ложные аневризмы. что делать и кто виноват.

[oldangio]

[quote=rsr;1841982
По поводу второй части Вашего сообщения, мне хотелось бы попросить Вас любезно предоставить какие-либо достоверные источники, подтверждающие обоснованность иерархии причин, указанных Вами.[/QUOTE]
Несколько абстрактов по Вашей просьбе
1. Int J Cardiol. 2007 Aug 21;120(2):167-71. Location of femoral artery puncture site and the risk of postcatheterization pseudoaneurysm formation. Gabriel M, Pawlaczyk K, Waliszewski K, Krasiński Z, Majewski W. Department of Vascular Surgery, University of Medical Sciences, Poznan, Poland. [Ссылки доступны только зарегистрированным пользователям ]
Iatrogenic causes constitute increasingly frequent sources of pseudoaneurysms due to endovascular interventions. However, till now, all analyses focused on evaluating different risk factors contributing to the development of pseudoaneurysm, overlooking the issue of localization of femoral puncture. The aim of this study was to assess the influence of position of femoral artery puncture on the risk of pseudoaneurysm formation. 116 patients were evaluated for the site of catheter insertion into femoral arteries. Another group of 273 patients, suspected of vascular complications after endovascular procedures, were diagnosed with pseudoaneurysms which were analyzed for the location of arterial wall disruption. Puncture sites of groin arteries, i.e. EIA (2.7%), CFA (77.5%), SFA and DFA (19.8%), correlated with pseudoaneurysm location reaching 7.6% (EIA), 54.3% (CFA) and 38.1% (SFA, DFA). Type of procedure influenced these values. Duplex ultrasound mapping of CFA before the endovascular intervention eliminated discrepancies between the incidence of pseudoaneurysm formation and the frequency of arterial puncture in the selected vascular segments. Pseudoaneurysms formed in 4.5% of patients undergoing traditional palpation-guided vessel cannulation and in 2.6% of patients after ultrasound-guided puncture of the femoral artery. Upon further analysis, we concluded that the likelihood of the development of pseudoaneurysm depends on the artery punctured in the groin. This risk increases dramatically for external iliac artery, superficial and deep femoral arteries. A simple means of prevention of this dangerous complication of femoral artery puncture is duplex ultrasound mapping of the groin arteries.

2. Int J Cardiol. 2010 May 14;141(1):75-80. Femoral pseudoaneurysms and current cardiac catheterization: evaluation of risk factors and treatment. Popovic B, Freysz L, Chometon F, Lemoine J, Elfarra M, Angioi M, Selton-Suty C, de Chillou C, Aliot E. Department of Cardiology, University Hospital of Vandoeuvre les Nancy, France. [Ссылки доступны только зарегистрированным пользователям ]
OBJECTIVES: We sought to determine the incidence of femoral pseudoaneurysm (FPA) following cardiac catheterization, identify the risk factors for FPA and factors influencing therapeutic strategy. METHODS: 11,992 consecutive patients who underwent cardiac catheterization via femoral artery were studied over a period of four years in one University Hospital. Our prospective case control group analysis registered patients who developed FPA after the procedure. Patient-related factors, procedure related factors and peri-procedure treatment were compared between the two groups. RESULTS: 76 FPA were diagnosed over the study period accounting for a global incidence of 0.6% procedures. By univariate analysis, interventional procedure (p<0.01), rhythmologic procedure (p=0.03), sheath>or=6F (p=0.04) and left groin puncture (p<0.001) were FPA risk factors. By multivariate analysis, interventional procedure (adjusted odds ratio [OR]=1.99; 95% confidence interval [CI]1.14-3.44 p=0.01) and left groin puncture (OR=4.65; 95% CI, 1.78-12.1 p=0.001) are independent predictive factors of FPA. FPA thrombosis was obtained by ultrasound guided compression (UGC) in 71% of the cases. By univariate analysis, PFA diameter larger than 4 cm (p<0.001), the use of anticoagulation (p<0.01) or GPIIbIIIa inhibitors (p=0.001) and UGC under anticoagulation (p=0.01) are predictive factors of need for FPA surgical repair. By multivariate analysis, FPA diameter>4 cm and use of GPIIbIIIa inhibitors are independent predictive factors of FPA's surgical treatment. Superficial femoral puncture was predictive of successful UGC both by uni and multivariate analysis. CONCLUSIONS: Our study shows that FPA occurrence is mainly due to by procedure-related factors. FPA size, level of puncture and the use of GPIIbIIIa inhibitors are independent predictive factors of need for surgical therapy.

3.Ann Vasc Surg. 1990 May;4(3):264-9. Anatomic and clinical factors associated with complications of transfemoral arteriography. Lilly MP, Reichman W, Sarazen AA Jr, Carney WI Jr. Brown University, Rhode Island Hospital, Providence.
Complications of transfemoral arteriography requiring surgery are rare but carry significant morbidity. To evaluate clinical factors that might relate to such complications, we retrospectively reviewed our experience from January 1, 1985, to December 31, 1988 (four years). Forty-seven complications requiring surgery occurred among 10,589 cases. The risk was higher after cardiac catheterization than after peripheral arteriography (0.55% versus 0.17%, p less than 0.025). In nearly 40% of these cases, arterial puncture was not in the common femoral artery. Acute bleeding complications were more likely among patients with puncture outside the common femoral artery (p less than 0.001). Older patients and women were at slightly higher risk for complications requiring surgery, but this difference was not statistically significant. The frequency of bleeding complications was not significantly higher among patients who were anticoagulated following the procedure. The distribution of puncture sites was identical in obese and nonobese patients. Three patients died (two from myocardial infarction, one from multisystem organ failure). Two limbs did not improve; one required major amputation. Four limbs had persistent paresthesia and two had persistent weakness. We conclude that complications of transfemoral arteriography requiring surgery occur more frequently among patients who are undergoing cardiac catheterization and who suffer aberrant punctures. Age, sex, body habitus, and anticoagulation have less impact on patient risk.

