CathLabHub

CathLabHub complications toolkitcathlabhub.com/toolkit/pseudoaneurysm-av-fistulaIn review, October 24, 2026

Recognize

The signs on the monitor, the image and the patient.

  • PatientA pulsatile, tender groin mass with a bruit (pseudoaneurysm) 1.
  • PatientA continuous bruit and a palpable thrill (fistula); rarely leg swelling or high output failure 12.
  • ImageDuplex: flow in and out of a cavity through a neck (pseudoaneurysm), or flow from artery to vein 1.
  • PatientRisk is higher with low punctures, combined arterial and venous access and heavy anticoagulation 1.

Act now

In the order the operator does them. The first three come first, whatever else is happening.

  1. Duplex ultrasound to confirm and measure 1.
  2. Pseudoaneurysm under 2 cm: observe; many close on their own 1.
  3. Pseudoaneurysm 2 cm or more with a narrow neck: ultrasound guided thrombin injection, then repeat ultrasound in 2 to 3 days 1.
  4. Wide neck, over 6 cm, infection, ischemia, skin necrosis or a synthetic graft: surgery 1.
  5. Ultrasound guided compression is an alternative, sometimes for over 30 to 45 minutes 1.
  6. Fistula: usually no treatment; a covered stent or surgery for large symptomatic ones 1.
  7. Sources differ: Kern reports about one third of persistent fistulas close in 12 months and about 10 percent need repair; Brilakis says many close within a year 21.

Equipment

From the complications cart. Linked items open in the equipment directory.

  • Duplex ultrasound with a linear probeNot in the directory yet.
  • 22 gauge spinal needleFor thrombin injection 2.Not in the directory yet.
  • Thrombin, 1000 unitsDiluted in 1 mL of saline 2.Not in the directory yet.
  • Peripheral covered stentDirectory: Viabahn.

Drugs

Adult doses as the cited source gives them. Check your formulary and the label.

  • Thrombin1000 units in 1 mL saline (100 units per 0.1 mL), injected slowly under ultrasound until flow in the cavity stops 2.
  • Lidocaine 1 percentLocal anesthesia.Product in the directory

Who to call

The escalation ladder, first call first.

  1. Vascular ultrasound: to confirm and measure.
  2. Interventional cardiology or radiology: for thrombin injection.
  3. Vascular surgery: wide neck, large, infected or ischemic 1.

The bailout step by step

Ultrasound guided thrombin injection 21

  1. Confirm a narrow neck on duplex; avoid thrombin with a wide neck, which risks distal embolization 1.
  2. Dilute 1000 units of thrombin in 1 mL of saline 2.
  3. Under ultrasound, place a 22 gauge needle tip in the cavity away from the neck 2.
  4. Inject in 0.1 mL steps while watching color flow until the cavity thromboses 2.
  5. Check the distal pulses and the femoral artery flow.
  6. Repeat ultrasound in 2 to 3 days 1.

Prevent

  • Common femoral puncture, not the superficial femoral or profunda 2.
  • Remove the arterial sheath before the venous sheath when both are used 1.
  • Adequate compression after sheath removal 1.

After care and documentation

  • Repeat ultrasound and pulse checks.
  • Document size, neck, treatment and thrombin dose.

Practice

No emergency simulator case for pseudoaneurysm or fistula yet. Browse the case library.

References

  1. Brilakis ES. Manual of Percutaneous Coronary Interventions. Elsevier; 2021. Chapter 29, Vascular access complications.
  2. Berg R, Lim MJ. Complications of percutaneous coronary interventions. In: Kern MJ, ed. The Interventional Cardiac Catheterization Handbook. 3rd ed. Saunders, Elsevier; 2013. Chapter 4.

Educational reference for cath lab teams, not medical advice and not a standard of care. Your local policy, the device instructions for use and current guidelines govern. Verify every dose before use. Printed from cathlabhub.com/toolkit/pseudoaneurysm-av-fistula. First version, in clinical review: an interventional cardiologist is checking every card before it is final. Every number cites its source on the card.