Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms

[Treatment of postcatheterization femoral false aneurysms]

The incidence of iatrogenic femoral false aneurysms has risen dramatically in recent years and is estimated at 0,5% for diagnostic procedures and may rise to 9% or more for therapeutic procedures. This increased incidence is related to the increased number of arterial punctures performed for diagnostic or therapeutic purposes and their major complexity and duration. Risk factors for the development of iatrogenic false aneurysms include operator inexperience, age greater than 60, female gender, catheter size greater than 8F and concurrent anticoagulation. Prevention of false aneurysms is based upon an atraumatic arterial puncture, good compression therapy after sheath removal and use of percutaneous arterial closure devices. Contrarily to the arterial lesions following severe injuries, the natural course of false aneurysms is quite benign with spontaneous occlusion in the majority of cases. Therefore, a mandatory surgical approach is no longer advocated and alternative therapeutic options have been proposed. These include sonographic surveillance, compression ultrasonography, percutaneous thrombin or coil embolization. Surgery is still clearly indicated in presence of local nervous or venous compression, associated homolateral lower limb ischemia, great size of the aneurysm, and unsuccessful non-invasive treatment. Sonographic surveillance has shown to be safe in hospitalized or ambulatory patients. However, fear of aneurysm rupture and cost of repeated ultrasonographic exams preclude widespread utilisation. Compression ultrasonography is safe and effectiveness varies between 70 and 100%, according to studies. Compression ultrasonography may be painful, has often to be associated with mild analgesia, is time consuming and less effective in presence of concurrent anticoagulation. Thrombin injection seems particularly effective, is painless and has a limited rate of complications in expert hands. Severe anaphylactic reactions and severe coagulopathy in reexposed patients have been described and represent clear contra-indications to thrombin injection. Coil embolization of the false aneurysm is as effective as thrombin injection and is reported in a limited number of patients. There is no formal consensus about treatment of the vast majority of non-surgical false aneurysms. In an absence of stringent indication to surgical approach, compression ultrasonography may be used first as it is widely available, and does not require highly specialized skills. Compression therapy should be done after a transient interruption of anticoagulant treatment, if allowed by clinical context. If compression therapy fails, percutaneous injection of thrombin or coil embolization are effective and associated with a low complication rate. However, these techniques are less widely available and necessitate an experienced operator. As recurrences have been described with each of these techniques, every non-surgically-treated false aneurysm should be monitored for 24 hour with ultrasonography control to ensure effective thrombosis.

Arterial injuries: a sonographic approach

Acute arterial emergencies can arise from direct traumatic injury to the artery or be spontaneous. This article emphasizes the various presentations of arterial emergencies. These include acute arterial occlusions; excessive bleeding; and hematoma formation caused by penetrating arterial wall injuries, pseudoaneurysms, and arteriovenous fistulas. The broad category of arterial occlusions includes traumatic lacerations, embolizations, and arterial dissections. Modern ultrasound equipment is a rapid and convenient imaging approach in many of these clinical scenarios. In combination with MR angiography and CT angiography, these noninvasive tests can diagnose the presence of most arterial injuries, and be used to measure their impact.

Occlusion of pseudoaneurysms using human or bovine thrombin using contrast-enhanced ultrasound guidance

Percutaneous thrombin occlusion of pseudoaneurysms complicating invasive coronary interventions has emerged as a useful therapeutic tool. To facilitate thrombin occlusion and make the procedure even more secure, preinjection of echo contrast medium during duplex ultrasound was tested in 132 patients. Complete and immediate occlusion of the pseudoaneurysm was achieved in 99.2% (131 of 132 patients). No complications related to the injection of thrombin were documented. Contrast-enhanced ultrasound-guided thrombin occlusion was a safe and effective therapeutic option. In aneurysms with complex morphology or multiple cavities, preinjection of contrast medium was helpful for documenting the flow pattern.

Exclusion of a Crural Pseudoaneurysm With a PTFE-Covered Stent-Graft

PURPOSE

To describe the successful endovascular treatment of an iatrogenic anterior tibial artery pseudoaneurysm with a polytetrafluoroethylene-covered stent-graft.

CASE REPORT

A 58-year-old man was admitted to our hospital with pseudoarthrosis and malunion of the right distal tibia. Fibulotomy and intramedullary fixation were performed, which was complicated by a pseudoaneurysm of the anterior tibial artery. Under local anesthesia, a 4x31-mm Symbiot covered stent was successfully placed over the origin of the pseudoaneurysm. At 12 months, the pseudoaneurysm remained excluded, and the anterior tibial artery was patent.

CONCLUSIONS

Endovascular treatment of a crural artery pseudoaneurysm seems to be a feasible treatment option. Further experience with this technique is needed to validate its safety and long-term patency.

Brachial Artery Pseudoaneurysm in a 6-Week-Old Infant

Trauma to the wall of an artery may lead to the development of a pseudoaneurysm. There are infrequent case reports of children who have developed pseudoaneurysms after vascular access attempts. The options for management are limited in children and even more so in neonates. We describe the presentation and management of a 6-week-old infant who had attempts at insertion of an intravenous catheter as a newborn. She presented with an enlarging mass of the right upper extremity with no palpable radial pulse on examination. Workup included radiographs, Doppler ultrasound, and magnetic resonance imaging that established the diagnosis of pseudoaneurysm of the brachial artery. She underwent a repair of the right brachial artery by identifying the site of the arterial injury and oversewing the defect in the wall. Intraoperatively, she had good arterial flow with a return of the radial pulse. The patient did well immediately postoperatively and has been followed for more than a year with normal pulses and growth of the upper extremity. Patients that have had previous attempts at vascular access and subsequently develop a mass in the area of puncture should be worked up for the potential of a pseudoaneurysm. Doppler ultrasound and magnetic resonance imaging may help with diagnosis. Primary repair is advocated in this injury to ensure adequate growth of the limb.

