Can A Pseudoaneyrism Be Repaired Through Cathdrization

A pseudoaneurysm (PSA) is a contained rupture; in that location is a disruption in all 3 layers of the arterial wall (Figure 1). PSAs may occur under 4 circumstances: (ane) after catheterization (Figure ii); (2) at the site of native artery and synthetic graft anastomosis (eg, aortofemoral bypass graft); (3) trauma; and (4) infection (eg, mycotic PSA) (Figure 3). This review will focus on PSAs that occur after cardiac and peripheral endovascular procedures. PSAs occur when an arterial puncture site does not adequately seal. Pulsatile blood tracks into the perivascular space and is contained by the perivascular structures, which then accept on the advent of a sac. Hematoma and the surrounding tissue form the wall of the PSA.

**Figure ane.** Artist's rendition of a postcatheterization PSA with proper placement of the needle for thrombin injection. There is a disruption in all three layers of the arterial wall. In essence, this represents a contained rupture.

**Figure two.** Arteriogram that demonstrates an axillary artery PSA after a diagnostic arteriographic process. Annotation the disruption in the vessel wall (white arrow) and the larger PSA sac (black arrow).

**Figure 3.** Ultrasound of a spontaneous PSA in the left brachial artery. Annotation the absence of a tract. The PSA bedchamber is straight connected to the brachial avenue. This type of PSA must be treated surgically. This patient had infective endocarditis.

Postcatheterization PSA is one of the most common vascular complications of cardiac and peripheral angiographic procedures. The incidence of PSA after diagnostic catheterization ranges from 0.05% to 2%.¹ When coronary or peripheral intervention is performed, the incidence increases to 2% to half-dozen%. In 1 series where diagnostic ultrasound was performed on 536 sequent patients who underwent catheterization, the incidence of PSA was 7.7%, with 83% of the PSAs associated with interventional procedures.² Despite a low incidence, PSAs are commonly encountered when more circuitous coronary and peripheral interventions are performed, especially with the utilize of potent antithrombotic and antiplatelet therapy. Since 1996, the number of peripheral interventions has more than doubled to an estimated 750 000 procedures in 2005.ⁱⁱⁱ In 2003, the Centers for Illness Command/National Center for Health Statistics estimated ane.4 million inpatient diagnostic cardiac catheterization procedures, and 1.2 million angioplasties were performed in the United states of america.⁴

It has been suggested that PSAs may thrombose spontaneously. In 1 study, spontaneous thrombosis occurred in 72 of 82 patients with PSA <three cm at a mean of 23 days,⁵ whereas in another prospective study only nine of 16 patients had spontaneous thrombosis at a mean of 22 days. Failure to thrombose was associated with size >1.8 cm and concomitant use of anticoagulation or antiplatelet agents.^six Most of the studies that suggested observation occurred prior to the era of aggressive antithrombotic and dual antiplatelet therapy. The rate of spontaneous thrombosis in patients who have aspirin+clopidogrel or warfarin is actually not known. In the absence of severe pain, observation of small PSAs (<ii.0 cm) is reasonable. Nonetheless, if the patient has severe pain, treatment is indicated.

The most catastrophic complication of PSA is rupture. Although the exact charge per unit is unknown, the gamble of spontaneous rupture of PSA is related to size >iii cm, presence of symptoms, large hematoma, or continued growth of the sac.^5,7,8 Although most postcatheterization PSAs are sterile, infection of a PSA significantly increases the risk of rupture as well as septic emboli.^ix

