Aggressive Management of Cath-Related Femoral Artery Pseudoaneurysms and Arterio-Venous Fistulae: Can it be Justified?

The incidence of puncture-related femoral artery pseudoaneurysms (PSA) is relatively low but not insignificant. Unlike PSAs of a surgical or post-traumatic nature, catheterization-induced pseudoaneurysms have a largely benign natural history. Clinical manifestations include pain — at times severe — and consequent ambulatory limitations. A palpable pulsatile mass is often present. The symptoms tend to be most prominent during the first few days after the procedure. For reasons that are not altogether clear (to me, at least), many if not the majority of surgeons have (over the years) displayed a rather aggressive attitude toward these lesions, even to the extreme of undertaking operative repair in most cases — even in the middle of the night! This mindset has been propelled by the mistaken belief that an untreated PSA carries significant potential for serious morbidity. Again, the above-stated extrapolation from similar lesions with a very different etiology (surgical suture lines and penetrating external trauma) may help explain such excessive zeal for intervention, in spite of the fact that the benign natural course of these pseudoaneurysms was defined and reported — largely — by surgeons in the surgical literature many years ago.¹ More recently, non-operative repair of PSA has gradually emerged as the preferred management option, and a very welcomed addition to our armamentarium, given the notorious technical difficulties and morbidity associated with surgical treatment. Induced thrombosis evolved as an attractive treatment modality, first through external compression (ultrasound-guided or not), and later by ultrasound-guided thrombin injection that, undeniably, has become the preferred option. In fact, most if not all patients with catheterization-related femoral PSAs (whether small or large) are so treated in busy cardiovascular centers around the world today. The method has been proven safe and effective. Nonetheless, it seems to me that it is (or should be) intellectually difficult to justify performing an operation, routinely and universally, for a condition that has been shown to be largely benign and to resolve spontaneously in at least 80% of the cases! For some reason, a great number of both interventional specialists and vascular surgeons “choose” (seemingly) to ignore the well-documented body of evidence that favors – unequivocally – conservative management, and supports reserving intervention (or operation) for the minority of patients who really need it because of continuing or worsening severe pain and/or growth of the PSA. Such failure rate and subsequent need for repair may be higher when the PSA is large (> 3.0 cm) at initial diagnosis. An additional justification for “routine treatment” may be found in some referral practices where patients come from afar, making follow-up and repeat testing difficult or impossible. This may be, in fact, the most significant disadvantage of the approach advocated in this editorial: conservative management and observation-only imply the need for follow-up visits and repeat duplex ultrasound studies. Both the patient and the physician must make a commitment in this regard. In my own, somewhat “uncontrolled” but long clinical experience dealing with these issues, I have found that well over 80% of these PSAs will thrombose spontaneously if given the chance — usually within 2–6 weeks, almost regardless of initial size and use of anticoagulants. Continuing pain and growth constitute the main reasons for “failure” of such an approach. I have never seen a serious or catastrophic complication that could be attributed to an untreated PSA of this type. The worst “problem” is usually related to the reluctance on the part of other physicians involved that feel “uneasy about sending the patient home with an aneurysm…” And, unquestionably, routine treatment of all such lesions may be found by some to be easier and justified.² The perspective and landscape related to catheterization-related arterio-venous fistulae (AVF) is not all that different. The occurrence is relatively common, and the rate of discovery has gone up exponentially because of the proliferation of two practices: auscultation of the groin, and duplex ultrasound scanning. Hearing a bruit in the groin post-cath… leads to an ultrasound examination… and, often, to the diagnosis of an AVF. What’s the clinical implication or morbidity potential of such diagnosis? Essentially nil! Like PSA, AVFs related to femoral artery catheterization are relatively frequent, and will resolve spontaneously in 80% or more instances. Clinical indication for intervention, whether endovascular or surgical, should be extraordinarily rare. I can’t even recall the last time I felt it was necessary to treat one of these. In the end, I hope a majority of VDM readers feel the above-stated thoughts and reflections resonate as incentives for more of the same. Increasingly, we must all focus on safety and the benefit for each and every one of our patients. And it does not hurt to question everyday practices, as they can have profound impact on treatment outcomes and the actual lives of those we care for.