Successful Conservative Management of Iatrogenic Femoral Arterial Trauma Steven P. Rivers, MD, Elizabeth Slass Lee, MD, Ross T. Lyon, MD, Scott Monrad, MD, Tom Hoffman, BS, Frank J. Veith, MD, N e w York, N e w York
We have developed a protocol for nonoperative management of pseudoaneurysms and arteriovenous fistulas secondary to cardiac catheterization. Hemodynamically stable patients were placed at bed rest and underwent serial physical examination, hematocrit, and duplex ultrasonography for a minimum of three days prior to discharge and subsequently as outpatients. Sixteen initially stable patients out of 56 with femoral artery catheter trauma managed over a four-year period underwent deliberate conservative management. Their lesions included six arteriovenous fistulas, seven pseudoaneurysms, and three patients with both complications. All but one of the pseudoaneurysms resolved spontaneously within four weeks regardless of initial size or associated arteriovenous fistula. One patient receiving anticoagulant therapy required surgery for bleeding after a three-day period of observation of a pseudoaneurysm. Six of the nine arteriovenous fistulas also resolved within the initial period of observation. The remaining three have been followed for four to 20 months and have remained asymptomatic. Nonoperative therapy of catheter-related femoral artery trauma is both safe and effective. Conservative management avoids potential wound complications associated with dissection through surrounding hematoma as well as the additional hospitalization required for postoperative care. We recommend a period of observation for all hemodynamically stable patients with catheter-induced pseudoaneurysms and arteriovenous fistulas of the femoral vessels, with surgery reserved for hemorrhage, expanding masses, or compromised cardiac output. (Ann Vasc Surg 1992;6:45-49). KEY WORDS: Pseudoaneurysm; arteriovenous fistula; catheterization; femoral artery; trauma.
aggressive protocol may be appropriate for mass casualty situations involving otherwise healthy young individuals, the applicability of universal surgical intervention for civilian and iatrogenic trauma has been questioned [I-3]. Clearly, the likelihood of a successful outcome of conservative management requires further investigation and is determined in part by the mechanism of injury, its location, and the general medical status of the patient. A particularly well-defined category of vascular trauma involves patients sustaining iatrogenic femoral injury from diagnostic and interventional cath-
The principles of liberal arteriography, prompt exploration of all wounds, and immediate repair of all arterial and venous lesions dictate the management of most vascular trauma. While a rigid and From the Divisions of Vascular Surgeo' and Cardiology, Albert Einstein College of Medicine/Montefiore Medical Center, New York, New York. Presented at the 16th Annual Meeting of the Peripheral Vascular Surgery Society, June 2, 1991, Boston, Massachusetts. Reprint requests: Steven P. Rivers, MD, 1825 Eastchester Road, Room 2S-32, New York, New York 10461.
45
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eterization. A previous study from our group found a significant postoperative complication rate from emergency repair [4]. Although surgery was obligatory for those patients with thrombotic or hemorrhagic lesions and accounted for most of the more serious problems, a number of complications were noted following repair of nonocclusive and nonhemorrhagic lesions. We have therefore begun a trial period of conservative management for pseudoaneurysms and arteriovenous (AV) fistulas secondary to cardiac catheterization, and we present the results of our initial experience.