Factors Associated With Pseudoaneurysm Formation

Several patient and procedural factors may contribute to the formation of PSA as shown in Tabular array ane.¹⁰ Of detail importance is the increased incidence of femoral avenue PSAs when the puncture site is not in the common femoral artery, but rather is located in the superficial or deep femoral avenue or the external iliac artery.¹¹ The complexity of interventions such as coronary stenting, atherectomy, intraprocedural thrombolytic therapy, and repeat coronary angioplasty has also been shown to increase the take a chance of vascular complications.^12,13 In a meta-analysis of randomized trials, there was no increased vascular complication rate with Angio-Seal (St. Jude Medical, St. Paul, Minn) or Perclose (Abbott Vascular Devices, Redwood City, Calif) for patients who underwent either diagnostic catheterization or percutaneous coronary intervention.¹⁴ There was an increase in the vascular complication rate with VasoSeal (Datascope Corp, Montvale, NJ) (odds ratio, two.25; 95% CI, 1.07 to four.71). This study did not report the PSA rate, only the full vascular complication charge per unit, a composite of PSA, arteriovenous fistula, retroperitoneal hematoma, femoral artery thrombosis, surgical vascular repair, admission site infection, and claret transfusion.¹⁴ In a meta-analysis that was performed by Koreny and assembly and involved thirty trials and upwardly to 4000 patients, closure devices showed a relative risk of PSA formation of 1.19 (95% CI, 0.75 to one.88; P=0.46). Withal, in the 2 studies that reported intention-to-treat analysis, the occurrence of PSA formation was five.four times greater with the use of closure devices compared with manual pinch.^fifteen At that place are no expert prospective information to predict who will develop a PSA. However, information technology makes intuitive sense that the accurateness of the initial puncture and the expertise and duration of pinch of the puncture site after the sheath is removed may be important factors in the evolution of PSAs. Vascular complications are less common when the interventionalist uses ultrasound^sixteen or fluoroscopy with localization of the femoral head¹⁷ to puncture the femoral artery in the correct location and with the kickoff attempt (eg, no posterior wall puncture, particularly in obese patients and those with weak pulses.¹⁸

**TABLE ane. Factors Associated With the Formation of Pseudoaneurysm**
Antiplatelet agents (often aspirin and clopidogrel)
Anticoagulation
Large sheath size, >8F
Age >65 years
Obesity
Poor postprocedural compression
Simultaneous artery and vein catheterization
Hypertension
Peripheral arterial affliction
Hemodialysis
Circuitous interventions
Low or high puncture sites

Diagnosis

The presence of hurting or swelling in the groin after catheterization is the most mutual presentation of a PSA. Swelling from a big PSA or hematoma may also lead to compression of nerves and vessels with associated neuropathy, venous thrombosis, claudication, or, rarely, critical limb ischemia. Local ischemia of the skin may lead to necrosis and infection. On physical examination, in that location may be a palpable pulsatile mass or the presence of a systolic bruit. However, it should be noted that none of these aforementioned physical findings may be present. Whatever patient who experiences hurting that is disproportionate to that expected after a percutaneous procedure should undergo an ultrasound test to exclude the presence of a PSA regardless of the presence of a bruit.

The diagnostic test of option is duplex ultrasound with a 5- to 7-MHz linear transducer. If the puncture site is high (eg, external iliac artery) or there is all-encompassing hematoma, a lower frequency transducer (curved linear or sector assortment) may be required to image deeper structures. B-mode scanning lonely is unable to differentiate PSA from hematoma (Figure iv). Color Doppler enhances the diagnostic accuracy of ultrasound by identification of pulsatile catamenia within the sac (Figure 5A).¹⁹ The sensitivity of duplex ultrasound to identify a PSA is 94% with a specificity of 97%.²⁰

**Effigy 4.** B-mode ultrasound of PSA with echolucent sac. The only way to tell if this is a PSA or a hematoma is to employ color Doppler. If flow is present, it is a PSA. If menses is absent, it is consistent with a hematoma.

**Figure 5.** A, Color ultrasound of PSA. There are 2 chambers and a long track that connects the avenue to each of the chambers. There is marked turbulence (not visualized on this still image) within the track and the chamber. B, When a pulsed-wave Doppler is placed in the PSA tract, one can see the typical "to and fro" indicate that indicates that blood flows (often at a very loftier speed) both into and out of the PSA sleeping room. This is diagnostic of a PSA.

The typical appearance of a PSA on ultrasound is demonstrated in Figures iv and 5. The B-fashion image shows an echolucent sac that expands and contracts with cardiac wrinkle (Figure 4). On color Doppler, there is a swirling catamenia pattern with turbulence in the chamber(s), there may be 1 or more than chambers noted. A tract connects the PSA chamber to the feeding vessel (most commonly the common femoral artery) (Effigy 5A). When a pulsed wave Doppler is placed inside the rails, a "to-and-fro" signal is obtained, which signifies that this is in fact a PSA (Effigy 5B). In addition to identification of the number, size, and depth of the chambers of the PSA, the depth, width, and length of the tract that connects the artery to the PSA should be identified. Information technology is as well important to clearly identify the vessel that feeds the PSA in both transverse and long-axis views as well every bit record flow in the vessel proximal and distal to the PSA. The venous structures should exist conspicuously identified to rule out the presence of a deep venous thrombosis secondary to prolonged pinch on the groin or pressure level from an expanding hematoma. There are an increasing number of procedures performed from the arm, which thus increases the likelihood of PSAs in this location. The same principles utilise to diagnosis and handling of PSAs in the arm and leg.

