COLOR
AJR:159, November 1992
Fourteen
DOPPLER
of the 24 pseudoaneurysms
(58%)
IMAGING
spontaneously
throm-
bosed. Ten (42%) ultimately were treated surgically. The demographic and clinical features of both study groups are listed in Table 1.
Downloaded from www.ajronline.org by 117.255.232.156 on 10/09/15 from IP address 117.255.232.156. Copyright ARRS. For personal use only; all rights reserved
Differences
between
the two groups
were not statistically
minimum time to thrombosis. The maximum time was based on the interval between the cardiac catheterization and the color Doppler sonogram that showed thrombosis. The minimum and maximum times for each group were averaged to give the average minimum
and average maximum times to spontaneous thrombosis. The average minimum and maximum times to spontaneous thrombosis ranged from 4.7 ± 3.2 (mean ± SD) days to 24.1 ± 27.5 days, respectively. These values include four patients who were discharged with a known pseudoaneurysm who had late follow-up studies as an average
of 63 days
after
cardiac
catheterization.
If
these four outpatients are considered outliers and are excluded analysis, the average minimum and maximum times ranged 4.7 ± 3.2 to 7.8 ± 4.9 days, respectively. The average in the surgery group was 5.4 ± 1 .5 days.
time
from from
in the group
bosis was significantly
study,
with
spontaneous
less than in the surgery
throm-
group
(p
=
Differences in the other imaging findings were not statistically significant. However, the group with spontaneous thrombosis had a lower overall volume, lower volume of flow, 0.02).
lower percentage than
of flow, and longer pseudoaneunysm
did the surgery
1: Demographic
Pseudoaneurysms
of the
and Clinical Femoral
Features of Patients After Cardiac
with
Artery
Catheterization Patients Who Had Variable
Patients
Spontaneous Thrombosis
Had
Who
Surgery (n = 9)
p Value
Use of tissue plasminogen activator Bruit
7 7 13 9 13
0.33
4 (44) 5 (56) 9 (1 00)
1.00 1.00 i .00
(64)
4 (44)
0.42
(93)
8
(89)
1.00
3 (2i)
0
(0)
0.25
8
(89)
1.00 1.00
(88)
1 4 (1 00) in parentheses
72 ± 9
(50) (50) (93)
7
Hematoma Note-Numbers
67 ± 1 i
are percentages.
9 (1 00) An exact
(n
Group =
9)
p Value
Median
Median
Volume of pseudoaneurysm (ml) Volume of flow in lumen of pseudoaneurysm (ml) Volume of flow in lumen/volume of pseudoaneurysm
8.8
Wilcoxon
i4)
=
± 1 0.2
i .8 ± 2.5
32 ± 29
4.3
1 1 .5 ± 9.5
1 0.7
0.54
0.88
3.1 ± 2.5
2.3
0.28
28
36 ± 31
29
0.77
(%) Ratio of for-
2.4 ± 0.68
2.3
2.0 ± 1 .1
1 .8
0.43
to rein
neck of pseudoaneurysm % Diastole
Length of
83 1 .29
± 31 ± 0.56
1 00 1 .2
69 ± 35 i
.9
±
75
0.64
0.34
0.8
0.35
pseudoaneurysm
neck
(cm) Note-All p values were determined by using the exact version of the Wilcoxon test. The values given for volume of flow in lumen/volume of pseudoaneurysm are derived from the mean and standard deviation of each individual measurement. % Diastole = the percentage of the diastolic portion of the cardiac cycle that demonstrated flow.
oral puncture detected no abnormality at the site of the previously detected pseudoaneunysm. Thus, it was not possible to measure volumes of the pseudoaneunysms in these cases. These two final data points were excluded from Figunes 2A and 3A. Figure 2 shows the actual volumes of the pseudoaneurysms for both groups. Here, it can be seen that five patients in the group who had spontaneous thrombosis and two in the surgery group had an increase in volume on follow-up examinations.
The others
had no change
or a decrease
in volume.
Figure 3 shows the volume of flow in the lumen during the course of serial studies. In both groups, most patients had no
(n=14) Age, years (mean ± 1 SD) Men Women Arterial sheath Interventional procedure Heparin during procedure
(n
Surgery
neck
group.
