**Day Case Management of Varicose Veins**

Jesus Barandiaran, Thomas Hall, Naif El-Barghouti and Eugene Perry

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/51935

#### **1. Introduction**

72 Vascular Surgery – Principles and Practice

perspectives. Vascular. 2012 Feb;20(1):12-9.

[Randomized Controlled Trial]. 2007 Feb-Mar;41(1):27-32.

[45] Lauret GJ, van Dalen DC, Willigendael EM, Hendriks EJ, de Bie RA, Spronk S, et al. Supervised exercise therapy for intermittent claudication: current status and future

[46] Badger SA, Soong CV, O'Donnell ME, Boreham CA, McGuigan KE. Benefits of a supervised exercise program after lower limb bypass surgery. Vasc Endovascular Surg.

> Lower limb varicose veins are a common disease that affects almost a quarter of the adult population. They are one of the commonest conditions requiring intervention. They affect women more frequently than men, and are reported in 20-60% of the general population. Approximately one million people in the United Kingdom are affected with VV. Nearly half a million seek advice from their primary care practitioner about VV in the lower limbs and their related symptoms every year. Of those, 75,000 patients receive some form of intervention. It is estimated that surgical treatment of varicose veins are responsible for 54000 hospital episodes per year in England. They constitute a large part of elective surgical waiting lists [1, 2 and 3].

> The treatment of primary varicose veins is considered appropriate by the majority of vascular surgeons if the veins are symptomatic. Common symptoms include poor cosmesis, aching and itching. Less common problems are haemorrhage, thrombophlebitis, ankle pigmentation, lipodermosclerosis and ulceration. The extent of visible veins does not correlate with the severity of the symptoms experienced by patients [4].

> Treatment options available for varicose veins traditionally included either conservative management with lifestyle advice and compression hosiery or surgery. Surgery involves saphenofemoral junction disconnection and stripping of the long saphenous vein and multiple stab avulsions for varicose veins stemming from saphenofemoral reflux; saphenopopliteal disconnection for saphenopopliteal reflux [2].

> Results from traditional surgery are excellent and have stood the test of time. However, there has been an expansion of less invasive treatment modalities for VV, such as radiofrequency ablation, endovenous laser treatment, sclerotherapy (liquid and foam), transilluminated powered phlebectomy, and subfascial endoscopic perforator vein surgery. These minimally invasive therapies are attractive to both patients and healthcare professionals but there is paucity of good quality data from randomized control trials [5].

#### 74 Vascular Surgery – Principles and Practice

Moreover, the need for specialized equipment and additional training to become proficient at new techniques, prevent surgeons from practicing these procedures.

Day Case Management of Varicose Veins 75


4. Patients with Varicose veins of the Short Saphenous System distribution


and Emergency and Vascular facilities

Exclusion criteria included

2. Age below 18 years

5. Recurrent Varicose Veins

3. Allergy to Local Anaesthetic Agents

6. Patients with complex varicosities

7. Previous history of Deep Vein Thromboembolis 8. Areas of active ulceration (CEAP Classification C6)

**2.1. Veins and questionnaire assessment** 

measured using a cartographer's wheel (Figure 1)

measurement was done by a single assessor.

asymptomatic presentation

1. Pregnancy

questionnaires: **1. CEAP score** 

**Mark DEFINITION**



Suitable patients were seen preoperatively in the Outpatient Clinic. All the visible varicose veins were marked with a permanent ink pen. After that, the length of varicosities was

The outer ring of the cartographer's ring measures the length of varicosities in centimetres and gives us an accurate measurement of the extension of the Varicose Veins. This

A higher measurement on the wheel cartograph meant a greater volume of varicose veins.

Every patient taking part in the trial was asked to fill up four standardized health

**C** Clinical signs (grade 0-6) supplemented by (s) for symptomatic and (a) for

E Ethiological Classification (Congenital, Primary, Secondary)

**Table 1.** Classification of chronic lower extremity venous disease. CEAP score

A Anatomical Distribution (Superficial, Deep, Perforator)

P Pathophysiology Dysfunction (Reflux, Obstruction)

In the United Kingdom, until there is long-term follow-up with the less invasive procedures, the gold standard for VV surgery is still a standard saphenofemoral junction ligation and disconnection (SFJLD) with stripping of the long saphenous vein and multiple stab avulsions. As stripping of the long saphenous vein is painful, this surgery requires a general anaesthetic and an overnight in-patient stay for satisfactory recovery.

We propose a new approach to addressing problems with VV in the lower limb that obviates the need for a general anaesthesia. After SFJLD, the varicosities in the long saphenous system are rarely fed retrogradely unless there are incompetent perforators thus, varicosities in the lower limb would be expected to diminish in size and length. If the long saphenous vein is left in situ without stripping and stab avulsions are not done at the time of groin exploration for SFJLD, VV surgery can be done safely under local anaesthetic. Currently, we perform multiple stab avulsions (under local anaesthetic) as a second-stage procedure at 6 months post-SFJLD.

The purpose of this study was twofold. The first aim was to study the longitudinal functional and cosmetic outcome in a consecutive series of patients who had SFJLD under local anaesthetic. Our second aim was to identify the optimum time gap from SFJLD to multiple stab avulsions for residual VV.

## **2. Methods**

A prospective observational study was designed by the Scarborough General Hospital Vascular team. It was carried out between June 2006 and June 2008.

The patients were recruited in two different out patient clinics, including Scarborough General Hospital Outpatient department and Malton County Hospital Outpatient Department. Both clinics were supervised by a single Consultant Vascular Surgeon.

A very specific inclusion criteria was devised to select the patients to be included in this study:

	- Patients had a BMI less than 35
	- Patients had transport arranged to go back home as they were not allowed to drive themselves

Exclusion criteria included

1. Pregnancy

74 Vascular Surgery – Principles and Practice

procedure at 6 months post-SFJLD.

multiple stab avulsions for residual VV.

**2. Methods** 

study:

Varicose Veins.

themselves

distribution.

Moreover, the need for specialized equipment and additional training to become proficient

In the United Kingdom, until there is long-term follow-up with the less invasive procedures, the gold standard for VV surgery is still a standard saphenofemoral junction ligation and disconnection (SFJLD) with stripping of the long saphenous vein and multiple stab avulsions. As stripping of the long saphenous vein is painful, this surgery requires a general

We propose a new approach to addressing problems with VV in the lower limb that obviates the need for a general anaesthesia. After SFJLD, the varicosities in the long saphenous system are rarely fed retrogradely unless there are incompetent perforators thus, varicosities in the lower limb would be expected to diminish in size and length. If the long saphenous vein is left in situ without stripping and stab avulsions are not done at the time of groin exploration for SFJLD, VV surgery can be done safely under local anaesthetic. Currently, we perform multiple stab avulsions (under local anaesthetic) as a second-stage

The purpose of this study was twofold. The first aim was to study the longitudinal functional and cosmetic outcome in a consecutive series of patients who had SFJLD under local anaesthetic. Our second aim was to identify the optimum time gap from SFJLD to

A prospective observational study was designed by the Scarborough General Hospital

The patients were recruited in two different out patient clinics, including Scarborough General Hospital Outpatient department and Malton County Hospital Outpatient

A very specific inclusion criteria was devised to select the patients to be included in this

1. Patients met the National Institute of Clinical Excelence guidelines for treatment of

2. Patients with clinical evidence of Primary varicose veins of the Long Saphenous Vein

3. All patients had clinical and ultrasonographic evidence of incompetence at the Saphenofemoral junction. This was demonstrated using, either a Hand Held Doppler


4. All patients were suitable for Local Anaesthetic Surgery in a day case setting

Department. Both clinics were supervised by a single Consultant Vascular Surgeon.

at new techniques, prevent surgeons from practicing these procedures.

anaesthetic and an overnight in-patient stay for satisfactory recovery.

Vascular team. It was carried out between June 2006 and June 2008.

Machine or a Venous Duplex Ultrasound Scan.



#### **2.1. Veins and questionnaire assessment**

Suitable patients were seen preoperatively in the Outpatient Clinic. All the visible varicose veins were marked with a permanent ink pen. After that, the length of varicosities was measured using a cartographer's wheel (Figure 1)

The outer ring of the cartographer's ring measures the length of varicosities in centimetres and gives us an accurate measurement of the extension of the Varicose Veins. This measurement was done by a single assessor.

A higher measurement on the wheel cartograph meant a greater volume of varicose veins.

Every patient taking part in the trial was asked to fill up four standardized health questionnaires:

#### **1. CEAP score**


**Table 1.** Classification of chronic lower extremity venous disease. CEAP score

#### 76 Vascular Surgery – Principles and Practice

Day Case Management of Varicose Veins 77

**3. Aberdeen varicose vein severity score** 

association with your varicose veins?

work/housework or other daily activities?

1. In general, would you say your health is:

q Much better now than a year ago

activities(including sport,hobbies and social life)?

ache?

tights?

**4. SF36** 

SF-36 1

q Excellent q Very good q Good q Fair q Poor

**SF-36 Health survey** 

varicose veins?

1. Please draw in your varicose veins in the diagram below: Vein grid

4. In the last two weeks, how much ankle swelling have you had? 5. In the last two weeks, have you worn support stockings or tights?

8. Do you have a rash or eczema in the area of your ankle? 9. Do you have a skin ulcer associated with your varicose veins? 10. Does the appearance of your varicose veins cause you concern?

2. In the last two weeks, for how many days did your varicose veins cause you pain or

3. during the last two weeks, on how many days did you take painkilling tablets for your

6. In the last two weeks, have you had any itching in association with yourvaricose veins? 7. Do you have purple discolouration caused by tiny blood vessels in the skin, in

11. Does the appearance of your varicose veins influence your choice of clothing including

12. During the last two weeks, have your varicose veins interfered with your

13. During the last two weeks, have your varicose veins interfered with your leisure

Instructions for completing the questionnaire: Please answer every question. Some questions may look like others, but each one is different. Please take the time to read and answer each question carefully by filling in the bubble that best represents your response.

Patient Name: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

2. Compared to one year ago, how would you rate your health in general now?

SSN#: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Date: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Person heling to complete this form: \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

#### **Figure 1.**


**Table 2.** CEAP Clinical classification of chronic lower extremity venous disease

#### **2. Venous clinical severity score**


#### **3. Aberdeen varicose vein severity score**


#### **4. SF36**

76 Vascular Surgery – Principles and Practice

**Figure 1.**

**Class Cinical signs**

2 Varicose Veins

**2. Venous clinical severity score** 

3 Oedema without skin changes

lipodermatosclerosis)

0 No visible or palpable signs of venous disease 1 Telangiectases, reticular veins, malleolar flare

5 Skin changes in conjunction with healed ulceration 6 Skin changes in conjunction with active ulceration

**Table 2.** CEAP Clinical classification of chronic lower extremity venous disease

<sup>4</sup>Skin changes ascribed to venous disease (pigmentation,venous eczema,

**Attribute Absent = 0 Mild = 1 Moderate = 2 Severe = 3**  Pain None Occasional Daily Limit activities Varicose veins None Few, scattered Multiple (LSV) Extensive (LSV, SSV)

Venous Oedema None Evening, Ankle Afternoon, leg Morning, leg Pigmentation None Limited area Wide (lower 1/3) Wider (Above 1/3)

Size of AC None <2 cm diameter 2-6 cm diameter >6 cm diameter Comp therapy Not used Intermittent use Most days Continually

Inflamation None Cellulitis Cellulitis Cellulitis Induration None Focal (<5 cm) <lower 1/3 Entire lower 1/3

Number of AC None 1 2 3 Duration of AC None <3 months 3 months- 1 year >1 year SF-36 1

#### **SF-36 Health survey**

Instructions for completing the questionnaire: Please answer every question. Some questions may look like others, but each one is different. Please take the time to read and answer each question carefully by filling in the bubble that best represents your response.