1 common mistake during ultrasound exam is to image also superficially. Information technology is important to increase the depth on the ultrasound car and so that deep PSAs (>4 cm from the skin) are non overlooked. A complete examination should include imaging of the mid and distal external iliac artery, common femoral artery, and proximal portions of the superficial femoral and profunda femoral arteries.

Treatment

Until the early 1990s, the only treatment available for PSA was surgery. Since that time, ultrasound-guided compression (USGC) repair, ultrasound-guided thrombin injection (UGTI), and a whole host of other treatment modalities such as FemStop compression devices,²¹ gyre insertion,²² fibrin adhesives,²³ or balloon occlusion take been used with variable success. The three most mutual treatment strategies are discussed below in more detail.

Surgical Management

Surgical direction of PSA is still an important and necessary direction strategy in a minority of patients with PSA (Table 2). Any PSA that occurs at the site of a vascular anastomosis (eg, aortobifemoral bypass) should be repaired surgically considering it results from a disruption at the suture site and may be caused by infection. As well, spontaneously occurring PSAs are often mycotic (Figure 3) and should be repaired surgically. Compression on underlying structures by an expanding pulsatile mass, which causes claudication, neuropathy, or critical limb ischemia, requires urgent surgical decompression and resection of the PSA. Rarely, the PSA is and then large that it has or will cause skin necrosis. In this situation it is imperative to decompress this area surgically.^5,10,24 Withal, surgery is rarely employed to treat the usual postcatheterization PSA. The disadvantages of surgery for the treatment of PSA are that it requires anesthesia and an incision unremarkably in the groin, an area known to get infected easily subsequently a surgical procedure. Lumsden and colleagues reported a surgical complexity rate of 20% after PSA repair. Complications included bleeding, infection, neuralgia, prolonged hospital stay, perioperative myocardial infarction, and, rarely, death.²⁵

**TABLE 2. Indications for Surgical Repair of Pseudoaneurysm**
Infected pseudoaneurysm
Rapid expansion
Failure of other therapies
Skin necrosis
Compressive syndromes
Neuropathy
Claudication
Critical limb ischemia

Ultrasound-Guided Compression

In 1991, Fellmeth and associates introduced a safe and noninvasive method to care for PSA: USGC.²⁶ USGC has been shown to have a success charge per unit of 75% to 98%.^27–29 With the use of ultrasound to place the bedchamber and tract of the PSA, the ultrasound transducer is positioned and pressure is applied to shrink the chamber and tract while flow in the native artery is allowed. Directly ultrasound visualization confirms cessation of flow into the PSA. Compression is usually held for cycles of x minutes. This can be repeated until success or until a discretionary failure time. Although it would exist advantageous to use manual compression devices, the vertical angle created by the device does not allow selective compression of the PSA chamber and tract. Nonselective compression leads to longer compression times, more than discomfort to the patient, and a lower success rate, in addition to an increase in the likelihood of complications such as deep venous thrombosis.²⁹ Trunk habitus, size, depth, and number of chambers, as well as concurrent anticoagulation may limit the success of USGC.

In patients on anticoagulation, the success has been reported to be in the range of 30% to 73%.^27,30 Two serial from the same institution evaluated the role of USGC of postcatheterization PSAs in patients who did not receive anticoagulation and in those who did.^thirty,31 In the first 100 cases of postcatheterization PSA, USGC was immediately successful in 94 patients (94%), which included 30 (86%) of 35 patients who received anticoagulation and 64 (98%) of 65 patients who were non on anticoagulation. In that location were recurrences in a total of x patients who after underwent repeat USGC⁸ or surgery.² We later demonstrated that USGC was successful in 56 (73%) of 77 patients who received anticoagulation. Seven (12.5%) of these patients required 2 or 3 compression attempts to induce sustained thrombosis.³⁰ There were no pregnant complications reported in either of these studies.

