Percutaneous ultrasound-guided balloon-assisted embolization of iatrogenic femoral artery pseudoaneurysms with Glubran®2 cyanoacrylate glue: safety, efficacy and outcomes

Abstract

Background: Femoral pseudoaneurysm (PA) is a frequent complication of arterial access for endovascular procedures. Surgery has traditionally been considered as the gold standard of therapy. We aimed to report our experience of percutaneous ultrasound (US)-guided balloon-assisted embolization with cyanoacrylate glue for the treatment of iatrogenic femoral PAs.

Methods: Retrospective two-center study of patients with femoral iatrogenic PAs treated by N-butyl cyanoacrylate-methacryloxy sulfolane (NBCA-MS) Glubran^®2 glue embolization between July 2013 and November 2017. All patients underwent contralateral arterial access with balloon placement of an appropriate size in front of the PA neck before glue/lipiodol embolization in a 1:1 ratio by percutaneous US-guided puncture of the aneurysmal sac under fluoroscopy control.

Results: Twenty-three patients (12 females, 11 males; median age, 79 years; range, 18-93 years) were included. Median PA size was 34 mm (range, 17-60 mm). The median time to treatment was 5 days (range, 1-30 days). Twenty patients (86.9%) were successfully treated by glue injection alone. The three remaining patients (13.1%) with persistent PA or associated arterial-venous fistula were immediately treated during the same procedure by additional stent-graft. Then, overall immediate and 1-month clinical success rates were 100%. No surgical conversion was necessary. No recurrence was reported during the median follow-up of 11 months (range, 2-73 months). Two (8.7%) puncture-related complications occurred at the contralateral arterial access site, which spontaneously resolved. No non-target glue embolization occurred.

Conclusions: US-guided balloon-assisted glue embolization is safe and effective to treat iatrogenic femoral PAs in most cases, offering complete exclusion of the PA and avoiding the morbidity of open surgery.

Keywords: Pseudoaneurysm (PA); access site complication; cyanoacrylate glue; embolization; femoral artery.

Figure 1

Example of a 62-year-old man who developed a pulsatile mass with pain and groin hematoma 2 days after coronary angioplasty. (A) Color-Doppler US at the groin puncture site showed a 23 mm × 13 mm PA arising from the right proximal superficial femoral artery. The PA had 1 lobe and its neck is well seen (arrow); (B) arteriography by crossover from the left side confirmed the PA from the superficial femoral artery (arrow); (C) the PA sac was then punctured under US guidance with a 17-G metallic needle with hyperechoic tip (arrow); (D) after inflating a Mustang™ balloon of 7 mm in diameter in the parent artery in front of the PA neck to avoid reflux, a mixture of NBCA-MS (Glubran^®2) and Lipiodol Ultra-Fluide in a ratio of 1:1 was injected into the PA sac under fluoroscopy control until complete filling of the PA (arrow); (E) image after deflating easily the balloon showed, 3 minutes after the end of glue injection, showed no glue migration (arrow); (F) angiographic control after gluing demonstrated complete embolization of the PA (arrow) and confirmed patency of the parent artery; (G) Color-Doppler images obtained 1 day after the procedure confirmed that the absence of flow in the thrombosed PA sac and complete exclusion of the lesion (arrow). US, ultrasound; PA, pseudoaneurysm; NBCA-MS, N-butyl cyanoacrylate-methacryloxy sulfolane.