1. In general, would you say your health is:

q Excellent q Very good

q Good

q Fair

q Poor

2. Compared to one year ago, how would you rate your health in general now?

q Much better now than a year ago

q Somewhat better now than a year ago

q About the same as one year ago

q Somewhat worse now than one year ago

q Much worse now than one year ago

3. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

Day Case Management of Varicose Veins 79

i. Walking one block. q Yes, limited a lot. q Yes, limited a little. q No, not limited at all.

q Yes, limited a lot. q Yes, limited a little. q No, not limited at all.

c Yes c No

c Yes c No

c Yes c No

c Yes c No

c Yes c No

c Yes c No

c Yes c No

q Not at all q Slightly q Moderately q Quite a bit q Extremely

q Not at all q Slightly q Moderately q Quite a bit

depressed or anxious)?

j. Bathing or dressing yourself.

b. Accomplished less than you would like?

b. Accomplished less than you would like

c. Didn't do work or other activities as carefully as usual

7. How much bodily pain have you had during the past 4 weeks?

c. Were limited in the kind of work or other activities

4. During the past 4 weeks, have you had any of the following problems with your work or

d. Had difficulty performing the work or other activities (for example, it took extra time)

5. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling

6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?

other regular daily activities as a result of your physical health?

a. Cut down the amount of time you spent on work or other activities?

a. Cut down the amount of time you spent on work or other activities?

a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.

q Yes, limited a lot.

q Yes, limited a little.

q No, not limited at all.

b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?

q Yes, limited a lot.

q Yes, limited a little.

q No, not limited at all.

c. Lifting or carrying groceries.

q Yes, limited a lot.

q Yes, limited a little.

q No, not limited at all.

d. Climbing several flights of stairs.

q Yes, limited a lot.

q Yes, limited a little.

q No, not limited at all.

e. Climbing one flight of stairs.

q Yes, limited a lot.

q Yes, limited a little.

q No, not limited at all.

f. Bending, kneeling or stooping.

q Yes, limited a lot.

q Yes, limited a little.

q No, not limited at all.

#### SF-36 2

g. Walking more than one mile. q Yes, limited a lot. q Yes, limited a little. q No, not limited at all. h. Walking several blocks. q Yes, limited a lot. q Yes, limited a little.

q No, not limited at all.

i. Walking one block.

q Yes, limited a lot.

78 Vascular Surgery – Principles and Practice

sports.

q Yes, limited a lot. q Yes, limited a little. q No, not limited at all.

q Yes, limited a lot. q Yes, limited a little. q No, not limited at all.

q Yes, limited a lot. q Yes, limited a little. q No, not limited at all.

q Yes, limited a lot. q Yes, limited a little. q No, not limited at all.

q Yes, limited a lot. q Yes, limited a little. q No, not limited at all.

q Yes, limited a lot. q Yes, limited a little. q No, not limited at all. h. Walking several blocks.

q Yes, limited a lot. q Yes, limited a little. q No, not limited at all.

SF-36 2

c. Lifting or carrying groceries.

d. Climbing several flights of stairs.

e. Climbing one flight of stairs.

f. Bending, kneeling or stooping.

g. Walking more than one mile.

playing golf? q Yes, limited a lot. q Yes, limited a little. q No, not limited at all.

q Somewhat better now than a year ago q About the same as one year ago

q Somewhat worse now than one year ago q Much worse now than one year ago

health now limit you in these activities? If so, how much?

3. The following items are about activities you might do during a typical day. Does your

a. Vigorous activities, such as running, lifting heavy objects, participating in strenuous

b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or


4. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

a. Cut down the amount of time you spent on work or other activities?

c Yes c No

b. Accomplished less than you would like?

c Yes c No

c. Were limited in the kind of work or other activities

c Yes c No

d. Had difficulty performing the work or other activities (for example, it took extra time) c Yes c No

5. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

a. Cut down the amount of time you spent on work or other activities?

c Yes c No

b. Accomplished less than you would like

c Yes c No

c. Didn't do work or other activities as carefully as usual

c Yes c No

6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?

q Not at all q Slightly q Moderately q Quite a bit q Extremely

7. How much bodily pain have you had during the past 4 weeks?

q Not at all q Slightly q Moderately q Quite a bit

q Extremely

SF-36 3

8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

Day Case Management of Varicose Veins 81

e. did you have a lot of energy?

f. have you felt downhearted and blue?

q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time

q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time

g. did you feel worn out?

h. have you been a happy person?

10. During the past 4 weeks, how much of the time has your physical health or emotional

problems interfered with your social activities (like visiting friends, relatives, etc.)?

q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time

q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time i. did you feel tired? q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time

q All of the time q Most of the time q Some of the time

SF-36 4

q Not at all q Slightly q Moderately q Quite a bit q Extremely

9. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks.

a. did you feel full of pep? q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time b. have you been a very nervous person? q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time c. have you felt so down in the dumps nothing could cheer you up? q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time d. have you felt calm and peaceful? q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time

e. did you have a lot of energy? q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time f. have you felt downhearted and blue? q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time

#### SF-36 4

80 Vascular Surgery – Principles and Practice

a. did you feel full of pep?

b. have you been a very nervous person?

d. have you felt calm and peaceful?

q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time

q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time

q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time

q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time

both work outside the home and housework)?

8. During the past 4 weeks, how much did pain interfere with your normal work (including

9. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way

you have been feeling. How much of the time during the past 4 weeks.

c. have you felt so down in the dumps nothing could cheer you up?

q Extremely

q Not at all q Slightly q Moderately q Quite a bit q Extremely

SF-36 3

g. did you feel worn out? q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time h. have you been a happy person? q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time i. did you feel tired? q All of the time q Most of the time q A good bit of the time q Some of the time q A little of the time q None of the time

10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?

q All of the time q Most of the time q Some of the time q A little of the time q None of the time 11. How TRUE or FALSE is each of the following statements for you? a. I seem to get sick a little easier than other people q Definitely true q Mostly true q Don't know q Mostly false q Definitely false b. I am as healthy as anybody I know q Definitely true q Mostly true q Don't know q Mostly false q Definitely false c. I expect my health to get worse q Definitely true q Mostly true q Don't know q Mostly false q Definitely false d. My health is excellent q Definitely true q Mostly true q Don't know q Mostly false q Definitely false

The clinical component from CEAP scores ranges from 0 to 6; Higher scores denote greater severity.

Day Case Management of Varicose Veins 83

populations, comparing the relative burden of diseases, and in differentiating the health

Patients were prepared with non alcoholic povidone-iodine and drapped with sterile

1% Lignocaine with Adrenaline was used to anaesthesize the groin and perform a Ilioinguinal nerve block, according with the guidelines of Local Anaesthetic use [11] (Figure 2)

The incision in the groin is placed medial to the Femoral pulse and 1 centimetre above the

The dissection begins with the identification of the Long Saphenous Vein and the Sapheno-Femoral junction where the Long Saphenous Vein joins the Deep Femoral Vein. All

benefits produced by a wide range of different treatments.

The procedure was carried out by, or supervised by, a single consultant.

**3. Operative details** 

disposable materials.

**Figure 2.**

inguinal crease.

The VCSS consist of clinical variables, each ranging from 0(none) to 3 (severe). Thus, the VCSS ranged form 0 to 30; Higher scores denote greater severity of varicose veins.

The AVVSS assessment consisted of 13 clinical variables and the completion of a vein grid. Each question was given a weighted score. For each limb, the AVVSS produced a score ranging from 0 to 50; Higher scores meant greater severity of Varicose Veins.

The SF-36 is a multi-purpose, short-form health survey with only 36 questions. It yields an 8 scale profile of functional health and well-being scores as well as psychometrically-based physical and mental health summary measures and a preference-based health utility index. It is a generic measure, as opposed to one that targets a specific age, disease, or treatment group. Accordingly, the SF-36 has proven useful in surveys of general and specific populations, comparing the relative burden of diseases, and in differentiating the health benefits produced by a wide range of different treatments.

#### **3. Operative details**

82 Vascular Surgery – Principles and Practice

11. How TRUE or FALSE is each of the following statements for you?

The clinical component from CEAP scores ranges from 0 to 6; Higher scores denote greater

The VCSS consist of clinical variables, each ranging from 0(none) to 3 (severe). Thus, the

The AVVSS assessment consisted of 13 clinical variables and the completion of a vein grid. Each question was given a weighted score. For each limb, the AVVSS produced a score

The SF-36 is a multi-purpose, short-form health survey with only 36 questions. It yields an 8 scale profile of functional health and well-being scores as well as psychometrically-based physical and mental health summary measures and a preference-based health utility index. It is a generic measure, as opposed to one that targets a specific age, disease, or treatment group. Accordingly, the SF-36 has proven useful in surveys of general and specific

VCSS ranged form 0 to 30; Higher scores denote greater severity of varicose veins.

ranging from 0 to 50; Higher scores meant greater severity of Varicose Veins.

a. I seem to get sick a little easier than other people

b. I am as healthy as anybody I know

c. I expect my health to get worse

q A little of the time q None of the time

q Definitely true q Mostly true q Don't know q Mostly false q Definitely false

q Definitely true q Mostly true q Don't know q Mostly false q Definitely false

q Definitely true q Mostly true q Don't know q Mostly false q Definitely false

q Definitely true q Mostly true q Don't know q Mostly false q Definitely false

severity.

d. My health is excellent

The procedure was carried out by, or supervised by, a single consultant.

Patients were prepared with non alcoholic povidone-iodine and drapped with sterile disposable materials.

1% Lignocaine with Adrenaline was used to anaesthesize the groin and perform a Ilioinguinal nerve block, according with the guidelines of Local Anaesthetic use [11] (Figure 2)

#### **Figure 2.**

The incision in the groin is placed medial to the Femoral pulse and 1 centimetre above the inguinal crease.

