Steppich Birgit, Schürmann Friederike, Bruskina Olga, Hadamitzky Martin, Kastrati Adnan, Schunkert Heribert, Fusaro Massimiliano, Ott Ilka
1 Deutsches Herzzentrum der Technischen Universität München, Munich, Germany.
Vasa. 2018 Oct;47(6):507-512. doi: 10.1024/0301-1526/a000732. Epub 2018 Sep 3.
Increasing volume of complex percutaneous endovascular procedures in highly anticoagulated patients generate a not negligible percentage of femoral pseudoaneurysms (PSA) with concomitant arteriovenous fistulas (AVF). While ultrasound-guided thrombin injection (UGTI) is the therapy of choice for PSA, concomitant AVF is regarded as a contraindication for UGTI, as venous thromboembolism is feared. In this retrospective, register-based cohort study, we report on and evaluate the use of UGTI for the treatment of PSA with AFV.
All patients (n = 523), who underwent UGTI for femoral PSA at the German Heart Centre Munich from January 2011 until January 2018, were retrospectively reviewed for the presence of a concomitant AVF and outcomes were recorded.
Forty femoral PSA/AVFs treated by UGTI were identified. The mean enddiastolic arterial-flow-velocity above the AVF, an estimate of the AVF size, was 14.61 ± 1.7 cm/sec. The Majority of patients exhibited flow-velocities < 25 cm/sec (n = 31; 77.5 %) and were on either uninterrupted oral anticoagulation (n = 32; 80 %) or dual antiplatelet therapy (n = 8). Twenty-eight (70 %) PSA/AVFs could be successfully closed by UGTI. In eight multicompartmental PSAs, partial obliteration necessitated combined treatment with manual compression, while one partial occlusion was treated by observation. There were three failures, of which two underwent covered-stent-graft-implantation and one surgical repair. One DVT (2.5 %) occurred two days after UGTI in the by far largest AVF (60 cm/sec) included in the study. Besides two late PSA recurrences treated by surgery, no other complications were observed. AVF persisted in 65 %, all of them asymptomatic. The mean follow-up was 6 ± 15.5 months.
UGTI appears to be a treatment option in femoral PSA/AVF, at least under oral anticoagulation in small fistulas with enddiastolic arterial-flow-velocities ≤ 25 cm/sec. However, caution is necessary in larger AVFs, which should remain a contraindication for UGTI.
在高度抗凝的患者中，复杂经皮血管内手术的数量不断增加，导致股动脉假性动脉瘤（PSA）并伴有动静脉瘘（AVF）的比例不可忽视。虽然超声引导下注射凝血酶（UGTI）是PSA的首选治疗方法，但由于担心静脉血栓栓塞，伴有AVF被视为UGTI的禁忌症。在这项基于登记的回顾性队列研究中，我们报告并评估了UGTI在治疗伴有AFV的PSA中的应用。
回顾性分析了2011年1月至2018年1月在德国慕尼黑心脏中心接受UGTI治疗股动脉PSA的所有患者（n = 523），以确定是否存在合并AVF，并记录结果。
共识别出40例接受UGTI治疗的股动脉PSA/AVF。AVF上方的平均舒张末期动脉血流速度（可估计AVF大小）为14.61±1.7 cm/秒。大多数患者的血流速度<25 cm/秒（n = 31；77.5%），且正在接受不间断的口服抗凝治疗（n = 32；80%）或双联抗血小板治疗（n = 8）。28例（70%）PSA/AVF可通过UGTI成功闭合。在8例多腔PSA中，部分闭塞需要联合手法压迫治疗，1例部分闭塞通过观察治疗。有3例治疗失败，其中2例接受了覆膜支架植入术，1例接受了手术修复。在研究中纳入的迄今为止最大的AVF（60 cm/秒）中，UGTI后两天发生一例深静脉血栓形成（DVT，2.5%）。除了2例通过手术治疗的晚期PSA复发外，未观察到其他并发症。65%的患者AVF持续存在，均无症状。平均随访时间为6±15.5个月。
UGTI似乎是治疗股动脉PSA/AVF的一种选择，至少在口服抗凝治疗的情况下，对于舒张末期动脉血流速度≤25 cm/秒的小瘘管是可行的。然而，对于较大的AVF，必须谨慎，其仍应被视为UGTI的禁忌症。
