Percutaneous fluoroscopically guided n-butyl cyanoacrylate (NBCA) injection for iatrogenic femoral arterial pseudoaneurysm under temporary balloon occlusion of arterial blood flow

Injection of n-Butyl-2-Cyanoacrylate into the Abdominal Aortic Aneurysm Sac during Endovascular Aortic Repair to Prevent Type II Endoleaks Caused by Lumbar Arteries

PURPOSE

To evaluate midterm results of whether the strategy to occlude target lumbar arteries using n-butyl-2-cyanoacrylate (nBCA) injection during endovascular aneurysm repair (EVAR) reduced the incidence of Type II endoleak (T2EL) after EVAR.

MATERIALS AND METHODS

Between 2013 and 2020, 187 patients underwent EVAR; 106 in the treatment group received nBCA injection during EVAR, whereas 81 in the historical control group did not. The incidence of T2EL at 7 days, need for reintervention, and post-EVAR aneurysmal shrinkage were compared between the groups.

RESULTS

Between the treatment group and the control group, significant differences were achieved in the incidence of T2EL (2.8% vs 28.4%; P < .0001) and decreased aneurysmal diameter was observed at 1 year after EVAR (-5.2 vs -3.8 mm; P = .034). In multivariate analysis, nBCA injection (odds ratio [OR], 0.04; P = .001) and younger age (OR, 0.92; P = .036) were significantly associated with a reduced incidence of T2EL. As a possible adverse event associated with nBCA injection, 2 cases of transient lower-limb motor dysfunction (1.9%) were observed. Propensity score analysis revealed that the treatment group had a significantly lower incidence of T2EL than that in the control group (P = .0002) even though there was no difference in the incidence of inferior mesenteric artery coil embolization between the groups. The survival rate without aneurysm sac enlargement (100.0% vs 69.8%; P = .014) and the reintervention-free rate (100.0% vs 63.1%; P = .034) in the treatment group were significantly higher than those in the control group.

CONCLUSIONS

Concomitant nBCA injection can provide durable EVAR without T2EL, as supported by the avoidance of reintervention associated with aneurysm sac enlargement.

Development and Experimental Study of a Polytetrafluoroethylene-Tipped Microcatheter Poorly Adhesive to n-Butyl-2-Cyanoacrylate

PURPOSE

We have developed a new microcatheter (designated "NSX") with an outer layer of polytetrafluoroethylene (PTFE) at its tip. We compared the adhesion of the new NSX microcatheter and a conventional microcatheter with n-butyl-2-cyanoacrylate (NBCA) in vitro and in swine blood vessels.

MATERIALS AND METHODS

The 3 cm tip of the NSX microcatheter is composed of PTFE, which can be identified by double platinum markers. The tips of the NSX and conventional microcatheters were inserted into a vascular model filled with porcine blood with no flow, and NBCA mixed with lipiodol (1:2) was injected from the microcatheters. Two minutes after the injection of NBCA, the microcatheter was withdrawn and the degree of its adhesion to NBCA was evaluated by measuring the resistance value (N) during catheter removal with a digital force gauge. These measurements were repeated with 20 catheters of each type. Similarly, 5 injections were performed with both the NSX and conventional microcatheters in swine vessels. The degree of adhesion of the catheter and blood vessel was evaluated by 2 radiologists under X-ray fluoroscopy on a 3-point scale: 1, no adhesion; 2, mild adhesion; 3, strong adhesion.

RESULTS

The mean resistance values (N) for the NSX and conventional microcatheters were 0.503±0.186 and 1.051±0.367 (N), respectively (p<0.001). The NSX adhered negligibly to the NBCA and was easily removed, whereas the conventional microcatheter adhered strongly to the NBCA in the blood vessels and was difficult to remove from the swine vessels (p=0.008).

CONCLUSIONS

The new NSX microcatheter with a PTFE tip exhibits poorer adhesion to NBCA than do conventional microcatheters and allows for safer injection of NBCA than conventional microcatheters, without requiring immediate catheter retrieval.

CLINICAL IMPACT

The NSX microcatheter with a PTFE tip adheres less strongly to NBCA than do conventional microcatheters and allows the safe injection of NBCA. The NSX microcatheter has double platinum markers on its tip, which make it easy to distinguish the PTFE-covered region. As the NSX does not adhere firmly to the arterial wall, it is less likely to cause vascular injury during removal of the catheter compared with conventional microcatheters, so there is no need to remove the NSX immediately after injecting NBCA. Even operators unfamiliar with NBCA can use NBCA safely with this new NSX microcatheter without requiring special training or skill.