The dissection begins with the identification of the Long Saphenous Vein and the Sapheno-Femoral junction where the Long Saphenous Vein joins the Deep Femoral Vein. All tributaries of the Long Saphenous Vein are tied with 3.0 Vicryl sutures (Ethicon Inc Somerville, NJ). Smaller tributaries are dealt with Bipolar Diathermy. The proximal end of the Long Saphenous Vein is suture-ligated with 1.0 Vicryl and disconnected 0.5 cm flush from the Deep Femoral Vein.

Day Case Management of Varicose Veins 85

The results from the aforementioned analysis suggest that improvement in both the extent and severity of VV can occur to a maximum of 6 months after SFJLD under local anaesthetic. The second-stage procedure of multiple stab avulsions can therefore be performed to a

maximum of 6 months after the index procedure without clinical deterioration.

**Figure 3.** Follow-up of burden of varicose veins after surgery.

**Figure 4.** Follow-up of Clinical Etiology Anatomy Pathology scores after surgery.

Fascial layers are closed with interrupted 2.0 Vicryl sutures and the skin approximated with 2.0 Monocryl sutures (Ethicon Inc., Somerville, NJ).

Patients go back to the Day Unit where they are observed for 2 hours after their proedure and discharged from the Unit provided there are not complications.

## **3.1. Follow up**

All patients who had Sapheno-Femoral junction Ligation and Disconnection(SFJLD) under Local Anaesthetic were reviewed in the Outpatient Department at 1,3 and 6 months postoperatively. At each of this times, the veins were examined clinically, marked and measured with the cartographer's wheel and the four questionnaires were repeated.

After a final assessment post- SFJLD, patients are listed for Multiple Stab Avulsions under Local Anaesthetic.

A three month Outpatient Department appointment is given to every patient for futher clinical assessment. In addition, all patients were contacted at the end of the study to assess the recurrence of Varicose Veins.

#### **3.2. Statistics**

The data collected were found to be parametric. The repeated measures analysis of variance test was used to compare continuous variables within the same groups of patients. Means and 95% confidence intervals were calculated for all variables. A *p* value of <0.05 was deemed significant

#### **3.3. Results**

There were 48 patients (15 men; mean age: 54 years; 95% CI: 29-79). Mean follow-up period after surgery was 43 (95% CI: 38-48) months. In all, 30 (91%) patients had immediate cosmetic and symptomatic improvement after surgery.

On follow-up, the volume of VV reduced significantly over the three postoperative time points when compared with preoperatively (112 [95% CI: 88-136] vs. 75 [95% CI: 55-97] vs. 65 [95% CI: 43-87] vs. 58 [95% CI: 31-86], *p* = 0.001) (Fig. 3).

Using the CEAP (Fig. 4), VCSS (Fig. 5), and AVVSS (Fig. 6) questionnaires, severity of VV improved postoperatively when compared with preoperatively (*p* = 0.001 for all three). Likewise, using the SF-36 questionnaire, significant improvements in quality of life were noted postoperatively (Fig. 7) (*p* = 0.032).

The results from the aforementioned analysis suggest that improvement in both the extent and severity of VV can occur to a maximum of 6 months after SFJLD under local anaesthetic. The second-stage procedure of multiple stab avulsions can therefore be performed to a maximum of 6 months after the index procedure without clinical deterioration.

**Figure 3.** Follow-up of burden of varicose veins after surgery.

84 Vascular Surgery – Principles and Practice

from the Deep Femoral Vein.

**3.1. Follow up** 

Local Anaesthetic.

**3.2. Statistics** 

deemed significant

**3.3. Results** 

the recurrence of Varicose Veins.

cosmetic and symptomatic improvement after surgery.

65 [95% CI: 43-87] vs. 58 [95% CI: 31-86], *p* = 0.001) (Fig. 3).

noted postoperatively (Fig. 7) (*p* = 0.032).

2.0 Monocryl sutures (Ethicon Inc., Somerville, NJ).

and discharged from the Unit provided there are not complications.

tributaries of the Long Saphenous Vein are tied with 3.0 Vicryl sutures (Ethicon Inc Somerville, NJ). Smaller tributaries are dealt with Bipolar Diathermy. The proximal end of the Long Saphenous Vein is suture-ligated with 1.0 Vicryl and disconnected 0.5 cm flush

Fascial layers are closed with interrupted 2.0 Vicryl sutures and the skin approximated with

Patients go back to the Day Unit where they are observed for 2 hours after their proedure

All patients who had Sapheno-Femoral junction Ligation and Disconnection(SFJLD) under Local Anaesthetic were reviewed in the Outpatient Department at 1,3 and 6 months postoperatively. At each of this times, the veins were examined clinically, marked and

After a final assessment post- SFJLD, patients are listed for Multiple Stab Avulsions under

A three month Outpatient Department appointment is given to every patient for futher clinical assessment. In addition, all patients were contacted at the end of the study to assess

The data collected were found to be parametric. The repeated measures analysis of variance test was used to compare continuous variables within the same groups of patients. Means and 95% confidence intervals were calculated for all variables. A *p* value of <0.05 was

There were 48 patients (15 men; mean age: 54 years; 95% CI: 29-79). Mean follow-up period after surgery was 43 (95% CI: 38-48) months. In all, 30 (91%) patients had immediate

On follow-up, the volume of VV reduced significantly over the three postoperative time points when compared with preoperatively (112 [95% CI: 88-136] vs. 75 [95% CI: 55-97] vs.

Using the CEAP (Fig. 4), VCSS (Fig. 5), and AVVSS (Fig. 6) questionnaires, severity of VV improved postoperatively when compared with preoperatively (*p* = 0.001 for all three). Likewise, using the SF-36 questionnaire, significant improvements in quality of life were

measured with the cartographer's wheel and the four questionnaires were repeated.

**Figure 4.** Follow-up of Clinical Etiology Anatomy Pathology scores after surgery.

Day Case Management of Varicose Veins 87

On maximum follow-up, six (13%) patients had recurrent VV. Of these, two patients opted for redo surgery. This consisted of re-exploration of the groin and stripping of the long

The results from present study suggest that SFJLD under local anaesthetic confers symptomatic and cosmetic improvement 1 month after the procedure. Improvements are sustained on early follow-up, thereby allowing multiple stab avulsions to be performed as a

Currently, there is an increasing demand and need for VV surgery. Despite this demand, waiting lists are increasingly "controlled" and the funding is "regulated" by primary care trusts because VV are deemed to be a cosmetic disease without any life-threatening consequences. Ligation of the great saphenous vein at the SFJ, with or without stripping, is a long described method of VV surgery with varying successes [12, 13, 14]. We believe that SFJLD under a local anaesthetic, is a feasible procedure for VV disease, particularly for those with early disease. There are several advantages. Our method does not require a general anaesthetic and the procedure can be done as a day case without an in-patient stay. As such, surgery for VV can be done in peripheral cottage hospitals where specialized equipment and support from anaesthetic colleagues may be unavailable. The shift of work to peripheral hospitals reduces the demand and pressure on waiting list in larger central hospitals where

The results obtained from the various VV questionnaires were reassuring. The procedure used in the present study resulted in significant cosmetic and functional improvement on

saphenous veins under a general anaesthetic.

**Figure 7.** Follow-up of Short Form 36 scores after surgery.

staged procedure within 6 months of the index procedure.

general anaesthetic lists are being done.

**4. Discussion** 

**Figure 5.** Follow-up of Venous Clinical Severity Scores after surgery.

**Figure 6.** Follow-up of Aberdeen Varicose Vein Severity Scores after surgery.

On maximum follow-up, six (13%) patients had recurrent VV. Of these, two patients opted for redo surgery. This consisted of re-exploration of the groin and stripping of the long saphenous veins under a general anaesthetic.

**Figure 7.** Follow-up of Short Form 36 scores after surgery.

#### **4. Discussion**

86 Vascular Surgery – Principles and Practice

**Figure 5.** Follow-up of Venous Clinical Severity Scores after surgery.

**Figure 6.** Follow-up of Aberdeen Varicose Vein Severity Scores after surgery.

The results from present study suggest that SFJLD under local anaesthetic confers symptomatic and cosmetic improvement 1 month after the procedure. Improvements are sustained on early follow-up, thereby allowing multiple stab avulsions to be performed as a staged procedure within 6 months of the index procedure.

Currently, there is an increasing demand and need for VV surgery. Despite this demand, waiting lists are increasingly "controlled" and the funding is "regulated" by primary care trusts because VV are deemed to be a cosmetic disease without any life-threatening consequences. Ligation of the great saphenous vein at the SFJ, with or without stripping, is a long described method of VV surgery with varying successes [12, 13, 14]. We believe that SFJLD under a local anaesthetic, is a feasible procedure for VV disease, particularly for those with early disease. There are several advantages. Our method does not require a general anaesthetic and the procedure can be done as a day case without an in-patient stay. As such, surgery for VV can be done in peripheral cottage hospitals where specialized equipment and support from anaesthetic colleagues may be unavailable. The shift of work to peripheral hospitals reduces the demand and pressure on waiting list in larger central hospitals where general anaesthetic lists are being done.

The results obtained from the various VV questionnaires were reassuring. The procedure used in the present study resulted in significant cosmetic and functional improvement on short-term follow-up. We saw significant improvements with all three VV-specific questionnaires (CEAP, VCSS, and AVVSS questionnaire). Although the AVVSS questionnaire was initially designed to assess severity of varicosities in both lower limbs, we were still able to use it for unilateral assessment. The assessment was performed unilaterally in our series of patients because the total volume of local anaesthetic that was used for the procedure was often the limiting factor in surgery. Results from the SF-36 questionnaire have to be interpreted with caution. We noted significant improvements in quality of life up to 6 months postoperatively. The SF-36 is a global quality of life questionnaire, which may not be sensitive enough to detect improvements in quality of life as a direct consequence of VV surgery. However, to date, we are unaware of a more specific quality of life questionnaire, which has been designed for patients who underwent VV surgery.

Day Case Management of Varicose Veins 89

SFJLD under local anaesthetic is a suitable procedure with early VV. Patients who undergo this procedure show improvement in cosmesis and function. However, on short-term follow-up, it appears to be associated with higher rates of recurrent VV when compared

[1] Rigby K A, Palfreyman S S J, Beverley C, Michaels J A. Surgery versus sclerotherapy for the treatment of varicose veins. Cochrane database reviews 2004, Issue 4. Art No.:

[2] Wolf B, Brittenden J. Surgical treatment of varicose veins. JR Coll Sur Edin. 2001; 46:

[4] Bradbury A, Evans C, Allan P et all. What are the symptoms of varicose veins? Edinburgh vein study cross sectional population survey. BMJ. 1999; 6: 318-356 [5] Badri H., Bhattacharya V. A review of current treatment strategies for varicose veins.

[7] Classification and grading of chronic venous disease in the lower limbs. A consensus statement. Ad Hoc Committee, American Venous Forum. *J Cardiovasc Surg (Torino)*.

[8] Rutherford RB, Padberg FT, Comerota AJ, Kistner RL, Meissner MH, Moneta GL. Venous severity scoring: an adjunct to venous outcome assessments. J Vasc Surg.