METHODS From 1987 through March 1991, approximately 3,400 cardiac catheterizations were performed at the Weiler Hospital of the Albert Einstein College of Medicine. The transfemoral route was utilized almost exclusively. Diagnostic procedures were performed through a 6, 7 or 8 French sheath left in the femoral artery, while percutaneous coronary angioplasties utilized 8 or 9 French sheaths. For diagnostic procedures, sheaths were removed at the completion of the study. Neither anticoagulation nor antiplatelet therapy were usually employed for diagnostic studies. Therapeutic procedures required overnight heparin therapy with the sheath left in place for possible reintervention. Anticoagulants were discontinued the following morning, and the sheath was removed after normalization of the coagulation profile. Sheath removal was followed by 20 minutes of direct manual compression, eight hours of sandbag compression, and strict bed rest until the following morning. There were a total of 56 femoral injuries, including hematomas, pseudoaneurysms, AV fistulas, thrombosis, distal embolization, and massive bleeding. The overall complication rate of approximately 2% is comparable to other reports [5-7]. Pseudoaneurysms and AV fistulas were occasionally repaired during subsequent cardiac surgery or at the patient's or referring physician's request despite a recommendation to continue conservative management. This left 16 patients for evaluation of the natural history of such lesions, and they form the subject of this report. All pseudoaneurysms or AV fistulas suspected on physical examination were evaluated by duplex scanning using the Acuson 128" with a 5mHz linear array transducer. Longitudinal and transverse views were obtained to identify the site of injury. A pseudoaneurysm was diagnosed by demonstrating flow within a periarterial hematoma (Fig. 1). Arteriovenous fistulas were identified by an increase in diastolic flow proximally (Fig. 2) with normal flow *Acuson, Mountain View, California.
Fig. 1. Large pseudoaneurysm (Ps) adjacent to femoral artery (A) demonstrated by duplex scan. Communicating channel (arrow) is quite narrow, despite size of lumen of false aneurysm.
distally. The actual site of communication was not visualized in every case and was not considered necessary for diagnosis. All patients were then placed at strict bed rest for 24 hours, followed by gradual ambulation. A repeat duplex examination was performed prior to discharge and subsequently at one- to two-week intervals, along with serial physical examinations. Any patient with initial evidence of hemodynamic instability or ongoing hemorrhage was explored immediately and therefore excluded from this review. Any pseudoaneurysm which failed to resolve completely during follow-up was electively repaired. Arteriovenous fistulas were only repaired if signs or symptoms of congestive heart failure, arterial insufficiency, or venous hypertension developed.
RESULTS Sixteen agreed to follow-up. diagnostic
patients met the above criteria and conservative management with careful Thirteen complications occurred after cardiac catheterization and three fol-
VOLUME 6 N o 1 - 1992
S U C C E S S F U L C O N S E R VA 7IVE MA NA G E M E N T
A
47
B
Fig. 2. (a) Arteriovenous fistula detected on duplex scan by increased flow and spectral broadening in diastole, Communication itself is not visualized. (b) Return to normal spectral waveform following spontaneous closure.
lowed percutaneous transluminal coronary angioplasty. Seven patients had isolated pseudoaneurysms, six had AV fistulas, and three patients had a combination of both lesions. The maximal intraluminal diameter of the 10 pseudoaneurysms ranged from 1.3 to 4.0 cm. Nine of 10 pseudoaneurysms thrombosed spontaneously. One of these patients was explored for a lesion which had expanded from 1.7 cm to 2.3 cm over a two-week interval. However, the lesion was thrombosed at the time of surgery, approximately four weeks after the injury, and no repair of the vessel was required. One patient who required continuous anticoagulation following catheterization was explored for persistent bleeding around a pseudoaneurysm four days after her study. Six of the nine AV fistulas also closed spontaneously during the initial period of observation. The remaining three have been followed for four to 20 months and have remained asymptomatic. No patient with either a pseudoaneurysm or AV fistula sustained a hemorrhagic episode during the period of observation. Of the two patients who were sur-
gically explored, neither developed a postoperative complication.