In two patients in the spontaneous thrombosis group, late follow-up examinations performed 58 and 86 days after femTABLE
Variable
velocity
no statistically significant differences were found between the groups. For the last imaging study showing flow, the volume of flow in the pseudoaneurysm
Spontaneous Thrombosis Group
in Initial of the Femoral
verse flow
The color Doppler sonographic findings of the initial study and of the last follow-up study that showed flow are listed in
2 and 3. For the first imaging
i 079
ARTERY
TABLE 2: Color Doppler Sonographic Findings Examination of Patients with Pseudoaneurysms Artery After Cardiac Catheterization
ward
to surgery
Results
Tables
FEMORAL
significant.
Because the precise number of days to spontaneous thrombosis was unknown, the time to spontaneous thrombosis was calculated as a range based on the minimum and maximum intervals. The time between cardiac catheterization and the final color Doppler sonogram that demonstrated flow was used as a conservative estimate of the
outpatients
OF
version
of the
x2 -test was used for analysis of all variables except age. In the spontaneous thrombosis group, the presence or absence of a bruit was described in only eight cases.
change
or a decrease
One patient decrease
in volume
on follow-up
in the spontaneous
thrombosis
in the volume
of flow
in the lumen
examinations.
group after
had a an initial
increase in volume. Three patients in the surgery group had an increase in the volume of flow in the lumen on follow-up studies; in one of these, the increase in volume of flow followed a decrease in the volume of flow. On the initial examination, 13 of 14 patients in the spontaneous thrombosis group had a circumferential thrombus; one had no detectable peripheral thrombus. On the initial examination, eight of 10 patients in the surgery group had a circumferential thrombus. Four patients in the spontaneous thrombosis
group
had
bibbed
pseudoaneurysms;
two
of
i 080
TABLE
PAULSON
3: Color Doppler
up Study
Showing
Sonographic
Flow
in Patients
Artery After Cardiac
the Femoral
Downloaded from www.ajronline.org by 117.255.232.156 on 10/09/15 from IP address 117.255.232.156. Copyright ARRS. For personal use only; all rights reserved
(n
of
9)
8.9 ± 1 1 .2
3.8
Mean
±iSD 1 2.0 ± 8.4
Wilcoxon
Median 1 6.0
1 .8 ± 3.3
0.47
4.4
± 3.2
4.5
0.02
29 ± 30
16
46 ± 34
41
0.19
bosis than in the surgery
2.3±1
2
3.3±1
2.8
neck of pseu76 ± 36
1 00
75 ± 35
1 00
of error.
of flow. This characteristic
was
group.
In both groups
of patients, in
Discussion
stantial
femoral
pseudoaneurysms
Finally,
the differences
in the volume
of flow
in the
lumen between the two groups of patients was statistically significant only for the final follow-up study showing flow. Thus, we think that in clinical practice, findings on color Doppler imaging cannot be used alone to predict subsequent thrombosis. This study confirms previous reports [i 0-i 3] that a sub-
these developed during the follow-up period. In the surgery group, two patients had bibbed pseudoaneurysms and one had a trilobed pseudoaneurysm. One of the bibbed pseudoaneurysms developed during the follow-up period.
surgically
be used
in both groups of patients. Second, the diameter of the lumen that would distinguish between the means of the two groups is only approximately 0.5 cm, as a cubic function is involved. Although a variation of this magnitude can be caused by differences in sensitivity settings of the instruments rather than by true differences in volumes, we attempted to standardize our technique in order to reduce this possible source
1.00
Note-All p values were determined by using the exact version of the Wilcoxon test. The values given for volume of flow in lumen/volume of pseudoaneurysm are derived from the mean and standard deviation of each individual measurement. % Diastole = the percentage of the diastolic portion of the cardiac cycle that demonstrated flow.
Traditionally,
could
a larger volume of flow has important limitations. First, there is substantial overlap between the volume of flow in the lumen
in
doaneurysm % Diastole
that
The suggestion that a pseudoaneurysm with a small volume of flow in the lumen is more likely to thrombose than one with
0.24
ward to reversed flow velocity
parameters
the volume of the pseudoaneurysm and the volume of flow the lumen tended to remain unchanged or to decrease.
