Contemporary management of postcatheterization pseudoaneurysms.

Apseudoaneurysm (PSA) is a contained rupture; there is a disruption in all 3 layers of the arterial wall (Figure 1). PSAs may occur under 4 circumstances: (1) after catheterization (Figure 2); (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 take on the appearance of a sac. Hematoma and the surrounding tissue form the wall of the PSA. 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 6%. In 1 series where diagnostic ultrasound was performed on 536 consecutive 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 complex coronary and peripheral interventions are performed, especially with the use of potent antithrombotic and antiplatelet therapy. Since 1996, the number of peripheral interventions has more than doubled to an estimated 750 000 procedures in 2005.3 In 2003, the Centers for Disease Control/National Center for Health Statistics estimated 1.4 million inpatient diagnostic cardiac catheterization procedures, and 1.2 million angioplasties were performed in the United States.4 It has been suggested that PSAs may thrombose spontaneously. In 1 study, spontaneous thrombosis occurred in 72 of 82 patients with PSA 3 cm at a mean of 23 days,5 whereas in another prospective study only 9 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.6 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 take aspirin clopidogrel or warfarin is really not known. In the absence of severe pain, observation of small PSAs ( 2.0 cm) is reasonable. However, if the patient has severe pain, treatment is indicated. The most catastrophic complication of PSA is rupture. Although the exact rate is unknown, the risk of spontaneous rupture of PSA is related to size 3 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.9