[9] Garratt AM, Macdonald LM, Ruta DA, Russell IT, Buckingham JK, Krukowski ZH. Towards measurements of outcomes for patients with varicose veins. Qual Health Care.

[10] Ware JE, Kosinski M, Dewey JE. How to score version two of the SF-36 Health Survey.

[12] Sarin S, Scurr JH, Coleridge Smith PD. Stripping of the long saphenous vein in the

[13] Rutgers PH, Kitslaar PJ. Randomized trial of stripping versus high ligation combined with sclerotherapy in the treatment of the incompetent greater saphenous vein. *Am J* 

treatment of primary varicose veins. *Br J Surg*. 1994;81:1455–1458

[3] Callam M J. Epidemiology of varicose veins Br. J. Surg. 1994; 81: 168-173

Jesus Barandiaran, Thomas Hall, Naif El-Barghouti and Eugene Perry

*Department of Surgery, Scarborough General Hospital, UK* 

CD004980.DOI: 10.1002/14651.CD004980.

[6] Available at: www.NICE.org.uk/guidelines.

Recent Pat Cardiovasc Drug Disco. 2008; 3: 126-136

Lincoln, RI: Quality Metric Incorporated; 2000; [11] British National Formulary. Available at: http://bnf.org/.

**5. Conclusion** 

**Author details** 

**6. References** 

154-158

1997;38:437–441

2000;31:1307–1312

*Surg*. 1994;168:311–315

1993;2:5–10

with conventional techniques.

There were several limitations to our study. First, the size of our patient population was small. We have been selective in the recruitment of patients for this study. Patients in our study had simple VV with minimal chronic venous changes; thus, they were patients who had early VV. We did not perform Duplex studies in any patients preoperatively. Certainly, the rates of early recurrent VV in our study are higher than conventional studies and this may be secondary to our failure to perform Duplex studies. This would have identified the anatomy of the long saphenous veins and potential perforators associated with it.

To further validate the study it may have been useful to have pre- and postoperative formal Duplex studies for comparison and to help explain disease recurrence. The reported rate of clinical recurrence ranges from 20 to 80% after a period between 5 and 20 years [15]. The average time between the first and the second surgical treatments is long ranging, from 6 to 20 years [16, 17].

As long-term data are lacking in our series, our recurrence rate of 13% at maximum 3 years follow-up may underestimate total disease recurrence. At 2 years follow-up, a recurrence rate of 16% was demonstrated by clinical and Duplex evaluation in a study by Coufinhal [18]

The rate of disease recurrence increases with time, probably because of progression of the disease. Kostas et al identified three main causes of disease recurrence [19]. The first was attributable to inadequate initial treatment and results in recurrence in 55-70% of cases. It arises either as a result of failure in identifying all incompetent veins or a failure in carrying out adequate primary treatment. The second group of causes arises from disease progression resulting in development of varices in previously normal veins and accounting for 20-25% of recurrences. The third cause of recurrence is neovascularization, in which varices arise in the track of previously stripped or ligated veins and account for 5-25% of recurrences. Dissection of the tributary vessels at the SFJ may contribute to our early rates of recurrence. Taking vessels back beyond the primary, or even the secondary tributaries, may be a cause of neovascularization in the groin. Duplex ultrasound surveillance has supported this finding [20].

#### **5. Conclusion**

88 Vascular Surgery – Principles and Practice

underwent VV surgery.

20 years [16, 17].

this finding [20].

[18]

short-term follow-up. We saw significant improvements with all three VV-specific questionnaires (CEAP, VCSS, and AVVSS questionnaire). Although the AVVSS questionnaire was initially designed to assess severity of varicosities in both lower limbs, we were still able to use it for unilateral assessment. The assessment was performed unilaterally in our series of patients because the total volume of local anaesthetic that was used for the procedure was often the limiting factor in surgery. Results from the SF-36 questionnaire have to be interpreted with caution. We noted significant improvements in quality of life up to 6 months postoperatively. The SF-36 is a global quality of life questionnaire, which may not be sensitive enough to detect improvements in quality of life as a direct consequence of VV surgery. However, to date, we are unaware of a more specific quality of life questionnaire, which has been designed for patients who

There were several limitations to our study. First, the size of our patient population was small. We have been selective in the recruitment of patients for this study. Patients in our study had simple VV with minimal chronic venous changes; thus, they were patients who had early VV. We did not perform Duplex studies in any patients preoperatively. Certainly, the rates of early recurrent VV in our study are higher than conventional studies and this may be secondary to our failure to perform Duplex studies. This would have identified the

To further validate the study it may have been useful to have pre- and postoperative formal Duplex studies for comparison and to help explain disease recurrence. The reported rate of clinical recurrence ranges from 20 to 80% after a period between 5 and 20 years [15]. The average time between the first and the second surgical treatments is long ranging, from 6 to

As long-term data are lacking in our series, our recurrence rate of 13% at maximum 3 years follow-up may underestimate total disease recurrence. At 2 years follow-up, a recurrence rate of 16% was demonstrated by clinical and Duplex evaluation in a study by Coufinhal

The rate of disease recurrence increases with time, probably because of progression of the disease. Kostas et al identified three main causes of disease recurrence [19]. The first was attributable to inadequate initial treatment and results in recurrence in 55-70% of cases. It arises either as a result of failure in identifying all incompetent veins or a failure in carrying out adequate primary treatment. The second group of causes arises from disease progression resulting in development of varices in previously normal veins and accounting for 20-25% of recurrences. The third cause of recurrence is neovascularization, in which varices arise in the track of previously stripped or ligated veins and account for 5-25% of recurrences. Dissection of the tributary vessels at the SFJ may contribute to our early rates of recurrence. Taking vessels back beyond the primary, or even the secondary tributaries, may be a cause of neovascularization in the groin. Duplex ultrasound surveillance has supported

anatomy of the long saphenous veins and potential perforators associated with it.

SFJLD under local anaesthetic is a suitable procedure with early VV. Patients who undergo this procedure show improvement in cosmesis and function. However, on short-term follow-up, it appears to be associated with higher rates of recurrent VV when compared with conventional techniques.

#### **Author details**

Jesus Barandiaran, Thomas Hall, Naif El-Barghouti and Eugene Perry *Department of Surgery, Scarborough General Hospital, UK* 

#### **6. References**

	- [14] Hammarsten J, Pederson P, Cederlund CG, Campanello M. Long saphenous vein saving surgery for varicose veins: a long-term follow-up. *Eur J Vasc Surg*. 1990;4:361–364

**Chapter 6** 

© 2012 Lee et al., licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

© 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution,

**Iatrogenic Pseudoaneurysms** 

Additional information is available at the end of the chapter

from dilation of all layers of the arterial wall.

**2. Femoral iatrogenic pseudoaneurysms** 

include obesity and the need for anticoagulation post-procedure.[2]

http://dx.doi.org/10.5772/51494

iatrogenic pseudoaneurysms.

**2.1. General considerations** 

**1. Introduction** 

Charles P.E. Milne, Regent Lee and Ashok I. Handa

A pseudoaneurysm refers to a defect in an arterial wall, which allows communication of arterial blood with the adjacent extra-luminal space. Blood extravasates out of the artery, but is contained by surrounding soft tissue and compressed thrombus which form a cavity or sac.[1] There is often a narrow tract stemming from the arterial wall to the pseudoaneurysm sac, termed the 'neck'. A pseudoaneurysm is distinct from a 'true' aneurysm, which results

Pseudoaneurysms are typically the result of traumatic arterial injury. With the increasing utilisation of percutaneous arterial interventions worldwide, iatrogenic arterial injury has become the predominant cause of pseudoaneurysm formation. The highest incidence of iatrogenic pseudoaneurysm formation is observed in the common femoral artery as a result of inadequate seal of the arterial puncture site following catheterisation procedures. It is reported that femoral pseudoaneurysms occur in up to 0.2% of diagnostic and 8% of interventional procedures.[2) Approach to the management of a pseudoaneurysm depends on its anatomical location. This chapter will focus primarily on the management of iatrogenic femoral pseudoaneurysms, with an overview of other peripheral and visceral

Factors which may increase the risk of iatrogenic femoral pseudoaneurysm formation after femoral catheterisation can be broadly categorised into procedural or patient factors. 'Procedural' factors include low femoral puncture, inadvertent catheterisation of the superficial femoral artery or profunda femoris artery, interventional rather than diagnostic procedures, and inadequate compression following removal of the sheath. 'Patient' factors

and reproduction in any medium, provided the original work is properly cited.


## **Iatrogenic Pseudoaneurysms**

Charles P.E. Milne, Regent Lee and Ashok I. Handa

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/51494

## **1. Introduction**

90 Vascular Surgery – Principles and Practice

UK: Bitterworths; 1989;p. 220–233

[14] Hammarsten J, Pederson P, Cederlund CG, Campanello M. Long saphenous vein saving surgery for varicose veins: a long-term follow-up. *Eur J Vasc Surg*. 1990;4:361–364 [15] Eklof B, Juhan C. Recurrences of primary varicose veins. In: Eklof B, Gores E, Thulesius O, Berqvist O editor. Controversies in the Management of Venous Disorders. London,

[16] Darke S. The morphology of recurrent varicose veins. *Eur J Vasc Surg*. 1992;6:512–517 [17] Kostas T, Ioannou CV, Touloupakis E, Dastalaki E, Giannoukas AD, Tsetis D, et al. Recurrent varicose veins after surgery: a new appraisal of a common and complex

[18] Coufinhal JC. Récidive de varices après chirurgie: definition, épidémiologie, physiopathologie. In: Kieffer B, Bahnini A editor. Chirurgie des Veines des Members

[19] Kostas T, Ioannou CV, Touloupakis E, Dastalaki E, Giannoukas AD, Tsetis D, et al. Recurrent varicose veins after surgery: a new appraisal of a common and complex

[20] Van Rij AM, Jiang P, Solomon C, Christie RA, Hill GB. Recurrence after varicose vein surgery: a prospective long-term clinical study with duplex ultrasound scanning and

problem in vascular surgery. *Eur J Vasc Endovasc Surg*. 2004;27:275–282

problem in vascular surgery. *Eur J Vasc Endovasc Surg*. 2004;27:275–282

Infe`rieurs. Paris, France: AERCV; 1996;p. 227–238

air plethysmography. *J Vasc Surg*. 2003;38:935–943

A pseudoaneurysm refers to a defect in an arterial wall, which allows communication of arterial blood with the adjacent extra-luminal space. Blood extravasates out of the artery, but is contained by surrounding soft tissue and compressed thrombus which form a cavity or sac.[1] There is often a narrow tract stemming from the arterial wall to the pseudoaneurysm sac, termed the 'neck'. A pseudoaneurysm is distinct from a 'true' aneurysm, which results from dilation of all layers of the arterial wall.

