ARTICLE IN PRESS

doi:10.1510/icvts.2008.188623

Interactive CardioVascular and Thoracic Surgery 8 (2009) 353–358

www.icvts.org

ESCVS article - Vascular general

Femoral pseudoaneurysms post-cardiac catheterization
surgically treated: evolution and prognosis夞
Enrique M. San Norberto Garcı́a*, José-Antonio González-Fajardo, Vicente Gutiérrez,
Santiago Carrera, Carlos Vaquero

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Division of Vascular Surgery, Valladolid University Hospital, Valladolid, Spain

Received 29 July 2008; received in revised form 13 October 2008; accepted 14 October 2008

Abstract

Objectives: To analyze the postoperative complications of patients who have undergone surgical repair of femoral pseudoaneurysm after
cardiac catheterization. Design: Prospective study. Materials: Cardiovascular risk factors, related to surgery and cardiac catheterization
were collected prospectively in 79 patients from 2003 to 2006 in Valladolid University Hospital. The indications of surgery included necrosis
of adjacent soft tissue, rapid growth, infection, bleeding, hemodynamic instability or failure of the percutaneous treatment (US-guided
compression and US-guided percutaneous thrombin injection). Methods: Patient and management related predictors for 30-day outcome
were analyzed. Results: Fifty-six patients (56y79, 71%) experienced some type of postoperative complication, the most frequent being the
need for a transfusion. Infection (15y79, 19%) and dehiscence of the surgical wound (10y79, 12.7%) were the other two most common
complications. The mortality related to the intervention was 3.8% (3y79). The mean hospital stay was 32.5 days ("28.4 days). Significant
risk factors in logistic regression model were gender (Ps0.023, ORs9.66), 70 years old (Ps0.049, ORs0.15) and the concurrent use of
anticoagulation or antiplatelet therapy after the cardiac catheterization (Ps0.005, ORs0.03). Conclusion: Patients who undergo surgical
treatment of femoral pseudoaneurysm post-cardiac catheterization experience a high postoperative morbidity and hospital stay. Factors
such as female gender, age over 70 years and treatment with anticoagulants or antiplatelets increase the postoperative morbidity. A
seasonal influence was appreciated, with a higher frequency during the summer period.
䊚 2009 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Keywords: Pseudoaneurysm; Cardiac catheterization; Surgical risk

1. Introduction The majority of studies about the surgical treatment of

Vascular Interventional and Interventional Cardiology
Laboratory have experienced remarkable advances in endo-
vascular techniques during the last few decades. The use
of an entry to the vascular tree constitutes an essential
part of the procedure. The commonly used arterial and
venous approach is the femoral route. The most important
group of technical complications is those related to the
site of puncture, femoral pseudoaneurysms are the most
frequent complication w1x.
The role of the surgery in the treatment of femoral
pseudoaneurysms has diminished since the development of
less invasive therapeutic methods like echo-guided com-
pression, echo-guided thrombin injection or endovascular
repair w2–4x. This avoids the need for general or locore-
gional anesthesia in a group of patients with a significant
morbidity and who do not tolerate vascular reconstruction
and bleeding. However, there still remain a subset of cases
in which open surgical repair is necessary.
夞 Presented at the 57th International Congress of the European Society for
Cardiovascular Surgery, Barcelona, Spain, April 24–27, 2008.
*Corresponding author. CyRamón y Cajal n83, 47005, Valladolid, Spain.
Tel.: q34-686754618; fax: q34-983420000.
E-mail address: esannorberto@hotmail.com (E.M. San Norberto Garcı́a).
䊚 2009 Published by European Association for Cardio-Thoracic Surgery
this pathology w5–8x were performed in the early 1990s.
After more than ten years, these patients have not been
studied, in spite of the great advances which have taken
place, both in the technique of cardiac catheterization and
in the treatment of critical patients. This article constitutes
an update on the evolution of patients submitted to a
surgical repair of femoral pseudoaneurysms following
cardiac catheterization.
2. Materials and methods
Between January 2003 and December 2006 we prospec-
tively recorded the data from every patient who experi-
enced femoral pseudoaneurysm following cardiac
catheterization surgery in a database at the Angiology and
Vascular Surgery Division of the University Hospital of
Valladolid. The diagnosis is usually straightforward and is
made on the combination of physical examination and
duplex ultrasound findings. Ultrasound diagnostic criteria
were: an echolucent cavity on B-mode ultrasound exami-
nation, pulsatile expansion and contraction of the suspect-
ed echolucent area and bidirectional flow at the neck of
 ARTICLE IN PRESS
354 E.M. San Norberto Garcı́a et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) 353–358