The main limiting factor in USGC is the time information technology takes to induce sustained thrombosis. The boilerplate compression time to achieve occlusion was 33 minutes with a range of 10 to 120 minutes.³¹ This is a very painful procedure for the patients, and they ofttimes have to exist pretreated with narcotic analgesia. In addition, information technology is hard work for the physician or ultrasound technologist who must use constant hard pressure level over the groin. It is difficult to maintain pressure in the right position for prolonged periods of time. Rare complications have been reported such as vasovagal reactions, PSA rupture, skin necrosis, and deep vein thrombosis, although we have not experienced this in our large series.^thirty,31

Ultrasound-Guided Thrombin Injection

UGTI has become the handling of choice for postcatheterization PSAs.^32–34 Percutaneous coagulation of a PSA was first reported by Cope and Zeit in 1986.³⁵ The process was later on adapted to utilise ultrasound guidance with the injection of thrombin.³⁶ It should exist noted that this is off-label apply of thrombin. There is a warning on the thrombin package that states "for topical use just, not for injection". The principle of thrombin injection into the PSA sleeping room is based on the fact that thrombin is of import in the conversion of fibrinogen to fibrin. Thus a fibrin clot is formed instantaneously (even in the presence of antiplatelet therapy or anticoagulation therapy) with UGTI, whereas information technology may take up to several hours with USGC. Success ranges from 91% to 100% in big serial.^32,37–49 More than 45 individual series have been published on the safety and efficacy of this therapy. The cumulative overall success rate in 1329 PSA injections was 97%. Table 3 reports the success and complications in the largest series.^32,37–49

**Table 3. Summary of Ultrasound-Guided Thrombin Injection Series**
First Author	Year	No.	Bedrest (Hours)	Percent Success	Dose (Units)	Recurrence	Complications	Embolic	Clarification of Complications
Kruger⁴³	2003	50	12	100	357 vs 638	4	0	0	…
Calton³⁷	2001	52	…	94	…	2	1	1	Thrombotic complication of native artery
Sheiman⁴⁷	2001	54	one	93	g+	4	0	0	…
Sheiman⁴⁸	2003	54	3	91	703 vs 1510	v	0	0	…
Etemad³⁸	2003	61	…	100	435.0	0	1	0	Vasovagal
La Perna³²	2000	70	two	94	1150.0	three	1	0	Soleal deep vein thrombosis on follow-upwards with dogie pain
Kang³⁶	2000	83	1	99	820.0	vii	i	one	Brachial artery thrombosis that resolved spontaneously
Mohler⁴⁵	2001	91	NR	98	500 to 1000	2	ane	0	Pulmonary embolus unrelated to process
Vasquez⁴⁹	2005	96	half dozen	99	yard vs 300	0	3	0	Local erythema at injection site (bovine); groin pain×ii (human)
Maleux⁴⁴	2003	101	…	98	200.0	2	0	0	…
Paulson⁴⁶	2001	114	half-dozen	96	306.0	0	iv	ii	Infected abscess; blue toe; pain in leg and buttocks; anaphylaxis
Khoury⁴¹	2002	131	4	96	NR	9	3	ii	2 intra-arterial thrombin injections with critical limb ischemia; PSA rupture after thrombosis
Grewe³⁹	2004	132	0	99	669.0	0	0	0	…
Krueger⁴²	2005	240	half dozen to 24	100	425.0	6	2	1	Allergic reaction (fever); decreased posterior and inductive tibial artery Doppler velocity
Overall		1329	…	97.five	…	44	17	7 (0.5%)	…

Bovine thrombin, manufactured by GenTrac, Inc (Middleton, Wis) and distributed by Jones Pharma Inc (Bristol, Va), is available in a commercial kit, and it is by and large reconstituted in normal saline to a concentration of 1000 U/mL. Several authors accept advocated lower concentrations of thrombin (eg, 100 U/mL)^50,51 or the use of man thrombin because of the theoretical concept that it may produce a lower likelihood of allergic reactions.^44,49 In >400 thrombin injections, we take not experienced an allergic reaction to bovine thrombin.

Technique of Ultrasound-Guided Thrombin Injection

After informed consent is obtained, duplex ultrasound is performed as previously described. Distal pulses are confirmed manually and documented. The injection site is prepared in a sterile fashion, and local anesthesia is used with ane% to 2% lidocaine infiltrated into the skin and subcutaneous tissue.