DISCUSSION The traditional surgical approach to vascular trauma remains entirely appropriate for most hemorrhagic and occlusive lesions [8-10], although conservative management may occasionally be appropriate for thrombotic events which do not result in tissue ischemia. For more subtle forms of vascular injury, the need for mandatory operative repair has recently been questioned [11,12], as has the role of arteriography to document lesions which may be clinically insignificant [1,2,13,14]. The nature of lesions which are suitable for conservative management remains a subject of current investigation and controversy. The present study confines itself to a specific form of iatrogenic trauma in which the size and location of the arterial wall injury are relatively uniform and well-defined. Our results indicate that
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48
TABLE
l.--Conservative management of pseudoaneurysms
Series
Type of injury
Stein (1989) [12] n = 7 Kotval (1990) [16] n = 3 Dennis (1990) [1] n = 5 Kresowick (1991) [15] n = 9 Present series n = 9
All penetrating trauma Cardiac catheterization All penetrating trauma PTCA Cardiac catheterization and PTCA
Total n = 33
Spontaneous resolution
Elective repair
5 3 3 7 8
2 0 2 2 1
26 (79%)
7 (21%)
PTCA = percutaneous transfemorat coronary angioplasty
conservative management of pseudoaneurysms and AV fistulas resulting from these injuries is both safe and effective. Other series have documented a similar outcome for pseudoaneurysms [15,16], although the conservative treatment of AV fistulas has received less attention. Table I summarizes the results of five reports of conservative management of pseudoaneurysms after penetrating trauma, with an overall rate of spontaneous resolution of 79%. Equally important, no series reports a case of severe hemorrhage during the period of observation, whether or not the patient ultimately required surgical repair. We believe that the size of the hematoma and the intraluminal diameter of the pseudoaneurysm are not relevant determinants of outcome when the arterial wall is lacerated rather than disrupted and the laceration is known to be quite small. Our data also confirm the value of an initial trial of conservative management for AV fistulas. Clearly, the long-term conservative management of persistent lesions is more controversial. While the risk of late complications is virtually unknown because of the likelihood of prophylactic surgical correction, we believe it is actually quite small for communications no larger than that made by a puncture wound of 3 mm or less in diameter. A number of large series reporting late complications for generally larger hemodialysis fistulas demonstrate a very low incidence of high output cardiac failure, venous congestion, or distal arterial insufficiency [17-20], while persistent AV fistulas following in situ bypass procedures may even be beneficial. Unlike assault victims with penetrating trauma, patients with cardiac catheterization injuries are generally followed closely for many years. For the minority of patients who may develop late symptoms, surgical correction can therefore be accomplished prior to the development of irreversible sequelae while sparing most patients an unnecessary operation. While the long-term role of such an approach cannot be evaluated by the small number of patients in this report, the benefit of an initial effort to achieve spontaneous closure certainly seems justified. Initial conservative therapy, while frequently
effective in achieving spontaneous closure, must also address the potential problems for delayed repair against the efficacy of uniformly prompt surgical correction. Although too few patients in this series required surgery to establish a reliable complication rate, we believe that delayed repair would actually result in a lower incidence of wound infection, femoral neuralgia [21], and transfusion requirement than that which occurs following immediate operation. The results of delayed surgical management of other forms of penetrating trauma are quite acceptable for patients whose lesions were not readily apparent at initial presentation [22,23]. While several reports have noted higher complication rates from delayed repair of iatrogenic arterial injuries [24-26], the majority of problems were encountered in thrombosed or persistently bleeding vessels. We certainly support an aggressive approach to the management of these lesions but do not feel that the same principles apply to the treatment of nonocclusive and nonhemorrhagic injuries. Of critical importance to the conservative approach has been the observation that no patient sustained a major hemorrhage during conservative treatment of a stable pseudoaneurysm or AV fistula. The duplex scan was utilized as the sole diagnostic laboratory test for both initial identification and subsequent follow-up of pseudoaneurysms and AV fistulas in the groin. While arteriographic confirmation of these lesions was not obtained, we believe that noninvasive scanning is a highly accurate method of evaluating nonocclusive vascular trauma. The role of arteriography in penetrating trauma continues to be debated [2,3,27,28], but we predict that duplex scanning will ultimately replace arteriography in the majority of patients with penetrating extremity trauma [29].
CONCLUSION We conclude that a trial of conservative management is warranted for pseudoaneurysms and AV fistulas resulting from cardiac catheterization. The results of this study should not be extrapolated to other forms of penetrating trauma until further data
VOLUME 6 No 1 - 1992
SUCCESSFUL CONSERVATIVE MANAGEMENT
on the natural history of such lesions are acquired. Furthermore, centers which utilize larger sheaths and catheters for transfemoral procedures may have less satisfactory results with nonoperative therapy. Prompt exploration remains the appropriate treatment for actively bleeding or serious thrombotic injuries.
t3.
