For an adult with a <2 cm groin pseudo‑aneurysm that developed 7 days after catheterisation, what is the recommended duration of strict bed rest and how should activity be progressed?

Management of Groin Pseudoaneurysm <2 cm at 7 Days Post-Catheterization

Immediate Management Decision

For an asymptomatic groin pseudoaneurysm <2 cm discovered 7 days after catheterization, conservative management with strict activity restriction is appropriate, as approximately 61% of these small lesions resolve spontaneously within 7–52 days. 1

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Bed Rest Duration and Initial Activity Restrictions

• Strict bed rest or minimal ambulation should be maintained initially upon diagnosis of the <2 cm pseudoaneurysm. 1

• After the initial ultrasound-guided compression repair (if performed), apply a groin compression bandage and maintain bed rest for 12–18 hours, followed by repeat ultrasound the next day to confirm closure. 2

• No heavy lifting, straining, or vigorous activity for at least 1–2 months during the entire observation period. 1

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Mandatory Surveillance Protocol

• Duplex ultrasound at 1 month is obligatory for all conservatively managed lesions to assess for spontaneous thrombosis. 1

• Weekly clinical assessments combined with ultrasound examinations are advised until complete thrombosis is documented. 1

• If the pseudoaneurysm persists at 2 months, proceed to definitive treatment (ultrasound-guided thrombin injection or surgical repair) regardless of size. 1

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Critical Exclusion Criteria for Conservative Management

Conservative observation is contraindicated if any of the following are present:

• Symptomatic lesions: pain, expanding mass, or compressive neuropathy 1
• Rupture, active bleeding, or overlying skin erosion 1
• Venous thrombosis (DVT from femoral vein compression) 1, 3
• Limb ischemia from arterial compression or distal thromboembolism 1
• Rapid enlargement (e.g., overnight growth from 1.5 cm to 3 cm indicates a patent neck requiring immediate intervention) 1

Any of these findings mandate immediate ultrasound-guided thrombin injection or surgical repair, not observation. 1

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Activity Progression Algorithm

Week 1 (Days 1–7 post-diagnosis):

• Strict bed rest or minimal ambulation only 1
• No weight-bearing activities beyond bathroom privileges 2

Weeks 2–4:

• Gradual ambulation within the home if follow-up ultrasound shows stable or decreasing size 1
• Continue avoiding lifting >5 pounds, straining, or Valsalva maneuvers 1

Month 1 checkpoint:

• Mandatory duplex ultrasound to assess for spontaneous thrombosis 1
• If thrombosed: gradually resume normal activities over 2–4 weeks
• If persistent: continue restrictions and schedule 2-month follow-up 1

Month 2 checkpoint:

• If pseudoaneurysm remains patent, proceed to ultrasound-guided thrombin injection (93% success rate) or surgical repair 1
• Activity restrictions continue until imaging verifies complete resolution 1

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Impact of Antiplatelet Therapy

• Continuing low-dose aspirin (75–100 mg daily) does not impede spontaneous thrombosis of small (<2 cm) pseudoaneurysms and should not be stopped, as ACC/AHA guidelines (Class I, Level A) mandate aspirin continuation after cardiac catheterization to prevent stent thrombosis and major adverse cardiovascular events. 1

• Ultrasound-guided thrombin injection achieves 94% technical success even in patients on antithrombotic medications, so antiplatelet therapy does not reduce treatment efficacy if definitive intervention becomes necessary. 1

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Common Pitfalls to Avoid

• Do not rely on physical examination alone, as it misses >60% of pseudoaneurysms; duplex ultrasound is mandatory whenever the diagnosis is suspected. 1, 4

• Do not adopt "watch-and-wait" for lesions ≥2 cm; conservative management is reserved exclusively for asymptomatic lesions <2 cm. 1

• Do not delay imaging if the groin mass enlarges or becomes symptomatic; overnight growth signals a patent neck requiring immediate thrombin injection or surgery. 1

• Do not skip the 1-month ultrasound follow-up; failure to document thrombosis or persistence at 2 months necessitates definitive treatment. 1

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Rationale for Conservative Management in This Scenario

• Natural history studies demonstrate that 61% of small (<2 cm) asymptomatic pseudoaneurysms close spontaneously within 7–52 days when patients are not receiving anticoagulation (mean closure time 18 days, range 7–42 days). 1, 5

• This favorable outcome depends entirely on strict activity restriction and serial ultrasound monitoring to detect complications early. 1, 5

• When anticoagulation is required, spontaneous resolution rates fall markedly, and a more aggressive treatment approach is recommended. 1

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When to Escalate to Definitive Treatment

Proceed immediately to ultrasound-guided thrombin injection (first-line, 93% success) or surgical repair if:

• The pseudoaneurysm persists at 2 months despite conservative management 1
• Any symptoms develop (pain, neuropathy, venous thrombosis) 1
• Enlargement occurs on serial ultrasound 1
• Skin erosion or rupture is observed 1

Thrombin injection uses 100–1,000 IU thrombin injected under real-time ultrasound guidance, with distal thromboembolism occurring in <2% of cases and a recurrence rate of approximately 5%. 1