Liver transplantation in a randomized controlled trial of emergency treatment of acutely bleeding esophageal varices in cirrhosis.

BACKGROUND: Bleeding esophageal varices (BEV) in cirrhosis has been considered an indication for liver transplantation (LT). This issue was examined in a randomized controlled trial (RCT) of unselected, consecutive patients with advanced cirrhosis and BEV that compared endoscopic sclerotherapy (EST; n = 106) to emergency direct portacaval shunt (EPCS; n = 105). METHODS: Diagnostic work-up and treatment were initiated within 8 hours. Patients were evaluated for LT on admission and repeatedly thereafter; 96% underwent over 10 years of regular follow-up. The analysis was supplemented by 1300 unrandomized cirrhotic patients who previously underwent portacaval shunt (PCS) with 100% follow-up. RESULTS: In the RCT long-term bleeding control was 100% following EPCS, only 20% following EST. Also, 3-, 5-, 10-, and 15-year survival rates were 75%, 73%, 46%, and 46%, respectively, following EPCS compared with 44%, 21%, 9%, and 9% following EST, respectively (P < .001). Only 13 RCT patients (6%) were ultimately referred for LT mainly because of progressive liver failure; only 7 (3%) were approved for LT and only 4 (2%) underwent LT. The 1- and 5-year LT survival rates were 0.68% and 0, respectively, compared with 81% and 73%, respectively, after EPCS. In the 1300 unrandomized PCS patients, 50 (3.8%) were referred and 19 (1.5%) underwent LT. The 5-year survival rate was 53% compared with 72% for all 1300 patients. CONCLUSIONS: If bleeding is permanently controlled, as occurred invariably following EPCS, cirrhotic patients with BEV seldom require LT. PCS is effective first-line and long-term treatment. Should LT be required in patients with PCS, although technically more demanding, numerous studies have shown that PCS does not increase mortality or complications. EST is not effective emergency or long-term therapy.

Yield of repeated screening for abdominal aortic aneurysm after a 4-year interval. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators.

BACKGROUND: Little is known about the rate at which new abdominal aortic aneurysms (AAAs) develop or whether screening older men for AAA, if undertaken, should be limited to once in a lifetime or repeated at intervals. METHODS: A large population of veterans, aged 50 through 79 years, completed a questionnaire and underwent ultrasound screening for AAA. Of these, 5151 without AAA on the initial ultrasound (defined as infrarenal aortic diameter of 3.0 cm or larger) were selected randomly to be invited for a second ultrasound screening after an interval of 4 years. Local records and national databases were searched to identify deaths and AAA diagnoses made during the study interval in subjects who did not attend the rescreening. RESULTS: Of the 5151 subjects selected for a second screening, 598 (11.6%) had died (none due to AAA), and 20 (0.4%) had an interim diagnosis of AAA. A second screening was performed on 2622 (50.9%), of whom 58 (2.2%; 95% confidence interval, 1.6%-2.8%) had new AAA. Three new AAAs were 4.0 to 4.9 cm, 10 were 3.5 to 3.9 cm, and 45 were 3.0 to 3.4 cm. Independent predictors of new AAA at the second screening included current smoker (odds ratio, 3.09; 95% confidence, 1.74-5.50), coronary artery disease (odds ratio, 1.81; 95% confidence interval, 1.07-3.07), and, in a separate model using a composite variable, any atherosclerosis (odds ratio, 1.97; 95% confidence interval, 1.16-3.35). Adding the interim and rescreening diagnosis rates suggests a 4-year incidence rate of 2.6%. Rescreening only in subjects with infrarenal aortic diameter of 2.5 cm or greater on the initial ultrasound would have missed more than two thirds of the new AAAs. CONCLUSIONS: A second screening is of little practical value after 4 years, mainly because the AAAs detected are small. However, the incidence that we observed suggests that a second screening after longer intervals (ie, more than 8 years) may provide yields similar to those seen in initial screening and therefore warrants further study.