Percutaneous thrombin injection for the treatment of a post-pancreatitis pseudoaneurysm

Visceral artery pseudoaneurysms are often treated surgically or by transcatheter embolisation. We report a case of a pseudoaneurysm in a patient with chronic pancreatitis, which was successfully occluded by percutaneous injection of thrombin into the pseudoaneurysmal sac as a first-line management.

Embolization of traumatic pseudoaneurysms after total knee arthroplasty

We report on 2 cases of traumatic pseudoaneurysm after total knee arthroplasty. In one patient, a hemarthrosis and a pulsatile antecubital mass developed 1 month after arthroplasty, prompting angiography. In the second patient, evacuation of a large hemarthrosis was performed before angiography and embolization. In both patients, the pseudoaneurysm was successfully treated without the need for surgical repair, using percutaneous thrombin injection or transcatheter embolization. No recurrence of hemarthrosis was seen in either patient at up to 24 months of follow-up evaluation. These cases show the use of angiography in reconstructed joints when acute or delayed hemarthrosis occurs, and the role of embolization techniques in this setting.

Iatrogenic Femoral Pseudoaneurysms That Are Unresponsive to Percutaneous Thrombin Injection: Potential Causes

OBJECTIVE

We sought to determine whether any quantitative selection criteria can be established to predict which pseudoaneurysms of the common femoral artery will fail to respond to thrombin. SUBJECTS AND METHODS. Under sonographic guidance, we injected thrombin into 54 consecutive iatrogenic pseudoaneurysms of the common femoral artery. We statistically compared the volume, maximum dimension, and neck diameter of the pseudoaneurysms and thrombin doses injected into the successfully treated (persistent thrombosis on a follow-up duplex sonogram obtained 7-10 days after thrombin injection) and unresponsive (sonographically documented recurrence within 24 hr) pseudoaneuryms to determine whether any of these factors could help to predict a failure to respond to thrombin. For all patients in whom treatment failed, findings at surgical repair were noted and sonograms were reviewed to confirm the dimensions and appearance of the pseudoaneurysm and the absence of an associated arteriovenous fistula.

RESULTS

Complete and persistent thrombosis was achieved in 49 (91%) of the 54 common femoral artery pseudoaneurysms. In comparing the 49 successfully treated patients and the five patients in whom treatment failed, we identified no significant differences in the volume, maximum dimension, or neck diameter of the pseudoaneurysm (two-sample t test) or in the thrombin dose (Wilcoxon's rank sum test). In all five patients with failed treatment, an arteriotomy site laceration measuring at least 8.0 mm (n = 4) or infection (n = 1) was identified at surgical repair, none of which were identifiable even in retrospect on duplex and color Doppler sonography.

CONCLUSION

Failure of an iatrogenic pseudoaneurysm of the common femoral artery to respond to thrombin may indicate an occult vascular injury. In these patients, surgical repair, rather than reinjection of thrombin, should be considered.

Treatment of a radial artery pseudoaneurysm with ultrasound-guided percutaneous thrombin injection in a patient with Behçet's syndrome

A 57-year-old man with Behçet's syndrome and recurrent deep vein thrombosis of the lower limbs presented with a painful, pulsating mass on the volar aspect of the radial edge of his left wrist. One month before this visit, he had had venous blood drawn from the same site. Using color Doppler sonography, we diagnosed an iatrogenic pseudoaneurysm of the left radial artery, which was then treated with an ultrasound-guided percutaneous injection of thrombin. A follow-up examination 6 months after the treatment revealed complete resolution of the pseudoaneurysm. To our knowledge, this is the first case report to demonstrate the use of this technique for thrombosis of a pseudoaneurysm in a patient with Behçet's syndrome. We believe that the safety, efficiency, speed, and minimal invasiveness of this procedure make it feasible for use as a treatment for peripheral pseudoaneurysms in such patients.

Transluminal Occlusion of a Pseudoaneurysm Arising from a Thoracic Aortic Graft Patch Using Catheter Delivery of Thrombin

A 39-year-old man with Marfan syndrome underwent replacement of the aortic valve, root, and ascending aorta for acute type A dissection. Subsequently, he underwent infrarenal aortic replacement for aortic rupture and then graft repair of a thoracoabdominal aneurysm with patch-bearing intercostals. After the third procedure, massive intraperitoneal hemorrhage required three subsequent laparotomies. CT scan showed two thoracic aortic pseudoaneurysms at the patch-graft junction that were sequentially embolized with transcatheter delivery of thrombin.

Treatment of pancreatic pseudoaneurysm with percutaneous transabdominal thrombin injection

Severe acute pancreatitis is associated with significant morbidity and mortality. Although rare, pancreatic pseudoaneurysm is a serious and often fatal complication of acute pancreatitis. This case report describes an alcoholic male patient with a psuedoaneurysm that was successfully treated with percutaneous transabdominal thrombin injection.

Percutaneous ultrasonographically guided thrombin injection of iatrogenic pseudoaneurysms in unusual sites

OBJECTIVES

To evaluate the effectiveness and safety of percutaneous ultrasonographically guided thrombin injection as treatment of unusually positioned and unusually large iatrogenic pseudoaneurysms.