14.
15.
ACKNOWLEDGMENTS This study was supported in part by the Manning Foundation, the Anna S. Brown Trust, and the New York Institute for Vascular Studies.
16.
17.
REFERENCES
18.
1. DENNIS JW, FRYKBERG ER, CRUMP JM, et al. New perspectives on the management of penetrating proximity trauma. J Vasc Surg 1990;11:84-93. 2. RIVERS SP, PATEL Y, DELANY HM, et al. Limited role of arteriography in penetrating neck trauma. J Vase Surg 1988;8:112-116. 3. FRYKBERG ER, CRUMP JM, VINES FS, et al. A reassessment of the role of arteriography in penetrating proximity extremity trauma: a perspective study. J Trauma 1989; 29:1041-50. 4. FRANCO CD, GOLDSMITH J, VEITH FJ. Nature and management of arterial injuries resulting from invasive procedures via the femoral artery. In Veith FJ, ed. Current Critical Problems in Vascular Surgery, Volume 3. St. Louis, Quality Medical Publishers, in press. 5. OWE1DA SW, ROUBIN GS, SMITH RB, et al. Post catheterization vascular complications associated with percutaneous transluminal coronary angioplasty. J Vase Sttrg 1990;12:310-315. 6. MCMILLIAN I, MURIE JA. Vascular injury following caridac catheterization. Br J Surg 1984;71:832-835. 7. CHIVERON SG, MURIE JA. Incidence and management of arterial injuries from left heart catheterization. J R Coil Phys Lond 1986;20:126-128. 8. BURNETT HF, PARNEL CL, WILLIAMS GD, et at. Peripheral arterial injuries: a reassessment. Ann Surg 1983; 183:701-709. 9. RAICHLE FA, GOLSURKHI M. Diagnosis and management of penetrating arterial and venous injuries in the extremities. Am J. Surg 1980;140:365-367. 10. PERRY MO, THAL ER, SHIRES GT. Management of arterial injuries. Ann Surg 1971;173:403-408. 11. SIRINEK KR, LEVINE BA, GASKILL HV, et al. Reassessment of the role of routine operative exploration in vascular trauma. J Trauma 1981;21:339-344. 12. STAIN SC, YELLIN AE, WEAVER FA, et al. Selective
t9. 20. 21. 22. 23. 24.
25. 26.
27.
28, 29.
II II II
49
management of nonocclusive arterial injuries. Arch Surg 1989;124:1136-1141. ROSE SC, MOORE EE. Angiography in patients with arterial trauma. Correlation between angiographic abnormalities, operative findings and clinical outcome. Am J Radiol 1987;149:613-619. PANETTA T, SCLAFAN1 SJA, GARBACZ ES, et al. The natural history of nonoperated vascular injuries. J Trauma 1985:25:708-713. KRESOW1K TF, KHOURY MD, MILLER BV, et al. A prospective study of the incidence and natural history of femoral vascular compliations after percutaneous transluminal coronary angioplasty. J Vasc Surg 1991;13:328-335. KOTVAL PS, KHOURY A, SHAH PM, et al. Doppler sonographic demonstration of the progressive spontaneous thrombosis of pseudoaneurysms. J Ultrasound Med 1990;9: 185-190. ZIBARI GB, ROHR MS, LANDRENEAU MD, et al. Complications from permanent hemodialysis vascular access. Surgery 1988;104:681-685. HAIMOV M, BAEZ A, NEFF M, et al. Complications of arteriovenous fistulas for hemodialysis. Arch Surg 1975;110: 708-712. WINSETT OE, WOLMA FJ. Complications of vascular access for hemodialysis. South Med J t985;78:513-517. CONNOLLY JE, BROWNELL PA, LEVINE EF, et al. Complications of renal dialysis access procedures. Arch Surg 1984;119:1325-1328. HALLETT JN, WOLK SW, CHERRY KJ, et al. The femoral neuralgia syndrome after arterial trauma. J Vase Surg 1990;1t:702-706. RICH NM, HOBSON RW, COLLINS GJ. Elective vascular reconstruction after trauma. Ann Surg 1975;130:712-719. ESCOBAR GA. ESCOBAR, SC, MARQUEZ L, et al. Vascular Trauma: late sequelae and treatment. J Cardiovasc Surg 1980;21:35-40. MILLS JL, WIEDEMAN JE, ROBISON JG, et al. Minimizing mortality and morbidity from iatrogenic arterial injuries: the need for early recognition and prompt repair. J Vasc Surg 1986; 