The aneurysm detection and management study screening program: validation cohort and final results. Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators.

BACKGROUND: We previously reported the prevalence and associations of abdominal aortic aneurysm (AAA) in 73451 veterans aged 50 to 79 years who underwent ultrasound screening. OBJECTIVE: To understand the prevalence of and principal positive and negative risk factors for AAA, and to assess reproducibility of our previous findings. METHODS: In the new cohort of veterans undergoing screening, 52 745 subjects aged 50 to 79 without history of AAA underwent successful ultrasound screening for AAA, after completing a questionnaire on demographics and potential risk factors. RESULTS: We detected AAA of 4.0 cm or larger in 613 participants (1.2%; compared with 1.4% in the earlier cohort). The direction and magnitude of the important associations reported in the first cohort were confirmed. Respective odds ratios for the major associations with AAA for the second and for the combined cohorts were as follows: 1.81 and 1.71 for age (per 7 years), 0.12 and 0. 18 for female sex, 0.59 and 0.53 for black race, 1.94 and 1.94 for family history of AAA, 4.45 and 5.07 for smoking, 0.50 and 0.52 for diabetes, and 1.60 and 1.66 for atherosclerotic diseases. The excess prevalence associated with smoking accounted for 75% of all AAAs of 4.0 cm or larger in the total population of 126 196. Associations for AAA of 3.0 to 3.9 cm were similar but tended to be somewhat weaker. CONCLUSIONS: Our findings confirm our previous cohort findings. Age, smoking, family history of AAA, and atherosclerotic diseases remained the principal positive associations with AAA, and female sex, diabetes, and black race remained the principal negative associations.

Compression therapy for acute iatrogenic femoral pseudoaneurysms.

The marked increase in performance of percutaneous catheter-based vascular interventions combined with aggressive anticoagulation regimens has resulted in a greater frequency of iatrogenic femoral artery pseudoaneurysms. Of the available treatment modalities, ultrasound-guided compression has been shown to be widely available, easy to perform, noninvasive, effective, safe, and inexpensive. It is currently the procedure of choice for treatment of these iatrogenic femoral artery injuries.

Validation of selective cardiac evaluation prior to aortic aneurysm repair.

OBJECTIVE: To evaluate perioperative and long-term morbidity in patients undergoing selective evaluation of coronary artery disease prior to abdominal aortic aneurysm (AAA) repair. DESIGN: Case series. SETTING: University and Veterans' Administration medical centers. PATIENTS: One hundred eighty-nine consecutive patients undergoing AAA repair between January 1989 and September 1996 were selectively evaluated for coronary artery disease and assigned to 1 of 3 groups: group 1, no abnormal cardiac history, normal electrocardiogram; group 2, minimal symptoms, history of myocardial infarction (MI), older than 70 years, diabetes mellitus, or congestive heart failure; or group 3, severe or unstable angina, ventricular dysfunction. INTERVENTIONS: Group 1 patients proceeded to AAA repair without further workup. Group 2 patients underwent pharmacologic or exercise stress testing followed by coronary angiography and intervention as required. Group 3 patients went directly to coronary angiography and intervention as needed. MAIN OUTCOME MEASURES: Perioperative MI, arrhythmias, or death. Long-term follow-up measures included MI and death. RESULTS: Adequate documentation was available on 171 patients. Twenty-four patients (14%) were in group 1. Of 136 patients (79.5%) in group 2, coronary angiography was performed in 36 (26%), followed by percutaneous transluminal coronary angioplasty (PTCA) in 9 (7%) and coronary artery bypass (CAB) in 5 (4%). Of 11 patients in group 3, 3 (27%) each received PTCA and CAB. Remote CAB or PTCA had been performed in 32 (19%) and 12 (7%) patients, respectively. Two perioperative deaths (1.1%) occurred in the 189 patients, one due to MI in a group 2 patient. There were 2 (1%) nonfatal MIs, both in group 2 patients who had no preoperative intervention. Arrhythmias and/or congestive heart failure occurred in 17 (9%) cases, 7 (39%) having had recent coronary revascularization (P = .001). By univariate analysis, only preoperative renal dysfunction predicted perioperative complications (P = .03) Overall survival by lifetable analysis was 87.9% and 69.7% at 3 and 5 years, respectively. CONCLUSION: Coronary artery disease is common in patients undergoing AAA repair, with 35.7% having preoperative coronary revascularization at some point. Selective preoperative coronary artery disease screening achieves excellent perioperative and late results in this population.