Pseudoaneurysms are typically the result of traumatic arterial injury. With the increasing utilisation of percutaneous arterial interventions worldwide, iatrogenic arterial injury has become the predominant cause of pseudoaneurysm formation. The highest incidence of iatrogenic pseudoaneurysm formation is observed in the common femoral artery as a result of inadequate seal of the arterial puncture site following catheterisation procedures. It is reported that femoral pseudoaneurysms occur in up to 0.2% of diagnostic and 8% of interventional procedures.[2) Approach to the management of a pseudoaneurysm depends on its anatomical location. This chapter will focus primarily on the management of iatrogenic femoral pseudoaneurysms, with an overview of other peripheral and visceral iatrogenic pseudoaneurysms.

#### **2. Femoral iatrogenic pseudoaneurysms**

#### **2.1. General considerations**

Factors which may increase the risk of iatrogenic femoral pseudoaneurysm formation after femoral catheterisation can be broadly categorised into procedural or patient factors. 'Procedural' factors include low femoral puncture, inadvertent catheterisation of the superficial femoral artery or profunda femoris artery, interventional rather than diagnostic procedures, and inadequate compression following removal of the sheath. 'Patient' factors include obesity and the need for anticoagulation post-procedure.[2]

© 2012 Lee et al., licensee InTech. This is an open access chapter distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2012 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Patients with femoral pseudoaneurysms typically present with pain and swelling of the affected groin, along with a palpable mass which may be pulsatile with a thrill or bruit.[1] Clinical diagnosis can usually be made in slim patients, but can be difficult in those who are obese, where a high index of suspicion is required to prompt further investigation. Small pseudoaneurysms may resolve spontaneously without intervention. Pseudoaneurysms which persist may enlarge and lead to complications related to compression of the adjacent femoral vein, nerve, and overlying skin. This can lead to leg swelling, deep vein thrombosis, compressive neuropathy and skin necrosis. Although rare, pseudoaneurysms may also expand and eventually rupture.[3]

Iatrogenic Pseudoaneurysms 93

surrounding structures. Problems with the technique include availability, time duration and cost. In patients with allergies to iodinated contrast, MRA is a potential alternative imaging technique.[1] Gadolinium-based agents are also associated with the rare complication of nephrogenic systemic fibrosis in patients with impaired renal function which should be

A proportion of iatrogenic femoral pseudoaneurysms will resolve spontaneously without any form of intervention. An accepted approach is to monitor small (less than 3cm), stable, asymptomatic pseudoaneurysms, as the majority of them will thrombose within 4 weeks.[7] In one large series of small (<3cm) pseudoaneurysms, Toursarkissian *et al* reported a rate of spontaneous thrombosis of ~90% at 60 days of follow-up.[7] However, the need for regular follow-up resulting in possible delayed discharge from the hospital, and difficulty in patients reducing their activity while awaiting pseudoaneurysm resolution, has led to the early active management of most pseudoaneurysms.[2] An exception may be for very small (<1cm), stable, asymptomatic pseudoaneurysms, which could be managed conservatively with repeat imaging at one week after diagnosis to see if spontaneous thrombosis has occurred. In addition, spontaneous thrombosis of the pseudoaneurysm may be less likely in patients who are fully anticoagulated or receiving combination antiplatelet therapy, where

Traditionally, most iatrogenic femoral pseudoaneurysms requiring intervention were treated with open surgical repair. With the increasing availability of DUS during the 1990s, less invasive treatment options using DUS-guidance gained popularity. These methods included ultrasound-guided compression (UGC) and percutaneous ultrasound-guided

Open surgical repair (OSR) has traditionally been considered the 'gold standard' treatment for iatrogenic femoral pseudoaneurysms, as the arterial defect is repaired definitively. Principle steps of OSR involve obtaining proximal and distal control of the affected artery, evacuating the aneurysm sac and repairing the defect in the arterial wall (either by primary or patch closure).[10] Complications of OSR include blood loss and infection. Other major adverse events such as myocardial infarction or death are recognised. In high cardiac risk patients, OSR may be performed under local or regional anaesthesia. Recovery time and

The advent of less invasive treatment strategies utilising ultrasound (discussed later), have led to a paradigm shift in treatment strategies. OSR is now typically reserved for emergency situations such as rapidly expanding pseudoaneurysms, ruptured pseudoaneurysms, pseudoaneurysms causing mass effect (with overlying skin ischaemia or neurovascular compromise), or when other treatment options have failed.[11] Infective complication of iatrogenic femoral pseudoaneurysms are less common but represent a distinct entity which require open surgical treatment over other interventional techniques and will be considered

considered as a relative contra-indication.[6]

**2.3. Approach to management** 

active management is preferred.

thrombin injection (UGTI). [8,9]

later in this chapter.

inpatient stay may be prolonged following OSR.

#### **2.2. Diagnosis**

Duplex ultrasonography (DUS) is the modality of choice for diagnosis of femoral pseudoaneurysms, particularly in centres with a dedicated vascular ultrasound laboratory.[4] DUS has been reported to have a sensitivity of 94% and a specificity of 97% in the detection femoral pseudoaneurysms.[5] Compared to other imaging techniques, DUS is safe and non-invasive. It can also be performed at the bedside. Clear views of the femoral vessels and associated pathology can be achieved rapidly in experienced hands. Another advantage of DUS is that definitive treatment (discussed later) can be performed in the same session.

On DUS, a pseudoaneurysm appears as a hypoechoic sac adjacent to the affected artery, with colour flow observed within it. Thrombus may be identified within part of the sac. The hallmark of diagnosis is the demonstration of a neck communicating between the sac and the affected artery, with a 'to-and-fro' waveform.[1] The 'to' representing blood flow into the pseudoaneurysm and the 'fro' representing blood flow out of the pseudoaneurysm. Waveform analysis of the affected artery is useful to establish a baseline for subsequent comparison. The adjacent vein should be inspected for compression or the presence of thrombus.

Computed Tomography Angiography (CTA) is another effective diagnostic modality, particularly in centres without ready access to vascular ultrasound services. It is also useful in cases where duplex ultrasound findings are equivocal or the anatomy is not well defined.[2] CTA allows accurate assessment of the pseudoaneurysm, its surrounding structures, arterial inflow and distal run-off to the leg. Drawbacks of CTA include radiation exposure (of particular concern in younger patients) and use of iodinated contrast agents (with risk of anaphylaxis and nephropathy).[6] Use of contrast is important to establish that active flow is present within the pseudoaneurysm cavity, which would be otherwise indistinguishable from a haematoma. Patients with mild renal impairment can be prehydrated before a CTA to minimise the risk of nephropathy. In those with moderate to severe renal impairment, alternative imaging should be considered.[6]

Magnetic Resonance Angiography (MRA) has emerged as an alternative to CTA in recent years. Gadolinium-enhanced MRA allows 3D visualisation of the pseudoaneurysm and surrounding structures. Problems with the technique include availability, time duration and cost. In patients with allergies to iodinated contrast, MRA is a potential alternative imaging technique.[1] Gadolinium-based agents are also associated with the rare complication of nephrogenic systemic fibrosis in patients with impaired renal function which should be considered as a relative contra-indication.[6]

#### **2.3. Approach to management**

92 Vascular Surgery – Principles and Practice

expand and eventually rupture.[3]

**2.2. Diagnosis** 

session.

thrombus.

Patients with femoral pseudoaneurysms typically present with pain and swelling of the affected groin, along with a palpable mass which may be pulsatile with a thrill or bruit.[1] Clinical diagnosis can usually be made in slim patients, but can be difficult in those who are obese, where a high index of suspicion is required to prompt further investigation. Small pseudoaneurysms may resolve spontaneously without intervention. Pseudoaneurysms which persist may enlarge and lead to complications related to compression of the adjacent femoral vein, nerve, and overlying skin. This can lead to leg swelling, deep vein thrombosis, compressive neuropathy and skin necrosis. Although rare, pseudoaneurysms may also

Duplex ultrasonography (DUS) is the modality of choice for diagnosis of femoral pseudoaneurysms, particularly in centres with a dedicated vascular ultrasound laboratory.[4] DUS has been reported to have a sensitivity of 94% and a specificity of 97% in the detection femoral pseudoaneurysms.[5] Compared to other imaging techniques, DUS is safe and non-invasive. It can also be performed at the bedside. Clear views of the femoral vessels and associated pathology can be achieved rapidly in experienced hands. Another advantage of DUS is that definitive treatment (discussed later) can be performed in the same

On DUS, a pseudoaneurysm appears as a hypoechoic sac adjacent to the affected artery, with colour flow observed within it. Thrombus may be identified within part of the sac. The hallmark of diagnosis is the demonstration of a neck communicating between the sac and the affected artery, with a 'to-and-fro' waveform.[1] The 'to' representing blood flow into the pseudoaneurysm and the 'fro' representing blood flow out of the pseudoaneurysm. Waveform analysis of the affected artery is useful to establish a baseline for subsequent comparison. The adjacent vein should be inspected for compression or the presence of

Computed Tomography Angiography (CTA) is another effective diagnostic modality, particularly in centres without ready access to vascular ultrasound services. It is also useful in cases where duplex ultrasound findings are equivocal or the anatomy is not well defined.[2] CTA allows accurate assessment of the pseudoaneurysm, its surrounding structures, arterial inflow and distal run-off to the leg. Drawbacks of CTA include radiation exposure (of particular concern in younger patients) and use of iodinated contrast agents (with risk of anaphylaxis and nephropathy).[6] Use of contrast is important to establish that active flow is present within the pseudoaneurysm cavity, which would be otherwise indistinguishable from a haematoma. Patients with mild renal impairment can be prehydrated before a CTA to minimise the risk of nephropathy. In those with moderate to

Magnetic Resonance Angiography (MRA) has emerged as an alternative to CTA in recent years. Gadolinium-enhanced MRA allows 3D visualisation of the pseudoaneurysm and

severe renal impairment, alternative imaging should be considered.[6]

A proportion of iatrogenic femoral pseudoaneurysms will resolve spontaneously without any form of intervention. An accepted approach is to monitor small (less than 3cm), stable, asymptomatic pseudoaneurysms, as the majority of them will thrombose within 4 weeks.[7] In one large series of small (<3cm) pseudoaneurysms, Toursarkissian *et al* reported a rate of spontaneous thrombosis of ~90% at 60 days of follow-up.[7] However, the need for regular follow-up resulting in possible delayed discharge from the hospital, and difficulty in patients reducing their activity while awaiting pseudoaneurysm resolution, has led to the early active management of most pseudoaneurysms.[2] An exception may be for very small (<1cm), stable, asymptomatic pseudoaneurysms, which could be managed conservatively with repeat imaging at one week after diagnosis to see if spontaneous thrombosis has occurred. In addition, spontaneous thrombosis of the pseudoaneurysm may be less likely in patients who are fully anticoagulated or receiving combination antiplatelet therapy, where active management is preferred.

