REVIEW ARTICLES Diagnosis and Treatment of Iatrogenic Femoral Artery Pseudoaneurysm: A Review Itzhak Kronzon, MD, New York, New York A pseudoaneurysm is a pulsatile hematoma that com- municates with an artery through a disruption in the arterial wall. Femoral pseudoaneurysm is a common complication of invasive procedures. It occurs in 0.1% to 0.2% of diagnostic angiograms and 3.5% to 5.5% of interventional procedures. Longer procedures, large- bore catheters, anticoagulation, and a faulty lower site of puncture are associated with a higher incidence of femoral pseudoaneurysm. Pseudoaneurysms are associ- ated with the characteristic findings of a pulsatile mass, a palpable thrill, and an audible to-and-fro murmur. The diagnosis is confirmed by imaging of the pseudo- aneurysm. A femoral arterial duplex study is the diag- nostic imaging modality of choice. It can show the pseudoaneurysm, the degree of clotting, the commtmi- caüon with the femoral artery, and the blood flow velocity pattern within the artery, the communication, and the pseudoaneurysm. Small (less than 2 cm) femo- ral pseudoaneurysms dot spontaneously and usually require no treatment. Larger femoral pseudoaneurysms may lead to complications including rupture and com- pression of the adjacent femoral vein (with resulting venous thrombosis) or of the femoral nerve. Treatment may be surgical. However, recently it has been shown that direct, noninvasive compression of the pseudoan- eurysm stops the blood flow in the communication and leads to pseudoaneurysm clotting and obliteration. (J Am Soc Echocardiogr 1997;10:236-45.) Arterial complications area known risk ofdiagnostic and therapeutic cardiologic and radiologic proce- dures. These complications include bleeding, dissec- tion, infection, thromboembolism, arteriovenous fis- tula, and arterial pseudoaneurysm) The femoral artery is the most common site ofaccess to the arterial system and the left side of the heart. The usual technique is percutaneous arterial cannulation ac- cording to the Seldinger technique or a modification of it. At the end ofthis procedure, after the catheters are removed, control of arterial bleeding is obtained by direct pressure. The most frequent complication of femoral artery catheterization is pseudoaneurysm (PAN). Todäy's medical economy emphasizes and pursues a short hospital stay. Many pafients who undergo diagnostic or interventional cardiologic and radio- logic procedures äre discharged from the hospital less than 24 hours after the procedure. Subcutaneous groin hematoma, which is common in these patients, offen masks the PAN. Many of the patients with iatrogenic femoral PAN, therefore, are discharged from the hospital before the diägnosis ofPAN can be made. It is therefore important that general inter- From the Department of Medicine, New York University School of Medicine. Reprint requests: Itzhak Kronzon, MD, 560 First Ave., New York, NY 10016. Copyright © ]997 by the Amcrican Sociery of Echocardiography. 0894-7317/97 $5.00 + 0 27/1/78261 236 nists, primary-care physicians, and family practitio- ners be able to diagnose this not-uncommon compli- cation and be able to select the best diagnostic and therapeutic approach for their pafients. This manu- script will review the clinical aspects, imaging tech- niques, and therapeuuc approach to this complica- tion of arterial puncture. ANATOMY AND PATHOPHYSIOLOGY A PAN is a pulsatile hematoma that communicates with an artery through a disruption in the wall of the artcry. Unlike a true aneurysm that is bounded by the vessel walls, a PAN is bounded by surrounding tissue. The communication between the artery and the PAN is almost always much narrower than the diameter of the PAN cavity. During systole, the arterial pressure rises above the pseudoaneurysm intracavitary pres- sure and thus flow is from the artery into the PAN. The pressure in the aneurysmal cavity approaches the arterial systolic blood pressure during systole. At the onset of diastole, the arterial diastolic pressure drops below the intracavitary PAN pressure and therefore flow is from the PAN into the artery. The volume of blood that enters the PAN during systole equals (in most cases) the volume of blood that returns to the artery in diastole. In rare cases, when systolic filling is greater than diastolic emptying, the result may be rapid expansion of the aneurysm with possible cata- strophic complications such as rupture and bleeding.
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