Duplex-guided Thrombin Injection for theTreatment of Iatrogenic PseudoaneurysmsKathleen Greene, RN, BS, RVT, RDMS

This study compares duplex-guided thrombin injection (DGTI) with duplex-guided compression (DGC) for thetreatment of iatrogenic pseudoaneurysms. A nonrandomized prospective study, approved by the institutional reviewboard, was performed to evaluate the success rate in DGTI versus DGC (with the use of historical data) in patients whoarrive at the vascular surgery service for the treatment of iatrogenic pseudoaneurysm as identified by ultrasoundexamination. DGTI has been shown to have major advantages over DGC, such as improved patient and operatoracceptance, shorter pseudoaneurysm thrombosis times, broader patient applications, and higher success rate. (J VascNurs 2002;20:117-22)

The population of elderly Americans will increase dramat-ically in the next 30 years.1 This growing population will becarrying with it a need for treatment of their vascular disease;this will have an increase in the volume of vascular interven-tion services that will be provided. In addition, as the popu-lation ages, the patients develop substantial comorbities, suchas peripheral vascular disease, coronary artery disease, anddiabetes. Treating patients with less invasive procedures willhave an effect on the nurses who monitor these patients.Nurse will need to assess the femoral artery puncture site forbleeding after catheterization or angiogram. The purpose ofthis article is to compare duplex-guided thrombin injection(DGTI) with duplex-guided compression (DGC) for the treat-ment of pseudoaneurysms (PA). The treatment of atheroscle-rotic occlusive disease for cardiac and vascular disease hasevolved from direct open surgical repair to embrace lessinvasive repair for stenotic lesions. Those less invasive re-pairs are percutaneous transluminal coronary angioplasty,stent, directional atherectomy, catheter-directed thrombolysis,and laser angioplasty.2 As the interventions begin to increasein complexity, so does the size of the introducer sheath in theaccess arteries and veins. This access site is a potential forsignificant hematoma, arterial thrombosis, PA formation, ret-roperitoneal hematoma, and arterial dissection (PA are com-monly described in literature as false aneurysms). Nursingassessment after catheterization or angiogram includes thefollowing: maintaining intravenous fluids, monitoring vital

signs, checking the site for bleeding, evaluating for hematomaexpansion, obtaining necessary laboratory values, dispensingappropriate medications, and palpating pedal pulses at inter-vals.3-5 A PA may be recognized upon examination by thepresence of visible or palpable hematoma expansion. In ad-dition, an audible bruit at the puncture site may indicate ofpossible PA.6 If hematoma is present on physical examina-tion, a baseline size (length and width) should be documentedin the patient’s chart. Our protocol requires follow-up mea-surements every half hour for 6 hours as needed, with appro-priate documentation. Physicians may order an ultrasound ifthe hematoma has expanded, the patient has increased tender-ness to the access site, or a bruit has been acutely identified.Identification of a PA by ultrasound can be performed at thepatient’s bedside by a trained vascular technician.

DGTI takes approximately 45 minutes. Included in the 45minutes is the time necessary for obtaining baseline vitals (bloodpressure, pulse, and pedal pulse assessment), patient preparation(no clothing below the waist with the exception of loose fittingundergarments), positioning into the supine or hob elevated 10°to 20°, betadine cleansing of the PA site, time for the vascularlaboratory team to set-up the ultrasound imager, the DGTI, andthen obtaining vitals (blood pressure, pulse, pedal pulse assess-ment) after the procedure. Most patients will be on bed rest for2 hours immediately after the procedure, and then they mayresume the activity orders from before the DGTI. During the 2hours of bed rest, it may be permissible for the patient to log rollside to side or lie supine with hob elevated 45°. Patient teachingafter the procedure includes, but is not limited to, the following:(1) gently cleanse the area with soap and water; (2) dry thor-oughly and do not apply bandages to the site; (3) keep groinclean and dry; (3) bleeding from the groin site is not normal afterDGTI—contact physician or nurse or proceed to the nearestemergency room if bleeding is noted; (4) call physician if anysigns of infection are present, such as increased redness, pain,swelling, fever, or chills. A follow-up groin ultrasound is usuallycompleted 24 hours after DGTI. Potential DGTI complications,such as intra-arterial injections and PA rupture, are unusual buthave occurred.