Traditionally, most iatrogenic femoral pseudoaneurysms requiring intervention were treated with open surgical repair. With the increasing availability of DUS during the 1990s, less invasive treatment options using DUS-guidance gained popularity. These methods included ultrasound-guided compression (UGC) and percutaneous ultrasound-guided thrombin injection (UGTI). [8,9]

Open surgical repair (OSR) has traditionally been considered the 'gold standard' treatment for iatrogenic femoral pseudoaneurysms, as the arterial defect is repaired definitively. Principle steps of OSR involve obtaining proximal and distal control of the affected artery, evacuating the aneurysm sac and repairing the defect in the arterial wall (either by primary or patch closure).[10] Complications of OSR include blood loss and infection. Other major adverse events such as myocardial infarction or death are recognised. In high cardiac risk patients, OSR may be performed under local or regional anaesthesia. Recovery time and inpatient stay may be prolonged following OSR.

The advent of less invasive treatment strategies utilising ultrasound (discussed later), have led to a paradigm shift in treatment strategies. OSR is now typically reserved for emergency situations such as rapidly expanding pseudoaneurysms, ruptured pseudoaneurysms, pseudoaneurysms causing mass effect (with overlying skin ischaemia or neurovascular compromise), or when other treatment options have failed.[11] Infective complication of iatrogenic femoral pseudoaneurysms are less common but represent a distinct entity which require open surgical treatment over other interventional techniques and will be considered later in this chapter.

#### 94 Vascular Surgery – Principles and Practice

#### *2.3.1. Ultrasound-Guided Compression*

Ultrasound-Guided Compression (UGC) of pseudoaneurysms to induce thrombosis of the aneurysm sac was proposed as an alternative to surgery by Fellmeth et al in 1991.[8] Principles of UGC involve locating the aneurysm sac using the ultrasound transducer and applying enough pressure to stop flow within the sac, but maintain flow in the affected artery.[5] Flow within the sac is reassessed at 10 - 20 minute intervals until thrombosis is achieved.[1] Unfortunately, efficacy of this technique is limited, with success rates between 62% - 86%.[1,2] Compression times can also be lengthy. This occupies vascular ultrasound laboratory resources and can be uncomfortable for both the patient and clinician.[9] Other problems include incompressible pseudoaneurysms, limited success in patients being treated with anticoagulants & some early recurrences.[9] Despite this, before other minimally invasive treatment options were available, Perkins et al reported that UGC reduced the need for open surgery by about 50%, avoiding the associated risks of surgery in these patients.[9]

Iatrogenic Pseudoaneurysms 95

by a vascular surgeon (or senior surgical fellow), together with a specialist vascular ultrasonographer. The patient is placed in the supine position. The ultrasonographer uses Bmode and colour flow imaging to define the pseudoaneurysm. As a baseline, pre-procedure imaging of adjacent major vessels (e.g. common femoral artery and vein) is performed. 500 IU of lyophilised human thrombin is dissolved in 1ml calcium chloride solution. This is

A safe angle of approach to the aneurysm sac is confirmed by the ultrasonographer and vascular surgeon. The area of skin puncture is prepared with chlorhexidine solution. The ultrasonographer provides a constant good view of the pseudoaneurysm using B-mode imaging while the needle is advanced slowly into the pseudoaneurysm cavity. The needle tip is positioned away from the neck of the pseudoaneurysm, but within a flowing component of the sac. Appropriate positioning within the sac is confirmed by the ultrasonographer using multiple views. Once the ultrasonographer and vascular surgeon are satisfied with the needle position, thrombin injection is performed. On occasions, the needle tip may be difficult to identify on ultrasound and a 20 gauge spinal needle is used to

Thrombin injection is then performed slowly under constant colour flow imaging to observe thrombosis of the aneurysm sac. When colour flow within the cavity stops completely, injection is ceased. It is uncommon for us to require more than **0.25ml** of thrombin solution to achieve thrombosis, even for relatively large pseudoaneurysms. Another way of ensuring controlled injection of thrombin is to administer small (e.g. 0.125ml) aliquots of solution at a

All patients are followed up at one week with repeat duplex ultrasound. Further injections may be undertaken at this stage if deemed appropriate. We advise caution and

Infected femoral pseudoaneurysms are more commonly seen in the intravenous drug using (IVDU) population, arising from repeated non-sterile needle groin punctures as part of the pursuit of easy peripheral venous access. However, it may also complicate iatrogenic pseudoaneurysms. Clinical presentation mirrors that for non-infected femoral pseudoaneurysms, with the added serious complication of infection. The 'aneurysmal abscess' carries with it a significant risk of sepsis, rupture, limb loss and death.[15] Diagnosis can be made by DUS, but direct DUS imaging can be challenging due to inflammation and even gas. CTA avoids these problems, and can give an appreciation of the

Primary repair is not recommended as appropriate surgical management by some authors because the ongoing infection and destruction of the arterial wall usually results in secondary haemorrhage and infection.[15] Ligation and excision of the infected artery and pseudoaneurysm, with aggressive debridement of surrounding infected tissue is the

consideration of alternative treatment if more than two injections are required.

drawn into a 2ml syringe and a 22 gauge spinal needle is attached.

time whilst assessing colour flow within the aneurysm sac.

**2.5. Infected femoral pseudoaneurysms** 

extent of inflammation/infection.

improve visualisation.

#### *2.3.2. Ultrasound-Guided Thrombin Injection*

Ultrasound-Guided Thrombin Injection (UGTI) of pseudoaneurysms is a technique first described by Kang *et al* in 1998.[12] The technique involves needle infiltration of the aneurysm sac using ultrasound guidance and injection of thrombin to induce thrombosis of the cavity. Previously published studies have documented rates of thrombosis between 86 - 100% (the majority successful on the first attempt).[2] The procedure has the advantage of being relatively quick and simple. The most serious complication of UGTI is distal arterial embolisation, which is a relatively rare outcome (less than 2% in reported series). If this occurs, intra-arterial thrombolysis may be undertaken.[13]

At the Oxford University Hospitals, UGTI has been used as first-line therapy for the treatment of iatrogenic femoral pseudoaneurysms. Between August 2005 and July 2011, 94 patients underwent UGTI for treatment of iatrogenic pseudoaneurysms. Patients were included in a prospective registry and underwent follow up DUS examination to assess treatment efficacy. 97% of pseudoaneurysms suitable for UGTI were successfully treated by this technique, avoiding the risks associated with surgical repair. 91.1% of treatments were successful on the first attempt, and no significant complications were recorded.

In our experience, we have found UGTI to be a simple, quick and safe technique for the treatment of suitable pseudoaneurysms. For small pseudoaneurysms (<1cm), a repeat DUS was performed one week later to see if spontaneous thrombosis had occurred. Pseudoaneurysms with a neck width >1cm were not treated by this method, as wide necks may be related to higher risk of thromboembolic complications.[14] Given the availability of DUS in most major vascular surgery units, UGTI should be the treatment of choice for all suitable iatrogenic pseudoaneurysms.

#### **2.4. Technique of UGTI**

Our unit has adapted the original technique for UGTI described by Kang *et al* for the treatment of suitable femoral iatrogenic pseudoaneurysms.[12] Each procedure is performed by a vascular surgeon (or senior surgical fellow), together with a specialist vascular ultrasonographer. The patient is placed in the supine position. The ultrasonographer uses Bmode and colour flow imaging to define the pseudoaneurysm. As a baseline, pre-procedure imaging of adjacent major vessels (e.g. common femoral artery and vein) is performed. 500 IU of lyophilised human thrombin is dissolved in 1ml calcium chloride solution. This is drawn into a 2ml syringe and a 22 gauge spinal needle is attached.

A safe angle of approach to the aneurysm sac is confirmed by the ultrasonographer and vascular surgeon. The area of skin puncture is prepared with chlorhexidine solution. The ultrasonographer provides a constant good view of the pseudoaneurysm using B-mode imaging while the needle is advanced slowly into the pseudoaneurysm cavity. The needle tip is positioned away from the neck of the pseudoaneurysm, but within a flowing component of the sac. Appropriate positioning within the sac is confirmed by the ultrasonographer using multiple views. Once the ultrasonographer and vascular surgeon are satisfied with the needle position, thrombin injection is performed. On occasions, the needle tip may be difficult to identify on ultrasound and a 20 gauge spinal needle is used to improve visualisation.

Thrombin injection is then performed slowly under constant colour flow imaging to observe thrombosis of the aneurysm sac. When colour flow within the cavity stops completely, injection is ceased. It is uncommon for us to require more than **0.25ml** of thrombin solution to achieve thrombosis, even for relatively large pseudoaneurysms. Another way of ensuring controlled injection of thrombin is to administer small (e.g. 0.125ml) aliquots of solution at a time whilst assessing colour flow within the aneurysm sac.

All patients are followed up at one week with repeat duplex ultrasound. Further injections may be undertaken at this stage if deemed appropriate. We advise caution and consideration of alternative treatment if more than two injections are required.

#### **2.5. Infected femoral pseudoaneurysms**

94 Vascular Surgery – Principles and Practice

*2.3.1. Ultrasound-Guided Compression* 

*2.3.2. Ultrasound-Guided Thrombin Injection* 

suitable iatrogenic pseudoaneurysms.

**2.4. Technique of UGTI** 

occurs, intra-arterial thrombolysis may be undertaken.[13]

Ultrasound-Guided Compression (UGC) of pseudoaneurysms to induce thrombosis of the aneurysm sac was proposed as an alternative to surgery by Fellmeth et al in 1991.[8] Principles of UGC involve locating the aneurysm sac using the ultrasound transducer and applying enough pressure to stop flow within the sac, but maintain flow in the affected artery.[5] Flow within the sac is reassessed at 10 - 20 minute intervals until thrombosis is achieved.[1] Unfortunately, efficacy of this technique is limited, with success rates between 62% - 86%.[1,2] Compression times can also be lengthy. This occupies vascular ultrasound laboratory resources and can be uncomfortable for both the patient and clinician.[9] Other problems include incompressible pseudoaneurysms, limited success in patients being treated with anticoagulants & some early recurrences.[9] Despite this, before other minimally invasive treatment options were available, Perkins et al reported that UGC reduced the need for open

surgery by about 50%, avoiding the associated risks of surgery in these patients.[9]

Ultrasound-Guided Thrombin Injection (UGTI) of pseudoaneurysms is a technique first described by Kang *et al* in 1998.[12] The technique involves needle infiltration of the aneurysm sac using ultrasound guidance and injection of thrombin to induce thrombosis of the cavity. Previously published studies have documented rates of thrombosis between 86 - 100% (the majority successful on the first attempt).[2] The procedure has the advantage of being relatively quick and simple. The most serious complication of UGTI is distal arterial embolisation, which is a relatively rare outcome (less than 2% in reported series). If this

At the Oxford University Hospitals, UGTI has been used as first-line therapy for the treatment of iatrogenic femoral pseudoaneurysms. Between August 2005 and July 2011, 94 patients underwent UGTI for treatment of iatrogenic pseudoaneurysms. Patients were included in a prospective registry and underwent follow up DUS examination to assess treatment efficacy. 97% of pseudoaneurysms suitable for UGTI were successfully treated by this technique, avoiding the risks associated with surgical repair. 91.1% of treatments were

In our experience, we have found UGTI to be a simple, quick and safe technique for the treatment of suitable pseudoaneurysms. For small pseudoaneurysms (<1cm), a repeat DUS was performed one week later to see if spontaneous thrombosis had occurred. Pseudoaneurysms with a neck width >1cm were not treated by this method, as wide necks may be related to higher risk of thromboembolic complications.[14] Given the availability of DUS in most major vascular surgery units, UGTI should be the treatment of choice for all

Our unit has adapted the original technique for UGTI described by Kang *et al* for the treatment of suitable femoral iatrogenic pseudoaneurysms.[12] Each procedure is performed

successful on the first attempt, and no significant complications were recorded.