METHODS

Five patients with iatrogenic pseudoaneurysms were evaluated by color duplex ultrasonography. Two patients had additional digital angiography, and 2 had additional computed tomographic angiography. In 3 of the patients, large, painful iatrogenic pseudoaneurysms located proximal (2 patients) and distal (1 patient) to the arteriovenous hemodialysis fistulas had developed, most likely due to erroneous puncture of the arterial side (brachial artery) or venous side (cephalic vein) of the fistulas. An iatrogenic pseudoaneurysm of the anterior tibial artery had developed in the fourth patient after osteotomy of the fibula, and an iatrogenic pseudoaneurysm of the superficial femoral artery had developed in the fifth patient after erroneous puncture during venous transfemoral angiography. With a sterile technique and color duplex ultrasonographic guidance, a diluted solution of bovine thrombin was slowly injected directly into the iatrogenic pseudoaneurysms until cessation of blood flow was seen. Follow-up color duplex ultrasonography was performed 24 to 48 hours after the ultrasonographically guided thrombin injection.

RESULTS

Four iatrogenic pseudoaneurysms were successfully thrombosed during 1 session. Two large iatrogenic pseudoaneurysms necessitated multiple repositions of the injecting needle and several injections of small amounts of thrombin into the residual patent lumen to induce complete thrombosis without an appreciable increase in the total thrombin dosage. Follow-up examinations revealed complete and persistent thrombosis without evidence of distal embolization. One iatrogenic pseudoaneurysm involving the cephalic vein, distal to an arteriovenous hemodialysis fistula, recurred after apparently successful initial thrombosis.

CONCLUSIONS

Most iatrogenic pseudoaneurysms are amenable to ultrasonographically guided thrombin injection as long as they are imaged adequately by color duplex ultrasonography.

Delayed femoral vein thrombosis after ultrasound-guided thrombin injection of a postcatheterization pseudoaneurysm

Ultrasound-guided thrombin injection is a highly effective therapy for postcatheterization pseudoaneurysm. Despite a very low complication rate, a number of severe arterial thrombotic events have been reported. We present an unusual case of acute femoral vein thrombosis occurring several hours after successful treatment of femoral artery pseudoaneurysm by ultrasound-guided thrombin injection. Pathophysiologic mechanisms are discussed. This case highlights the potential hazards of instilling such a powerful thrombogenic substance in the immediate vicinity of other vascular structures.

[Usefulness of sonographically guided thrombin injection of iatrogenic femoral pseudoaneurysms]

BACKGROUND AND OBJECTIVE

In december 2000, we began to treat iatrogenic femoral pseudoaneurysms with direct thrombin injection under sonographic guidance after failed sonographically guided compression repair. Our purpose was to determine the success and complications rate of this technique.

PATIENTS AND METHOD

We treated 50 patients who had iatrogenic femoral pseudoanerysms using direct thrombin injection. A 22-gauge spinal needle was placed into the psudoaneurysm lumen with sonographic guidance, and bovine thrombin (mean dose, 1200 units; range 200-7000 units) was injected under continous color Doppler sonographic visualization. Patient demographics clinical variables, and pseudoaneurysms characteristics were collected.

RESULTS

The overall success rate was 98% (49/50). 30 patiens only required one thrombin injection, with mean thrombosis time of 4 s. When more than one injection was required the mean thrombosis time increased to 9,5 s. There was correlation between thrombosis time and the pseudoaneurysm size (p < 0.005); and between pseudoaneurysm size and the dose of thrombin used. No mayor sedation was needed and no recurrent pseudoaneurysms were observed. With the exception of a mild local eritema in one patient no complications were found.

CONCLUSION

The thrombin injection under sonographic guidance is a quick, effective and secure method of therapy for the treatment of iatrogenic femoral pseudoaneurysms. Failures and complications are infrequents. At our hospital sonographically guided thrombin injection had replaced compression repair.

Treatment of femoral artery pseudoaneurysms using ultrasound-guided thrombin injection

Femoral artery pseudoaneurysms, a complication of femoral arterial puncture, is increasing in frequency with the proliferation of endovacular interventions. Pseudoaneurysms have historically been treated by open surgical repair, and more recently by ultrasound-guided compression. Ultrasound-guided compression is painful, and has a relatively low success rate of 51% to 73%. Since 1991, ultrasound-guided thrombin injection has become a treatment option. During injection of thrombin into a pseudoaneurysm, immediate thrombosis can be demonstrated within seconds. The entire procedure can be accomplished within 5 minutes, is simple to learn, and can be performed safely on an outpatient basis.

Current treatment methods for postcatheterization pseudoaneurysms

Pseudoaneurysms are a recognized complication of arterial catheterization. Until recently, the standard method of treatment has been surgical. The past decade has seen the introduction of several minimally invasive techniques that have largely replaced surgical treatment of pseudoaneurysms. The most commonly used methods are ultrasound-guided compression and percutaneous injection of thrombin into the pseudoaneurysm. This review article describes all the methods available for the treatment of postcatheterization pseudoaneurysms, presents results from the largest published series, and discusses the relative merits of each technique.

Pseudoaneurysm of the dorsalis pedis artery: color Doppler sonographic and angiographic findings

Pseudoaneurysm of the dorsalis pedis artery is an uncommon condition that is usually caused by a traumatic injury or an iatrogenic intervention. The patient usually complains of an enlarging painless, pulsatile mass. A tentative diagnosis may be made by palpation of the pulsatile mass and detection of an associated systolic bruit. Color Doppler sonographic and arteriographic examinations can be used to confirm the diagnosis. We report the case of a 17-year-old patient with a posttraumatic pseudoaneurysm of the dorsalis pedis artery. Sonographic examinations revealed pulsatile flow into and out of a cystic structure surrounded by a thick hypoechoic wall and a "to-and-fro" pattern in the neck of the vascular mass; these findings were consistent with the diagnosis of a pseudoaneurysm. Angiography confirmed the diagnosis. The patient was treated with ligation of the artery and resection of the pseudoaneurysm. He recovered well after surgery and remained free of symptoms 3 months postoperatively. We believe that color Doppler sonography should be the procedure of choice for use in diagnosing pseudoaneurysms; arteriography can then be used to evaluate the alternative blood supply before surgery is undertaken.