Percutaneous Thrombin Injection with Balloon Protection for a Large Iatrogenic Femoral Artery Pseudoaneurysm: A Case Report with Review of Literature

Iatrogenic femoral artery pseudoaneurysms (IFAPs) are not uncommon due to the increase in various minimally-invasive endovascular procedures. Percutaneous thrombin injection is an established technique for large pseudoaneurysms. When ultrasound-guided compression of an aneurysmal neck is not feasible, percutaneous thrombin injection can be combined with endovascular balloon occlusion to prevent leakage of thrombin into the parent artery. We describe a large IFAP following the removal of the femoral dialysis catheter after an inadvertent arterial puncture, which was managed with percutaneous ultrasound-guided (USG) thrombin injection with simultaneous balloon occlusion at the level of the aneurysmal neck without any complications. Follow-up imaging showed thrombosed IFAP without any recurrence.

Transaneurysmal Occlusion of Complicated Common Femoral Artery Pseudoaneurysms Using the Angio-Seal Closure Device-A Promising Technique

PURPOSE

Pseudoaneurysm (PSA) developing after catheter examinations is one of the most frequent vascular complications and a nonsurgical technique with utmost low risk of complications is warranted. Our aim was to investigate the technical feasibility, success, and safety of transaneurysmal occlusion of complicated post-interventional common femoral artery (CFA) PSA using the Angio-Seal Closure Device (ASCD) and a technique that we describe as the transaneurysmal (TA) maneuver.

MATERIAL AND METHODS

We used the Angio-Seal (Terumo, Tokyo, Japan) Closure System to manage complicated PSAs in patients who would otherwise have needed surgery after failure of all conservative therapies. The TA maneuver was performed in 14 consecutive patients from July 2021 to July 2022. After ultrasound-guided puncture of the PSA close to its neck, the CFA was entered radiographically with micro-guidewires, and the neck of the PSA was closed with the ASCD after changing the sheaths and wires. All patient had to wear a pressure dressing until the next day, when successful closure was verified by sonography.

RESULTS

All procedures were performed with technical success and without any complications. No patient had to undergo surgery. All sonographies on the next day confirmed complete absence of perfusion within the PSA and normal flow conditions of the CFA and vessels below.

CONCLUSION

The TA maneuver a promising minimally invasive procedure for closing complicated PSA of the CFA after catheter examination.

US-guided percutaneous thrombin injection to treat non-femoral artery pseudoaneurysms: preliminary experience and review of the literature

PURPOSE

To evaluate the clinical outcome of US-guided percutaneous thrombin injection in the treatment of non-femoral artery pseudoaneurysms (NFAP).

MATERIALS AND METHODS

Among all pseudoaneurysms treated in our institution, we retrospectively collected NFAP embolized with percutaneous thrombin injections from January 1, 2015, to December 31, 2021. The embolization was prompted for an ongoing antiaggregating/anticoagulation therapy, NFAP optimal US visibility, or high surgery-related risks. Causes, location, size and neck of NFAP, complications, number of repeated treatments, clinical success and patients clinical conditions at discharge were annotated. The endpoint for clinical success was the resolution of NFAP at postprocedural imaging, with no resort to surgery.

RESULTS

Eight consecutive patients (5 females, median age 73 years, range 46-84) underwent 16 procedures. Arterial damage was due to catheterization (3), CVC mispositioning (2), trauma, hemorrhagic diathesis and endoprosthesis endoleak. We treated humeral (2), subclavian (2), thyrocervical, anterior tibial, radial and pancreaticoduodenal arteries. Median pseudoaneurysm size was 530 mm² (range 32-2400 mm²), with a thin (7/8) or non-visible (1/8) neck. No complications occurred. Clinical success was obtained in 7/8 patients (88%), with a single treatment in 4, multiple in 3 cases (4 embolizations, 3 and 2, respectively). One patient underwent surgical suture after the second failed attempt of percutaneous embolization. Seven patients were discharged in good clinical conditions; one died during hospitalization, due to the worsening of the underlying cardiac disease.

CONCLUSIONS

Percutaneous US-guided thrombin injection to treat NFAP is feasible in selected cases, with rare complications. Clinical success is often reached, also by repeated injections.

Endovascular Embolization of Femoral Pseudoaneurysm Associated with Therapeutic and Diagnostic Neuroendovascular Procedures

Objective

We aimed to evaluate the usefulness of endovascular embolization for femoral iatrogenic pseudoaneurysms (PAs) following therapeutic and diagnostic neuroendovascular procedures.

Methods

This study included 12 patients with femoral PA due to femoral puncture at our department between May 2014 and April 2021. We performed an analysis of baseline characteristics, treatment, and outcome of these cases.

Results

Endovascular embolization was performed in 10 of the 12 PAs using coils and/or N-butyl-2-cyanoacrylate. Of these, 10 PAs were treated with endovascular embolization and 9 were successfully occluded, whereas complete occlusion was not achieved in 1 case of PA (success rate: 90%). No new intraoperative or postoperative complications or postoperative recurrences occurred.