the pseudoaneurysm in systole and diastole. Intraarterial
angiography was reserved for patients who experienced
associated lower extremity ischemia.
A total of 79 patients were included in this analysis, 5371
cardiac catheterizations were performed during the same
period (incidence 1.47%), 57 (1.06%) were treated success-
fully by ultrasound-guided compression and 21 (0.39%) by
thrombin injection. Their mean diameter was 3.2 cm
(range 1.4–7.3 cm). The indications for surgical repair
were: rapidly expanding pseudoaneurysm, infected pseu-
doaneurysm (this diagnosis was supported by fever, leuko-
cytosis or positive blood cultures), distal ischemia caused
by local pressure of the pseudoaneurysm on the femoral
artery, neuropathy caused by local pressure on the femoral
cal risk factors and 30-day overall complications and death
rate was assessed by univariate analysis using the x2 and
the Fisher exact test. The variables that positively associ-
ated with postoperative outcome at P-0.05 were selected
for a multivariate analysis using forward stepwise logistic
regression. Odds ratios (OR) and 95% confidence interval
(CI) were calculated. A risk factor was considered statis-
cally significant when P-0.05.
3. Results
Of the 79 patients treated, 32 were women and 47 men.
The mean age was 70 years (47–87). The diagnosis of
femoral pseudoaneurysm after cardiac catheterization was

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nerve, jeopardized viability of soft tissues and the superad-
jacent skin, failure of percutaneous treatment (US-guided
compression and US-guided percutaneous thrombin injec-
tion), previous history of allergic reaction to thrombin or
bovine products, bleeding or hemodynamic instability.
Demographic data such as age and gender were gathered
in the registry. The presence of accompanying cardiovas-
cular co-morbidity (chronic coronary artery disease, arte-
rial hypertension, diabetes mellitus, hyperlipidemia) or of
another type (respiratory insufficiency, renal insufficiency,
auricular fibrillation, peripheral arterial disease) was also
obtained. Data related to the nature of cardiac catheteri-
zation (diagnostic vs. therapeutic) as well as post-cathe-
terization anticoagulation or antiplatelet therapy were also
incorporated into our analysis. Postoperative surgical and
medical 30-day complications were also recorded. The
sheath size of the devices used in the diagnostic interven-
tions was 5F and in therapeutics 6F and 7F. Arterial closure
devices (Prostar䊛, Perclose Peripheral Vascular Surgery,
Menlo Park, USA) were used in all the therapeutic
procedures.
The surgical approach to the femoral arteries for a pseu-
doaneurysm was direct and gentle. A longitudinal groin
incision over the femoral pulse was elected. Instead of
entering the hematoma, the surgeon carried the dissection
made by duplex ultrasound in 88.6% of the cases, requiring
arteriography study only in the remaining 11.4%. Arterio-
venous fistula accompanied the pseudoaneurysm in 13.9%
of the cases. Indications of surgical treatment collected
were: necrosis of soft tissues and skin adjacent to the
pseudoaneurysm 32.9%, rapid growth 25.3%, infection 22.8%
or failure of the percutaneous treatment 10.1%, shock 6.3%
and femoral neuropathy 2.5%. Baseline characteristics and
catheterization details are summarized in Table 1.
The postinterventional treatment included antiplatelet
therapy in 37 patients (56.7%, 22.4% aspirin and 34.3%
aspirin plus clopidogrel), anticoagulation and antiplatelet
therapy in 19.2% (15y79) of the subjects and double anti-
coagulant and antiplatelet therapy in six patients. In four
patients (5.5%), the IIbyIIIa receptor antagonist was used.
Seventy-nine patients underwent 98 surgical procedures.
Fig. 1 shows the various surgical techniques that were
utilized. The most frequently performed procedure was
direct closure and resection of the sac 84 (79.7%), followed
by patch angioplasty 9 (11.4%), bypass grafting 5 (6.3%) or
vein angioplasty 2 (2.5%). The operation was performed on
the same day of the diagnosis in 40.6% (32y79) of the cases
Table 1
Baseline characteristics of patients and catheterization technique