Hepatic artery pseudoaneurysm after liver transplantation: treatment with percutaneous thrombin injection

Pseudoaneurysms of the hepatic artery are a rare complication of liver transplantation. Early diagnosis and treatment are essential to avoid life-threatening hemorrhage. Conventional treatment consists of surgical resection and vascular reconstruction or transarterial coil embolization. More recently, percutaneous thrombin injection has been successfully used in the treatment of femoral artery pseudoaneurysms. We describe a 70-year-old woman who had a hepatic artery pseudoaneurysm after orthotopic liver transplantation, which was successfully treated by percutaneous thrombin injection.

Femoral pseudoaneurysms: management with percutaneous thrombin injections--success rates and effects on systemic coagulation

PURPOSE

To determine the success rate of percutaneous ultrasonographically (US) guided thrombin injection in the treatment of femoral pseudoaneurysms and to evaluate the effects of thrombin injection on systemic coagulation parameters.

MATERIALS AND METHODS

Fifty femoral pseudoaneurysms (37 simple pseudoaneurysms with one lobe and 13 complex pseudoaneurysms with two or three lobes) were treated with US-guided percutaneous thrombin injections. Pseudoaneurysm size, neck length and width, thrombin dose, outcome of therapy, and complications were documented prospectively. Duplex sonographic follow-up examinations were performed at 12-24 hours and 5-7 and 21-25 days. In 25 patients, activated thromboplastin time, Quick test (prothrombin time), thrombin time, fibrinogen, D-dimer, antithrombin III, thrombin-antithrombin III complex, and prothrombin fragments 1 and 2 were determined before and at 2, 5, and 10 minutes after thrombin injection. Differences in results before and those after thrombin injection were evaluated by means of the one-sample t test.

RESULTS

Mean volume of pseudoaneurysms was 5.84 cm(3) +/- 4.89 (SD). Fifty-eight thrombin injections were performed. Mean thrombin dose was 357 IU +/- 291 in simple and 638 IU +/- 549 in complex pseudoaneurysms. Primary success rate was 36 of 37 (97%) for simple and eight of 13 (61%) for complex pseudoaneurysms. Reperfusion occurred in four complex pseudoaneurysms (none in simple ones). Secondary success rate was 100%. No thromboembolic, infectious, or allergic complications occurred. During follow-up, reperfusion was detected in one patient with a complex pseudoaneurysm. Levels of thrombin-antithrombin III complex increased significantly (P <.05) after thrombin injection, whereas changes in all other laboratory tests were not significant.

CONCLUSION

US-guided percutaneous injection of thrombin is successful and safe in the management of femoral pseudoaneurysms. The increase of thrombin-antithrombin III complex indicates the possibility of thrombin passage into the arterial circulation.

Complication rates of percutaneous brachial artery access in peripheral vascular angiography

The brachial artery has been considered a secondary choice for percutaneous access due to reported increased complication rates compared to femoral access despite potential advantages in peripheral vascular disease (PVD) patients. A prospectively collected database of 1326 PVD patients undergoing angiography with percutaneous brachial access between January 1, 1990 and December 31, 1999 was retrospectively reviewed. All patient charts with coded brachial pathology during this time period were reviewed to ensure complete data capture. The protocol for patients undergoing brachial access included a vascular surgery evaluation after each angiogram and telephone follow-up by a nurse at 24 hr. During this 10-year period, a percutaneous brachial artery approach was used to perform 1084 angiograms in men and 242 angiograms in women. A subset of 111 patients had multiple studies (range: 2 to 7) via brachial access without complication. Rates of failed access (2.1% female vs. 0% male, p <0.001) and brachial thrombosis (1.24% female vs. 0.28% male, p <0.04) were significantly higher in women. The complication rate for all patients was 1.28%. Percutaneous brachial access for angiography can be safely and repetitively performed in PVD patients, although women have an increased risk of thrombosis and failed access. The brachial approach allows early ambulation and discharge, and can be considered a primary choice for diagnostic angiographic access.

Thrombin injection for failed stent graft repair of perforated atherosclerotic aortic ulcer

We used direct thrombin injection to occlude a pseudoaneurysm that formed from a contained rupture of a penetrating atherosclerotic ulcer at the junction of the thoracic and abdominal aorta after we failed to seal the perforation with an endovascular stent graft. The principles of thrombin injection and the technical modifications specific for use in a false aneurysm of aortic origin are described. An evolving role for thrombin in endovascular therapy is suggested.

Duplex-guided thrombin injection for the treatment of iatrogenic pseudoaneurysms

This study compares duplex-guided thrombin injection (DGTI) with duplex-guided compression (DGC) for the treatment of iatrogenic pseudoaneurysms. A nonrandomized prospective study, approved by the institutional review board, was performed to evaluate the success rate in DGTI versus DGC (with the use of historical data) in patients who arrive at the vascular surgery service for the treatment of iatrogenic pseudoaneurysm as identified by ultrasound examination. DGTI has been shown to have major advantages over DGC, such as improved patient and operator acceptance, shorter pseudoaneurysm thrombosis times, broader patient applications, and higher success rate.