Relationship of age, gender, race, and body size to infrarenal aortic diameter. The Aneurysm Detection and Management (ADAM) Veterans Affairs Cooperative Study Investigators.

PURPOSE: To assess the effects of age, gender, race, and body size on infrarenal aortic diameter (IAD) and to determine expected values for IAD on the basis of these factors. METHODS: Veterans aged 50 to 79 years at 15 Department of Veterans Affairs medical centers were invited to undergo ultrasound measurement of IAD and complete a pre-screening questionnaire. We report here on 69,905 subjects who had no previous history of abdominal aortic aneurysm (AAA) and no ultrasound evidence of AAA (defined as IAD > or = 3.0 cm). RESULTS: Although age, gender, black race, height, weight, body mass index, and body surface area were associated with IAD by multivariate linear regression (all p < 0.001), the effects were small. Female sex was associated with a 0.14 cm reduction in IAD and black race with a 0.01 cm increase in IAD. A 0.1 cm change in IAD was associated with large changes in the independent variables: 29 years in age, 19 cm or 40 cm in height, 35 kg in weight, 11 kg/m2 in body mass index, and 0.35 m2 in body surface area. Nearly all height-weight groups were within 0.1 cm of the gender means, and the unadjusted gender means differed by only 0.23 cm. The variation among medical centers had more influence on IAD than did the combination of age, gender, race, and body size. CONCLUSIONS: Age, gender, race, and body size have statistically significant but small effects on IAD. Use of these parameters to define AAA may not offer sufficient advantage over simpler definitions (such as an IAD > or = 3.0 cm) to be warranted.

Management of infectious and cutaneous complications in vascular access.

Infectious complications in vascular access grafts, primarily seen in those using synthetic graft material, are the major cause of morbidity and mortality in this high-risk group of dialysis-dependent patients. These patients are more prone to infection because of their age, renal failure, and other associated diseases such as diabetes, and they do not fight infections well. This chapter discusses the pathogenesis and bacteriology of these infections and their clinical signs and symptoms. Preventive management can obviate most of these infectious complications and is also outlined. Surgical intervention must be specifically tailored to each patient and their graft, and in many cases alternatives need to be considered.

Diagnosis and management of patients with peripheral macroemboli from thoracic aortic pathology.

Transesophageal echocardiography (TEE) has improved the detection of thoracic aortic pathology and further elucidated its role as a source of peripheral arterial emboli. Since 1993 we have used TEE to evaluate the thoracic aorta in patients with peripheral emboli without identifiable cardiac sources. Five patients suffered a total of eight embolic events originating from thoracic aortic mural thrombus (TAMT). The four females and one male ranged in age from 56 to 82 years. Emboli occurred to the upper extremities in four instances, lower extremities in three instances, and the visceral vessels in a single instance. Thromboembolectomy was performed in each case except for a patient who initially underwent aortobifemoral bypass. He was discovered to have TAMT after a subsequent embolic event. All patients were anticoagulated after TAMT was identified but in one case anticoagulants were discontinued after an intraabdominal hemorrhage. All patients are alive without limb loss while one patient has experienced recurrent embolization despite anticoagulation. TEE is a sensitive and useful diagnostic modality in patients with "cryptogenic" arterial embolization. Whether surgical management or anticoagulation for the primary lesion is optimal therapy remains a question. However, anticoagulation appears effective in this small experience.

