Traumatic Inferior Gluteal Artery Aneurysm Managed with Emergency Transcatheter Thrombin Injection

Catheter-directed endovascular application of thrombin: Report of 3 cases and review of the literature

PURPOSE

To report 3 new cases of catheter-directed endovascular application of thrombin and explore trends by analysis of published case series.

MATERIALS AND METHODS

Institutional Review Board approved this retrospective study. All cases of non-tumoral arterial embolization performed from January 2003 to January 2015 at our institution were retrospectively reviewed. Thrombin was used in 7 of 589 cases. In 3 cases intra arterial thrombin was injected via catheter to treat active hemorrhage. Four cases were excluded due to percutaneous injection into visceral pseudoaneurysms (n=3) and making ex vivo autologous clot to be injected via catheter (n=1). Fisher's exact and the Wilcoxon rank sum tests were used to assess for association with acute nontarget thrombosis.

RESULTS

Catheter-directed thrombin was used in 3/589 (0.5%) cases at our institution. All three cases were technically successful with no further bleeding (100%). Nontarget thrombosis of proximal branches occurred in 2 patients (67%) with no significant clinical consequences. Including our 3 cases, a total of 28 cases were reviewed. Of the variables examined-location (p=0.99), size (p=0.66) and etiology of vascular lesion (p=0.92), pseudoaneurysm neck anatomy (p=0.14), thrombin units (p=0.47), volume (p=0.76) or technique of use of small doses (p=0.99), use of other embolic material (p=0.67) and use of adjunct techniques (p=0.99)-none were found to be significantly associated with acute nontarget thrombosis. Technical success was 96% with no reports of reperfusion after treatment.

CONCLUSIONS

Catheter-directed endovascular thrombin can be an additional tool to treat pseudoaneurysms not amenable to conventional embolization. Further studies are required to optimize technique and outcomes.

A Pulsatile Mass in the Right Buttock

Gluteal artery pseudoaneurysms are a rare cause of buttock pain, with few cases reported in the recent literature. Although small pseudoaneurysms are usually asymptomatic, larger can be painful and require treatment. Most of these cases are pseudoaneurysms resulting from local trauma. We report in this case a patient with a gluteal artery pseudoaneurysm. The pseudoaneurysm was successfully thrombosed using ultrasound-guided thrombin injection. This article reviews the literature, discusses the imaging diagnostics and the treatment of gluteal artery aneurysms.

Inferior gluteal artery pseudoaneurysm related to intramuscular injection

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A case of pseudoaneurysm of the IGA following intramuscular injection in the buttock.

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Importance careful physical examination in order to avoid misdiagnosis.

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Diagnosis and therapy are facilitated by catheter angiography.

INTRODUCTION

Gluteal artery pseudoaneurysms are rare, yet the most common in cases involving the superior gluteal artery. Pseudoaneurysms of the inferior gluteal artery are uncommon and are often related to blunt or penetrating trauma, infections and fractures of the pelvis.

PRESENTATION OF CASE

The authors present a case of pseudoaneurysm of the inferior gluteal artery related to an iatrogenic injury due to intramuscular injection of medication, which was treated with selective embolization of the artery during angiography.

DISCUSSION

The most common manifestation of an inferior gluteal artery pseudoaneurysm is the presence of a painful mass in the buttock that may or may not be associated with neurological symptoms due to compression of the sciatic nerve. Ultrasound with color Doppler and computerized tomography with multi-detectors are useful non-invasive tools for diagnosis. However, both diagnosis and therapy are facilitated by catheter angiography.

CONCLUSION

This case cautions that although pseudoaneurysms are rare, pseudoaneurysms of the inferior gluteal artery require a high index of suspicion and careful physical examination by the physician in order to avoid misdiagnosis. It also illustrates the usefulness of a minimally invasive modality for treatment of these lesions.

Delayed presentation and management of blunt traumatic inferior gluteal artery pseudoaneurysm with associated arteriovenous fistula

Disruption of arterial wall integrity as a result of trauma, iatrogeny, inflammation, or infection may result in pseudoaneurysm formation. Gluteal artery aneurysms are rare and represent less than 1% of all arterial aneurysms. Pseudoaneurysms of the inferior gluteal artery (IGA) following blunt trauma are exceptionally rare with only 6 reported cases in the English literature. We describe an 82-year-old female with a remote history of a fall presenting with an enlarging buttock mass. Imaging confirmed an IGA pseudoaneurysm with associated arteriovenous fistula that was successfully treated with endovascular embolization.

Transarterial thrombin injection secured with an embolic protection device as a treatment for a superior mesenteric artery pseudoaneurysm

A pseudoaneurysm of the superior mesenteric artery (SMA) is a rare and life-threatening condition of various etiology. Even unruptured it can cause severe health problems or death. We report a 71-year-old male with a SMA pseudoaneurysm who was successfully treated with a transarterial thrombin injection secured with an embolic protection device used in carotid angioplasty. To our knowledge, this is the first case of a SMA pseudoaneurysm treated by this method.