4:22-27. YOUKEY JR, CLAGETT GP, RICH NM, et al. Vacular trauma secondary to diagnostic and therapeutic procedures: 1974 through 1982. Am J Surg 1983;146:788-791. BABU SC, PICCORELL1 GO, SHAH PH, et al. Incidence and results of arterial complications among 16,500 patients undergoing cardiac catheterization. J Vasc Surg 1989;t0: 113-116. O'GORMAN RB, FELICIANO DV, BITONDO CG, et al. Emergency center arteriography in the evaluation of suspected peripheral vascular injuries. Arch Surg 1984;119:568573. TURCOTTE JK, TOWNE JB, BERNHARD VM. Is arteriography necessary in the management of vascular trauma of the extremities. Surgery 1978;84:557-583. PANETTA T, HUNT J, BUECHTER K, et al. Duplex scanning vs. arteriography for arterial trauma: an experimental study. J Trauma (in press).
We have developed a protocol for nonoperative management of pseudoaneurysms and arteriovenous fistulas secondary to cardiac catheterization. Hemodynamically stable patients were placed at bed rest and underwent serial physical examination, hematocrit, and duplex ultrasonography for a minimum of three days prior to discharge and subsequently as outpatients. Sixteen initially stable patients out of 56 with femoral artery catheter trauma managed over a four-year period underwent deliberate conservative management. Their lesions included six arteriovenous fistulas, seven pseudoaneurysms, and three patients with both complications. All but one of the pseudoaneurysms resolved spontaneously within four weeks regardless of initial size or associated arteriovenous fistula. One patient receiving anticoagulant therapy required surgery for bleeding after a three-day period of observation of a pseudoaneurysm. Six of the nine arteriovenous fistulas also resolved within the initial period of observation. The remaining three have been followed for four to 20 months and have remained asymptomatic. Nonoperative therapy of catheter-related femoral artery trauma is both safe and effective. Conservative management avoids potential wound complications associated with dissection through surrounding hematoma as well as the additional hospitalization required for postoperative care. We recommend a period of observation for all hemodynamically stable patients with catheter-induced pseudoaneurysms and arteriovenous fistulas of the femoral vessels, with surgery reserved for hemorrhage, expanding masses, or compromised cardiac output. (Ann Vasc Surg 1992;6:45-49). KEY WORDS: Pseudoaneurysm; arteriovenous fistula; catheterization; femoral artery; trauma.
aggressive protocol may be appropriate for mass casualty situations involving otherwise healthy young individuals, the applicability of universal surgical intervention for civilian and iatrogenic trauma has been questioned [I-3]. Clearly, the likelihood of a successful outcome of conservative management requires further investigation and is determined in part by the mechanism of injury, its location, and the general medical status of the patient. A particularly well-defined category of vascular trauma involves patients sustaining iatrogenic femoral injury from diagnostic and interventional cath-
The principles of liberal arteriography, prompt exploration of all wounds, and immediate repair of all arterial and venous lesions dictate the management of most vascular trauma. While a rigid and From the Divisions of Vascular Surgeo' and Cardiology, Albert Einstein College of Medicine/Montefiore Medical Center, New York, New York. Presented at the 16th Annual Meeting of the Peripheral Vascular Surgery Society, June 2, 1991, Boston, Massachusetts. Reprint requests: Steven P. Rivers, MD, 1825 Eastchester Road, Room 2S-32, New York, New York 10461.