(%)
Ratiooffor-
imaging
statistically significant only for the final sonogram showing flow. Although no other differences in imaging characteristics were statistically significant, the overall volume of the pseudoaneurysm, the volume of flow in the lumen, and the percentage of flow were all lower and the neck of the pseudoaneurysm was longer in the group with spontaneous throm-
pseudoaneurysm (ml) Volume of flow in lumen/volume of pseudoaneurysm
determining
are those with larger volumes
0.28
pseudoaneu-
rysm (ml) Volume of flow in lumen of
to surgical management; however, complications with this procedure have been reported [i 4]. as some pseudoaneurysms thnombose sponta-
to predict spontaneous thrombosis would be important to potentially obviate other intervention. This study shows that pseudoaneurysms with small volumes of flow in the lumen are more likely to thnombose than
Group =
p Value
Median
±1SD
substitute associated Inasmuch
of
AJR:159, November 1992
AL.
neously, Surgery (n
14)
=
Mean
Volume
in Final Follow-
Pseudoaneurysms
Catheterization
Spontaneous Thrombosis Group
Variable
Findings with
ET
proportion
of pseudoaneurysms
occurring
after
diac catheterization will thrombose spontaneously. On age, patients had surgery within i day of the average mum time to spontaneous thrombosis. This suggests the surgery patients had been observed longer, more
have been treated
to avoid the potential complication of rupture [4, 7nonsungical sonognaphically guided compnestherapy has been suggested as a feasible
9]. Recently, sion-occlusion
car-
averminithat if of the
40 30 35 25
30 25
.
20
20
15
-a 15
10 10
5 0 1
SERIAl.
A
cou ExAMU4A’noN
3
2 SERIAL
CDU
EXAMINATiON
B
Fig. 2.-A, Graph shows actual volumes of pseudoaneurysm on follow-up color Doppler (CDU) images 14). B, Graph shows actual volumes of pseudoaneurysm in patients who had surgery (n = 9).
in patients
with spontaneous
thrombosis
(n
=
AJR:159, November 1992
Fourteen
DOPPLER
of the 24 pseudoaneurysms
(58%)
IMAGING
spontaneously
throm-
bosed. Ten (42%) ultimately were treated surgically. The demographic and clinical features of both study groups are listed in Table 1.
Downloaded from www.ajronline.org by 117.255.232.156 on 10/09/15 from IP address 117.255.232.156. Copyright ARRS. For personal use only; all rights reserved
Differences
between
the two groups
were not statistically
minimum time to thrombosis. The maximum time was based on the interval between the cardiac catheterization and the color Doppler sonogram that showed thrombosis. The minimum and maximum times for each group were averaged to give the average minimum
and average maximum times to spontaneous thrombosis. The average minimum and maximum times to spontaneous thrombosis ranged from 4.7 ± 3.2 (mean ± SD) days to 24.1 ± 27.5 days, respectively. These values include four patients who were discharged with a known pseudoaneurysm who had late follow-up studies as an average
of 63 days
after
cardiac
catheterization.
If
these four outpatients are considered outliers and are excluded analysis, the average minimum and maximum times ranged 4.7 ± 3.2 to 7.8 ± 4.9 days, respectively. The average in the surgery group was 5.4 ± 1 .5 days.
time
from from
in the group
bosis was significantly
study,
with
spontaneous
less than in the surgery
throm-
group
(p
=
Differences in the other imaging findings were not statistically significant. However, the group with spontaneous thrombosis had a lower overall volume, lower volume of flow, 0.02).
lower percentage than
of flow, and longer pseudoaneunysm
did the surgery
1: Demographic
Pseudoaneurysms
of the
and Clinical Femoral
Features of Patients After Cardiac
with
Artery
Catheterization Patients Who Had Variable
Patients
Spontaneous Thrombosis
Had
Who
Surgery (n = 9)
p Value
Use of tissue plasminogen activator Bruit
7 7 13 9 13
0.33
4 (44) 5 (56) 9 (1 00)
1.00 1.00 i .00
(64)
4 (44)
0.42
(93)
8
(89)
1.00
3 (2i)
0
(0)
0.25
8
(89)
1.00 1.00
(88)
1 4 (1 00) in parentheses
72 ± 9
(50) (50) (93)
7
Hematoma Note-Numbers
67 ± 1 i
are percentages.
