Pseudoaneurysm Repair in the Catheterization Lab: Safe and Underutilized

By Sohail Khan MD, FACC, and Hamid Salam MD, FACC

Pseudoaneurysm of the common femoral artery is a known complication in the cardiac catheterization lab following diagnostic or interventional procedures using groin access. Risk factors for pseudoaneurysm formation include low and high arterial punctures, poor arterial compression after the procedure, obesity, female gender, older age, larger sheath size, peripheral artery disease, calcified arteries, concurrent anticoagulation, and simultaneous artery and vein catheterization.

The most common treatments are ultrasound-guided compression, ultrasound-guided thrombin injection, and surgery. However, repairing pseudoaneurysm with angiographic guidance via contralateral access is possible and underused. We present a case where a pseudoaneurysm was successfully repaired in the cardiac catheterization lab without any complications.

Case

A 92-year-old female with past medical history of hyperlipidemia, otherwise in good health, presented to the emergency department with an acute inferior ST elevation myocardial infarction with right ventricular involvement. The patient was taken to the cardiac catheterization lab where she was found to have an acutely occluded proximal RCA. She received two drug-eluting stents with TIMI 3 flow at the end of the procedure. Angiomax (The Medicines Company) was used for anticoagulation while Clopidogrel was used as an antiplatelet agent. Right groin hemostasis was achieved using manual pressure due to the low arterial puncture.

The patient did well post procedure with no significant bleeding that day however she felt a "pop" in her groin when she tried to ambulate the next day. It was associated with severe pain. The ultrasound of the groin demonstrated a pseudoaneurysm measuring approximately 2.0 cm x 2.5 cm. There was a prominent hematoma seen anterior to this measuring 4.1 cm x 6.2 cm. Ultrasound-guided thrombin injection was not attempted due to the complexity and inability to clearly define the neck of the pseudoaneurysm. Because of the growing hematoma and patient discomfort during the next 2 days, we decided to repair the pseudoaneurysm in the cardiac catheterization lab.

Left groin access was achieved using a micropuncture needle kit, and a 6 Fr short sheath was inserted in the left common femoral artery. After obtaining initial diagnostic distal aortogram, the 6 Fr sheath was exchanged for an Ansel 6 Fr 45 cm sheath, which was advanced up and over into the right EIA. The initial angiogram of the right lower extremity clearly defined the pseudoaneurysm sac (Figure 1).

Next, the right CFA was crossed with an angled Glidewire (Terumo Medical). Heparin at low dose was used for anticoagulation. Initially, balloon occlusion of the pseudoaneurysm was performed using the 5 mm x 20 mm Charger (Boston Scientific) for 3 minutes without any change in the sac size. Under fluoroscopic guidance, the pseudoaneurysm sac was punctured using micropuncture needle and the entry was confirmed with a diluted contrast injection (Figure 2).

Thrombin was administered into the sac (400 units) simultaneously with the balloon occlusion of the neck of the sac. The balloon was deflated after 3 minutes and the angiogram showed more than 50% reduction in the size of the sac. The balloon occlusion was again performed for another 3 minutes and final angiogram showed complete resolution of the sac with good flow in the CFA and 3-vessel run-off in the right lower extremity (Figure 3).

This case clearly demonstrates the efficacy and safety of pseudoaneurysm repair in the catheterization lab without the discomfort involved with the ultrasound technique and much lower risk of arterial thrombosis.