45
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SUCCESSFUL CONSERVATIVE M A N A G E M E N T
46
eterization. A previous study from our group found a significant postoperative complication rate from emergency repair [4]. Although surgery was obligatory for those patients with thrombotic or hemorrhagic lesions and accounted for most of the more serious problems, a number of complications were noted following repair of nonocclusive and nonhemorrhagic lesions. We have therefore begun a trial period of conservative management for pseudoaneurysms and arteriovenous (AV) fistulas secondary to cardiac catheterization, and we present the results of our initial experience.
METHODS From 1987 through March 1991, approximately 3,400 cardiac catheterizations were performed at the Weiler Hospital of the Albert Einstein College of Medicine. The transfemoral route was utilized almost exclusively. Diagnostic procedures were performed through a 6, 7 or 8 French sheath left in the femoral artery, while percutaneous coronary angioplasties utilized 8 or 9 French sheaths. For diagnostic procedures, sheaths were removed at the completion of the study. Neither anticoagulation nor antiplatelet therapy were usually employed for diagnostic studies. Therapeutic procedures required overnight heparin therapy with the sheath left in place for possible reintervention. Anticoagulants were discontinued the following morning, and the sheath was removed after normalization of the coagulation profile. Sheath removal was followed by 20 minutes of direct manual compression, eight hours of sandbag compression, and strict bed rest until the following morning. There were a total of 56 femoral injuries, including hematomas, pseudoaneurysms, AV fistulas, thrombosis, distal embolization, and massive bleeding. The overall complication rate of approximately 2% is comparable to other reports [5-7]. Pseudoaneurysms and AV fistulas were occasionally repaired during subsequent cardiac surgery or at the patient's or referring physician's request despite a recommendation to continue conservative management. This left 16 patients for evaluation of the natural history of such lesions, and they form the subject of this report. All pseudoaneurysms or AV fistulas suspected on physical examination were evaluated by duplex scanning using the Acuson 128" with a 5mHz linear array transducer. Longitudinal and transverse views were obtained to identify the site of injury. A pseudoaneurysm was diagnosed by demonstrating flow within a periarterial hematoma (Fig. 1). Arteriovenous fistulas were identified by an increase in diastolic flow proximally (Fig. 2) with normal flow *Acuson, Mountain View, California.
Fig. 1. Large pseudoaneurysm (Ps) adjacent to femoral artery (A) demonstrated by duplex scan. Communicating channel (arrow) is quite narrow, despite size of lumen of false aneurysm.
distally. The actual site of communication was not visualized in every case and was not considered necessary for diagnosis. All patients were then placed at strict bed rest for 24 hours, followed by gradual ambulation. A repeat duplex examination was performed prior to discharge and subsequently at one- to two-week intervals, along with serial physical examinations. Any patient with initial evidence of hemodynamic instability or ongoing hemorrhage was explored immediately and therefore excluded from this review. Any pseudoaneurysm which failed to resolve completely during follow-up was electively repaired. Arteriovenous fistulas were only repaired if signs or symptoms of congestive heart failure, arterial insufficiency, or venous hypertension developed.
RESULTS Sixteen agreed to follow-up. diagnostic
patients met the above criteria and conservative management with careful Thirteen complications occurred after cardiac catheterization and three fol-
VOLUME 6 N o 1 - 1992
S U C C E S S F U L C O N S E R VA 7IVE MA NA G E M E N T
A
47
B
Fig. 2. (a) Arteriovenous fistula detected on duplex scan by increased flow and spectral broadening in diastole, Communication itself is not visualized. (b) Return to normal spectral waveform following spontaneous closure.
