European Journal of Vascular & Endovascular Surgery
Volume 36, Issue 2 , Pages 160-163, August 2008

Vascular Injuries Caused by Acupuncture

  • D. Bergqvist

      Affiliations

    • Corresponding Author InformationTel: +46 18 611 4633; fax: +46 18 611 4632.

Department of Surgical Sciences, Section of Surgery, Uppsala University Hospital, SE 751 85 Uppsala, Sweden

Received 26 February 2008; accepted 14 April 2008. published online 06 June 2008.

Article Outline

Abstract 

Aim

To systematically review the literature on vascular injuries caused by acupuncture.

Method

Systematic literature search in Medline and PubMed.

Results

Twentyone cases were identified and the majority developed symptoms in direct connection with the acupuncture treatment. Three patients died, two from pericardial tamponade and one from an aortoduodenal fistula. There were five more tamponades, seven pseudoaneurysms, two with ischaemia, two with venous thrombosis, one with compartment syndrome and one with bleeding. The two patients with ischaemia had remaining sequeleae. Information on follow-up was suboptimal with no information in nine patients.

Conclusion

Vascular injuries are rare, bleeding and pseudoaneurysm dominating. Follow-up is insufficient in the hitherto published papers.

Keywords: Vascular injury, Acupuncture, Iatrogenic

 

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Introduction 

Acupuncture is a very old treatment for various disorders. It has survived and is still frequently used, also in non-eastern countries. Although patient records are not always used as in western medicine it seems reasonable to consider the treatment as very safe. Reported complications are rare but some are serious such as infections (bacterial endocarditis, septicaemia, HIV, hepatitis), pneumothorax, spinal cord lesion and allergic reactions.1

The aim of this systematic review is to analyze injuries of the cardiovascular system induced by acupuncture.

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Method 

MEDLINE and PubMed were searched without time limitation. Acupuncture was combined with various vascular terms as well as with vessel anatomy. Reference lists in identified papers were scrutinized. Articles in English, German, French and Scandinavian languages were read as were papers with English summary (one Japanese identified: Nakanishi et al. 2007).2

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Results 

Twentyone cases were identified (21 publications).3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 There were twelve females, eight males and in one patient the gender was not given. Age was not reported in two patients, in the remaining median age was 61 years (range 25–83). The indications for acupuncture were back pain in seven, abdominal pain in two and shoulder stiffness, fibromyalgia, knee joint arthrosis, rheumatoid arthritis, ulcerative colitis, intermittent claudication and asthma in one each. In five patients the indication was not reported. Nine acupuncture treatments were given by experienced acupuncturists, two patients were treating themselves and in ten there is no information about the education or skill of the acupuncturist. In three cases it is stated that electroacupuncture was used.

Eighteen patients experienced symptoms immediately in relation to the acupuncture treatment, in one patient symptoms started after several hours and in one after one day. In one there is no exact information. In three patients the diagnosis was made at autopsy, in the remaining the diagnostic delay was four days (median; range immediately to 6 months).

In Table 1 the acupuncture site is shown, as well as symptomatology, diagnostic test used and how the patients were treated. As could be expected from a vascular puncture injury the symptoms are due to bleeding, the development of a pseudoaneurysm or vascular occlusion. Thee was no information on underlying vascular pathophysiology. Three patients died before treatment, two from pericardial tamponade and one from an aortoduodenal fistula with massive haematemesis. In the last case the diagnosis was made with CT, the patient dying from haemorrhagic shock while waiting for surgery. When diagnosis was established the remaining patients were treated accordingly. One patient with a popliteal occlusion came to diagnosis after half a year, developing symptom of ischaemia immediately after the puncture but with spontaneous improvement. She was treated without invasive intervention and suffered from mild claudication. One patient with some calf muscle necrosis after compartment syndrome had a small functional defect. In one patient severe ischaemia developed leading to gangrene and amputation. The remaining survivors had an uneventful course. The problem, however, is the poor information on follow-up time: Three patients died and one underwent arm amputation, in nine no time is reported and in the remaining eight it was in median 4 months (one week–3 years).