9 (1 00) An exact
(n
Group =
9)
p Value
Median
Median
Volume of pseudoaneurysm (ml) Volume of flow in lumen of pseudoaneurysm (ml) Volume of flow in lumen/volume of pseudoaneurysm
8.8
Wilcoxon
i4)
=
± 1 0.2
i .8 ± 2.5
32 ± 29
4.3
1 1 .5 ± 9.5
1 0.7
0.54
0.88
3.1 ± 2.5
2.3
0.28
28
36 ± 31
29
0.77
(%) Ratio of for-
2.4 ± 0.68
2.3
2.0 ± 1 .1
1 .8
0.43
to rein
neck of pseudoaneurysm % Diastole
Length of
83 1 .29
± 31 ± 0.56
1 00 1 .2
69 ± 35 i
.9
±
75
0.64
0.34
0.8
0.35
pseudoaneurysm
neck
(cm) Note-All p values were determined by using the exact version of the Wilcoxon test. The values given for volume of flow in lumen/volume of pseudoaneurysm are derived from the mean and standard deviation of each individual measurement. % Diastole = the percentage of the diastolic portion of the cardiac cycle that demonstrated flow.
oral puncture detected no abnormality at the site of the previously detected pseudoaneunysm. Thus, it was not possible to measure volumes of the pseudoaneunysms in these cases. These two final data points were excluded from Figunes 2A and 3A. Figure 2 shows the actual volumes of the pseudoaneurysms for both groups. Here, it can be seen that five patients in the group who had spontaneous thrombosis and two in the surgery group had an increase in volume on follow-up examinations.
The others
had no change
or a decrease
in volume.
Figure 3 shows the volume of flow in the lumen during the course of serial studies. In both groups, most patients had no
(n=14) Age, years (mean ± 1 SD) Men Women Arterial sheath Interventional procedure Heparin during procedure
(n
Surgery
neck
group.
In two patients in the spontaneous thrombosis group, late follow-up examinations performed 58 and 86 days after femTABLE
Variable
velocity
no statistically significant differences were found between the groups. For the last imaging study showing flow, the volume of flow in the pseudoaneurysm
Spontaneous Thrombosis Group
in Initial of the Femoral
verse flow
The color Doppler sonographic findings of the initial study and of the last follow-up study that showed flow are listed in
2 and 3. For the first imaging
i 079
ARTERY
TABLE 2: Color Doppler Sonographic Findings Examination of Patients with Pseudoaneurysms Artery After Cardiac Catheterization
ward
to surgery
Results
Tables
FEMORAL
significant.
Because the precise number of days to spontaneous thrombosis was unknown, the time to spontaneous thrombosis was calculated as a range based on the minimum and maximum intervals. The time between cardiac catheterization and the final color Doppler sonogram that demonstrated flow was used as a conservative estimate of the
outpatients
OF
version
of the
x2 -test was used for analysis of all variables except age. In the spontaneous thrombosis group, the presence or absence of a bruit was described in only eight cases.
change
or a decrease
One patient decrease
in volume
on follow-up
in the spontaneous
thrombosis
in the volume
of flow
in the lumen
examinations.
group after
had a an initial
increase in volume. Three patients in the surgery group had an increase in the volume of flow in the lumen on follow-up studies; in one of these, the increase in volume of flow followed a decrease in the volume of flow. On the initial examination, 13 of 14 patients in the spontaneous thrombosis group had a circumferential thrombus; one had no detectable peripheral thrombus. On the initial examination, eight of 10 patients in the surgery group had a circumferential thrombus. Four patients in the spontaneous thrombosis
group
had
bibbed
pseudoaneurysms;
two
of
i 080
TABLE
PAULSON
3: Color Doppler
up Study
Showing
Sonographic
Flow
in Patients
Artery After Cardiac
the Femoral
Downloaded from www.ajronline.org by 117.255.232.156 on 10/09/15 from IP address 117.255.232.156. Copyright ARRS. For personal use only; all rights reserved
(n
of
9)
8.9 ± 1 1 .2
3.8
Mean
±iSD 1 2.0 ± 8.4
Wilcoxon
Median 1 6.0
1 .8 ± 3.3
0.47
4.4
± 3.2
4.5
0.02
29 ± 30
16
46 ± 34
41
0.19
bosis than in the surgery
2.3±1
2
3.3±1
2.8
neck of pseu76 ± 36
1 00
75 ± 35
1 00
of error.
of flow. This characteristic
was
group.