From the Connecticut Vascular Institute, Hartford.

Address reprint requests to Kathleen Greene, RN, BS, RVT,RDMS, Connecticut Vascular Institute, Suite 911, 85 Seymour St,Hartford, CT 06106.

Copyright © 2002 by the Society for Vascular Nursing, Inc.

1062-0303/2002/$35.00 � 0 40/1/129998

doi:10.1067/mvn.2002.129998

Vol. XX No. 4 PAGE 117JOURNAL OF VASCULAR NURSINGwww.mosby.com/vascnurs

LITERATURE REVIEW

Historically PA has been treated with open surgical repair ofthe femoral artery and then later treated with DGC; morerecently it has been treated with DGTI. Color flow ultrasoundimaging has evolved from the primary diagnostic modality foriatrogenic PA to the initial treatment option for these lesions.The use of real time color flow ultrasound to guide compressionof the puncture site of a PA leading to thrombosis was intro-duced in 1991 by Fellmeth et al.7 This option soon became thetreatment of choice so as to avoid surgery in patients withsignificant cardiac morbidity. Several disadvantages becameapparent as experience increased with this procedure. Patientacceptance of the procedure often waned with the prospect of thepain associated with additional compression in an already tendergroin area. Operator enthusiasm was also tempered as the phys-ical demands of the procedure became recognized. DGTI avoidscompression of the groin; instead, practitioners use a pharmaco-logic agent to thrombose the PA sac and thereby seal the arterialpuncture site. Introduced by Kang et al,8-13 in 1998, this ap-proach was successful in many patients who could not toleratethe discomfort of groin compression and has been associatedwith PA thrombosis rates of greater than 90%.

METHODS

An approved protocol (by the institutional review board[IRB]) for ultrasound guided thrombin injection for the treatmentof iatrogenic PA at St. John Hospital and Medical Center inDetroit, Michigan was evaluated in this study. No control groupwas used and patients were treated with DGC before the imple-mentation of this study. The vascular surgeons performed allDGTI procedures and the majority of the DGC performed, withthe exception of 25 DGC that were performed by the vascularlaboratory technician under the supervision of the vascularsurgeons. Imaging was performed with a Toshiba 140A ColorFlow Imager (Toshiba America Systems, Inc; Carrollton, TX), aBiosound AU4 or AU5 Color Flow Imager (Biosound Esaote;Indianapolis, IN), or an Agilent Image Point HX Color FlowImager (Agilent Technologies; Naperville, IL). This study pre-sents our experience with this maneuver and compares theprospective results with historical data of our DGC patientpopulation. The IRB approved protocol included positive duplexidentification of PA, consent for research procedure (DGTI) byvascular surgeon, and patient outcome data communicated to theIRB committee on a yearly basis. The nurse-vascular laboratorytechnical director, the surgical resident, the nurse assigned to thepatient, or the vascular surgeon obtained the consent for DGTI.The subjects were not randomized. All patients who had apositive duplex scan demonstrating the presence of a PA andwho were referred to the vascular surgeons for consultation wereincluded in the study. Exclusionary criteria included the follow-ing: patient clinically unstable, failure to demonstrate inflow andoutflow vessels on duplex scan and wide (�5 mm) neck of PA.Ninety-six percent of the patients who had DGTI were treatedsuccessfully versus 75% of the patients who had DGC. Duringthe diagnostic imaging of a PA, the anterior-posterior and lateraldimensions were recorded as well as the parent artery. Pulsestatus and ankle-brachial indices of the involved extremity wereobtained before and after thrombin injections. A 3.5 in, 22-gauge