directly to the inguinal ligament, where the femoral artery Number %

or distal external iliac artery can be exposed and con-
trolled. If femoral artery thrombosis had occurred or if Total 79
Sex
arterial repair with a graft or patch angioplasty was deemed Female 32 40.5
necessary, a low dose of intravenous heparin (2000–3000 U) Male 47 59.5
was administered. After the femoral artery was clamped Hypertension 47 59.5
at the inguinal ligament, the hematoma could be incised Diabetes 13 16.5
Hyperlipidemia 23 29.1
and evacuated. The puncture site could be identified and
Coronary artery disease 38 48.1
controlled with finger pressure. Usually a simple suture was Atrial fibrillation 38 48.1
sufficient. Large hematoma cavities were drained with a Renal failure 5 6.3
closed suction catheter. A separate suprainguinal external PAD 15 18.9
iliac approach was necessary for control in patients because Catheterization
Diagnostic 44 55.7
of proximal injury, massive pseudoaneurysm, morbid obe- Therapeutic 35 44.3
sity, or extensive groin scarring (ns11). Most pseudoaneu- Cardiac disease
ryms could be repaired by simple suture of the arterial Coronary 39 49.4
puncture. A patch angioplasty was necessary if it appears Valvulopathy 17 21.5
CorqVal 16 20.3
that closure of the defect in the arterial wall would Therapeutics
compromise the lumen. General anesthesia was used in 42 Valvuloplasty 39 49.4
cases (53.2%) and regional anesthesia in 37 (46.8%). Electrophysiologic intervention 24 30.4
Statistical analysis was carried out using the SPSS 14.0 for PTCAyStent 10 12.7
Windows program (SPSS Inc., Chicago, IL, USA). The cor- PAD, peripheral artery disease; PTCA, percutaneous transluminal coronary
relation between potential factors cardiovascular or surgi- angioplasty.
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E.M. San Norberto Garcı́a et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) 353–358 355

Table 2
Postoperative complications

Complication Number %

Blood transfusion 42 53
Infection
Without dehiscence of surgical wound 16 20.3
With dehiscence of surgical wound 10 12.7
Cardiac insufficiency 5 6.3
Respiratory insufficiency 4 5.1
Acute myocardium infarction 3 3.8
Acute renal insufficiency 3 3.8
Atrial fibrillation 2 2.5
Pneumonia 2 2.5
Aortic insufficiency 2 2.5
Septic shock 2 2.5
Bronchospasm 2 2.5