Several injection techniques have been reported in the literature, but the technique that we use is the 3-way stopcock technique (Figure 6). This technique alleviates the demand to change syringes during the procedure (Table iv).³² Normal saline is placed into a v-mL syringe via a 22-gauge needle. Three milliliters of bovine thrombin is placed in the other syringe, and they are connected to the three-manner stopcock. For near injections, a 1.five-inch 22-gauge needle is used. If the PSA is deeper than iii.75 cm, a 21 gauge × nine cm Echotip (Cook Inc., Bloomington, Ind) needle that tin can be visualized under ultrasound will be used. With the thrombin "off" and the saline "on," the needle is advanced nether ultrasound guidance. The needle and transducer are positioned in parallel to puncture the PSA chamber every bit superficial and far from the PSA tract as possible. Although the needle tip may sometimes be visualized on B-mode imaging, confirmation of proper needle placement is fabricated with aspiration of arterial blood and small injections of saline to produce a wink of color within the sleeping room and allow direct visualization of the needle tip. Once appropriately placed, the thrombin port is turned "on" and the saline port "off". Aliquots of 0.2 mL are injected into the PSA chamber and visualized with color Doppler until no flow is observed. This usually occurs within seconds (Effigy 7). The goal is to produce complete obliteration of catamenia in the chamber and tract. Nevertheless, if tract flow continues, it commonly disappears by the time the ultrasound is performed the side by side 24-hour interval. Under no circumstances should an injection be made direct into the tract, as this will increase the likelihood of thrombosis of the native avenue. In that location is some controversy about how to approach patients with >1 chamber. Injection into the deeper chamber volition nigh certainly cause all other chambers to thrombose. Nevertheless, the needle placement is closer to the native artery, and the potential for complications may be higher. We prefer to inject into the most superficial bedroom first. This usually results in thrombosis of all chambers. However, if flow is still present in the deeper chambers, a 2d injection may need to be performed. Less than 1 mL of thrombin is used in near all cases, and many PSAs tin be completely thrombosed with every bit little equally 0.two to 0.4 mL. Steps utilized in the 3-way stopcock technique are summarized in Table 4.

**Figure half-dozen.** Iii-fashion stopcock for UGTI.

**TABLE four. Iii-Mode Stopcock Technique**
one. Measure the distance from the skin to the most superficial portion of the pseudoaneurysm cavity and the distance to the pseudoaneurysm track.
2. Infiltrate the skin and subcutaneous tissue with 1% to 2% lidocaine.
three. With the 3-manner stopcock assembled as described in the text (Figure 6), insert the needle to the depth measured in footstep 1 at the well-nigh superficial portion of the most superficial cavity. Apply negative pressure level on the syringe that contains saline and when arterial claret appears in the syringe, inject saline to document that the tip is in the proper location. Be sure that the injection is not almost the runway itself. If it is, remove and start over. Be certain you are in the pseudoaneurysm crenel and not the artery or the vein.
four. Turn the stopcock and gently inject 0.2 mL of topical thrombin. Inject 0.2 mL aliquots until the pseudoaneurysm and tract are thrombosed or until 1.0 mL of thrombin is used.
five. If there are ii or more cavities, inject the well-nigh superficial cavity first. Most of the fourth dimension all cavities will thrombose. If not, get afterward the deeper cavities.
vi. If the tract persists, follow the patient. It will commonly thrombose by the next day. Never inject directly into the tract.
vii. After successful thrombosis, image (pulsed wave and colour Doppler) the external iliac, mutual femoral, superficial femoral, and profunda femoral arteries and their associated veins to certificate normal flow and no evidence of deep venous thrombosis.
8. This procedure may exist performed as an outpatient. The patient is sent domicile immediately later on injection.
nine. Echo the ultrasound in 24 to 72 hours to confirm continued thrombosis. If the pseudoaneurysm reopens, reinject on follow-up visit.

**Figure 7.** A, PSA that arises from the mutual femoral artery. At that place is a thrombus in the PSA (black surface area around the color), and the color represents catamenia (ii.0×1.8 cm) into the PSA. B, Paradigm subsequently UGTI. Notation the thrombus nowadays. There is no period within the chamber.

Results of Thrombin Injection

The chief success rate is very loftier at 91% to 100% (Table 3). In our early series of lxx consecutive patients who underwent UGTI, the PSA arose from the distal external iliac artery in 11%, common femoral artery in 65%, superficial femoral avenue in 16%, profunda femoral artery in four%, and brachial artery in 3%. A total of 66 of 70 patients (94%) had complete thrombosis of the PSA with thrombin injection; 20 of 21 anticoagulated patients (95%) had successful thrombin injections.³² In this early series, ii of the failures were in patients after aortic stent graft insertion, and the PSA tract was brusque and wide. The third failure was the first patient in the series and was likely a technical failure as a result of inexperience with the technique. Occasionally, the majority of the PSA thromboses but a minor portion remains patent. In these situations, we use compression immediately after thrombin injection to manually disperse the thrombin into the open portion of the PSA.⁵²