spinal needle was used for the injection of the thrombin solutionthat consisted of bovine thrombin at a concentration of 1000units/cc. This solution was placed in a 1-cc syringe to which theneedle was attached for injection. The PA was then imaged, andunder real time gray scale imaging, the needle advanced into thePA sac. Once inside the sac, color flow imaging was used tomonitor the thrombin injection heralded by increased turbulencein the PA. Loss of color flow and formation of thrombus withinthe PA sac and a loss of Doppler signals in the PA documentedthrombosis of the sac. Upon completion of the procedure thepatients were maintained at bed rest for 4 hours followed bybathroom privileges that day. All PA were imaged again within24 hours of injection. Those PA that persisted received anotherinjection in a similar fashion. Attempts were made to obtainultrasound imaging at 1 week and 1 month after thrombosis ofthe PA. The etiology of the PA, success rate of thrombininjection, and complication rates were all reviewed. This datawas then compared with the similar data of PA treated withDGC.

RESULTS

During the 31-month study period, 155 PA were diagnosedwith duplex imaging. Eight of these patients were removed fromthe group as a result of the following: 5 lesions involving theupper extremity; one PA resulting from a remote gunshotwound; one complicating a total knee replacement; and oneinfected PA. Of the remaining 147 PA, DGTI was not attemptedfor a variety of reasons (Table I), leaving 131 iatrogenic PA ofthe lower extremity initially treated with DGTI. The etiologies ofthe PA of the study group are listed in Table II. Interventionalcardiac procedures (percutaneous transluminal coronary angio-plasty, coronary stenting, or atherectomy) accounted for morethan half of the PA in the group. Successful thrombosis wasachieved with DGTI in 126 (96%) PA; of these 9 patientsrequired a second injection for incomplete thrombosis noted onfollow-up imaging, and one patient required 3 separate injectionsfor complete PA thrombosis. DGTI was unsuccessful in 5patients. In one patient thrombin injection was attempted in a 2cm femoral artery PA. Ultrasound visualization of the needlecould not be obtained, and no thrombin was injected. Follow-upimaging 5 days later demonstrated spontaneous thrombosis of

TABLE I

DGTI NOT ATTEMPTED

Spontaneous thrombosis 12

Unstable 2

Compression used 1

Repair combined CABG 1

Death unrelated topseudoaneurysm 1after CABG

Total 17

CABG, Coronary artery bypass graft surgery.

PAGE 118 DECEMBER 2002JOURNAL OF VASCULAR NURSINGwww.mosby.com/vascnurs

the PA. Persistence of a 3 cm PA after 2 injections led tooperative repair in one patient. The remaining 3 failures werea result of complications of the thrombin injections (2 patientshad intra-arterial thrombin injections and 1 patient had arupture of an iliac artery PA one day after DGTI) (Table III).During the course of the study we started to use a biopsyguide (Civco Ultra-Pro II) attached to the transducer head.Before this, the needle was advanced into the PA cavityfreehanded, often requiring multiple punctures or redirectionof the needle for ultrasound visualization. The introduction ofthe biopsy guide after the first 15 patients receiving DGTI hassimplified this procedure and allowed immediate ultrasoundvisualization of the needle, eliminating the majority of needlemanipulations seen when this is completed free hand. Overallsuccess of this maneuver occurred in 126 of the 131 patientstreated (96%). This compares favorably to our success ratewith DGC (75%; successful thrombosis in 142 of 189 PAtreated) (Table IV). The major reasons for unsuccessful DGCwere groin tenderness in 34% (16 or 47) of compressionfailures or unfavorable local anatomy (too deep for successfulcompression in 64% of cases).