Factors influencing the outcome of paramalleolar bypass grafts.

Reported patency rates for paramalleolar bypass grafts have varied widely. To determine factors predictive of outcome, we reviewed our experience with 80 consecutive paramalleolar reconstructions in 68 patients performed between December 1986 and May 1995. All procedures were performed for critical limb ischemia defined as nonhealing ulcer or gangrene (n = 72, 90%) and rest pain (n = 8, 10%). Risk factors present were diabetes (n = 52, 65%), hypertension (n = 64, 80%), and history of smoking (n = 57, 71%). Of the 80 bypasses, in situ saphenous vein conduits were used in 39 (49%). In the remainder non-in situ grafts were used including reversed vein (n = 25, 31%), composite vein (n = 11, 14%), polytetrafluoroethylene (PTFE; n = 4, 5%), and composite PTFE/vein (n = 1, 1%). The recipient vessel was the dorsalis pedis artery in 26 procedures (33%), the posterior tibial artery in 32 (40%), the distal anterior tibial artery in 18 (22%), and tarsal or plantar vessels in four (5%). Primary and secondary patency rates were 52% and 68% at 36 months, respectively, by life-table analysis. The limb salvage rate was 86% and patient survival was 56% at 36 months. Secondary patency was significantly higher in diabetic patients than in their nondiabetic counterparts (86% vs. 50% at 36 months, p < 0.03). Similarly, patients undergoing in situ reconstructions had better secondary patency than patients with non-in situ conduits (86% vs. 51% at 36 months, p = 0.03). Diabetic patients tended to be younger (median age 69 years vs. 72 years) and had fewer prior reconstructions (7 [13%] vs. 13 [46%], p < 0.01). Diabetic patients received a higher proportion of in situ reconstructions (54% vs. 39%) but the difference did not achieve statistical significance (p = 0.09). We conclude that the long-term patency for paramalleolar bypass is acceptable but inferior to reported figures for more proximal reconstructions. The factors that most influence patency are the quality of the venous conduit and the presence of diabetes. The improved patency seen in diabetic patients is likely related to the fact that these patients require paramalleolar bypass at an earlier age, are less likely to have had previous reconstructions, and are therefore more likely to have a good quality venous conduit.

Ruptured renal artery aneurysm during pregnancy.

A 38-year-old woman (gravida 4, para 1) underwent arteriography at 19 weeks' gestation after two exploratory laparotomies had failed to identify a source of retroperitoneal and intra-abdominal hemorrhage. The arteriogram demonstrated a large right renal artery aneurysm (RAA) and a very small left RAA. Emergency repair of the aneurysm was attempted but was impossible, so a right nephrectomy was performed. The fetus had died prior to arteriography and a cesarean section was performed concomitantly. The postoperative course was unremarkable. RAAs are rare and usually asymptomatic, but pregnancy is associated with a higher risk of rupture. Prior to 1970, reported rupture occurred most often on the left side, during the third trimester, and was associated with a 92% maternal mortality and a 100% fetal mortality rate. Since 1970, published reports have not shown a left-sided predominance, and survival after this catastrophic event has greatly improved, even though preoperative diagnosis is still rare. The possibility of a ruptured RAA should be considered in pregnant women with evidence of retroperitoneal hemorrhage. Arterial repair should be attempted but has not been feasible in most cases. This case was unusual because it occurred during the second trimester of pregnancy. Recent cases and technical considerations regarding repair are discussed.

Detection and treatment of dysfunctional hemodialysis access grafts: effect of a surveillance program on graft patency and the incidence of thrombosis.