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Coagulopathy 2 2.5
Ventricular fibrillation 1 1.3
Endocarditis 1 1.3
Fig. 1. Surgical techniques.
Cholestasis 1 1.3
Atrial-ventricular block 1 1.3
Digestive hemorrhage 1 1.3
Hemoptysis 1 1.3
and within the following day in 12.5% (10y79). One case
Embolism 1 1.3
required the substitution of the arterial suture material to Death 3 3.8
a vein angioplasty following the initial repair and it was
necessary to carry out 18 postoperative surgical resections
of devitalized skin limits (22.8%). No amputations were Table 3
Age and hospital stay of patients with complications and no complications
required.
Seventy-one percent of the subjects underwent some type No complication P Complication
of 30-day perioperative complication. Necessity for blood
transfusion was the most frequent non-lethal complication Age
M 63.64 0.03 73.20
42 (53%), with a maximum of 10 red blood cell concentrates S.D. 9.17 7.79
and an average of more than one red blood cell concentrate Hospital stay
per patient affected. Infection without 16 (20.3%) and with M 16 0.0983 40
dehiscence of the surgical wound 10 (12.7%) were the other S.D. 8.85 31.24
two most common complications (Table 2). The cultures M, mean; S.D., standard deviation.
taken from the infected wounds were primarily polymicro-
bial infections 18 (22.8%) in comparison with monomicro- anticoagulation or antiplatelet therapy after cardiac cath-
bial 8 (10.1%). The most frequently isolated microorganisms eterization (Ps0.005, ORs0.03).
were E. coli, S. epidermidis and S. aureus. Patients with A histogram of frequencies during the study period showed
infected wounds were treated with 10 days of intravenous a seasonal influence, around the summer months, focused
antibiotics. The infection rate was not correlated with the on May and August, correlates with a higher incidence of
employment of percutaneous closure devices (Ps0.836). femoral pseudoaneurysm at the same period, without a
Three postoperative intervention related deaths occurred higher overall catheterization techniques volume during
(mortality: 3.8%). Of the expired patients, the cause of this interval (Fig. 2).
death was attributed to cardiac failure in a 59-year-old
patient, and another two of 67 and 68-year-olds expired
4. Discussion
due to septic shock related infected pseudoaneurysms.
The mean hospital stay of this series was 32.5 days This is the first study to report a prospective review of
("28.4 days). patients submitted to surgical repair of femoral pseudo-
Statistically significant differences were found in relation aneurysm after cardiac catheterization. This study aims to
to the length of hospital stay (Ps0.027) and the age of contribute new knowledge to this literature.
the patients (Ps0.031) who underwent a perioperative Oweida et al. w5x in 1990, analyzed patients with any
complication and those who did not (Table 3). No other vascular complication after cardiac catheterization, includ-
demographic differences were found between patients with ing arterial thrombosis or embolization and even a case of
or without complications after surgical repair. Higher rates mesenteric ischemia. In our opinion, the patients examined
of adverse outcome were found in patients with hyperten- in this study constitute groups with very different pathol-
sion (5.7 vs. 2.9%, Ps0.072); however, the difference did ogies and prognoses. Hence an exclusive study of the
not reach statistical significance. Univariate and multivar- patients with pseudoaneurysm is required.
iate logistic regression models of risk factors predicting 30- Patients with vascular complications or pseudoaneurysms
day complication rates are shown in Table 4. Strong related to the use of an intraaortic balloon pump have also
independent predictors were female gender (Ps0.023, been excluded from this study in light of their severely
ORs9.66), age over 70 years (Ps0.049, ORs0.15) and depressed cardiac function and grim prognosis, making it
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356 E.M. San Norberto Garcı́a et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) 353–358

Table 4
Risk factors as independent factor for perioperative overall morbidity

Variable Univariate analysis Multivariate analysis

P OR (95% CI) P OR (95% CI)

Female 0.001 0.05 (0.06–0.42) 0.023 9.66 (1.37–68.23)

)70 years 0.010 6.33 (1.45–27.74) 0.049 0.15 (0.02–1.08)
AnticoagulantyAntiplatelet therapy 0.023 0.20 (0.46–0.85) 0.005 0.03 (0.00–0.34)
Anticoagulant therapy 0.654 0.74 (0.19–2.81)
DiagnosticyInterventional 0.885 1.01 (0.31–3.92)
Catheter size 0.231 0.05 (0.01–2.93)
Previous procedure through same femoral 0.351 1.34 (0.04–4.21)
Fibrinolytic therapy 0.771 2.34 (0.08–3.02)
Coronary artery disease 0.763 0.82 (0.23–2.96)
Hypertension 0.072 3.26 (0.87–12.11)
Diabetes mellitus 0.667 0.71 (0.14–3.47)

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Hyperlipidemia 0.975 1.02 (0.25–4.13)
Chronic renal insufficiency 0.228 0.03 (0.01–4.16)
Atrial fibrillation 0.321 2.32 (0.53–10.04)
Peripheral artery disease 0.428 0.48 (0.11–2.16)