lowed percutaneous transluminal coronary angioplasty. Seven patients had isolated pseudoaneurysms, six had AV fistulas, and three patients had a combination of both lesions. The maximal intraluminal diameter of the 10 pseudoaneurysms ranged from 1.3 to 4.0 cm. Nine of 10 pseudoaneurysms thrombosed spontaneously. One of these patients was explored for a lesion which had expanded from 1.7 cm to 2.3 cm over a two-week interval. However, the lesion was thrombosed at the time of surgery, approximately four weeks after the injury, and no repair of the vessel was required. One patient who required continuous anticoagulation following catheterization was explored for persistent bleeding around a pseudoaneurysm four days after her study. Six of the nine AV fistulas also closed spontaneously during the initial period of observation. The remaining three have been followed for four to 20 months and have remained asymptomatic. No patient with either a pseudoaneurysm or AV fistula sustained a hemorrhagic episode during the period of observation. Of the two patients who were sur-
gically explored, neither developed a postoperative complication.
DISCUSSION The traditional surgical approach to vascular trauma remains entirely appropriate for most hemorrhagic and occlusive lesions [8-10], although conservative management may occasionally be appropriate for thrombotic events which do not result in tissue ischemia. For more subtle forms of vascular injury, the need for mandatory operative repair has recently been questioned [11,12], as has the role of arteriography to document lesions which may be clinically insignificant [1,2,13,14]. The nature of lesions which are suitable for conservative management remains a subject of current investigation and controversy. The present study confines itself to a specific form of iatrogenic trauma in which the size and location of the arterial wall injury are relatively uniform and well-defined. Our results indicate that
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48
TABLE
l.--Conservative management of pseudoaneurysms
Series
Type of injury
Stein (1989) [12] n = 7 Kotval (1990) [16] n = 3 Dennis (1990) [1] n = 5 Kresowick (1991) [15] n = 9 Present series n = 9
All penetrating trauma Cardiac catheterization All penetrating trauma PTCA Cardiac catheterization and PTCA
Total n = 33
Spontaneous resolution
Elective repair
5 3 3 7 8
2 0 2 2 1
26 (79%)
7 (21%)
PTCA = percutaneous transfemorat coronary angioplasty
conservative management of pseudoaneurysms and AV fistulas resulting from these injuries is both safe and effective. Other series have documented a similar outcome for pseudoaneurysms [15,16], although the conservative treatment of AV fistulas has received less attention. Table I summarizes the results of five reports of conservative management of pseudoaneurysms after penetrating trauma, with an overall rate of spontaneous resolution of 79%. Equally important, no series reports a case of severe hemorrhage during the period of observation, whether or not the patient ultimately required surgical repair. We believe that the size of the hematoma and the intraluminal diameter of the pseudoaneurysm are not relevant determinants of outcome when the arterial wall is lacerated rather than disrupted and the laceration is known to be quite small. Our data also confirm the value of an initial trial of conservative management for AV fistulas. Clearly, the long-term conservative management of persistent lesions is more controversial. While the risk of late complications is virtually unknown because of the likelihood of prophylactic surgical correction, we believe it is actually quite small for communications no larger than that made by a puncture wound of 3 mm or less in diameter. A number of large series reporting late complications for generally larger hemodialysis fistulas demonstrate a very low incidence of high output cardiac failure, venous congestion, or distal arterial insufficiency [17-20], while persistent AV fistulas following in situ bypass procedures may even be beneficial. Unlike assault victims with penetrating trauma, patients with cardiac catheterization injuries are generally followed closely for many years. For the minority of patients who may develop late symptoms, surgical correction can therefore be accomplished prior to the development of irreversible sequelae while sparing most patients an unnecessary operation. While the long-term role of such an approach cannot be evaluated by the small number of patients in this report, the benefit of an initial effort to achieve spontaneous closure certainly seems justified. Initial conservative therapy, while frequently
effective in achieving spontaneous closure, must also address the potential problems for delayed repair against the efficacy of uniformly prompt surgical correction. Although too few patients in this series required surgery to establish a reliable complication rate, we believe that delayed repair would actually result in a lower incidence of wound infection, femoral neuralgia [21], and transfusion requirement than that which occurs following immediate operation. The results of delayed surgical management of other forms of penetrating trauma are quite acceptable for patients whose lesions were not readily apparent at initial presentation [22,23]. While several reports have noted higher complication rates from delayed repair of iatrogenic arterial injuries [24-26], the majority of problems were encountered in thrombosed or persistently bleeding vessels. We certainly support an aggressive approach to the management of these lesions but do not feel that the same principles apply to the treatment of nonocclusive and nonhemorrhagic injuries. Of critical importance to the conservative approach has been the observation that no patient sustained a major hemorrhage during conservative treatment of a stable pseudoaneurysm or AV fistula. The duplex scan was utilized as the sole diagnostic laboratory test for both initial identification and subsequent follow-up of pseudoaneurysms and AV fistulas in the groin. While arteriographic confirmation of these lesions was not obtained, we believe that noninvasive scanning is a highly accurate method of evaluating nonocclusive vascular trauma. The role of arteriography in penetrating trauma continues to be debated [2,3,27,28], but we predict that duplex scanning will ultimately replace arteriography in the majority of patients with penetrating extremity trauma [29].
