Remote endovascular treatment of femoral pseudoaneurysms in hostile groins: technical note.

Pseudoaneurysms (PSAs) are false aneurysms that typically arise due to the inappropriate closure of arterial wall perforations during endovascular procedures. Femoral pseudoaneurysm (F-PSA) has an incidence ranging from 0.2% to 7.0% for all procedures, with therapeutic coronary angiography contributing a vast number of these complications1-3. Risk factors correlated with post-interventional F-PSA have been classified into procedure-related or patient-related factors. Patient-related factors include scars in the groin and body mass index (BMI) > 28 kg/m2. The latter represents a particularly at-risk population for complications after open inguinal procedures, and therefore, the obese are not ideal patients for open repair of F-PSA. Furthermore, obesity presents a challenge for manual compression, which, when performed improperly, poses a significant risk factor for developing a pseudoaneurysm1. Obese patients and those with hostile groins (including previously operated, history of radiation, close infection, skin candidiasis, or prominent skin folds) represent a population in which all measures should be taken to reduce the possibility of F-PSA. However, suppose iatrogenic F-PSA arises despite such measures. In that case, these groups must be considered “non-ideal candidates” for open surgery, as they carry an increased risk for postoperative complications (blood transfusion and re-exploration, surgical wound infection, lymphatic fistula, distal arterial embolization, seroma, wound dehiscence, neuropraxia, and venous thrombosis)1. When an F-PSA is detected, a treatment plan must be established expediently. In the case of symptomatic F-PSA, progression, skin breakdown, hemodynamic instability, and pseudoaneurysm rupture are the primary concerns. As such, symptomatic F-PSAs classically have undergone surgical repair. However, the ultrasound-guided compression therapy (USGCT) represented an easy-to-perform and rapid alternative management strategy1. In the case of unsuccessful USGCT, the following widely accepted step is thrombin injection. Thrombin is injected into the new-formed sac under ultrasound guidance, producing rapid thrombosis of the PSA. However, in cases of either short neck of the PSA or failure after the first attempt of thrombin injection, a surgical procedure is indicated1. In selected patients at higher risk of developing complications, we propose a technique of Keeping the EndovasculaR Balloon in place during thrombin Injection (KERBI). This employs a left brachial approach for endovascular balloon placement and ultrasound-guided thrombin injection.