PURPOSE: To determine the value of a hemodialysis graft surveillance program in reducing the incidence of graft thrombosis and prolonging graft patency by means of early detection and percutaneous transluminal angioplasty (PTA) of graft-related stenoses. MATERIALS AND METHODS: For 4-1/2 years, routine graft examination and measurement of several dialysis parameters were used to identify 106 cases of suspected graft dysfunction in 57 patients (56 men, one woman; aged 27-76 years). Graft-related stenoses detected with angiography were treated with PTA. RESULTS: Abnormal physical examination findings were the most common sole indication of graft dysfunction. Of the 106 cases referred for angiographic evaluation, 97 (92%) had at least one lesion. PTA was successful in 88 of 90 treated cases. The primary patency rates at 1 year were 16% for arteriovenous fistulas (AVFs) and 23% for polytetrafluoroethylene (PTFE) grafts. Early detection of stenoses by means of surveillance and repeated PTA enabled 1-year primary assisted patency rates of 67% for AVFs and 68% for PTFE grafts. The incidence of graft thrombosis fell from 48% in 1988 to 17% in 1994 (P < .001). CONCLUSION: The hemodialysis graft surveillance program resulted in a statistically significant reduction in the incidence of graft thrombosis. Although primary patency rates after PTA were low, repeated PTA of detected stenoses allowed good primary assisted patency rates.

An unusual variant of popliteal artery entrapment.

A 43-year-old woman presented with incapacitating exertional pain in the right foot, ankle, and lower calf of 1 years' duration following a minor ankle sprain. Evaluation by several physicians had been inconclusive. Physical examination identified normal pedal pulses at rest but obliteration of pulses with active plantar flexion. Segmental pressures were normal at rest and duplex scanning showed occlusion of the popliteal artery with active plantar flexion. The findings were confirmed by arteriography despite a normal course of the popliteal artery. Magnetic resonance imaging (MRI) showed no muscular abnormality. At exploration entrapment was noted to be the result of compression by branches of the sural nerve and vein as they coursed medially inserting into the medial head of the gastrocnemius muscle. Division of the neurovascular bundle resulted in complete resolution of symptoms and arterial compression on duplex examination postoperatively. This case was unusual because of the patient's age, sex, and the pathologic findings that had not been previously reported. In this case MRI was not useful in demonstrating a muscular or neurovascular bundle abnormality, supporting the use of duplex scanning as the noninvasive diagnostic modality of choice.

Hand ischemia in patients with hemodialysis access grafts: angiographic diagnosis and treatment.

PURPOSE: To determine the cause of symptoms and efficacy of transcatheter therapy in a series of patients with dialysis grafts and hand pain referred for arteriography. MATERIALS AND METHODS: Thirteen patients with 14 hemodialysis grafts underwent arteriography for possible hand ischemia. The sites of proximal graft anastomosis were the distal radial artery (n = 6) and the mid- to distal brachial artery (n = 6). Transcatheter therapy was performed via the graft or by antegrade brachical puncture. RESULTS: The cause of symptoms was ischemia from obstructive arterial disease in seven cases (three with superimposed steal), graft steal alone in three, ischemic monomelic neuropathy in two, and carpal tunnel syndrome in two. Five arterial stenoses were treated with angioplasty, with improvement or resolution of symptoms in four patients. CONCLUSION: In this group, symptoms were usually the result of inflow or outflow arterial disease, alone or in combination with graft steal. Transcatheter therapy (angioplasty or embolization) is effective in selected cases.

Nitroglycerin decreases medial smooth muscle cell proliferation after arterial balloon injury.