OR, odds ratio; CI, confidence interval.

complications after surgical repair of femoral pseudoaneu-

Fig. 2. Seasonal distribution of femoral pseudoaneurysm post-cardiac cath-
eterization surgically treated.
impossible to objectively and clearly differentiate surgical
morbidity from the patient’s underlying pathology w9x.
The published literature has identified several variables
that are responsible for a greater risk of peripheral vascular
complications after cardiac catheterization. Such risks
include increasing age, female gender, fibrinolytic therapy,
postprocedural anticoagulation w5x or the procedure being
diagnostic or interventional w6, 10–12x. Other variables
have been studied with heretofore unjustified validity,
including hypertension, diabetes, catheter size, peripheral
vascular arteriopathy, hemodialysis or a previous history of
another percutaneous procedure through the same vascular
entry w11x. All these risk factors, in the development of
rysm after a cardiac catheterization, were evaluated in our
study.
The morbidity experienced by patients in our study is
greater than in the morbidity reported in other
publications. In our study the need for transfusion has been
considered a perioperative complication which increases
our incidence of perioperative morbidity to 71%. The most
noteworthy postoperative complication of surgical repair is
its requirement of blood transfusion. If we excluded the
need for transfusion as a complication the percentage,
however, remains high, reaching 46%. The morbidities pub-
lished in prior studies range from 7.4 to 31.7% w5,10,13x.
This large disparity is explained by the lack of unanimity
in criteria for the registration of any complications. A
complication that has been commented on in these articles
has been the need for amputation of the affected member
in some cases. In the study by Messina et al. there were
up to three amputations. Unlike our study, the Messina
study analyzed all vascular complications after cardiac
catheterization, not only those with pseudoaneurysms, and
in these patients, although it is not detailed, the respon-
sible pathology is likely ischemia of the member in ques-
tion. The mortality observed in our study reached 3.8% of
the subjects. Mortalities of 7.9% have been reported in
prior studies amongst patients who have undergone thera-
peutic catheterizations w10x.
The only publication that established clear difference
among patient groups was that of Messina et al. w6x pub-
lished in 1991, in which 64 patients are considered inter-
vened after a diagnostic catheterization and 37 after a
therapeutic procedure. In their analysis, morbidity differ-
ences (27% as opposed to 19%) and mortality differences
(2.7 and 7.9%, respectively), were observed between both
groups. No statistical study between both groups was car-
ried out. Technical advances during the last years have
developed therapeutic sheaths with smaller diameters,
closer to the size of diagnostic devices.
Results demonstrate that female patients, age over 70
years and treatment with anticoagulants or antiplatelets
 ARTICLE IN PRESS
E.M. San Norberto Garcı́a et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) 353–358
are at higher risk for adverse outcomes following surgical
repair of femoral pseudoaneurysm after cardiac catheter-
ization. The explanation for the increased risk in most
elderly patients may be related to age related changes in
the arterial wall associated, mediated by increasing calci-
fication and loss of elastin w14x. Careful monitoring of
physical findings and ultrasound examination is recom-
mended in these patients to offer early non-invasive treat-
ment procedures as ultrasound-guided compression or
thrombin injection. The radial approach offers a safer
alternative to femoral access in selected patients.
Our study has several limitations. One limitation is the
fact that this study is a post-hoc analysis on a prospectively
compiled database. Another limitation is the use of differ-
ent surgical techniques in this study. Additionally, our study
has a relatively low prevalence of diabetes (13%) and
follow-up time is low (30 days). Furthermore, the popula-
tion constitutes a selective group of patients who could not