DISCUSSION

DGTI can be viewed as the second generation of ultrasoundguided treatment of iatrogenic PA. Compared with DGC, majoradvantages with thrombin injection included improved patientand operator acceptance, shorter PA thrombosis times, broaderpatient applications, and a higher success rate. Compression ofPA is a painful experience in patients with tender groins afterfemoral artery access and subsequent catheter removal withmanual and mechanical compression of the puncture site. For theoperator, compression is physically demanding, there is consid-erable wear on the transducer head, and the maneuver requiressignificant time demands on the imager itself. Once in position,thrombin is injected causing thrombosis of the PA cavity, whichseals the arterial puncture site. Our experience with DGTI hasrealized all of these advantages. Patient acceptance of the pro-cedure is evident by reviewing the reasons for failure in each of

the maneuvers (Table V). In contrast, in 5 PA that failed DGTI,3 failures resulted from complications of the maneuver itself, 2intra-arterial injections, and 1 ruptured PA. Local groin anatomyor tenderness did not prevent application of thrombin injection.Another advantage was the rapidity in which the PA was throm-bosed with DGTI—all within minutes of injection. This com-pares favorably with the mean DGC compression time of 44minutes in those PA successfully thrombosed (142) with com-pression.

Other than failure to thrombose the PA, ultrasound compres-sion has not been associated with significant complications.Intra-arterial thrombin injection has been recognized as a signif-icant complication of DGTI, resulting in limb threatening isch-emia.14 Two instances of this complication occurred in the 131PA treated (Table VI). Both of these occurred in PA �2.6 cm (2of 54; 4%) and were successfully treated operatively with acombination of mechanical thrombectomy and lysis. No in-stances of limb loss have been reported (Table VI). There havebeen cases reported in the literature of thrombin anaphylaxis,15,16

but we have had no cases in our study population. Care is takento obtain patient history of medication allergy before any inter-ventional procedure.

There was one instance of PA rupture after successful throm-bosis of an iliac artery PA. Visualization of the needle wasstraightforward and thrombosis of the PA cavity was clearlydemonstrated. The patient did not receive an anticoagulate, andno specific factor was identified that resulted in the PA rupture.This points to the wide applicability of the maneuver in treatingPA in which the compression maneuver was not an option andsurgical repair is usually performed (iliac artery and upper-extremity PA).

In summary, our experience with DGTI has realized many ofthe advantages of this maneuver already documented in theliterature: improved patient and operator acceptance and a sig-nificant decrease in the time to PA thrombosis when comparedwith DGC. A higher success rate is achieved by including thosepatients with tender groins and difficult anatomy resulting fromobesity or surrounding hematoma that have historically beenfailures with ultrasound compression. The wide applicability ofthis procedure has led to its use in lesions not confined to thefemoral artery. The only PA rupture and death occurred in aniliac PA, and the use of DGTI for these lesions cannot berecommended as a result of this. Intra-arterial thrombin injectionis a complication of this maneuver that was seen in 4% of thePAs �2.6 cm (2 of 54). The use of the biopsy guide hassimplified this maneuver by eliminating many of the needlemanipulations, and its use is recommended. Furthermore, thepatient outcomes were unchanged when the use of a biopsyguide was employed.

IMPLICATIONS FOR NURSING PRACTICE

The nursing care of patients after DGTI is essential tocomplete the successful transition from identification of PA,to after DGTI and hospital discharge. Areas of concern fornurses include, but are not limited to, education of patients,assisting medical staff at the patient’s bedside when re-quested, recovery care, and discharge planning. Nurses playkey roles in the communication with and education of patients

TABLE II

PSEUDOANEURYSM ETIOLOGY

Type of study No. (%)

Diagnostic cardiac catheterization 35 (27)

Interventional cardiac catheterization* 67 (51)

Electrophysiology study 2 (1)

Intra-aortic balloon pump 2 (1)

Diagnostic angiography 2 (1)

Peripheral intervention 1 (�1)

Miscellaneous procedure from outsideinstitution 22 (18)

Total 131

*Percutaneous transluminal coronary angioplasty, stent, or atherectomy.