Later on cessation of the period in the PSA, preservation of distal pulses should exist documented if they were nowadays prior to injection. Pulsed-moving ridge and color Doppler flow should be documented in the artery and vein proximal and distal to the PSA and compared with images recorded prior to the intervention. Although bedrest is not required later on injection, it is advisable to recommend avoidance of strenuous activity for 24 hours. We treat many of these patients as outpatients and permit them ambulate immediately after the procedure. There is a recurrence rate of 0% to nine% when imaged the next day (Tabular array three). A follow-up duplex ultrasound is obtained within 24 to 72 hours after thrombin injection. Recurrence of PSA can be treated with a second (or tertiary) injection with excellent results.

The most serious complications associated with thrombin injection are the development of deep venous thrombosis (if the thrombin is inadvertently injected into the vein), pulmonary embolism,⁴⁵ or thrombosis of the artery (if thrombin is injected into the PSA tract or the artery itself). This is nearly likely to occur if an injection is made directly into the neck of the PSA.^36,41 Although some clinicians take the patient immediately to surgery should this complication occur, other patients have been observed while anticoagulated and reported spontaneous resolution with no significant clinical sequelae.^46,53,54 Although information technology has been suggested that short broad tracts may increase the risk of thrombin injection, nosotros have not altered our indications on the footing of the tract anatomy and have non experienced an increased complication rate in our large series.

Allergic reactions and anaphylaxis have been reported in patients previously exposed to bovine thrombin.^42,55,56 Pope and Johnston recommend pare testing in patients with prior exposure to bovine thrombin;⁵⁵ this has non been observed in most reports and rarely skin testing is performed. There have been previous reports of antibodies that form against bovine gene V contamination of thrombin preparations. This has potential for serious hemorrhagic complications in humans; yet, it has not been observed in whatsoever of the series of patients treated with UGTI. The overall complication rate from UGTI is 1.3% with an embolic rate of 0.5% (Table 3). There is a definite learning bend, and the reported embolic complications are quite rare every bit one gains more experience with the technique of injection.

Contraindications to Ultrasound-Guided Thrombin Injection

Thrombin injections should but exist performed in patients who develop PSA secondary to a catheterization procedure. If a PSA occurs spontaneously, a mycotic PSA (Figure iii) should be suspected, and UGTI should not be undertaken. Additionally, a PSA that occurs at the anastomosis of a synthetic graft and native avenue should exist treated surgically and not with UGTI. The size of the PSA chamber is not, in of itself, a contraindication to UGTI. Nonetheless, if the PSA is large plenty to cause pare necrosis or compression of nerves or claret vessels, then surgery should be performed instead of thrombin injection (Table 2).

Special Circumstances

Occasionally a PSA is noted on the completion angiogram, prior to removal of the sheath. If this occurs, there are several techniques that can be utilized to correct the state of affairs at that fourth dimension. Covered stents and coils have been utilized with good results.^57,58

Prevention

There are no prospective studies that take addressed measures to prevent the germination of PSA. More complex procedures and more than potent antithrombotic therapy have led to the occurrence of more frequent PSA formation. The most important strategies to prevent PSA germination are:

Clinch a needle puncture in the proper location with the use of either fluoroscopy or ultrasound, thus accomplish vascular access on the beginning puncture without access through the posterior wall.
Appropriate groin compression later sheath removal. Adherence to the start makes this accomplishment easier.

Decision

PSAs are mutual after catheterization procedures. Duplex ultrasound is the diagnostic method of selection because information technology is noninvasive, accurate, and toll-effective. Surgical repair of PSAs is rare just is indicated in patients who exhibit rapid expansion, infection, compression syndrome, or failure of UGTI. UGTI has an excellent chief success rate of 97% and a low complication charge per unit of ≤1.3%. Proper technique with adequate ultrasound visualization of thrombin injected into the PSA will minimize embolic complications. Although USGC is safe and successful, procedural limitations take made UGTI the technique of option for kickoff-line management of PSAs that occur afterward percutaneous catheterization procedures.

Footnotes

Correspondence to Dr Jeffrey W. Olin, Practice, Professor of Medicine, Director, Vascular Medicine, Zena and Michael A. Wiener Cardiovascular Institute and the Marie-José and Henry R. Kravis Middle for Cardiovascular Health, Mount Sinai School of Medicine, Ane Gustave Fifty. Levy Pl, Box 1033, New York, NY 10029. Electronic mail [email protected]

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