Obliteration of femoral artery pseudoaneurysm by thrombin injection

BACKGROUND

Femoral artery pseudyoaneurysms are a common complication after femoral access for transcatheter procedures, frequently requiring operative repair. We review the safety and efficacy of a novel nonsurgical method of pseudoaneurysm treatment

METHODS

From June 1998 to November 2001, a total of 47 femoral artery pseudoaneurysms in 46 patients were treated by bedside ultrasound-guided injection of dilute topical thrombin. All pseudoaneurysms occurred after femoral access for transcatheter procedures, and were diagnosed clinically and confirmed with ultrasound imaging. Clinical follow-up was performed and included ultrasound (2 hours to 1 month) in 64.4% of patients, including any patient with a symptomatic or clinical change.

RESULTS

Pseudoaneurysms ranged in size from 1.5 to 4.5 cm. Of 47 pseudoaneurysms, 45 were successfully obliterated on the initial injection. After successful obliteration of pseudoaneurysm, 1 patient sustained thrombosis of the tibioperoneal trunk that required surgical embolectomy, yielding a complication rate of 2%. Four pseudoaneurysms recurred after initially successful obliteration. In 1 of these cases, the patient was taken directly to surgery, and 3 were successfully treated with repeat injection, for an overall success rate of 93.6%.

CONCLUSIONS

Obliteration of femoral artery pseudoaneurysm by injection is safe and effective, and may be associated with decreased morbidity. Recurrent pseudoaneurysms may be safely reinjected, with a high success rate.

Ultrasound-guided percutaneous thrombin injection for treatment of extrarenal pseudoaneurysm after renal transplantation

A patient who received two kidney transplants was placed on hemodialysis after failure of both grafts. He had complained of abdominal pain during the preceding month and was found to have a pulsating mass in his right pelvic region. Computed tomography and color Doppler studies showed a large pseudoaneurysm of the common iliac artery. We describe the treatment of this lesion by the use of ultrasound-guided thrombin injection. To the best of our knowledge, this is the first report regarding the use of ultrasound-guided percutaneous thrombin injection for treatment of such a pseudoaneurysm.

Treatment of iatrogenic femoral artery false aneurysms with ultrasound-guided thrombin injection

The aim of this paper is to review our results of treating iatrogenic pseudoaneurysms of the femoral artery with ultrasound-guided thrombin injection. A retrospective review was carried out of all patients referred for this procedure over a 1-year period from December 1999 to December 2000. Forty-five patients were referred and, of these, 44 were eligible for this treatment, with 300-2500 units of thrombin being injected directly into the false aneurysms under ultrasound guidance. The procedure was well tolerated with no patients requiring sedation or analgesia. There was a primary success rate of 95%, although in four of the patients, there was recurrence on repeat ultrasound performed 2-5 days post-procedure and a second injection of thrombin was required for permanent thrombosis to be achieved. No complications relating to the procedure occurred. Our results confirm increasing evidence in the published research that thrombin injection of femoral artery false aneurysms is a safe and effective treatment.

Percutaneous management of access site complications

Percutaneous cardiac catheterization and endovascular procedures are associated with complications at the vascular access site. While surgery has been the traditional treatment for vascular access complications, the current state of the art permits percutaneous management of many access site complications. Surgical repair may be required only when percutaneous methods fail, are not available, or are unsuitable.

Treatment of femoral pseudoaneurysms. Percutaneous US-guided thrombin injection versus US-guided compression

PURPOSE

Thrombin injection in femoral pseudoaneurysms has been suggested to be superior to traditional US-guided compression. Our aim was to evaluate results with compression therapy with special reference to use of thrombin in case of failure. We also studied 7 patients who underwent primary thrombin injection.

MATERIAL AND METHODS

We retrospectively reviewed all (n=44) femoral artery pseudoaneurysms diagnosed at our department during October 1998-May 1999. US-guided compression with the Femostop device or US-guided thrombin injection (100-1000 IU) was the first choice according to the physicians' preference, followed by the other regime if the first choice was non-successful.

RESULTS

Thirty-nine (89%) of the patients received anticoagulation treatment and/or concomitant antiplatelet drugs. Out of the 44 patients, 37 were treated with compression as the first choice. This regime was successful in 22 (59%). This group included 2 lesions that resolved spontaneously after initially failed compression and 1 deep venous thrombosis after treatment. The persistent 15 pseudoaneurysms after failed compression received thrombin injection, and it was also the primary therapy in 7 patients. Complete thrombosis within the pseudoaneurysm was immediately induced after treatment. One early recurrence required a second injection. No complication of thrombin was noted and no surgery was required.

CONCLUSION

US-guided thrombin injection is an effective treatment for embolisation of pseudoaneurysms. The technique is superior to compression therapy.

Ipsilateral femoral vein compression: a contraindication to thrombin injection of femoral pseudoaneurysms

Development of a femoral artery pseudoaneurysm occurs in 0.6% to 3.2% of interventional procedures. Nonsurgical treatment has consisted of ultrasound scan-directed compression and, more recently, direct thrombin injection into the pseudoaneurysm cavity to achieve thrombosis. Reported complications after thrombin injection are rare. We report two cases of femoral venous compression associated with pseudoaneurysm injection and review the literature. A 76-year-old man and an 86-year-old man both underwent thrombin injection of pseudoaneurysms compressing the ipsilateral common femoral vein. Both patients were diagnosed with deep venous thrombosis and subsequently needed surgical exploration for repair of the pseudoaneurysm and release of the venous compression. At exploration, both were found to have significant inflammation surrounding the femoral vessels, which made vessel exposure challenging. Because of the venous outflow obstruction involved in femoral pseudoaneurysms with secondary venous compression and the surgical difficulty caused by surrounding inflammation, avoidance of thrombin injection in favor of early surgical intervention is suggested.

