Stone Patrick A, Thompson Stephanie N, Hanson Brent, Masinter David
Division of Vascular and Endovascular Surgery, Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV, USA
Charleston Area Medical Center Health Education and Research Institute, Charleston, WV, USA.
Vasc Endovascular Surg. 2016 May;50(4):217-20. doi: 10.1177/1538574416637448. Epub 2016 Mar 13.
A plethora of papers have been written regarding postcatheterization femoral pseudoaneurysms. However, literature is lacking on pseudoaneurysmal management in patients undergoing coronary artery bypass grafting (CABG). Thus, we examined if pseudoaneurysms with subsequent CABG can be managed with the same strategies as those not exposed to the intense anticoagulation accompanying CABGs.
During a 14-year study period, we retrospectively examined femoral iatrogenic pseudoaneurysms (IPSAs) diagnosed postheart catheterization in patients having a subsequent CABG. Patient information was obtained from electronic medical records and included pseudoaneurysm characteristics, treatment, and resolution. Outcomes of interest included the occurrence of IPSA treatment failures and complications.
In the 66 patients (mean age, 66 ± 11 years, 46% male) meeting inclusion criteria, mean dose of heparin received during the CABG procedure was 34 000 ± 23 000 units. The IPSA size distribution was the following: 17% of IPSAs measured <1 cm, 55% between 1 and 3 cm, and 21% measured >3 cm. Pseudoaneurysms were managed with compression, duplex-guided thrombin injection, and surgical repair (1%, 27%, and 26% of cases, respectively). Thrombin injection and surgical repair were 100% effective at treating pseudoaneurysms, with 1 patient experiencing a surgical site infection postsurgical repair. Observation-only management was employed in 30 (45%) patients. Nine of 30 patients with no intervention beyond observation had duplex documented resolution/thrombosis during follow-up. One patient initially managed by observation required readmission and surgical repair of an enlarging pseudoaneurysm (6 cm growth) following CABG.
Management of pseudoaneurysms in patients prior to CABG should be similar to those patients not undergoing intense anticoagulation. In appropriate cases, small aneurysms can be safely observed, while thrombin injections are effective and safe as well. Thus, routine open surgical repair is not routinely required in patients with femoral pseudoaneurysms at time of CABG.
关于导管插入术后股部假性动脉瘤已有大量论文发表。然而，关于冠状动脉旁路移植术（CABG）患者假性动脉瘤的处理，文献却很匮乏。因此，我们研究了伴有后续CABG的假性动脉瘤是否能用与未接受CABG相关高强度抗凝治疗的患者相同的策略来处理。
在一项为期14年的研究期间，我们回顾性研究了在接受后续CABG的患者中，心脏导管插入术后诊断出的股部医源性假性动脉瘤（IPSA）。患者信息从电子病历中获取，包括假性动脉瘤特征、治疗及转归。感兴趣的结局包括IPSA治疗失败和并发症的发生情况。
在符合纳入标准的66例患者（平均年龄66±11岁，46%为男性）中，CABG手术期间接受肝素的平均剂量为34000±23000单位。IPSA大小分布如下：17%的IPSA直径<1 cm，55%在1至3 cm之间，21%直径>3 cm。假性动脉瘤的处理方式有压迫、双功超声引导下注射凝血酶和手术修复（分别占病例的1%、27%和26%）。注射凝血酶和手术修复治疗假性动脉瘤的有效率为100%，1例患者在手术修复后发生手术部位感染。30例（45%）患者采用仅观察的处理方式。30例仅观察而未进行其他干预的患者中，9例在随访期间经双功超声记录显示假性动脉瘤消退/血栓形成。1例最初采用观察处理的患者在CABG后因假性动脉瘤增大（增长6 cm）需再次入院并接受手术修复。
CABG术前患者假性动脉瘤的处理应与未接受高强度抗凝治疗的患者相似。在适当情况下，小动脉瘤可安全观察，而注射凝血酶也是有效且安全的。因此，CABG时股部假性动脉瘤患者通常无需常规进行开放性手术修复。