По поводу нарушений пациентами режима (как Вы это назвали) зарубежные коллеги рекомендуют раннюю активацию пациентов.
Angiology. 2007 Dec-2008 Jan;58(6):743-6. Early ambulation after diagnostic heart catheterization. Boztosun B, Günes Y, Yildiz A, Bulut M, Saglam M, Kargin R, Kirma C. Kosuyolu Heart and Research Centre, Cardiology Department, Istanbul, Turkey.
The general recommended strategy after arterial invasive procedures is a 4- to 6-hour bed rest that is associated with patient discomfort and increased medical costs. We hypothesized that mobilization of selected patients at the second hour would not increase vascular complications. Coronary angiography was performed through the femoral route via 6-Fr catheters. Homeostasis was achieved by manual compression and maintained with a compressive bandage. A total of 1,446 patients were ambulated at the second hour and 1,226 of them were discharged without complication. A total of 220 patients required further follow-up due to blood oozing; 154 patients were conventionally ambulated due to difficult arterial access, longer (>15 minutes) compression time, hematoma formation within 2 hours, or hypertensive state (blood pressure >180/100 mm Hg). Twenty-five (16%) of those patients developed minor bleeding after ambulation. No major bleeding or large hematoma was observed during in-hospital observation. Ecchymosis (10% [2-hour group] vs 21% [4-5 hour group]) and small hematomas (22% vs 9%) were the most frequent complications after discharge. Early mobilization of selected patients undergoing diagnostic heart catheterization through the femoral artery via 6-Fr catheters is safe and associated with acceptable bleeding complication rates.
Извините за много буков.

[Abugov]

"Вы должны добавить отзыв кому-то ещё, прежде чем сможете снова добавить его oldangio."

[oldangio]

Сообщение от Abugov

"Вы должны добавить отзыв кому-то ещё, прежде чем сможете снова добавить его oldangio."

Cережа! Система нас не любит, а вообще с праздником

[rsr]

Уважаемый Оldangio поздравляю Вас с праздником, и хотел бы поблагодарить за предоставленную информацию.

[oldangio]

Нашел в архиве небольшую подборку статей по осложнениям бедренной катетеризации, может кому-нибудь пригодится [Ссылки доступны только зарегистрированным пользователям ]

[rsr]

Продолжая тему хотел бы узнать ваше мнение по поводу ниже изложенного:

Circulation.
2007; 115: 2666-2674
Contemporary Reviews in Cardiovascular Medicine
Contemporary Management of Postcatheterization Pseudoaneurysms
Geoffrey W. Webber, MD; James Jang, MD; Susan Gustavson, RVT; Jeffrey W. Olin, DO

The incidence of PSA after diagnostic catheterization ranges from 0.05% to 2%. When coronary or peripheral intervention is performed, the incidence increases to 2% to 6%.

[angio]

* FAPs are usually caused by punctures of the femoral artery which are too distal, that is, at the level of bifurcation of the femoral artery or below. ([Ссылки доступны только зарегистрированным пользователям ])

* [Ссылки доступны только зарегистрированным пользователям ]

* It has been suggested that false aneurysms are more likely to occur if the superficial femoral artery has been punctured. This has not been our experience. (взято отсюда (full text): [Ссылки доступны только зарегистрированным пользователям ]) Но ссылаются на старенькую статью (не нашел) - Rapoport S, Sniderman KW, Morse SS, Proto MH, Ross GR. Pseudoaneurysm: a complication of faulty technique in femoral arterial puncture. Radiology 1985; 154:529-30.
к слову в этой статье есть интересная табличка по соотношению расположения псевдоаневризм и места вкола в артерию.

* It has been suggested that cannulation of the superficial femoral artery rather than the common femoral artery is associated with a higher incidence of lower limb ischaemia. This has not been our experience. (взято здесь: [Ссылки доступны только зарегистрированным пользователям ])
ссылаются на статью: McMillan, I. & Murie, J.A. Vascular injury following cardiac catheterisation. Br J Surg 1984, 71: 832-835.

__________________________
Хоть и с опозданием, но ответил, еще бы вот этот full text посмотреть ([Ссылки доступны только зарегистрированным пользователям ])

_______________________________________
А если честно и откровенно - то в нашей клинике из 6 докторов пункцию и гемостаз все делают по-разному. А разнообразие техник по выполнению доступа, возникает из отсутствия общепринятого 100%-го метода (в общем, примерно как с герниопластикой) - ИМХО.

[oldangio]

Сообщение от rsr

Продолжая тему хотел бы узнать ваше мнение по поводу ниже изложенного:

Circulation.
2007; 115: 2666-2674
Contemporary Reviews in Cardiovascular Medicine
Contemporary Management of Postcatheterization Pseudoaneurysms
Geoffrey W. Webber, MD; James Jang, MD; Susan Gustavson, RVT; Jeffrey W. Olin, DO

The incidence of PSA after diagnostic catheterization ranges from 0.05% to 2%. When coronary or peripheral intervention is performed, the incidence increases to 2% to 6%.

Все достаточно объяснимо- при диагностике используем 5-6 Ф, при интервенциях инструмент чаще толще, хорошая антикоагуляция, ингибиторы ГПР, дольше время.