Pseudoaneurysms

Vascular complications that are the result of invasive diagnostic or therapeutic procedures requiring arterial access occur frequently. A common complication, pseudoaneurysm, has significant risk of expansion, extrinsic compression on native arteries, rupture, embolization, and infection. A pseudoaneurysm represents a persistent defect in the walls of the artery, resulting in extravasation of blood outside of the artery. This extravascular blood is confined to the surrounding soft tissues. Clinical suspicion and duplex ultrasonography are the primary diagnostic modalities. There are several options for treatment of pseudoaneurysms, including surgical repair and ultrasound-guided compression. However, a new therapeutic option, ultrasound-guided thrombin injection, has become the treatment of choice for pseudoaneurysms. This procedure is highly effective, rapid, and very safe. Using direct, real-time visualization of the pseudoaneurysm, a needle is inserted percutaneously into the pseudoaneurysm sac, and a small amount of dilute bovine thrombin is injected. Thrombosis of the sac is rapidly evident. Rare complications include thromboembolism into the native artery and hypersensitivity reaction to bovine thrombin.

Lumbar artery pseudoaneurysm following renal biopsy: treatment with ultrasound-guided thrombin injection

latrogenic pseudoaneurysms are usually seen following arterial catheterization. However, we describe a case of a 23-year-old woman who developed a pseudoaneurysm of a lumbar artery following renal biopsy. In view of her progressing renal failure, arterial embolization was felt to be inappropriate, and although the pseudoaneurysm could be seen ultrasonically, guided compression could not be applied because of the location of the aneurysm deep to the lumbar musculature. Hence, the pseudoaneurysm was thrombosed by percutaneous ultrasound-guided injection of thrombin directly into the pseudoaneurysm sac. This resulted in immediate thrombosis of the aneurysm and no recurrence on follow-up imaging. Thrombin injection for femoral artery pseudoaneurysms following catheterization is becoming more widely accepted, and our case demonstrates that this technique might be applied to pseudoaneurysms elsewhere in the body.

Ultrasound-guided thrombin injection of iatrogenic pseudoaneurysm at a community hospital

The purpose of this study was to report the success rate of treating pseudoaneurysm using ultrasound-guided thrombin injection at a community hospital. Over 16-month period, 42 patients with femoral artery pseudoaneurysms were treated using ultrasound-guided thrombin injection. Our results showed that ultrasound-guided thrombin injection has a high success rate, and can be safely performed at a community hospital.

Efficacy and safety of percutaneous treatment of iatrogenic femoral artery pseudoaneurysm by biodegradable collagen injection

OBJECTIVES; The goal of this study was to assess the safety and efficacy of femoral artery pseudoaneurysm (FAP) closure by collagen injection. BACKGROUND; The FAP is an infrequent but troublesome complication after percutaneous transfemoral catheter procedures. If ultrasound-guided compression repair (UGCR) fails, vascular surgery is indicated. We have developed a less invasive method to close FAPs percutaneously by injecting collagen and, thus, inducing clotting within the aneurysm.

METHODS

Via a 9F needle or 11F sheath, a biodegradable adhesive bovine collagen is injected percutaneously into the FAP, guided by angiography from the contralateral site.

RESULTS

From 1993 to 2000, compression and UGCR had failed to obliterate 110 FAPs. These patients have been treated by collagen injection. Mean age of the patients was 65.6 +/- 10.2 years (range: 32 to 85 years), and 50% were women. Immediate closure of the FAP was achieved in 107/110 patients (97.3%) without any complication or adverse effect. In one patient the collagen could not be applied due to unfavorable anatomy. One patient needed a second session of collagen injection. In one patient too much collagen was inserted, which resulted in external compression of the artery, and surgical intervention was required. The overall success rate was 108/110 (98%, 95% confidence interval: 93.5% to 99.8%). Among the patients with successful procedures, there were no recurrences during six months follow-up.

CONCLUSIONS

The percutaneous treatment of iatrogenic FAP, by injection with collagen, is an effective and safe strategy. This method provides an excellent therapeutic alternative to the traditional surgical management.

Autologous thrombin for treatment of pseudoaneurysms

Femoral pseudoaneurysms arise in up to 2% of patients after femoral cannulation for cardiac catheterisation. We used autologous thrombin for percutaneous obliteration of pseudoaneurysms occurring after catheterisation. We prepared autologous thrombin isolates from blood of ten patients with femoral pseudoaneurysms, and injected this solution into the pseudoaneurysms with duplex imaging guidance. We then assayed thrombin activity. All pseudoaneurysms were successfully thrombosed without substantial complications, although three patients needed a repeat procedure within 24 h. We have shown that autologous thrombin-induced thrombosis of pseudoaneurysms is reliable, simple, safe, and cheaper than commercial bovine or human thrombin, and avoids risks of anaphylaxis and contamination with prions.

Duplex scanning-guided thrombin injection for the treatment of iatrogenic pseudoaneurysms

PURPOSE

This study presents our current results with duplex scanning-guided thrombin injection (DGTI) for the treatment of lower-extremity iatrogenic pseudoaneurysms (PAs). These results were compared with the results from our patient population that was treated with duplex scanning-guided compression (DGC).