Infected femoral pseudoaneurysms are more commonly seen in the intravenous drug using (IVDU) population, arising from repeated non-sterile needle groin punctures as part of the pursuit of easy peripheral venous access. However, it may also complicate iatrogenic pseudoaneurysms. Clinical presentation mirrors that for non-infected femoral pseudoaneurysms, with the added serious complication of infection. The 'aneurysmal abscess' carries with it a significant risk of sepsis, rupture, limb loss and death.[15] Diagnosis can be made by DUS, but direct DUS imaging can be challenging due to inflammation and even gas. CTA avoids these problems, and can give an appreciation of the extent of inflammation/infection.

Primary repair is not recommended as appropriate surgical management by some authors because the ongoing infection and destruction of the arterial wall usually results in secondary haemorrhage and infection.[15] Ligation and excision of the infected artery and pseudoaneurysm, with aggressive debridement of surrounding infected tissue is the

#### 96 Vascular Surgery – Principles and Practice

preferred approach. There is debate among vascular surgeons regarding whether a bypass procedure is required during the same operation.[15]

Iatrogenic Pseudoaneurysms 97

iatrogenic pseudoaneurysms, most peripheral iatrogenic pseudoaneurysms occur following catheterisation of the affected artery. Clinical features will vary depending on the location and size of the pseudoaneurysm. Symptoms and signs will relate to the pseudoaneurysm itself and its effects on neighbouring structures. For example, brachial pseudoaneurysms often cause pain and swelling in the cubital fossa, along with a palpable mass. The mass may be pulsatile with a thrill or bruit. Compression of the adjacent brachial veins or median nerve can occur, as well as ischaemic compromise of the overlying skin. Arm swelling, deep vein thrombosis, compressive neuropathy, skin necrosis and rupture are also potential complications. Similarly, DUS is the modality of choice for diagnosis of other peripheral pseudoaneurysms, particularly in centres with a dedicated vascular ultrasound laboratory. CTA is best relied on in centres without ready access to vascular ultrasound services, in cases where duplex ultrasound findings are equivocal or the anatomy is not well defined. The options available for management of peripheral pseudoaneurysms are the same as for femoral pseudoaneurysms. Given easy percutaneous access to the peripheries, UGTI should be the treatment of choice for all suitable iatrogenic peripheral pseudoaneurysms. Published series have reported successful outcomes of UGTI with pseudoaneurysms involving the femoral, popliteal, tibial, axillary, brachial and radial arteries.[16] Radial artery iatrogenic pseudoaneurysms following arterial line insertion in critical care settings can be better treated with radial artery ligation if there is clinically good perfusion via the ipsilateral ulnar

Carotid artery pseudoaneurysms are a rare subset of pseudoaneurysms. Carotid aneurysms make up less than 1% of all carotid pathologies, and of these, roughly 1 in 3 are pseudoaneurysms.[13] In modern practice, the more common causes include inadvertent catherisation during attempted internal jugular vein central line placement, trauma (blunt or penetrating), and pseudoaneurysm formation in the anastomotic suture line following carotid endarterectomy. Local infection (e.g. TB, syphilis) causing pseudoaneurysm

A pulsatile neck mass is the most common clinical presentation, followed by neurological symptoms such as TIA, stroke and Horner's syndrome.[13] Diagnosis can again be made by duplex ultrasound, however, with the possibility of endovascular intervention, CTA is best to define aortic arch anatomy and suitability for endovascular repair. The potential severe sequelae of carotid pseudoaneurysms mandates surgical intervention. Given small numbers, only case series data is available for different types of carotid aneurysm repair, with only a small subset of these comprising pseudoaneurysms. Open surgical intervention includes resection and patch angioplasty, resection and interposition grafting, and ligation.[13] The latter should be considered a last resort. Surgical reconstruction of all types of carotid

aneurysm is associated with a combined stroke and mortality rate of about 10%.[17]

Endovascular interventions include covered stent grafts, bare stenting with trans-stent coiling, autogenous vein covered stents, and endovascular balloon occlusions.[13] Outcome data is limited to case series, but the data is promising. In a large single-centre series

artery.

formation is rarely seen these days.

**Figure 1.** Panel A- DUS of femoral pseudoaneurysm demonstrating "to and fro" flow (yellow arrow) between the native artery and the pseudoaneurysm via the neck. There is colour signal in the pseudoaneurysm (white arrow) representing active blood flow. Panel B: Thrombosed pseudoaneurysm following UGTI. The pseudoanerusym sac now contains newly formed thrombus (blue arrow). Note the residual blood flow within the pseudoaneurysm neck after thrombosis of the pseudoaneurysm sac.

In our experience, ligation and excision of the infected artery and pseudoaneurysm, with aggressive debridement of surrounding infected tissue is well tolerated overall. This also avoids extended procedure times and potential complications associated with infection of bypass grafts. A recent review publication by Georgiadis et al showed an early occurrence of rest pain in 10.8% of patients and early risk of amputation in 5.7% of patients. Triple ligation (for pseudoaneurysms occurring at the common femoral bifurcation) likely results in worse outcomes for patients than single ligation.[15] In these patients, we advocate close monitoring of the affected limb in the immediate post-operative period and consideration for immediate extra-anatomical bypass if signs of limb-threatening ischemia develop.

#### **2.6. Other peripheral iatrogenic pseudoaneurysms**

In addition to femoral pseudoaneurysms, the most common sites for iatrogenic pseudoaneurysm formation are the brachial artery and popliteal artery. As with femoral iatrogenic pseudoaneurysms, most peripheral iatrogenic pseudoaneurysms occur following catheterisation of the affected artery. Clinical features will vary depending on the location and size of the pseudoaneurysm. Symptoms and signs will relate to the pseudoaneurysm itself and its effects on neighbouring structures. For example, brachial pseudoaneurysms often cause pain and swelling in the cubital fossa, along with a palpable mass. The mass may be pulsatile with a thrill or bruit. Compression of the adjacent brachial veins or median nerve can occur, as well as ischaemic compromise of the overlying skin. Arm swelling, deep vein thrombosis, compressive neuropathy, skin necrosis and rupture are also potential complications. Similarly, DUS is the modality of choice for diagnosis of other peripheral pseudoaneurysms, particularly in centres with a dedicated vascular ultrasound laboratory. CTA is best relied on in centres without ready access to vascular ultrasound services, in cases where duplex ultrasound findings are equivocal or the anatomy is not well defined.

96 Vascular Surgery – Principles and Practice

procedure is required during the same operation.[15]

preferred approach. There is debate among vascular surgeons regarding whether a bypass

**Figure 1.** Panel A- DUS of femoral pseudoaneurysm demonstrating "to and fro" flow (yellow arrow) between the native artery and the pseudoaneurysm via the neck. There is colour signal in the

pseudoaneurysm (white arrow) representing active blood flow. Panel B: Thrombosed pseudoaneurysm following UGTI. The pseudoanerusym sac now contains newly formed thrombus (blue arrow). Note the residual blood flow within the pseudoaneurysm neck after thrombosis of the pseudoaneurysm sac.

In our experience, ligation and excision of the infected artery and pseudoaneurysm, with aggressive debridement of surrounding infected tissue is well tolerated overall. This also avoids extended procedure times and potential complications associated with infection of bypass grafts. A recent review publication by Georgiadis et al showed an early occurrence of rest pain in 10.8% of patients and early risk of amputation in 5.7% of patients. Triple ligation (for pseudoaneurysms occurring at the common femoral bifurcation) likely results in worse outcomes for patients than single ligation.[15] In these patients, we advocate close monitoring of the affected limb in the immediate post-operative period and consideration

for immediate extra-anatomical bypass if signs of limb-threatening ischemia develop.

In addition to femoral pseudoaneurysms, the most common sites for iatrogenic pseudoaneurysm formation are the brachial artery and popliteal artery. As with femoral

**2.6. Other peripheral iatrogenic pseudoaneurysms** 

The options available for management of peripheral pseudoaneurysms are the same as for femoral pseudoaneurysms. Given easy percutaneous access to the peripheries, UGTI should be the treatment of choice for all suitable iatrogenic peripheral pseudoaneurysms. Published series have reported successful outcomes of UGTI with pseudoaneurysms involving the femoral, popliteal, tibial, axillary, brachial and radial arteries.[16] Radial artery iatrogenic pseudoaneurysms following arterial line insertion in critical care settings can be better treated with radial artery ligation if there is clinically good perfusion via the ipsilateral ulnar artery.

Carotid artery pseudoaneurysms are a rare subset of pseudoaneurysms. Carotid aneurysms make up less than 1% of all carotid pathologies, and of these, roughly 1 in 3 are pseudoaneurysms.[13] In modern practice, the more common causes include inadvertent catherisation during attempted internal jugular vein central line placement, trauma (blunt or penetrating), and pseudoaneurysm formation in the anastomotic suture line following carotid endarterectomy. Local infection (e.g. TB, syphilis) causing pseudoaneurysm formation is rarely seen these days.

A pulsatile neck mass is the most common clinical presentation, followed by neurological symptoms such as TIA, stroke and Horner's syndrome.[13] Diagnosis can again be made by duplex ultrasound, however, with the possibility of endovascular intervention, CTA is best to define aortic arch anatomy and suitability for endovascular repair. The potential severe sequelae of carotid pseudoaneurysms mandates surgical intervention. Given small numbers, only case series data is available for different types of carotid aneurysm repair, with only a small subset of these comprising pseudoaneurysms. Open surgical intervention includes resection and patch angioplasty, resection and interposition grafting, and ligation.[13] The latter should be considered a last resort. Surgical reconstruction of all types of carotid aneurysm is associated with a combined stroke and mortality rate of about 10%.[17]

Endovascular interventions include covered stent grafts, bare stenting with trans-stent coiling, autogenous vein covered stents, and endovascular balloon occlusions.[13] Outcome data is limited to case series, but the data is promising. In a large single-centre series spanning 20 years, Zhou et al report that endovascular intervention is an effective alternative to open surgery, particularly for patients with high surgical risk or distally located aneurysms that preclude a safe surgical approach.[13]

Iatrogenic Pseudoaneurysms 99

**Acknowledgement** 

**4. References** 

9.