Conclusion

Endovascular embolization for PA can be immediately performed under local anesthesia without discontinuation of antithrombotic therapy and may be a safe and effective option for access site complication treatment.

Endovascular treatment of refractory iatrogenic femoral artery pseudoaneurysm using Amplatzer vascular plugs following unsuccessful retrograde Angio-Seal deployment

Iatrogenic common femoral artery pseudoaneurysm is a well-known vascular access complication of angiography and transfemoral intervention. Thrombin injection is a well-accepted technique in treating these pseudoaneurysms but possess a significant risk of distal lower extremity thrombosis leading to severe consequences. Several case reports described the novel approach to closing these pseudoaneurysms via a retrograde deployment of an Angio-Seal vascular closure device. We describe a case of a successful treatment of refractory iatrogenic femoral artery pseudoaneurysm using Amplatzer vascular plugs following unsuccessful retrograde deployment of an Angio-Seal vascular closure device.

Balloon-assisted Transcatheter arterial embolization using N-butyl cyanoacrylate for iatrogenic arterial bleeding by groin puncture: a new technology

Background

Balloon-assisted transcatheter arterial embolization (TAE) using n-butyl cyanoacrylate (NBCA) and lipiodol (Lp) mixture is a new endovascular treatment technique for iatrogenic arterial bleeding by groin puncture. It is less invasive compared to surgical repair, and NBCA migration into the circulation can be prevented by temporary balloon occlusion of the parent artery without ultrasound-guidance. This study aimed to report on the technical aspects and evaluate the efficacy and safety of fluoroscopically guided balloon-assisted transcatheter arterial embolization using NBCA for iatrogenic arterial bleeding by groin puncture.

Materials and methods

The study included five patients (mean age 54.6 years; 3 male and 2 female) with iatrogenic arterial bleeding by groin puncture. We performed transcatheter arterial embolization using NBCA while occluding the responsible artery with a balloon catheter during the embolization to prevent NBCA migration. Two sheaths were inserted into the common femoral artery. A microcatheter was advanced into the pseudoaneurysm or extravasation via the contralateral sheath. A balloon catheter was advanced into the responsible artery until the balloon portion covered the leakage site via another sheath. After balloon inflation, the NBCA and Lip mixture was slowly injected until the pseudoaneurysm, or the extravasation was filled without touching the balloon. The microcatheter was removed immediately after the filling. We assessed technical success, overall success, and complications.

Results

The injured arteries were the external iliac artery (n = 1), the common femoral artery (n = 2), and the proximal portion of the superficial femoral artery (n = 2). NBCA was injected once in four cases and twice in one case where complete hemostasis could not be achieved with one injection. The technical and overall success rate was 100% with no complications, including distal embolization of NBCA.

Conclusions

Balloon-assisted TAE using NBCA is a feasible, effective, and safe treatment for iatrogenic arterial bleeding by groin puncture. It may also be applicable in other arterial bleeding situations where the potential risk of distal embolization can be decreased by applying the balloon-assisted technique.

Successful Percutaneous Transcatheter Closure of a Common Femoral Artery Pseudoaneurysm With Use of MicroVascular Plug Despite Continued Catheter-Directed Thrombolysis

Common femoral artery pseudoaneurysm is a known complication of percutaneous vascular access. Treatment options include surgical repair of the pseudoaneurysm or endovascular methods such as ultrasound-guided compression and direct thrombin injection into the pseudoaneurysm sac. Treatment of pseudoaneurysm is more challenging when a patient is undergoing concurrent catheter-directed or systemic thrombolytic therapy. This is a case report of endovascular treatment of an iatrogenic pseudoaneurysm of common femoral artery in a patient receiving concurrent catheter-directed thrombolytic therapy. This was performed successfully by precise deployment of a MicroVascular Plug into the pseudoaneurysm neck with immediate closure of pseudoaneurysm. Midterm follow-up confirmed sustained exclusion of the pseudoaneurysm sac with continued patency of the treated femoral artery.

Endovascular Aortic Aneurysm Repair without Type 2 Endoleak Using Concomitant N-Butyl-2-Cyanoacrylate Injection into the Abdominal Aortic Aneurysm Sac

BACKGROUND

The aim of this study was to evaluate our new method to occlude target lumber arteries using N-butyl-2-cyanoacrylate (NBCA) during endovascular aneurysm repair (EVAR) for prevention of type 2 endoleak (T2E).