PURPOSE: Nitroglycerin and its effector molecules nitric oxide and cyclic guanosine monophosphate decrease smooth muscle cell proliferation in vitro. We examined the in vivo effect of nitroglycerin on intimal hyperplasia. METHODS: We treated rats after carotid artery balloon injury with nitroglycerin delivered paraarterially with a miniosmotic pump for 1 week. RESULTS: High nitroglycerin serum levels were achieved, and the level of cyclic guanosine monophosphate in the carotid artery wall was significantly increased (1.48 +/- 0.37 vs 0.86 +/- 0.39 pmol/mg protein; p < 0.05) in the nitroglycerin-treated group. Cellular proliferation in the arterial wall was assessed by incorporation of 5-bromo-2'-deoxyuridine 6 days after the injury and was lower in the nitroglycerin-treated group (15.2 +/- 3.4 vs 36.3 +/- 5.5 positive cells/section; p < 0.005). This was due to a decrease in the number of proliferating cells in the media (6.3 +/- 1.2 vs 21.8 +/- 4.5; p < 0.005), whereas in the budding neointima, the difference in the number of proliferating cells was not significant. Neointimal lesions 21 days after the injury did not differ in cross-sectional intimal area, in intimal/medial area ratio, and in cell density. CONCLUSION: Nitroglycerin decreased medial cellular proliferation after balloon injury and had no significant effect on intimal proliferation. The size of the neointimal lesion was not affected by nitroglycerin therapy.

Postangiographic femoral artery pseudoaneurysms: further experience with US-guided compression repair.

PURPOSE: To assess the efficacy of ultrasound-guided compression repair (UGCR) in postcatheterization femoral artery pseudoaneurysms. MATERIALS AND METHODS: One hundred thirty-three patients with pseudoaneurysms were considered for UGCR. Patients underwent compression with duplex and color Doppler ultrasound. Immediate and long-term successes were evaluated. RESULTS: Seven patients were not candidates for UGCR. UGCR was technically possible in 117 of the 126 patients who were candidates. UGCR was successful in 109 patients. The failure rate was significantly higher in patients who were receiving anticoagulant medication (P < .001). Pseudoaneurysm size, age, and structure (simple vs multiloculated) had no bearing on success or failure. The time required for successful compression was not related to treatment with anticoagulants but was related to pseudoaneurysm structure. Complications included one case of a distal embolus and two episodes of hypotension. CONCLUSION: UGCR is a simple and expedient method for the treatment of postcatheterization femoral artery pseudoaneurysms.

Ischemic monomelic neuropathy: an under-recognized complication of hemodialysis access.

During the past 3 years six episodes of ischemic monomelic neuropathy (IMN) have been identified in five patients as a complication of upper extremity dialysis grafts. All patients had long-standing insulin-dependent diabetes, peripheral neuropathy, and brachial artery graft origins, whereas 60% had peripheral vascular disease. Five episodes occurred immediately after graft placement, whereas one was due to a graft-related thromboembolus. Diagnostic delay was common with initial findings attributed to anesthesia, positioning, or surgical trauma. Electrophysiologic studies showed underlying diabetic neuropathy with severe multifocal neuropathy distal to the grafts. Digital pressure indices were reduced but there was no critical ischemia. In three cases ischemia was completely corrected with improvement in one. One patient had proximal balloon angioplasty with no improvement and of the two untreated patients, one improved slightly. Ischemic monomelic neuropathy is a rare but disabling complication of dialysis access in diabetic uremic patients. Its occurrence is unpredictable and diagnostic delay is common. Correction of ischemia is indicated but usually does not improve the neuropathy. Prevention requires further research to more accurately characterize the patients at risk.

Is thrombolysis of occluded popliteal and tibial bypass grafts worthwhile?

