-mL aliquots of 1000 IU/mL topical thrombin after reconstitution•Alternate between color Doppler and B-mode imaging during the injection to assess for thrombosis (Figs 2 and 3)Fig 2Echogenic needle tip is visualized in B-mode at the periphery of the pseudoaneurysm sac (away from the neck of the aneurysm).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3Successful thrombosis with lack of flow in the pseudoaneurysm and persistent flow in femoral arteries below the pseudoaneurysm sac is noted.View Large Image Figure ViewerDownload Hi-res image Download (PPT)•After thrombosis is achieved, assess the femoral arteries for Doppler and color flow, confirming similar pattern as preprocedure•Bed rest for 2 hours, then allow ambulation Critical technical points:•Maintain the needle tip in the periphery of the aneurysm sac.•Accessing the aneurysm sac in obese patients requiring curvilinear probes is more difficult secondary to significantly obscured visualization.•Do not inject an aneurysm with a sac size <1 cm. Highest arterial thrombosis risk.•Thrombosis or embolization is rare: Use the minimal amount of thrombin to occlude the aneurysm and always perform postinjection imaging, including Doppler and color flow imaging of femoral artery and waveform analysis or peripheral vascular resistance. In a prospective nonrandomized study of 274 patients with femoral artery pseudoaneurysms treated with DGTI, 52 (19%) were being treated with anticoagulation at the time of therapy. The overall success rate was 97% and was not adversely affected by anticoagulation use. Of the seven failures with the first injection, three underwent a successful second injection, three had successful adjunct ultrasound-guided compression therapy, and one patient required surgical correction.16Schneider C. Malisius R. Küchler R. Lampe F. Krause K. Bahlmann E. et al.Prospective study on ultrasound-guided percutaneous thrombin injection for treatment of iatrogenic post-catheterization femoral pseudoaneurysms.Int J Cardiol. 2009; 131: 356-361Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar The largest nonrandomized study directly comparing ultrasound-guided compression and DGTI was reported by Khoury et al.17Khoury M. Rebecca A. Greene K. Rama K. Colaiuta E. Flynn L. et al.Duplex scanning–guided thrombin injection for the treatment of iatrogenic pseudoaneurysms.J Vasc Surg. 2002; 35: 517-521Abstract Full Text Full Text PDF PubMed Scopus (92) Google Scholar With 189 patients undergoing compression and 131 with DGTI, the success rate favored DGTI (96%) over ultrasound-guided compression (75%). The primary reason for compression failure was pain with compression or an aneurysm depth that did not allow for adequate compression, whereas the failures occurring during DGTI were primarily related to intra-arterial injection of aneurysms 200 DGTI, we have had one patient with acute limb ischemia. This patient presented immediately after the injection procedure with common femoral artery occlusion and underwent successful open surgical thrombectomy. Most other series report symptoms immediately or within several hours, with varying degrees of management. Percutaneous-based thrombectomy and even catheter-directed lysis are options in patients with extensive arterial occlusion. Gorge et al18Gorge G. Kunz T. Kirstein M. A prospective study on ultrasound-guided compression therapy or thrombin injection for treatment of iatrogenic false aneurysms in patients receiving full dose antiplatelet therapy.Z Kardiol. 2003; 92: 564-570Crossref PubMed Scopus (31) Google Scholar prospectively evaluated the effectiveness of ultrasound-guided compression in 36 patients with current administration of acetylsalicylic acid and clopidogrel. If compression failed to achieve complete aneurysm thrombosis after 40 minutes, then DGTI was performed. In addition, two-thirds of patients had received heparin or enoxaparin ≤12 hours of treatment. Only 17% of patients had successful thrombosis with compression alone, with 30 patients subsequently receiving DGTI, with a success rate of 93%.18Gorge G. Kunz T. Kirstein M. A prospective study on ultrasound-guided compression therapy or thrombin injection for treatment of iatrogenic false aneurysms in patients receiving full dose antiplatelet therapy.Z Kardiol. 2003; 92: 564-570Crossref PubMed Scopus (31) Google Schola
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