Ultrasonographic evaluation of complications related to transfemoral arterial procedures

Abstract

The transfemoral arterial approach is used to gain access for angiography, percutaneous coronary interventions, or various endovascular therapies. To decrease the risk of procedure-related vascular complications, it is recommended to puncture the common femoral artery in its middle segment. However, due to inadequate access or anatomical variability, various complications, including hematoma, pseudoaneurysm, arteriovenous fistula, thrombosis, or dissection, can occur after transfemoral arterial interventions. Duplex ultrasound has proven to be an excellent noninvasive modality that provides not only anatomic but also hemodynamic information, effectively detecting and differentiating various femoral puncture-related complications. Radiologists should be familiar with the characteristic sonographic findings of the entire spectrum of transfemoral puncture-related vascular complications for early detection and proper treatment.

Keywords: Aneurysm, false; Arteriovenous fistula; Femoral artery; Punctures; Ultrasonography.

Fig. 1.. The anatomy relevant to percutaneous catheterization of the femoral artery and vein.

Femoral vessels pass underneath the inguinal ligament, which connects the anterior-superior iliac spine and the pubic tubercle. Approximately one whole and one half to two fingerbreadths (3 cm) below the inguinal ligament, the area where the femoral artery pulse is felt is the appropriate arterial puncture site. The venous puncture site should be medially placed approximately at one fingerbreadth at the same level.

Fig. 2.. Hematoma of a 56-year-old man with a palpable mass in the left inguinal areas 5 days after underlying a procedure using the transfemoral arterial approach.

A, B. A gray-scale image with longitudinal (A) and transverse (B) ultrasonography shows a lobulated anechoic lesion (arrows) along the left common femoral artery. C. A color Doppler ultrasonography reveals a hematoma (arrows) without internal flow or communication with the artery.

Fig. 3.. Hematoma of a 58-year-old man with a palpable hard mass in the left inguinal region 1 month after undergoing a procedure using the transfemoral arterial approach.

A gray-scale ultrasonography shows an ill-defined isoechoic lesion that is similar to the surrounding tissue due to disruption of the echotexture of the muscle by an intramuscular hematoma of intermediate age.

Fig. 4.. Pseudoaneurysm of a 79-year-old man who complained a palpable mass and audible bruit in the right inguinal area.

He underwent stent insertion at the left anterior descending coronary artery 1 week before the ultrasound. A. A gray-scale ultrasonography shows a well-defined anechoic cystic mass in which echogenic material has been deposited. B. Color Doppler ultrasonography shows a bidirectional, turbulent, swirling blood-flow pattern known as the “yin-yang” sign within a pseudoaneurysm. Note the small amount of peripheral thrombi (arrows) within the pseudoaneurysm.

Fig. 5.. Pseudoaneurysm of a 55-year-old man with a pulsatile inguinal mass and audible bruit 1 day after undergoing percutaneous stent insertion in the left anterior descending artery.

A. Computed tomography scan shows a partially thrombosed pseudoaneurysm (arrows) measuring about 3×5 cm. B. Spectral Doppler ultrasonography shows the “to-and-fro” flow in the communicating neck between the arterial vessel and pseudoaneurysmal sac.

Fig. 6.. Ultrasound-guided thrombin injection.

Guided by ultrasonography, the needle was inserted at the far away from the neck which communicating native common femoral artery, and the thrombin was carefully injected into the pseudoaneurysmal sac. During the procedure, ultrasonographic examination is essential to avoid embolic events in the native common femoral artery.

Fig. 7.. Arteriovenous fistula of a 66-year-old woman with audible bruit at the right femoral puncture site 3 days after undergoing femoral catheterization for radiofrequency ablation to treat ventricular tachycardia.

A. Color Doppler ultrasonography shows direct communication (arrow) between the superficial femoral artery (A) and the common femoral vein (V), as well as a turbulent, high-velocity flow spectrum at the junction of the artery and the vein (arrowheads). B. Spectral Doppler ultrasonography reveals a high-velocity arterialized waveform in the draining vein.

Fig. 8.. Arteriovenous fistula of a 72-year-old woman with audible bruit in the right inguinal area 2 days after undergoing cerebral angiography.

A. A color Doppler ultrasonography of the sagittal shows perivascular bruit and aliasing within the dilated common femoral vein (arrows), which indicates a high-velocity flow from the communicating artery, although the connecting channel is not clearly noted. B. Spectral Doppler ultrasonography reveals a high-velocity arterialized waveform in the draining vein, which is a direct sign of an arteriovenous fistula.

Fig. 9.. Combined arteriovenous fistula and pseudoaneurysm of a 39-year-old man who underwent femoral puncture 2 times due to cerebral coil embolization of the right posterior cerebral artery and patent foramen ovale closure.

A-C. Serial computed tomography images show an arteriovenous fistula (arrowheads, A) between the superficial femoral artery (sA) and common femoral vein (V). Another lobulated pseudoaneurysm (arrows, B, C) is found arising from the sA. D is a deep femoral artery.

Fig. 10.. Femoral artery dissection of a 57-year-old woman who complained right leg numbness 2 days after femoral angiography.

A, B. Gray-scale longitudinal (A) and transverse (B) ultrasonography shows a linear echogenic flap separating the lumen of the femoral artery. C, D. Color Doppler longitudinal (C) and transverse (D) ultrasonography also shows the double lumen partially separated by the echogenic flap (arrows).

Fig. 11.. Arterial thrombus of a 68-year-old woman who complained numbness and coldness in her right lower leg 4 days after femoral angiography.

A. A gray-scale ultrasonography shows inhomogeneous echogenic material filling the femoral artery. B. A color Doppler ultrasonography shows the absence of color flow within the arterial lumen, indicating a thrombus.

Fig. 12.. Retroperitoneal hemorrhage of a 57-year-old man who complained pain in his right lower quadrant and lower back 2 days after coil embolization of the right vertebral artery for a dissecting aneurysm.

A-C. Serial computed tomography images show the large retroperitoneal hematoma due to bleeding from the external iliac artery (arrows). D. Gray-scale ultrasonography shows an inhomogeneous echogenic retroperitoneal hemorrhage (arrows).