PURPOSE: We analyzed the short- and long-term results for patients undergoing thrombolysis of occluded infrainguinal bypass grafts at our institution over a 62-month period. METHODS: Thirty-one patients with 40 episodes of graft thrombosis in 33 grafts managed by thrombolysis were retrospectively reviewed. The effects of graft age, material, and anatomy, symptoms, treatment, anticoagulation, and occlusion duration were evaluated for impact on patency after thrombolysis. Dose and duration of therapy with use of the technique of pulse-spray thrombolysis was assessed. RESULTS: Thrombolysis successfully reestablished patency in 92% of grafts treated. Mean lysis time and urokinase dose were 118 minutes and 607,000 units, respectively. Responsible lesions were identified and treated by angioplasty or surgery in 35 of 37 cases. The patency rate after thrombolysis was 28% at 30 months, and the secondary patency rate was 46% at 18 months. Duration of occlusion, symptoms, treatment, graft anatomy, and prior graft revision did not impact on patency. Mean secondary patency was 21.5 months in grafts in place over 1 year and 7.0 months in grafts in place for less than 1 year. Mean secondary patency was 23.8 months in polytetrafluoroethylene grafts and 8.4 months in vein grafts. The limb salvage rate was 84% at 30 months, and the patient survival rate was 84% at 42 months. CONCLUSIONS: Pulse-spray thrombolysis is effective in rapidly recanalizing thrombosed infrainguinal grafts. Grafts failing in the first year after placement should generally be replaced, reserving thrombolysis and revision for grafts greater than 1 year old. Vein grafts tolerate thrombosis less well than synthetic conduits and have decreased long-term patency.

Pulse-spray pharmacomechanical thrombolysis for treatment of thrombosed dialysis access grafts.

The results of pulse-spray pharmacomechanical thrombolysis (PSPMT) of 209 thrombosed hemodialysis grafts were reviewed. In PSPMT, concentrated urokinase is injected forcefully through catheters with multiple tiny sideholes or sideslits. Catheters placed in a crisscross fashion cover the entire clot simultaneously. This therapy was successful in treating patients with thrombosed grafts. Of the 200 grafts with complete therapy, 197 grafts (99%) were patent at the end of the procedure. Mean time for pulsed-spray lysis was 40 minutes. Etiologies for graft thrombosis were anastomotic venous outflow stenosis, stenosis of the venous outflow away from the anastomosis, arterial stenosis, intragraft stenosis, pseudoaneurysms, and no identifiable cause in a small percentage. There were 16 complications, 8 of which required additional therapy or potentially compromised the graft. These results suggest that pharmacomechanical thrombolysis and angioplasty provide rapid, consistent, and safe recanalization of thrombosed hemodialysis grafts and represent an additional therapeutic approach to graft management.

Selective management of iatrogenic femoral artery injuries.

Increased femoral artery catheterization for therapy and diagnosis has resulted in a concomitant increase in iatrogenic femoral artery injuries. A 33-month experience at two affiliated institutions was reviewed to evaluate the results of a selective approach to management of these complications. During this period, 9576 femoral artery catheterizations were performed. Eighty-nine femoral artery injuries were treated surgically or by ultrasound-guided compression therapy. Cardiac catheterization procedures predominated and 61% of patients were anticoagulated. Thirty-eight cases were treated surgically: 14 pseudoaneurysms, 16 hematomas, 6 arteriovenous fistulas, 2 thromboses. Local anesthesia was used in 28 cases (74%). Arterial repair was required in 34 cases, with control being achieved below the inguinal ligament in 33 cases (97%). Punctures were found in the superficial femoral or profunda femoral rather than the common femoral artery in 17 of 38 cases (44%, P < 0.001 compared with the ultrasound group). There were two deaths (5.3%), six wound infections (16%), and no limb loss. Ultrasound-guided compression was preferentially used for stable or slowly expanding pseudoaneurysms. Cases with large hematomas causing skin ischemia were treated surgically. The pseudoaneurysms ranged from 2 to 7 cm in diameter. This technique was effective in 46 of 51 cases (90%). A single thromboembolic complication was treated by thrombolysis. There were no late recurrences. We conclude that (1) iatrogenic femoral artery injuries are associated with postcatheterization anticoagulation and punctures not located in the common femoral artery; (2) injuries requiring surgery can usually be treated under local anesthesia with infrainguinal arterial control; (3) ultrasound-guided compression is an effective method for treating iatrogenic pseudoaneurysms not associated with large hematomas.