CONCLUSION We conclude that a trial of conservative management is warranted for pseudoaneurysms and AV fistulas resulting from cardiac catheterization. The results of this study should not be extrapolated to other forms of penetrating trauma until further data
VOLUME 6 No 1 - 1992
SUCCESSFUL CONSERVATIVE MANAGEMENT
on the natural history of such lesions are acquired. Furthermore, centers which utilize larger sheaths and catheters for transfemoral procedures may have less satisfactory results with nonoperative therapy. Prompt exploration remains the appropriate treatment for actively bleeding or serious thrombotic injuries.
t3.
14.
15.
ACKNOWLEDGMENTS This study was supported in part by the Manning Foundation, the Anna S. Brown Trust, and the New York Institute for Vascular Studies.
16.
17.
REFERENCES
18.
1. DENNIS JW, FRYKBERG ER, CRUMP JM, et al. New perspectives on the management of penetrating proximity trauma. J Vasc Surg 1990;11:84-93. 2. RIVERS SP, PATEL Y, DELANY HM, et al. Limited role of arteriography in penetrating neck trauma. J Vase Surg 1988;8:112-116. 3. FRYKBERG ER, CRUMP JM, VINES FS, et al. A reassessment of the role of arteriography in penetrating proximity extremity trauma: a perspective study. J Trauma 1989; 29:1041-50. 4. FRANCO CD, GOLDSMITH J, VEITH FJ. Nature and management of arterial injuries resulting from invasive procedures via the femoral artery. In Veith FJ, ed. Current Critical Problems in Vascular Surgery, Volume 3. St. Louis, Quality Medical Publishers, in press. 5. OWE1DA SW, ROUBIN GS, SMITH RB, et al. Post catheterization vascular complications associated with percutaneous transluminal coronary angioplasty. J Vase Sttrg 1990;12:310-315. 6. MCMILLIAN I, MURIE JA. Vascular injury following caridac catheterization. Br J Surg 1984;71:832-835. 7. CHIVERON SG, MURIE JA. Incidence and management of arterial injuries from left heart catheterization. J R Coil Phys Lond 1986;20:126-128. 8. BURNETT HF, PARNEL CL, WILLIAMS GD, et at. Peripheral arterial injuries: a reassessment. Ann Surg 1983; 183:701-709. 9. RAICHLE FA, GOLSURKHI M. Diagnosis and management of penetrating arterial and venous injuries in the extremities. Am J. Surg 1980;140:365-367. 10. PERRY MO, THAL ER, SHIRES GT. Management of arterial injuries. Ann Surg 1971;173:403-408. 11. SIRINEK KR, LEVINE BA, GASKILL HV, et al. Reassessment of the role of routine operative exploration in vascular trauma. J Trauma 1981;21:339-344. 12. STAIN SC, YELLIN AE, WEAVER FA, et al. Selective
t9. 20. 21. 22. 23. 24.
25. 26.
27.
28, 29.
II II II
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