5.

2005;25 Suppl 1:S173-89.

Belg 2006;106:420-2.

Philadelphia, 2010.

This work is funded by the Nuffield Department of Surgical Sciences.

Scholar with the Royal Australian College of Surgeons.

artery pseudoaneurysms. Ultrasound Q 2005;21:3-17.

pseudoaneurysms. J Vasc Interv Radiol 2003;14:697-710.

endovascular stent. Nephrol Dial Transplant 2001;16:1728-9.

over two decades. J Vasc Surg 2006;43:493-6; discussion 497.

pseudoaneurysms. J Vasc Surg 1998;27:1032-8.

Regent Lee is a Lumley Surgical Research Fellow and Foundation of Surgery Research

[1] Saad NE, Saad WE, Davies MG, Waldman DL, Fultz PJ, Rubens DJ. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics

[2] Ahmad F, Turner SA, Torrie P, Gibson M. Iatrogenic femoral artery pseudoaneurysms- a review of current methods of diagnosis and treatment. Clin Radiol 2008;63:1310-6. [3] De Raet J, Vandekerkhof J, Baeyens I. Ruptured femoral pseudo-aneurysm through the skin: a rare vexing complication following aortobifemoral reconstruction. Acta Chir

[4] Middleton WD, Dasyam A, Teefey SA. Diagnosis and treatment of iatrogenic femoral

[5] Morgan R, Belli AM. Current treatment methods for postcatheterization

[6] Thomson K. Safe use of radiographic contrast media. Australia Prescriber 2010; :29-33. [7] Toursarkissian B, Allen BT, Petrinec D et al. Spontaneous closure of selected iatrogenic pseudoaneurysms and arteriovenous fistulae. J Vasc Surg 1997;25:803-8; discussion 808-

[8] Fellmeth BD, Roberts AC, Bookstein JJ et al. Postangiographic femoral artery injuries:

[9] Perkins JM, Gordon AC, Magee TR, Hands LJ. Duplex-guided compression of femoral artery false aneurysms reduces the need for surgery. Ann R Coll Surg Engl 1996;78:473-

[10] Cronenwett J, editor Rutherford's Vascular Surgery. 7th ed: Saunders Elsevier:

[11] Brummer U, Salcuni M, Salvati F, Bonomini M. Repair of femoral postcatheterization pseudoaneurysm and arteriovenous fistula with percutaneous implantation of

[12] Kang SS, Labropoulos N, Mansour MA, Baker WH. Percutaneous ultrasound guided thrombin injection: a new method for treating postcatheterization femoral

[13] Zhou W, Lin PH, Bush RL et al. Carotid artery aneurysm: evolution of management

[14] Edgerton JR, Moore DO, Nichols D et al. Obliteration of femoral artery

[15] Georgiadis GS, Lazarides MK, Polychronidis A, Simopoulos C. Surgical treatment of femoral artery infected false aneurysms in drug abusers. ANZ J Surg 2005;75:1005-10.

pseudoaneurysm by thrombin injection. Ann Thorac Surg 2002;74:S1413-5.

nonsurgical repair with US-guided compression. Radiology 1991;178:671-5.

#### **2.7. Visceral iatrogenic pseudoaneurysms**

Iatrogenic pseudoaneurysms arising from the thoraco-abdominal aorta and other visceral branches have all been reported. These are typically the complications of prior surgery (vascular or non-vascular) or endovascular intervention of arterial or venous pathologies.[18-21] Patients with visceral iatrogenic pseudoaneurysms may remain chronically asymptomatic with detection only after investigation for other complaints. Alternatively, presentation may be with local compressive symptoms, or even rupture. Endovascular treatment in the form of direct thrombin injection [22], coiling [23], occlusion devices [24], and endograft stenting [25,26] have all been described and often considered be first line option of treatment in most cases [27,28]. Open surgical repair of visceral iatrogenic pseudoaneurysms can be challenging, especially when in a previously exposed surgical field. Although there has been increasing utilization of endovascular techniques for the treatment of visceral iatrogenic pseudoaneurysms, there remains a clear role for OSR in selected situations, such as when local mass effect of pseudoaneurysms requires concurrent treatment.[27]

#### **3. Conclusion**

The incidence of iatrogenic pseudoaneurysms is increasing as a result of progressive uptake of percutaneous arterial interventions for cardiovascular disease and the increased use of combination antiplatelet therapy. Femoral iatrogenic pseudoaneurysms represent the most common form of this pathology, but the incidence of other peripheral / visceral pseudoaneurysms is also likely to increase in the future. In experienced hands, thrombin injection under DUS guidance can offer prompt resolution of the pathology. However, no large randomized trials to date have definitively addressed the efficacy of this treatment technique. Physicians should be aware of the potential for pseudoaneurysm formation following percutaneous arterial interventions, and be familiar with the clinical findings and potential treatment options.

## **Author details**

Charles P.E. Milne and Regent Lee *Oxford Regional Vascular Unit, John Radcliffe Hospital, Oxford, UK* 

Ashok I. Handa\* *Oxford Regional Vascular Unit, John Radcliffe Hospital, Oxford, UK Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, UK* 

<sup>\*</sup> Corresponding Author

#### **Acknowledgement**

98 Vascular Surgery – Principles and Practice

**3. Conclusion** 

potential treatment options.

Charles P.E. Milne and Regent Lee

*Oxford Regional Vascular Unit, John Radcliffe Hospital, Oxford, UK* 

*Oxford Regional Vascular Unit, John Radcliffe Hospital, Oxford, UK* 

*Nuffield Department of Surgical Sciences, John Radcliffe Hospital, Oxford, UK* 

**Author details** 

Ashok I. Handa\*

Corresponding Author

 \*

spanning 20 years, Zhou et al report that endovascular intervention is an effective alternative to open surgery, particularly for patients with high surgical risk or distally

Iatrogenic pseudoaneurysms arising from the thoraco-abdominal aorta and other visceral branches have all been reported. These are typically the complications of prior surgery (vascular or non-vascular) or endovascular intervention of arterial or venous pathologies.[18-21] Patients with visceral iatrogenic pseudoaneurysms may remain chronically asymptomatic with detection only after investigation for other complaints. Alternatively, presentation may be with local compressive symptoms, or even rupture. Endovascular treatment in the form of direct thrombin injection [22], coiling [23], occlusion devices [24], and endograft stenting [25,26] have all been described and often considered be first line option of treatment in most cases [27,28]. Open surgical repair of visceral iatrogenic pseudoaneurysms can be challenging, especially when in a previously exposed surgical field. Although there has been increasing utilization of endovascular techniques for the treatment of visceral iatrogenic pseudoaneurysms, there remains a clear role for OSR in selected situations,

such as when local mass effect of pseudoaneurysms requires concurrent treatment.[27]

The incidence of iatrogenic pseudoaneurysms is increasing as a result of progressive uptake of percutaneous arterial interventions for cardiovascular disease and the increased use of combination antiplatelet therapy. Femoral iatrogenic pseudoaneurysms represent the most common form of this pathology, but the incidence of other peripheral / visceral pseudoaneurysms is also likely to increase in the future. In experienced hands, thrombin injection under DUS guidance can offer prompt resolution of the pathology. However, no large randomized trials to date have definitively addressed the efficacy of this treatment technique. Physicians should be aware of the potential for pseudoaneurysm formation following percutaneous arterial interventions, and be familiar with the clinical findings and

located aneurysms that preclude a safe surgical approach.[13]

**2.7. Visceral iatrogenic pseudoaneurysms** 

This work is funded by the Nuffield Department of Surgical Sciences.

Regent Lee is a Lumley Surgical Research Fellow and Foundation of Surgery Research Scholar with the Royal Australian College of Surgeons.

#### **4. References**


100 Vascular Surgery – Principles and Practice

experience. J Vasc Surg 2000;31:702-12.

Intervent Radiol 2008;31:535-41.

Extra 2008;15:39-41.

Surg 2006;43:1278-82.

2009;32:2-18.

our experience with 49 cases. Ann Vasc Surg 2006;20:582-9.

nitinol inferior vena cava filter. J Vasc Interv Radiol 2005;16:535-8.

complication of coronary artery bypass. Anesth Analg 2008;106:767-8.

using a detachable balloon. AJR Am J Roentgenol 1987;149:1279-80.

process and treatment options. Vasc Endovascular Surg 2008;42:601-6.

pseudoaneurysms: an update. Curr Probl Diagn Radiol 2009;38:170-88.

2002;137:462-4.

[16] Friedman SG, Pellerito JS, Scher L, Faust G, Burke B, Safa T. Ultrasound-guided thrombin injection is the treatment of choice for femoral pseudoaneurysms. Arch Surg

[17] El-Sabrout R, Cooley DA. Extracranial carotid artery aneurysms: Texas Heart Institute

[18] Skourtis G, Bountouris I, Papacharalambous G et al. Anastomotic pseudoaneurysms:

[19] Monney P, Pellaton C, Qanadli SD, Jeanrenaud X. Aortic pseudo-aneurysm caused by complete dehiscence of the left coronary artery 7 years after a composite mechanicalvalved conduit aortic root replacement (Bentall operation). Eur Heart J 2012;33:60. [20] Putterman D, Niman D, Cohen G. Aortic pseudoaneurysm after penetration by a Simon

[21] Konia M, Uppington J, Moore P, Liu H. Ascending aortic pseudoaneurysm: a late

[22] Schellhammer F, Steinhaus D, Cohnen M, Hoppe J, Modder U, Furst G. Minimally invasive therapy of pseudoaneurysms of the trunk: application of thrombin. Cardiovasc

[23] Moneley D, Johnston KW, Tan KT, G O. Endovascular Treatment of an Iatrogenic Visceral Aortic Segment Aneurysm Following a Translumbar Vertebral Biopsy. EJVES

[24] Sharma RP, Shetty PC, Burke TH, Shepard AD, Khaja F. Treatment of false aneurysm by

[25] Medina CR, Indes J, Smith C. Endovascular treatment of an abdominal aortic pseudoaneurysm as a late complication of inferior vena cava filter placement. J Vasc

[26] Pasklinsky G, Gasparis AP, Labropoulos N et al. Endovascular covered stenting for visceral artery pseudoaneurysm rupture: report of 2 cases and a summary of the disease

[27] Kapoor BS, Haddad HL, Saddekni S, Lockhart ME. Diagnosis and management of

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## *Edited by Dai Yamanouchi*

This book aims to provide a brief overview of conventional open vascular surgery, endovascular surgery and pre- and post-operative management of vascular patients. The collections of contributions from outstanding vascular surgeons and scientists from around the world present detailed and precious information about the important topics of the current vascular surgery practice and research. I hope this book will be used worldwide by young vascular surgeons and medical students enhancing their knowledge and stimulating the advancement of this field.

Vascular Surgery - Principles and Practice

Vascular Surgery

Principles and Practice

*Edited by Dai Yamanouchi*

Photo by HYWARDS / iStock