Cath Lab Digest

How can cardiologists and vascular surgeons justify treating so many when most have been documented to resolve spontaneously without intervention?


In the 1996 November/December issue of VDM, I published an Editor’s Corner commentary on this subject. The issues discussed in that editorial have become all the more relevant today as rates of transfemoral catheterization continue to grow, as do the number of puncture-related pseudoaneurysms (PSAs) receiving treatment almost upon diagnosis — regardless of size or symptoms. To define the topic with clarity, here are a few paragraphs from the 1996 editorial:

“The incidence of puncture-related femoral artery pseudoaneurysms (PSAs) 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, 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. More recently, non-operative repair of PSAs 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 who 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.”

Nothing has really changed in the intervening 4 years since this editorial was penned. PSA lesions occurring after cardiac catheterization (and other similar procedures) continue to be treated, almost as a “knee-jerk reflex”. And also because it is easier and convenient, perhaps, for the physicians caring for these patients as the need for that aspect of the follow-up is eliminated and they need not worry about potential complications and annoying symptoms. These are clearly not good enough reasons to justify such an undertaking, as it makes no sense, either economically or from a patient-care perspective.

I’d love to see feedback on this, both from cardiologists and others who see these lesions after their procedures, and also from vascular surgeons who may be “on-board” with the thought of treating all PSAs just because they exist…

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Dr. Frank J Criado is a Board-Certified Vascular Surgeon and Endovascular Specialist at the Union Memorial Hospital-MedStar Health in Baltimore, Maryland – USA.

Dr. Criado is widely acknowledged to be a pioneer in endovascular therapy, with a 20-year + interventional experience. He has contributed extensively to the literature with more than 100 peer-reviewed published articles – mostly on various vascular and endovascular subjects, and Editor-in-Chief of Vascular Disease Management (VDM). He has also been active in clinical research, with a major focus on aortic stent-graft and carotid interventions, and endovascular technologies in general. He was the National Principal Investigator (P.I.) for the Medtronic Talent AAA clinical trials in the U.S., and a member of the Executive Committee for the Medtronic Valor Thoracic trial.

He is a founding member and immediate past President of the International Society of Endovascular Specialists (ISES), founder and current President of the endovascular surgery society of Latinamerica (CELA), and a member of all major U.S. and international vascular and endovascular societies. He is a Fellow of the American College of Surgeons (FACS) and of the Society of Vascular Medicine (FSVM), and a member of the Board of Directors of the Society for Vascular Surgery (SVS).