METHODS

This was a prospective evaluation of an institutional review board-approved protocol for ultrasound scanning-guided thrombin injection for the treatment of iatrogenic lower-extremity PAs. The maneuver was performed with continuous real-time color ultrasound scanning imaging to guide a needle into a PA sac. Then 0.5 to 1.0 mL of a thrombin solution (1000 U/mL) was injected, and thrombosis of the sac was monitored. All patients underwent an arterial evaluation of the involved extremity before and after thrombin injection. In addition, the size of the PA and its parent artery were documented by means of pre-injection imaging. After thrombosis of the PA, the patient was kept on bed rest for 4 hours, and activity was limited that day (bathroom privileges for inpatients). Follow-up imaging was performed after 24 hours, and attempts were made to obtain imaging 1 week and 1 month after injection.

RESULTS

In the 31 months of the study, 131 iatrogenic PAs of the lower extremity were initially treated with DGTI, and thrombosis was achieved in 126 of these cases (96%). Thrombosis of the PA sac was accomplished within seconds of thrombin injection. Five cases failed, three of which resulted from complications of the procedures, with two intra-arterial thrombin injections and one PA rupture after thrombosis.

CONCLUSION

Our experience indicates that DGTI is more effective than DGC (96% vs 75%) in the treatment of iatrogenic lower-extremity PAs. The DGTI procedure is completed in minutes, compared with a mean compression time of 44 minutes with DGC, which leads to increased patient and operator acceptance. Intra-arterial thrombin injection was seen in 4% of PAs that were 2.6 cm or smaller and resulted in limb-threatening ischemia requiring surgical intervention. Finally, the use of a biopsy guide attached to the ultrasound scanning transducer head simplifies the visualization of the needle, reducing the number of needle punctures and needle manipulation.

Percutaneous thrombin injection of carotid artery pseudoaneurysm

PURPOSE

To report the successful treatment of a carotid artery pseudoaneurysm by percutaneous thrombin injection.

CASE REPORT

A 71-year-old man with end-stage renal failure presented with acute left ventricular failure. The right common carotid artery (CCA) was punctured during attempted jugular line insertion, and he developed a large pseudoaneurysm connected to the CCA by a long, narrow neck. Ultrasound-guided compression was unsuccessful, so another technique was attempted. An occlusion balloon was inflated in the CCA at the neck of the aneurysm to avoid distal embolization, and 250 units of human thrombin were injected into the sac percutaneously; thrombosis was instantaneous. There were no procedural complications, and repeat ultrasound at 3 months showed resolution of the hematoma and no residual pseudoaneurysm. There were no neurological complications.

CONCLUSIONS

Percutaneous thrombin injection may be a new and successful method of treating carotid artery pseudoaneurysms.

Treatment of postcatheterisation false aneurysms: ultrasound-guided compression vs ultrasound-guided thrombin injection

OBJECTIVES

to compare the efficacy and cost-effectiveness of ultrasound-guided compression (UGC) with ultrasound-guided thrombin injection (UGTI) for treatment of postcatheterisation arterial false aneurysms (cFA).

DESIGN

prospective clinical study using historical controls.

MATERIALS AND METHODS

we prospectively collected data on 33 consecutive patients diagnosed with cFA larger than 1.5 cm in diameter. These were treated with UGTI. We performed a retrospective review of data on a former group of 33 consecutive historical control patients that were treated by UGC.

RESULTS

the groups were similar in respect of demographic and clinical variables. Thirty patients were suitable for UGC and 33 patients were suitable for UGTI. The success rate for UGC was 26/30 (87%) compared to 33/33 (100%) for UGTI (p<0.05). Thrombosis was achieved during the first treatment session in 7/26 patients treated by UGC, compared to 26/33 in the UGTI group (p<0.0001). Four patients that failed UGC and two patients that were unsuitable for UGC required surgical repair. UGTI as compared to UGC was shorter in duration (25 vs 75 min) and required no sedation. No thromboembolic or systemic complications occurred in either group. Cost analysis revealed savings of $US 517 for each patient treated by UGTI as compared with UGC.

CONCLUSIONS

in our study, UGTI is superior to UGC, and we suggest that UGTI should become the procedure of choice for the treatment of cFA.

Ultrasound guided human thrombin injection. A new modality in the management of femoral artery pseudo-aneurysms

OBJECTIVES

We report our initial results of a prospective study of duplex ultrasound-guided injection (UGTI ) of thrombin in the management of femoral artery pseudo-aneurysms. We used human thrombin to avoid the increase in the human antibodies directed against fibrinogen, with the use of bovine thrombus, that preclude further utilisation of the bovine fibrin glue during cardio-thoracic surgery.

METHODS

From 1999 to 2001, 19 patients, aged 69 (range 52-85) years presented with 21 femoral pseudo-aneurysms were treated. The mean pseudoaneurysm diameter was 30 (15-55) mm. All but two were secondary to cardiac procedures and the common femoral artery was the injured vessel in all instances. Patients were referred within 2-21 days following their iatrogenic injury.

RESULTS

Immediate thrombosis of the sac occurred in 19 (90%) of the 21 pseudo-aneurysms. After a second injection, complete occlusion occurred in the remaining two patients. Two patients (CI 95%; 1-19) with three femoral pseudo-aneurysms developed leg pain. Duplex ultrasound follow-up showed two recurrences (9.5% - CI 95%; 1-19) and both were treated by repeat UGTI. There was no conversion to surgical repair.

CONCLUSION

This percutaneous minimally invasive technique is safe and effective in the management of iatrogenic pseudo-aneurysms in this high-risk group of patients. Human thrombin has significant advantages over bovine thrombin.

