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Sa’ar Minha M.D, Chen David M.D, Alex Blatt M.D, Ricardo Krakover M.D and Alberto Hendler M.D FESC Dept. of Cardiology & Dept. of Vascular Surgery , Assaf Harofeh Medical Center. Zeriﬁn
Background Patient characteristics: 30-‐year-‐old male Hx of systemic lupus erythematosus (SLE) since the age of 15. Diagnosed as APLA syndrome at the age of 19 after an embolic event involving the spleen. On chronic warfarin therapy, corticoesteroids and anti-‐ inﬂammatory drugs (plaquanil). Positive family history of CAD.
Clinical Characteris3cs Eﬀort dyspnea and non-‐speciﬁc chest pain Echo-‐Doppler demonstrated LVEF of 50% & regional wall motion abnormalities (apico-‐inferior hypokinesis) Referred to an elective coronary angiography.
Procedural Characteris3cs 5 days prior to the procedure the oral anticoagulation therapy was replaced by LMWH (60 mg bid), while continuing the steroids and the anti-‐inﬂammatory medication. The last dose of LMWH was given the morning of the procedure, about 8 hours before. ASA 100 mg was added at admission.
Procedural Characteris3cs cont’ Coronary Angiography Right radial approach 6F radial vascular sheath. Prior to angiography we routinely inject through the vascular sheath: UFH 2500 units and 2 cc of 5 mg of Verapamil diluted to 10 cc with NS 0.9%. Coronary angiography was performed utilizing a Judkin’s technique and demonstrated normal coronary arteries. No additional UFH or Verapamil was administered. The vascular sheath was immediately removed and local hemostasis performed manually. The patient was discharged 4 hrs. after the procedure.
Procedural Outcome 3 days after parallel therapy with warfarin and LMWH, when a therapeutic INR was achieved, the LMWH was interrupted. Two weeks after the procedure, a 2x2 cm pulsatile bulge appeared at the puncture site and the patient was referred to a Dupplex-‐US of the puncture site.
Discussion Late appearance of pseudoaneurysm is rare with few reported cases in the literature. pseudoaneurysms are caused by trauma, vasculitis, infections and iatrogenic causes-‐all promoting weakness of the vessel wall supporting structures. Pseudoaneurysm rupture and bleeding to the forearm can have devastating outcome. We speculate that patients presenting with chronic inﬂammatory diseases (SLE, APLA, vasculitis), treated by both anticoagulation and steroids all may predispose to aforementioned complication.
Discussion Recommendation: Considering alternatives to diagnostic angiography MSCT/SPECT/CMR Close follow-‐up is warranted in patients predisposed to this complication. Issues of controversy Anticoagulation Option I: Due to its short half-‐life, a continuation of LMWH for one week before re-‐initiation of warfarin is suggested. Option II: Performing the procedure on warfarin with low initial INR Sheath removal and compression (manual vs. mechanical)