Vol. XX No. 4 PAGE 119JOURNAL OF VASCULAR NURSINGwww.mosby.com/vascnurs

and their families about DGTI. For instance, nurses may berequired to provide counseling to the patient and obtainpatient consent for the procedure. Another role nurses play isassessing the patient vital signs and distal pulse status atintervals. In conclusion, as the population of elderly patients

increases the volume of interventional procedures increases.This study shows that DGTI is an effective treatment foriatrogenic PA. Communication and clinical skills of themultidisciplinary team of vascular surgeons, vascular labora-tory technicians, and nurses has proven to be key in theefficacy and outcome of these patients who have PA.

A more specific algorithm used in our institution for evalu-ating femoral access sites for bleeding immediately after pullingthe femoral sheaths is indicated in Appendix A.17

TABLE III

DGTI STUDY POPULATION

PAs treated withDGTI

Age mean(Range) Sex

Treatmentinterval* mean

(range)PA size mean

(range)Sheath size

mean (range)

All pseudoaneurysm 70 y (40-93)59 Male72 Female 3.6 d (0-43) 2.8 cm (0.5-10.0) 6.8 Fr (5-10.5)

Successful thrombosis 70 y (40-86)57 Male69 Female 3.6 d (0-43) 2.9 cm (0.8-10.0) 6.6 Fr (5-10.5)

Unsuccessful 82 y (75-93)2 Male3 Female 1.7 d (0-4) 2.1 cm (1.3-2.6) 8.0 Fr (8.0)

Fr, French.

*Interval between causative catheterization and treatment of PA.

TABLE IV

ULTRASOUND-GUIDED INTERVENTION DGC VS DGTI

ModalityAge mean

(range) Sex ratioTotal PAs

treated SuccessfulPA

mean size

Meansheath

size

Compression (DGC) 67 y (18-88)85 Male

104 Female 189 142 (75%) 3.3 cm 7.0 Fr

Thrombin injection (DGTI) 70 y (40-93)59 Male72 Female 131 126 (96%) 2.8 cm 6.8 Fr

TABLE V

FAILURE OF DUPLEX-GUIDEDINTERVENTION: COMPRESSION VSTHROMBIN INJECTION

Reason for therapy failureDGC

(Compression)

DGTI(ThrombinInjection)

Groin tenderness 16 0

Groin anatomy 30 0

Unstable vital signs 1 0

Incomplete PA thrombosis 0 2

Arterial occlusion 0 2

PA rupture 0 1

TABLE VI

PSEUDOANEURYSM SIZE ANDCOMPLICATIONS OF DGTI

Pseudoaneurysms 1-2.6 cm >2.6-3.5 cm >3.5 cm

Total (131) 54 49 28

DGTI failures 3* 1† 1‡

*2 Intra-arterial injections, 1 spontaneous thrombosis.†Ruptured iliac pseudoaneurysm.‡Failure to thrombose pseudoaneurysm with DGTI � 2.

PAGE 120 DECEMBER 2002JOURNAL OF VASCULAR NURSINGwww.mosby.com/vascnurs

REFERENCES

1. Hallett Jr JW. Predicting the future of vascular health care:the impact of the baby boom generation. Sem Vasc Surg2001;14:54-63.

2. Halfman-Franey M, Coburn C. Techniques in cardiac care:lasers, stents, and atherectomy devices. AACN Clin IssuesCrit Care Nurs 1990;1:87-109.

3. Drummond Hayes D. Understanding coronary atherectomy.Adv J Nurs 1996;96:38-44.

4. Speroni R, Fiske J, et al. Coronary atherectomy: overviewand implications for nursing. J Cardiovasc Nurs 1992;2:25-33.

5. Borriello S, Cecchi Siegel S, et al. Directional coronaryatherectomy: a new treatment for coronary artery disease.Heart Lung 1994;23:199-204.

