Steven S. Kang

A70-year-oldfemalewithahistoryofhypertensiondevelopedchestpainandcameto the Emergency Room. Her electrocardiogram showed ST segment elevation. The patientwasadministeredaspirin,clopidogrel,andintravenousheparin.Within60min, sheunderwentcoronaryangiography,whichshowedacriticalstenosisoftheleftanterior descending artery. The lesion was treated with angioplasty and stent placement. The right femoral artery sheath was left in place overnight, and heparin was continued. The following morning after stopping heparin, the sheath was removed and a FemoStop device was placed over the groin for 4 h. Heparin was then restarted.

The next day, the patient was without any chest pain, but she did have mild discomfort in theright groin. There was alarge hematoma in the right groin.Theoverlying skin had ecchymosis. The femoral pulse was prominent, and popliteal and pedal pulses were normal. A systolic bruit was heard over the femoral artery.

Question 1

What test should be obtained at this time?

A.  Computed tomography scan with intravenous contrast B.  Duplex ultrasound

C.  Magnetic resonance angiogram D.  Contrast arteriogram

A false aneurysm was suspected and confirmed by duplex ultrasound examination. It was arising from the common femoral artery (CFA). The flow cavity measured 3 cm in diameter (Fig. 11.1).

S.S. Kang

Department of Surgery, Florida International University School of Medicine, Miami, FL, USA

Fig. 11.1  Duplex ultrasound demonstrates a false aneurysm arising from the common femoral artery

Question 2

The incidence of postcatheterization false aneurysms in the groin is higher under which of the following situations?

A.  Puncture of the CFA instead of the superficial femoral artery (SFA) B.  Use of larger sheaths

C.  Use of postprocedural anticoagulation D.  Patients with hypertension

E.  Manual compression versus mechanical compression with a FemoStop after catheter removal

Question 3

Which of the following statements about postcatheterization false aneurysms is/are true?

A.  Urgent surgical repair is indicated

B.  This aneurysm is likely to undergo spontaneous thrombosis if observed C.  Spontaneous thrombosis is less common in patients who are anticoagulated D.  They may cause deep venous thrombosis

Heparin was discontinued and ultrasound-guided compression repair (UGCR) was attempted.

Question 4

Which are disadvantages of UGCR?

A.  Thrombosis of the underlying artery is a frequent complication B.  Most patients find it painful

C.  It is less successful in patients who are anticoagulated

D.  Approximately 30% of successfully thrombosed false aneurysms recur

Due to patient discomfort, intravenous morphine and midazolam were administered. After 60 min of compression, the false aneurysm still had flow. Vascular surgery was consulted for ultrasound-guided thrombin injection.

Question 5

Which of the following statements regarding ultrasound-guided thrombin injection is/are true?

A.  It requires direct injection of thrombin into the neck of the false aneurysm B.  It involves simultaneous compression of the false aneurysm

C.  It is less painful but less effective than UGCR D.  It works well in anticoagulated patients

E.  It is appropriate only for femoral false aneurysms

Bovine thrombin solution (1,000 units/mL) was loaded into a small syringe and a 22-gauge spinal needle was attached. Under ultrasound guidance, the needle was placed into the center of the false aneurysm (Fig. 11.2) and 0.3 mL thrombin was injected slowly. Within 15 s, the false aneurysm was thrombosed completely (Fig. 11.3). The procedure was tolerated well. Flow in the underlying artery was preserved and pedal pulses were intact. As the patient was otherwise stable, she was discharged soon afterwards.

Question 6

What are the reported complications of thrombin injection?

A.  Anaphylaxis

B.  Intra-arterial thrombosis

C.  Prolonged urticaria

D.  Mad cow disease