undergo percutaneous repair of the pseudoaneurysms and
were therefore relegated to surgery. In spite of these
limitations, our findings, which were obtained in a large
number of consecutive, unselected patients, provide suffi-
cient support for our conclusions.
The technical procedure of cardiac catheterization by
femoral route takes time, in accordance with a learning
curve to attain a pre-defined level of proficiency w15, 16x.
The finding of a maximum incidence of pseudoaneurysms
postcatheterization in the summer vacation period, urges
thoughtful search of possible justifications. A possible rea-
son for this finding is the fact that it is a specialized
multidisciplinary technique. Previous to the puncture,
norms of asepsis and antisepsis are required to maintain to
prevent infection; especially when devices for percutane-
ous suture are implanted. Post-procedurally, an adequate
compression as well as of the patient are important factors.
In our opinion, these multiple factors that affect the
integrity of the femoral vessels after a catheterization
exist, making this procedure a multidisciplinary technique
with a steep learning curve. Periodic review of these
complications may help identify additional factors that can
be modified to reduce them.
In conclusion, female gender, increasing age and antico-
agulant or antiplatelet therapy, have an adverse influence
on the 30-day morbidity and complications of patients
submitted to surgical repair of femoral pseudoaneurysms
after cardiac catheterization. Additional studies will be
needed to expand the existing literature and thus improve
the perioperative management of the affected population.
References
w1x Skillman JJ, Kim D, Baim DS. Vascular complications of percutaneous
femoral cardiac interventions. Arch Surg 1988;123:1207–1212.
w2x Coley BD, Roberts AC, Fellmeth BD, Valji K, Bookstein JJ, Hye RJ.
Postangiographic femoral artery pseudoaneurysms: further experience
with US guided compression repair. Radiology 1995;194:307–311.
w3x Krueger K, Zaehringer M, Store D, Stuetzer H, Boecker J, Lackner K.
Postcatheterization pseudoaneurysm: results of US-guided percutaneous
thrombin injection in 240 patients. Radiology 2005;236:1104–1110.
w4x Kobeiter H, Lapeyre M, Becquemin JP, Mathieu D, Melliere D, Desgranges
P. Percutaneous coil embolization of postcatheterization arterial fem-
oral pseudoaneurysms. J Vasc Surg 2002;36:127–131.
w5x Oweida SW, Roubin GS, Smith RB 3rd, Salam AA. Poscatheterization
vascular complications associated with percutaneous transluminal cor-
onary angioplasty. J Vasc Surg 1990;12:310–315.
357
w6x Kresowik TF, Khoury MD, Miller BV, Winniford MD, Shamma AR, Sharp
WJ, Blecha MB, Corson JD. A prospective study of the incidence and
natural history of femoral vascular complications after percutaneous
transluminal coronary angioplasty. J Vasc Surg 1991;13:328–333.
w7x Lumsden AB, Miller JM, Kosinski AS, Allen RC, Dodson TF, Salam AA,
Smith RB 3rd. A prospective evaluation of surgically treated groin
complications following percutaneous cardiac procedures. Am Surg
1994;60:132–137.
w8x Carere RG, Webb JG, Ahmed T, Dodek AA. Initial experience using
Prostar: a new device for percutaneous suture-mediated closure of
arterial puncture sites. Cathet Cardiovasc Diagn 1996;37:367–372.
w9x Franco CD, Goldsmith J, Veith FJ, Calligaro KD, Gupta SK, Wengerter
KR. Management of arterial injuries produced by percutaneous femoral
procedures. Surgery 1993;113:419–425.
w10x Messina LM, Brothers TE, Wakefield TW, Zelenock GB, Lindenauer SM,
Greenfield LJ, Jacobs LA, Fellows EP, Grube SV, Stanley JC. Clinical
characteristics and surgical management of vascular complications in
Downloaded from https://academic.oup.com/icvts/article/8/3/353/703393 by guest on 03 July 2024
patients undergoing cardiac catheterization: interventional versus diag-
nostic procedures. J Vasc Surg 1991;13:593–600.
w11x Morgan R, Belli AM. Current treatment methods for postcatheterization
pseudoaneurysms. J Vasc Interv Radiol 2003;14:697–710.
w12x Khoury M, Rebecca A, Greene K, Rama K, Colaiuta E, Flynn L, Berg R.
Duplex scanning-guided thrombin injection for the treatment of iatro-
genic pseudoaneurysms. J Vasc Surg 2002;35:517–521.
