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Long-term compressive dressing for the treatment of postcatheterization pseudoaneurysm
(Portuguese PDF version)

Adalberto Pereira de Araujo¹, Cristiane Ferreira de Araujo Gomes², Átila Brunnet di Maio³, Fabio Monteiro da Costa⁴,Wellinton Draxler⁵

1. In charge of Vascular Surgery, Endovascular Surgery and Angiology, Hospital de Clínicas Rio Mar, Hospital Cardoso Rodrigues and Hospital Nortecor, Rio de Janeiro - RJ. Leading member of SBACV, of Colégio Brasileiro de Cirurgiões, of Academia Brasileira de Medicina Militar. PhD student, General Surgery, Division of Vascular Surgery, Universidade Federal do Rio de Janeiro.
2. Assistant at the Division of Vascular Surgery, Hospital Naval Marcílio Dias. Assistant at the Division of Endovascular Surgery, Hospital da Lagoa - Rio de Janeiro- RJ. Member of the Vascular and Endovascular Surgical Team, Hospital de Clínica Rio Mar, Hospital Cardoso Rodrigues and Hospital Nortecor - Rio de Janeiro.
3. Assistant at the Division of Endovascular Surgery, Hospital da Lagoa - Rio de Janeiro - RJ. Member of the Vascular and Endovascular Surgical Team of Hospital de Clínicas Rio Mar, Hospital Cardoso Rodrigues and Hospital Nortecor - Rio de Janeiro.
4. Assistant at the Division of Vascular Surgery of Hospital Antonio Pedro, School of Medicine, Universidade Federal Fluminense - Niterói - Rio de Janeiro - RJ. Assistant at the Division of Angiology and Vascular Surgery, Hospital da Gamboa. Member of the Vascular and Endovascular Surgical Team, Hospital de Clínicas Rio Mar - Rio de Janeiro- RJ.
5. Resident doctor, Division of General Surgery, Hospital Pedro Ernesto, School of Medicine of Universidade do Estado do Rio de Janeiro.

Correspondence:
Dr. Adalberto Pereira de Araujo
Rua Dona Claudina, 309/802
CEP 20725-060 - Rio de Janeiro - RJ
Tel.: +55 (11) 3259.4441
E-mail: adalbertopa@openlink.com.br

J Vasc Br 2003;2(1):29-32

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Vascular interventions by way of percutaneous catheterization may be hindered by the formation of pseudoaneurysm in 0.05% of diagnostic procedures and in 0.6 to 3.2% of therapeutic procedures.^1,2

The available treatments for postcatheterization pseudoaneurysm are: expectant therapy; conventional surgery, ultrasound- guided compression; and thrombin injection at the lumen of the pseudoaneurysm.

Several cases of spontaneous resolution have been described.^3,4 Paulson et al. prospectively monitored 24 pseudoaneurysms and found out that 60% of them healed spontaneously. Kent et al.⁴ detected spontaneous thrombosis in nine out of 16 prospectively studied pseudoaneurysms.

Surgical repair may provide resolution, but it is accompanied by morbidity rates of 1.4 to 30%, and long hospital stay.

Noninvasive and minimally invasive methods for the treatment of postcatheterization pseudoaneurysm were immediately adopted after their development, since they produce success rates of over 90%, have low incidence of complications and may be used in patients submitted to anticoagulant therapy.

On the other hand, ultrasound-guided compression may fail in up to 40% of the cases.⁷ Thrombin injection,^5-7 albeit highly efficient, may cause some remarkable complications, such as thrombosis of the native artery, anaphylaxis, and coagulopathy due to inhibition of factor V Leiden; moreover, it requires qualified personnel and is costly.

The technique used by us until recently⁸ consisted of ultrasound-guided C clamp, performed in the operating room with patient under spinal anesthesia. The drawbacks of this procedure are spinal anesthesia and the elevated cost due to the use of the operating room and mobilization of the surgical team.

Based on the observations made by Paulson & Kent⁴ on the spontaneous resolution of several postcatheterization pseudoaneurysms, we decided to treat these complications with only compressive dressing for a prolonged time, as a way to stimulate spontaneous resolution.

During the year 2002, we treated five patients with pseudoaneurysms of the femoral artery by using only compressive dressings for a prolonged time, and bed resting.

The aim of this Previous Notice is to draw some attention to the possibility of simplified and inexpensive treatment of this rare complication, which is significantly distressing if present.