METHODS AND RESULTS

Between 2013 and 2018, 176 patients who underwent EVAR for abdominal aortic aneurysm (AAA) were reviewed. Starting from October 2015, 83 patients (treatment group) underwent NBCA injection into the aneurysmal sac during EVAR. The incidence of T2E at 7 days and AAA sac diameter 12 months after EVAR were compared with those of the control group comprising 93 consecutive patients who underwent EVAR alone before 2015. The incidence of T2E at 7 days was significantly lower in the treatment group (2.4%) than in the control group (22.6%) (P < 0.001). AAA sac diameter at 12 months in the treatment group had a mean decrease of 6.6 mm as compared with the mean 4.4 mm in the control group (P = 0.026). In multivariate analysis, NBCA injection was significantly related to the reduction of incidence of T2E at 7 days (odds ratio = 11.8, P < 0.001) and a decrease in AAA sac diameter at 12 months (P < 0.001). There was no NBCA injection-related complication and reintervention in the treatment group.

CONCLUSIONS

NBCA injection might be safe and useful to reduce the incidence of T2Es and to prevent AAA sac expansion.

Type II endoleak model creation and intraoperative aneurysmal sac embolization with n-butyl cyanoacrylate-lipiodol-ethanol mixture (NLE) in swine

Background

The purpose of this study was to evaluate the feasibility of type II endoleak model creation and efficacy of intraoperative aneurysmal sac embolization using n-butyl-2-cyanoacrylate-lipiodol-ethanol mixture (NLE) for type II endoleak in swine.

Methods

In six swine (mean body weight 53.5 kg), abdominal aortic aneurysm (AAA) was created and then end-to-side anastomosis between the left renal artery and AAA sac was performed. And then, endovascular abdominal aortic aneurysm repair (EVAR) was performed, leading to creation of a type II endoleak model. As control group, EVAR without sac embolization was performed in two swine. In four swine, AAA sac was embolized using NLE immediately after EVAR via the microcatheter placed in AAA sac (NLE embolization group). Follow-up aortography was performed immediately and three days after the procedure, and then the aneurysms were extracted.

Results

The AAA sac and type II endoleak model were successfully created in all cases. In control group, type II endoleak persisted three days after the procedure. In NLE embolization group, endoleak disappeared immediately and three days after the procedure. In NLE embolization group, AAA sac was occupied with thrombus and embolic material. Inflammatory changes were recognized in aneurysmal sac wall in NLE embolization group.

Conclusions

This experimental study suggests that creation of a type II endoleak model in swine is feasible and that intraoperative AAA sac embolization with NLE during EVAR might reduce the occurrence of type II endoleak.

Ultrasound-guided thrombin injection in the management of pseudoaneurysm after percutaneous arterial access

Aim: The purpose of this paper was to evaluate the efficacy of ultrasound-guided percutaneous thrombin injection as a treatment method for arterial access site pseudoaneurysm. Materials and methods: A total of 148 patients with iatrogenic arterial access site pseudoaneurysms were treated in the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin. Of those, 142 pseudoaneurysms were located in the common femoral artery, 3 in the brachial artery and the remaining 3 in the radial artery. The study included 77 woman and 71 men (mean age 64.5 ± 14 years). Patients were qualified for percutaneous thrombin injection after Doppler examination during which pseudoaneurysm size and morphology were assessed as well as the presence of arteriovenous fistula was excluded. Results: In the reported study, 94.8% (128/135) of patients were successfully treated during the initial thrombin injection. Additional 400 IU dose of thrombin after 24 hours was effective in 5 out of 7 patients with recanalization during the follow-up. A total of 98.5% (133/135) of patients were successfully treated with a percutaneous ultrasound-guided thrombin injection. Conclusions: The 10-year experience presented in this study as well as literature reports prove that percutaneous ultrasound-guided thrombin injection is an effective and safe treatment method for iatrogenic arterial access site pseudoaneurysm.

Novel Technique to Treat Common Femoral Artery Pseudoaneurysm using Angio-Seal Closure Device

Iatrogenic common femoral artery pseudoaneurysm is a well-described vascular access complication. Several methods have been proposed to treat these pseudoaneurysms. In this report, we present three cases of successful pseudoaneurysm closure using a novel method of retrograde pseudoaneurysm access and thrombosis with Angio-Seal (St Jude Medical, St Paul, MN) closure device. This technique appears safe, effective, and reduces patient discomfort.

Successful endovascular treatment of iliac arteriovesical fistula with secondary stent-graft infection

A 58-year-old woman initially presented with massive gross hematuria and iliac arteriovesical fistula (IAVF). Endovascular stent-graft repair achieved complete exclusion of the IAVF and controlled the bleeding, but sepsis subsequently developed because of endograft infection. Endovascular embolization of the infected stent graft was performed after extraanatomic bypass surgery. The patient recovered and showed no signs of graft infection or recurrent fistulization at 14 months after treatment. Endovascular embolization of infected stent grafts combined with extraanatomic bypass may be an acceptable treatment option for graft-related sepsis in cases that are resistant to conservative treatment and pose high surgical risk for graft excision.