6. Axelberg A, Mayer D. Arterial closure method-pull, plug, orclose. Adv J Nurs 2000;100:11.

7. Fellmeth BD, Roberts AC, et al. Post angiographic femoralartery injuries: nonsurgical repair with ultrasound-guidedcompression. Radiol 1991;178:671-5.

8. Kang S, Labropoulous N, et al. Percutaneous ultrasoundguided thrombin injection: a new method for treating post-catheterization femoral pseudoaneurysms. J Vasc Surg 1998;27:1032-8.

9. Kang S, Labropoulous N, et al. Expanded indications forultrasound-guided thrombin injection of pseudoaneurysms. JVasc Surg 2000;31:289-98.

10. Liau CS, Ho FM, et al. Treatment of iatrogenic femoralartery pseudoaneurysm with percutaneous thrombin injec-tion. J Vasc Surg 1997;26:18-23.

11. LaPerna L, Olin JW, et al. Ultrasound guided thrombininjection for the treatment of postcatheterization pseudoan-eurysms. Circ 2000;102:2391-5.

12. Lennox AF, Delis KT, et al. Duplex-guided thrombin injec-tion for iatrogenic femoral artery pseudoaneurysm is effec-tive even in anticoagulated patients. Br J Surg 2000;87:796-801.

13. Paulson EK, Sheafor DH, et al. Treatment of iatrogenicfemoral arterial pseudoaneurysms: comparison of ultra-sound-guided thrombin injection with compression repair.Radiol 2000;215:403-8.

14. Sadiq S, Ibrahim W. Thromboembolism complicating throm-bin injection of femoral artery pseudoaneurysm: manage-ment with intra-arterial thrombolysis. J Vasc Intervent Ra-diol 2001;12:633-66.

15. Pope M, Johnston KW. Anaphylaxis after thrombin injectionof a femoral pseudoaneurysm: recommendations for preven-tion. J Vasc Surg 2000;32:190-1.

16. Sheldon PJ, Oglevie SB, et al. Prolonged generalized urti-carial reaction after percutaneous thrombin injection fortreatment of a femoral artery pseudoaneurysm. J Vasc Inter-vent Radiol 2000;11:759-61.

17. Internally developed nursing tool. Cardiac CatheterizationDepartment. St. John Hospital and Medical Center, Detroit,Michigan. June 2001.

WRITING AWARD

The Journal of Vascular Nursing Article Award honors nurse authors for their efforts to createa publishable manuscript. Manuscripts will be judged for accuracy of content, relevance to vascularnursing practice, and excellence of writing style. All feature articles published in the Journal ofVascular Nursing during the calendar year will be considered for the JVN Article Award. The awardrecipient will be given a plaque commemorating the award and a cash prize donated by Mosby. Theaward and cash prize will be presented at the annual symposium. Announcement of the awardrecipient will appear in the Journal of Vascular Nursing and in SVN...prn.

Vol. XX No. 4 PAGE 121JOURNAL OF VASCULAR NURSINGwww.mosby.com/vascnurs

Appendix A Patient bleeding or hematoma guideline

PAGE 122 DECEMBER 2002JOURNAL OF VASCULAR NURSINGwww.mosby.com/vascnurs

Duplex-guided Thrombin Injection for theTreatment of Iatrogenic Pseudoaneurysms

Contact Hours: 1.0 Minimum Passing Score: 70%Test ID: JVN02121 Test Processing Fee: $10.00

OBJECTIVES:

1. Describe treatments for iatrogenic pseudoaneurysms.

2. Identify differences between two types of treatment modalities.

1. What is the most invasive technique in repairingstenotic lesions?

a. Stentb. Directional atherectomyc. Open surgical repaird. Laser angioplasty

2. A pseudoaneruysm is recognized by the followingEXCEPT:

a. palpable hematomas.b. hematoma measuring more than 7 cm � 5 cm.c. bruit at the puncture site.d. visible hematomas.