Intra-arterial thrombin injection of an ascending aortic pseudoaneurysm complicated by transient ischemic attack and rescued with systemic abciximab

Thrombin injection as a means of inducing thrombus formation has recently received wide attention as an alternative treatment for pseudoaneurysm. We present a case of a 67-year-old man in whom a large mycotic pseudoaneurysm developed in the ascending aorta because of sternal osteomyelitis and mediastinitis after coronary artery bypass grafting. Transcatheter intra-arterial thrombin injection was performed, and it successfully induced pseudoaneurysm thrombosis. However, the procedure was complicated by a sudden transient ischemic attack caused by thrombus propagation into the cerebral circulation. Complete thrombus dissolution in the cerebral circulation with the resolution of neurologic symptoms was achieved by means of intravenous abciximab.

Therapeutic thrombin injection of pseudoaneurysms: a multicenter experience

The standard non-invasive treatment of pseudoaneurysms has been ultrasound-guided compression (UGC). Problems with UGC include pain at the site of compression, long compression times and incomplete closure. Each of these difficulties is exacerbated with large pseudoaneurysms. Recently, ultrasound-guided injection of pseudoaneurysms with thrombin has gained popularity. The goal of this study was to report a multicenter registry using this technique and in so doing detail the clinical utility and safety of this emerging procedure. The medical records of all patients diagnosed with pseudoaneurysm in the vascular laboratory who underwent thrombin injection over the past year were reviewed for patient characteristics and clinical outcome. There were 91 patients (55 male) with a mean age of 69 years. Three patients also had an arteriovenous fistula. The majority of patients were receiving one or more antiplatelet agents and/or anticoagulants. All patients underwent pseudoaneurysm injection with bovine thrombin. The mean aneurysm diameter was 3.3 cm, with a range of 1.5-6.3 cm. Successful thrombosis of the pseudoaneurysm was achieved in 89/91 (98%) of cases. Anticoagulation with heparin was used in one of the unsuccessful cases. In two cases, UGC was used to close a small active region that did not completely thrombose after thrombin injection. There were two patients who had recurrence of pseudoaneurysm the day after successful injection and thrombosis of the pseudoaneurysm. There were no local complications after injection; however, one patient suffered a pulmonary embolus that was thought to be unrelated to the procedure. In conclusion, thrombin injection for the treatment of pseudoaneurysms is safe and effective, even in patients receiving anticoagulation. This procedure should be considered as the initial therapeutic approach for peripheral pseudoaneurysms.

Low-dose thrombin injection to treat iatrogenic femoral artery pseudoaneurysms

OBJECTIVE

Treatment of iatrogenic femoral artery pseudoaneurysms with thrombin injection has been reported as an efficacious and safe procedure. The major risk of this procedure is distal limb ischemia from thrombosis, resulting from thrombin escape. The cumulative average dose of thrombin reported in the literature is approximately 1100 U per patient. Minimizing the thrombin dose may reduce the risks of the procedure. This study reports our experience with low-dose thrombin injection for the treatment of pseudoaneurysms.

MATERIALS AND METHODS

Twenty-three patients with 26 postcatheterization femoral pseudoaneurysms were administered thrombin injection with color-flow Doppler sonographic guidance. Pseudoaneurysm volume ranged from 1 to 41 cm(3) with an average of 6.7 cm(3) and a median of 4 cm(3). Two patients received therapeutic doses of IV heparin for anticoagulation. When possible, the neck of the pseudoaneurysm was occluded during the injection to promote stagnation and prevent thrombin leakage. Sonographic follow-up was routinely performed after 24 hr.

RESULTS

An average dose of 192 U of thrombin was used (range, 50-450 U), and time to coagulation ranged from 10 to 60 sec. All 26 pseudoaneurysms were successfully thrombosed, although one required repeated treatment because of recanalization noted at 1-day follow-up. There were no complications.

CONCLUSION

Doses of thrombin at an average of fivefold lower than previously reported were effective in the treatment of 26 iatrogenic femoral pseudoaneurysms, even in the presence of anticoagulation. This experience shows that a much smaller dose of a potentially dangerous medication can achieve the same efficacy as previously used higher doses.

Ultrasound-guided thrombin injection is a safe and durable treatment for femoral pseudoaneurysms

Ultrasound-guided percutaneous thrombin injection has recently been described as a treatment for postcatheterization femoral pseudoaneurysms. Although ultrasound guided compression offers another nonoperative treatment option, thrombin injection has shown superior initial success rates. Reports of follow-up for thrombin injection longer than 30 days are currently lacking. The authors reviewed their initial experience with thrombin injection and prospectively evaluated patients for occult late recurrences of pseudoaneurysm and for distal circulatory complications. Records and vascular laboratory data for all patients treated with ultrasound-guided thrombin injection were reviewed for an 18-month period. Tibial vessel Doppler waveforms and ankle/brachial indices were routinely obtained before and after thrombin injection. Follow-up duplex examinations were performed within 24 hours of initial treatment. In the prospective portion of the study, successfully treated patients underwent a repeat femoral duplex scan and lower extremity arterial examination for comparison with the pretreatment studies. Forty-nine of 52 femoral pseudoaneurysms (94%) were successfully treated with ultrasound guided thrombin injection. One immediate failure and 2 early recurrences were treated surgically. There was 1 thrombotic complication of the native circulation identified at the time of injection. Follow-up studies were obtained in 32 of 46 available patients with a mean length of follow-up of 9 months (range 3-17 months). No late recurrences of the pseudoaneurysms or arterial-venous fistulas were observed. No distal circulatory complications were detected by arterial waveform analysis. Three deaths occurred in the interim (cardiac related). Two patients were lost to follow-up. The remaining 12 patients reported no additional limb complications but declined to be restudied. Ultrasound-guided thrombin injection is a safe, effective, and durable treatment for iatrogenic pseudoaneurysms. Thrombin injection should be the therapy of choice for catheter-related femoral false aneurysms.