w13x Ricci MA, Trevisani GT, Pilcher DB. Vascular complications of cardiac
catheterization. Am J Surg 1994;167:375–378.
w14x Wixon CL. Hemodynamics. In: Hallett JW Jr, Mills JL, Earnshaw JJ,
Reekers JA. Comprehensive vascular and endovascular surgery. Edin-
burgh: Mosby, 2004;9–15.
w15x Wyman RM, Safian RD, Portway V, Skillman JJ, McKay RG, Baim DS.
Current complications of diagnostic and therapeutic cardiac catheteri-
zation. J Am Coll Cardiol 1988;12:1400–1406.
w16x Schaub F, Theiss W, Busch R, Heinz M, Paschalidis M, Schömig A.
Management of 219 consecutive cases of postcatheterization pseudo-
aneurysm. J Am Coll Cardiol 1997;30:670–675.
eComment: Follow-up for femoral pseudoaneurysms
Author: Narcis Hudorovic, Department for Cardiovascular Surgery, Uni-
versity Hospital Sestre Milosrdnice, Zagreb, Croatia
doi:10.1510/icvts.2008.188623A
I really appreciate the fascinating article by San Noberto Garcia and co-
workers w1x.
The authors stated that there is a maximum incidence of femoral pseudo-
aneurysms post cardiac catheterization in the summer vacation period, and
that this finding urges thoughtful search of possible justifications.
When we started to investigate satisfaction between cardiovascular surg-
eons and co-operating cardiologists in order to define the most frequent
postcatheterization complications needing surgical repair in the aim to
implement a quality management system according to EN ISO 9001:2000 w2x
at the University Clinic Cardiovascular Department (UCCD) in 2004 w3x, 1410
follow-up consultations of postcatheterization patients took place over a
one-year period. Our findings revealed that middle grade cardiologists dealt
with 58% of the catheterizations while young specialists performed 33% of
the catheterizations. When we analyzed the workload split (young specialist
– middle grade professor), it was evident that the postcatheterization
femoral pseudo-aneurysms predominantly persisted after the procedure had
been performed by young specialists.
It was notable that 96% of the catheterization procedures during the
summer period at UCCD were performed by young specialists without direct
supervision of middle grade specialists. Moreover, in 55 patients (4%) post-
procedural investigative procedures (DSA, CT or MR angiography) reported
the presence of postcatheterization aneurysmal formation in the femoral
region. In all 55 patients the catheterization were performed in the summer
period by young specialists.
Our study has highlighted that follow-up protocols after cardiac catheter-
ization need to introduce ‘specific staff data’ (date of birth, years of
experience, etc.) of investigators who performed cardiac catheterization.
Protocols, as an aid to limiting follow-up after cardiac catheterization do
exist, yet implementation appears to be only partly effective. Informed
education of staff and young specialists at ward level might be one way of
improving these figures: staff needs to be made aware of catheterization
procedure complications and given clear guidelines as to which postproce-
dural data might require special attention.
 ARTICLE IN PRESS
358 E.M. San Norberto Garcı́a et al. / Interactive CardioVascular and Thoracic Surgery 8 (2009) 353–358
By implementing postprocedural follow-up protocols which include the so-
called ‘specific staff data’ (referral source, workload split), the cardiovas-
cular community could find out the reasons why the incidence of femoral
postcatheterization aneurysms is highest in the summer period.
References
w1x San Noberto Garcia EM, Gonzalez-Fajardo JA, Gutierez V, Carrera S,
Vaquero C. Femoral pseudoaneurysms post cardiac catheterization
surgically treated: evolution and prognosis. Interact CardioVasc Thorac
Surg 2009;8:353–358.
w2x Beholz S, Konertz W. Improvement in cost-effectiveness and customer
satisfaction by a quality management system according to EN ISO
001:2000. Interact CardioVasc Thorac Surg 2005;4:569–573.
w3x Hudorovic N. Reduction in hospitalisation rates following simultaneous
carotid endarterectomy and coronary artery bypass grafting; experi-
ence from a single centre. Interact CardioVasc Thorac Surg 2006;5:367–
372.
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