3. Pre-procedure baseline vital signs for DGTI includethe following EXCEPT:

a. blood pressure.b. pulse.c. pedal pulse assessment.d. EKG.

4. At what angle should the head of the bed be pre-procedure?

a. Supine onlyb. 10 to 20 degreesc. 45 degreesd. 60 to 75 degrees

5. After the procedure, the head of bed can be at any ofthe following levels EXCEPT:

a. supine.b. 10 to 20 degrees.c. 45 degrees.d. 60 to 75 degrees.

6. If there is bleeding from the groin site post DGIT, thepatient should be instructed to:

a. call the physician/nurse and go to the nearestemergency room.

b. lay down, take foods rich in vitamin K, and reassessin 6 hours.

c. put manual compression on the site for 30 minutes.d. do nothing; this is normal.

7. Thrombosis of the sac was successful when all of thefollowing were observed EXCEPT:

a. Loss of color flowb. Loss of Doppler signalc. Thrombus formation in the sacd. Stronger pedal pulses

8. What was the most common pseudoaneurysm etiologyof the patients undergoing DGTI therapy?

a. Peripheral interventionb. Diagnostic angiographyc. IABPd. Interventional cardiac catheterization

9. The most common reason for unsuccessful DGC was:a. PA rupture.b. arterial occlusion.c. groin anatomy.d. unstable vital signs.

10. DGTI failures occurred when the pseudoaneurysmwas:

a. 1 to 2.6 cm.b. 2.7 to 3.5 cm.c. 3.6 to 4.0 cm.d. more than 4 cm.

Vol. XX No. 4 PAGE 123JOURNAL OF VASCULAR NURSINGwww.mosby.com/vascnurs

PAGE 124 DECEMBER 2002JOURNAL OF VASCULAR NURSINGwww.mosby.com/vascnurs

Nursing Continuing Education Answer/Enrollment Form

JOURNAL OF VASCULAR NURSINGTitle: Test ID#: Minimum Passing Score:

Contact Hours: 1.0

To receive CE credits,1. Read the article, then answer the questions (There is only one right answer for each question).

2. Include the test processing fee of $10 with this answer form. Make checks payable to BUCHANAN & ASSOCIATES(You may duplicate this answer form.)

3. Mail to: Buchanan & Associates, 1666 Garnet Ave #102, San Diego, CA 92109You should receive your certificate within 3 weeks of mailing. Call 800.929.1233 or www.nursingce.com

Name: (please print) RN License#:First M.I. Last

Mailing Address: City: State: Zip:

Phone: Soc Sec#:

ANSWERS:

1 6 11 16

2 7 12 17

3 8 13 18

4 9 14 19

5 10 15 20How long did it take you to complete this program? 1/2-1 hour 1-1 1/2 hours 1 1/2-2 hrs 2 hrs or moreCheck the appropriate boxPlease evaluate the program using the Strongly

Agree Neutral DisagreeStrongly Disagree*

following criteria. Agree (comments)The course was able to meet the objectives and they wererelated to the overall purpose and goals of this program

The objectives were related to the goals of this program

Objective #1

Objective #2

Objective #3

Objective #4

The information presented was accurate, current and at anappropriate educational level for this audience

The teaching method was appropriate and effective for thematerial presented

This program met my personal professional educationalneeds as it relates to this topic

The information presented was relevant to my practice

The teaching methodology (didactic) was appropriate to thematerial presentedThis form of continuing education was appropriate to thesubject matterYou may also submit the evaluation form to your local board of nursing in addition to Buchanan & Associates

Comments and suggestions for future topics:

Buchanan & Associates is accredited as a provider of continuing education in nursing by the: American Nurses Credentialing Center,Commission on Accreditation, California Board of Registered Nursing CEP# 9473, Florida Board of Nursing FBN 2159.

70%JVN02121Duplex-guided Thrombin Injection for the Treatment ofIatrogenic Pseudoaneurysms