Compressive dressing for a prolonged time period:
- Patient in the supine position with the bed in the horizontal position.
- Flex the patient's leg at 60º.
- Cleanse the antero-internal and posterior face of the ipsilateral thigh, genitocrural fold, inguinal region, ipsilateral flank and the suprapubic region with benzoin tincture.
- Place eight double-folded gauzes on the inguinal region, 2 cm above the puncture site and, lay another 20 gauzes (as they come from sterilization) on the folded gauzes.
- Apply two or three rows of 10-cm wide adhesive tapes from the posterior face of the thigh (as close as possible to the gluteal fold), passing by the genitocrural fold and inguinal region, going up to the costal margin of the corresponding side.
- Apply a row of adhesive tapes crosswise, from the upper contralateral gluteal region, passing by the inguinal region, and extending up to the ipsilateral upper gluteal region.
- Reposition the lower limb in anatomical supine position, so that the dressing exerts maximum pressure on the aneurysm sac, which will reduce or interrupt blood flow to the pathological site.
- Keep the patient in the supine position with the bed in the horizontal position for 72 hours, instructing him/her not to fold the corresponding limb, and only flex and extend the ipsilateral foot frequently and also flex the contralateral limb regularly.
- Remove the dressing after 72 hours and repeat the ultrasound.

If necessary, repeat the dressing for another 48 hours. Even after confirming the resolution of the aneurysm and allowing the patient to walk, it is recommended that a less compressive dressing be made for another 48 hours, in order to avoid recurrence.

This Previous Notice is relevant since it allows advertising and immediately applying a simple, low-risk and low-cost method, which can be used anywhere.

To reduce the possibility for postcatheterization pseudoaneurysms, it is imperative that total attention be paid to the homeostasis of the sheath insertion site after the procedures. Thus, the following sequence of events should be followed:
- Local manual compression for at least 30 minutes.
- Do not ease down manual compression while cleansing the site for compressive dressing.
- Do not ease down manual compression before placing the compressive dressing.
- Let the patient rest for al least 24 hours after diagnostic catheterization (first six hours in hospital) and, al least, 36 hours after therapeutic catheterization (first 24 hours in hospital).
- The compressive dressing must be kept in place for 36 hours, not for 6 to 24 hours, as some authors recommend (Figure 1).

Figure 1 - A) Pseudoaneurysm measuring 5-6 cm with 17 days. B) Healed after compressive dressing kept in place for four days; patient remained at rest with the bed in the horizontal position.

 

If these precautions and care are taken, postcatheterization pseudoaneurysms will seldom occur.

REFERENCES

1. Messina LM, Brothers TE, Wakefield TW, et al. Clinical characteristics and surgical management of vascular complications in patients undergoing cardiac catherization interventional versus diagnostic procedures. J Vasc Surg 1991;13:593-600.

2. Oweida SW, Roubin GS, Smith RB, Salam AA. Poscatherization vascular complications associated with percutaneous transluminal coronary angioplasty. J Vasc Surg 1990;12:310-5.

3. Rivers SP, Slass Lee E, Lyon RT, et al. Successful management of iatrogenic femoral arterial trauma. Ann Vasc Surg 1992;5:45-9.

4. Kent CK, McArdle C, Kennedy B, et al. A prospective study of the clinical outcome of femoral pseudoaneurysms and arteriovenous fistulas induced by arterial puncture. J Vasc Surg 1993;17:125-33.

5. Feld R, Patton GM. Carabasi RA, Alexander A, Merton D, Needleman L. Treatment of iatrogenic femoral artery injuries with ultrasound-guided compression. J Vasc Surg 1992;16:832-40.

6. Cox GS, Young JR, Gray BR, Grubb MW, Hertz NR. Ultrasound-guided compression repair of post-catherization pseudoaneurysms: results of treatment of one hundred cases. J Vasc Surg 1994;19:683-6.

7. Engelhorn CA, Picheth FS, Castro N Jr, et al. Compressão manual para tratamento dos falso-aneurismas femorais com ecoDopller colorido. Cir Vasc Angiol 1994;10:46-9.

8.Araujo AP. No hematoma pulsátil ou pseudo-aneurisma resultante de cateterismo, quando indicar: cirurgia, endoprótese, compressão guiada pelo ultra-som e injeção de trombina? In: Anais(programa final) do XXXIV Congresso de Angiologia e Cirurgia Vascular, 203-205, Rio de Janeiro, 20-25 de outubro de 2001.