Table 1. Summary of patients with vascular injuries caused by acupuncture
AuthorSexAgeAcupuncture siteSymptomsDiagnosisTreatmentOutcome
BergqvistF44Popliteal fossaLeg ischaemiaAngiography (popl art. occlusion)TrainingClaudication
BlanchardF64CalfPainVenography (deep vein thrombosis)NSAIDResolved
CantanF25BreastChockEchocardiography (tamponade)PericardiocentesisGood
ChangM68SupraumbilicalInfection, hematemesisCT (aortoduodenal fistula)0Mors
FujiwaraF58ShoulderPain, massAngiography (pseudoaneurysm a. costocerv.)ResectionGood
HalvorssenF40BreastPainAutopsy (tamponade)0Mors (congenital sternal foramen)
HasegawaM52BreastPain, chockEchocardiography (tamponade)Surgery (laceration of pulm artery)Good
KaoF61Left knee, thighPain, massAngiography (pseudoan. popl art)Surgery (suture)Good
KataokaF69Back, shoulderChest oppressionEchocardiography (tamponade)PericardiocentesisGood
KimM54BackAbdominal pain, pulsating massCT (pseudoan. Aortae)Surgery (PTFE tube)Good
KirchgattererF83BreastHeart failureEchocardiography (tamponade)Pericardiocentesis+surgery (perf. right ventr)Good
LordM43Popliteal fossaPain, swelling, bleedingAngiography (pseudoan. popl. art.)Surgery patchGood
MatsuyamaF72BackPainCT+angio (pseudoan×3 right kidney)Coil embolizationGood
NakanishiM71CalfPain, swellingCT+angio (pseudoan. popl. arteryPTFE covered stentGood
NiedaM55BreastPain, chockFluoroscopy (needle left thorax+tamponade)Surgery (needle extraction)Good
OriguchiM67?Back pain, feverCT+angio (pseudoaneurysm aort abd)PTFE+omentGood
Ruchkin??? legPainThrombophlebitis left crural vein??
SchiffF82BreastMorsAutopsy (tamponade)0Mors
SmithM68Hand, lips, right legPain, swellingCompartment syndromeFasciotomy, resection of leg necrosisMuscle defect
TukeF?AnkleBleedingClinical0Good
KarstaF47Hand, armPain, haematomaClinical, surgeryThromb-embolectomyArm amputation

aThis case caused debate whether the gangrene due to thrombotic occlusion of the brachial artery was caused by the acupuncture or by the underlying disease (ulcerative colitis) with increased thrombogenicity.10 One needle was used. For delay in handling probably caused the unfortunate outcome.

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Discussion 

With the background that acupuncture has been used for thousands of years in Asian countries and since a few decades also in the western part of the world – in fact increasingly so – the frequency of severe complications is extremely low.22, 23, 24 In a postal questionnaire covering 34 407 acupuncture treatments there were two cases of “heavy bruising” indicating vessel puncture.24 None required hospital admission, though. Serious adverse events have been estimated to 0.55 per 10 000 patients undergoing acupuncture treatment.25 This is well within the 95% confidence interval between 0–1.1 per 10 000 treatments suggested by MacPherson et al.,24 the incidence being calculated from 12 prospective studies including 109 152 patients undergoing 1107 270 treatments. This obviously means that vascular injuries are, indeed, rare. At the same time we have to realize that serious complications may be hidden in areas where reporting is suboptimal and where there is no regulation of acupuncturist practice. A limiatation of the study is that journals in Asian languages without English summary has not been possible to evaluate. None the less it is important to be aware of the existence of also rare major side effects and thus the possibility to meet such patients.

By scrutinizing the literature – the interest being stimulated by an own patient3 – only twentyone patients were identified. The most dramatic consequence is presternal puncture with cardiac tamponade, which may be fatal if not correctly diagnosed and promptly treated. Otherwise the dominating injury was development of a pseudoaneurysm. As the hole in the artery caused by an acupuncture needle must be very small the treatment of choice today would seem to be ultrasound guided thrombin injection.26 From a vascular surgical point of view the acupuncture induced injuries are not special and should be treated as other puncture induced injuries. The important message is to have knowledge of the possibility and as acupuncture is increasingly used, this information must be part of the medical history in unclear cases of vascular occlusion or pseudoaneurysm. Detailed anatomical knowledge by the acupuncturists obviously is a fundamental requirement for prevention. They should also be aware of potential serious complications that may occur. Acupuncture needles may be as long as 125mm, which explains the possibility of also rather deep injuries.

There has been a decrease in reported acupuncture complications between 1965 and 1999 with a peak incidence 1976 to 198523 and there are no recent indicence reports. This does not, however, necessarily mean a decrease in the true incidence as registration and reporting routines probably are far from optimal. As indicated in the results section of this paper this is valid also for case reports. There is an ongoing discussion on the value of case reports and some journals do not even publish them. Our view is that such an editorial restriction is basically correct, but some case reports are definitely of value increasing our knowledge on rare diseases and complications and new treatment options. Journals accepting case reports should, however, have criteria on which information is necessary for considering publication. When it comes to vascular injury the competence of the acupuncturist seems important as well as a long term enough follow up. A year or more seem reasonable in cases with vascular injuries. The optimal design of a trial dealing with acupuncture induced complications, however, would be having a prospective acupuncture registry with high attendance rate, high compliance and a sufficient number of patients.