In both groups
of patients, in
Discussion
stantial
femoral
pseudoaneurysms
Finally,
the differences
in the volume
of flow
in the
lumen between the two groups of patients was statistically significant only for the final follow-up study showing flow. Thus, we think that in clinical practice, findings on color Doppler imaging cannot be used alone to predict subsequent thrombosis. This study confirms previous reports [i 0-i 3] that a sub-
these developed during the follow-up period. In the surgery group, two patients had bibbed pseudoaneurysms and one had a trilobed pseudoaneurysm. One of the bibbed pseudoaneurysms developed during the follow-up period.
surgically
be used
in both groups of patients. Second, the diameter of the lumen that would distinguish between the means of the two groups is only approximately 0.5 cm, as a cubic function is involved. Although a variation of this magnitude can be caused by differences in sensitivity settings of the instruments rather than by true differences in volumes, we attempted to standardize our technique in order to reduce this possible source
1.00
Note-All p values were determined by using the exact version of the Wilcoxon test. The values given for volume of flow in lumen/volume of pseudoaneurysm are derived from the mean and standard deviation of each individual measurement. % Diastole = the percentage of the diastolic portion of the cardiac cycle that demonstrated flow.
Traditionally,
could
a larger volume of flow has important limitations. First, there is substantial overlap between the volume of flow in the lumen
in
doaneurysm % Diastole
that
The suggestion that a pseudoaneurysm with a small volume of flow in the lumen is more likely to thrombose than one with
0.24
ward to reversed flow velocity
parameters
the volume of the pseudoaneurysm and the volume of flow the lumen tended to remain unchanged or to decrease.
(%)
Ratiooffor-
imaging
statistically significant only for the final sonogram showing flow. Although no other differences in imaging characteristics were statistically significant, the overall volume of the pseudoaneurysm, the volume of flow in the lumen, and the percentage of flow were all lower and the neck of the pseudoaneurysm was longer in the group with spontaneous throm-
pseudoaneurysm (ml) Volume of flow in lumen/volume of pseudoaneurysm
determining
are those with larger volumes
0.28
pseudoaneu-
rysm (ml) Volume of flow in lumen of
to surgical management; however, complications with this procedure have been reported [i 4]. as some pseudoaneurysms thnombose sponta-
to predict spontaneous thrombosis would be important to potentially obviate other intervention. This study shows that pseudoaneurysms with small volumes of flow in the lumen are more likely to thnombose than
Group =
p Value
Median
±1SD
substitute associated Inasmuch
of
AJR:159, November 1992
AL.
neously, Surgery (n
14)
=
Mean
Volume
in Final Follow-
Pseudoaneurysms
Catheterization
Spontaneous Thrombosis Group
Variable
Findings with
ET
proportion
of pseudoaneurysms
occurring
after
diac catheterization will thrombose spontaneously. On age, patients had surgery within i day of the average mum time to spontaneous thrombosis. This suggests the surgery patients had been observed longer, more
have been treated
to avoid the potential complication of rupture [4, 7nonsungical sonognaphically guided compnestherapy has been suggested as a feasible
9]. Recently, sion-occlusion
car-
averminithat if of the
40 30 35 25
30 25
.
20
20
15
-a 15
10 10
5 0 1
SERIAl.
A
cou ExAMU4A’noN
3
2 SERIAL
CDU
EXAMINATiON
B
Fig. 2.-A, Graph shows actual volumes of pseudoaneurysm on follow-up color Doppler (CDU) images 14). B, Graph shows actual volumes of pseudoaneurysm in patients who had surgery (n = 9).
in patients
with spontaneous
thrombosis
(n
=
