Femoral pseudoaneurysm is a common complication in percutaneous catheterization. Ultrasound-guided thrombin injection (UGTI) therapy has been developed as a less invasive and highly successful treatment of a femoral pseudoaneurysm. We performed UGTI therapy for 3 patients with iatrogenic femoral pseudoaneurysms that formed after femoral artery catheterization. Case 1 was a 76-year-old woman. Following the catheterization procedure, she developed a right femoral pseudoaneurysm and refused operative repair. After obtaining informed consent, we performed UGTI therapy for the pseudoaneurysm. Immediately after the treatment, the pain caused by the pseudoaneurysm disappeared and no recurrence has been seen. Case 2 was a 72-year-old woman. Following withdrawal of the transfemoral catheter, a right femoral pseudoaneurysm appeared. We performed UGTI therapy for the pseudoaneurysm, which became thrombotic after treatment. Case 3 was an 87-year-old man with a right femoral pseudoaneurysm after the catheterization procedure. We performed UGTI therapy for the pseudoaneurysm on 2 separate occasions, however, recurrence occurred following both and he finally underwent open surgical repair. In the present Cases 1, 2, and 3, the sizes of the catheters used were 6, 8, and 11.5Fr, respectively. Two of the patients were receiving percutaneous coronary artery intervention and continued undergoing anticoagulant therapy at the time of the injection. For all 3 patients, we injected human thrombin into the pseudoaneurysm percutaneously under ultrasound guide. Cases 1 and 2 had no recurrence after the first treatment, whereas Case 3 had 2 instances of pseudoaneurysm recurrence after treatment and finally received surgical repair. There were no complications derived from the treatment in any of the cases, nor was there evidence of embolism or allergic reaction originating from the thrombin. We concluded that UGTI therapy should be considered as an alternative treatment for a femoral pseudoaneurysm that occurs after catheterization.

To determine the usefulness of arterial reconstruction, we studied the outcome of 430 patients with arteriosclerosis obliterans who had received either arterial reconstructive surgery or medical treatment. Of the 430, 301 patients were treated for intermittent claudication and 162 for limb-threating ischemia (rest pain or ischemic gangrene). Of the intermittent claudication patients 274 underwent arterial reconstruction and 27 were treated with anticoagulant therapy. In limb-threating ischemia, 137 patients underwent arterial reconstruction and 25 were treated with anticoagulant therapy. Among the 274 intermittent claudication patients treated by arterial reconstruction, none required major amputation within 30 days after surgery. Operative mortality was 1.1%. Five- and ten- year comulative patency rates were 95.4%, 94.3% in aortofemoral bypasses, 72.7%, 67.5% in aortofemoropopliteal bypasses, 79.7%, 77.9% in femoropopliteal bypasses and 92.3%, 92.3% in femorotibial bypasses, respectively. On long-term results, 86.4% improved and 5.9% deteriorated. Five patients (1.4%) underwent major amputation during the follow-up period due to graft occlusion. Four of 5 amputations involved patients whose initial reconstruction method was femoropopliteal bypass. In 27 patients treated medically, 77.8% did not show any change in symptoms and 22.2% deteriorated during the follow-up period. Two patients (5.6%) underwent bypass grafting in the late phase. Of 137 patients with limb-threating ischemia treated by arterial reconstruction, 3.3% required major amputation in the early postoperative period. Operative mortality was 5.1%. Five- and 10-year cumulative patency rates were 83.3%, 79.7% in aortofemoral bypasses, 65.5%, 65.5% in aortofemoropopliteal bypasses, 76.2%, 63.9% in femoropopliteal bypasses and 38.6% in femorotibial bypasses, respectively. In long-term results, 62.3% improved and 12.6% deteriorated. Thirteen patients (8.6%) underwent major amputation during the follow-up period. In 25 patients with limb-threating ischemia treated medically, 16.0% died during their hospital stay and 33.3% required major amputation during the follow-up period. Five- and 10-year cumulative survival rates in arterial reconstruction patients were 77.4%, 57.6% in intermittent claudication patients and 64.3%, 41.5% in limb-threating ischemia patients, respectively. The survival rate in limb-threating ischemia was significantly lower than that in intermittent claudication. The results of reconstructive surgery for intermittent claudication were better than those of medical treatment. However, 4 femoropopliteal bysass cases required major amputation in the late phase. This suggests that it is difficult to determine the indications for infrainguinal artery reconstruction in intermittent claudication. Arterial reconstructive surgery for limb-threating ischemia was useful for salvaging the limbs. In these patients, careful perioperative treatment was necessary. Limb salvage rate and survival rate in limb-threating ischemia patients were poorer than those in intermittent claudication patients. We recommend performing arterial reconstructive surgery for disabling claudication before the patient progresses to limb-threating ischemia.

Magnification of the surgical field is considered an essential technique for performing accurate surgery on small caliber arteries. For this reason, we use the transmicroscopic technique of vascular surgery on the tibial arteries. We obtained good results in long term patency. Our experience and results in bypass grafting to the tibial artery using a microscope are reported. Forty-four tibial artery bypasses using transmicroscopic techniques were performed in 38 consecutive patients between June 1984 and December 1992. Twenty-seven patients had arteriosclerosis obliterans, 5 had thromboangitis obliterans, 5 had acute arterial occlusion and 1 had traumatic vascular injury. Patient ages ranged from 37 to 78 years old. Thirty-five were men and 3 were women. Twenty-six surgeries were performed for limb threatening and 14 were for disabling claudication. All patients were examined with conventional aortic lower extremity angiography preoperatively. The reversed saphenous vein was used in 38, in-situ saphenous vein in 3 and composite vein to vein graft in 2. All distal anastomoses were performed by the transmicroscopic technique. Continuous sutures were used for recipient vessels larger than 1.0mm in diameter. However interrupted 8-0 sutures were chosen for smaller vessels. Distal anastomosis was made at the proximal portion of the tibial artery in 24 cases, while the distal portion of the tibial artery was used in 20 cases. On preoperative angiography, the condition of the tibial arteries affected the patency rate when runoff was poor or fair. Nine cases were judged to have “poor” runoff. Three of these became occluded during the early postoperative period, and 1 during the late phase. Eight cases were judged to have “fair” runoff. One of these became occluded during the early postoperative period, and 3 during the late phase. There were no graft failures identified throughout the follow-up period in patients with good runoff. Cumulative patency rates were 86.2% after 1 year, 79.0% after 5 years, and 67.7% after 8 years, respectively. The patency rate of the 24 grafts in which distal anastomosis was performed on the proximal tibial artery was 71. 4% after 5 years. The patency rate of the 20 grafts on the distal tibial artery was 93.3% after 5 years. There was no significant difference observed in the patency of these two groups. Hospital mortality was 2.6%. Femorotibial bypass using transmicroscopic technique could save severely ischemic limbs while maintaining hospital mortality at a low level and reducing limb loss. The advantage of microscopic surgery is achieving fine observation because the magnification level is changeable, depending on the field needed. In anastomosis of small caliber vessels like the tibial artery, magnification by 10 times is important to observe the characteristics of the intima of the recipient artery. Subsequently, the procedure is performed by transmicroscopic techniques under magnification by 5 times, which provides much higher accuracy for suture than surgical loupe. High magnification prevents intraoperative technical error and unexpected injury.