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References 

  1. Rosted P. Literature survey of reported adverse effects assocated with acupuncture treatment. Am J Acupunct. 1996;24:27–34
  2. Nakanishi N, Matsuo A, Matsuo K, Shiono Y, Yamaguchi S, Nishibori Y, et al. Successful deployment of a stent graft in the popliteal artery for pseudoaneurysm after acupuncture: a case report, J Cardiol. 2007;50(3):213–218
  3. Bergqvist D, Berggren AL, Bjorck M, Bostrom A, Karacagil S. Acupuncture can cause vascular injury, Lakartidningen. 1998;95(3):180–181
  4. Cantan R, Milesi-Defrance N, Hardenberg K, Vernet M, Messant I, Freysz M. Bilateral pneumothorax and tamponade after acupuncture, Presse Med. 2003;32(7):311–312
  5. Chang SA, Kim YJ, Sohn DW, Park YB, Choi YS. Aortoduodenal fistula complicated by acupuncture. Int J Cardiol. 2005;104(2):241–242
  6. Fujiwara T, Tanohata K, Nagase M. Pseudoaneurysm caused by acupuncture: a rare complication. AJR Am J Roentgenol. 1994;162(3):731
  7. Halvorsen TB, Anda SS, Naess AB, Levang OW. Fatal cardiac tamponade after acupuncture through congenital sternal foramen. Lancet. 1995;345(8958):1175
  8. Hasegawa J, Noguchi N, Yamasaki J, Kotake H, Mashiba H, Sasaki S, et al. Delayed cardiac tamponade and hemothorax induced by an acupuncture needle. Cardiology. 1991;78(1):58–63
  9. Kao CL, Chang JP. Pseudoaneurysm of the popliteal artery: a rare sequela of acupuncture. Tex Heart Inst J. 2002;29(2):126–129
  10. Karst M, Fink M, Molsberger A. Above elbow amputation due to acupuncture treatment?, Versicherungsmedizin. 2006;58(2):88–90[discussion: 1]
  11. Kataoka H. Cardiac tamponade caused by penetration of an acupuncture needle into the right ventricle. J Thorac Cardiovasc Surg. 1997;114(4):674–676
  12. Kirchgatterer A, Schwarz CD, Holler E, Punzengruber C, Hartl P, Eber B. Cardiac tamponade following acupuncture. Chest. 2000;117(5):1510–1511
  13. Kim DI, Huh SH, Lee BB, Kim DK, Do YS. Pseudoaneurysm of the abdominal aorta caused by acupuncture therapy. Surg Today. 2002;32(10):942–943
  14. Lord RV, Schwartz P. False aneurysm of the popliteal artery complicating acupuncture. Aust N Z J Surg. 1996;66(9):645–647
  15. Matsuyama H, Nagao K, Yamakawa GI, Akahoshi K, Naito K. Retroperitoneal hematoma due to rupture of a pseudoaneurysm caused by acupuncture therapy. J Urol. 1998;159(6):2087–2088
  16. Nieda S, Abe T, Kuribayashi R, Sato M, Abe S. Case of a cardiac injury resulting from acupuncture, Kyobu Geka. 1973;26(12):881–883
  17. Origuchi N, Komiyama T, Ohyama K, Wakabayashi T, Shigematsu H. Infectious aneurysm formation after depot acupuncture. Eur J Vasc Endovasc Surg. 2000;20(2):211–213
  18. Ruchkin IN, Burdeinyi AP. Auriculo-electropuncture in rheumatoid arthritis (a double-blind study), Ter Arkh. 1987;59(12):26–30
  19. Schiff AF. A fatality due to acupuncture. Med Times. 1965;93:630–631
  20. Smith DL, Walczyk MH, Campbell S. Acupuncture-needle-induced compartment syndrome. West J Med. 1986;144(4):478–479
  21. Tuke J. Complication of acupuncture. Br Med J. 1979;2(6197):1076
  22. Ernst E, White AR. Prospective studies of the safety of acupuncture: a systematic review. Am J Med. 2001;110(6):481–485
  23. Lao L, Hamilton GR, Fu J, Berman BM. Is acupuncture safe? A systematic review of case reports. Altern Ther Health Med. 2003;9(1):72–83
  24. MacPherson H, Thomas K, Walters S, Fitter M. A prospective survey of adverse events and treatment reactions following 34,000 consultations with professional acupuncturists. Acupunct Med. 2001;19(2):93–102
  25. White A. A cumulative review of the range and incidence of significant adverse events associated with acupuncture. Acupunct Med. 2004;22(3):122–133
  26. Tisi PV, Callam MJ. Surgery versus non-surgical treatment for femoral pseudoaneurysms. Cochrane Database Syst Rev. 2006;(1):CD004981

PII: S1078-5884(08)00217-7

doi:10.1016/j.ejvs.2008.04.004

European Journal of Vascular & Endovascular Surgery
Volume 36, Issue 2 , Pages 160-163, August 2008

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