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

Optimal thrombin injection method for the treatment of femoral artery pseudoaneurysm

BACKGROUND

Iatrogenic femoral artery pseudoaneurysm (IFP) incidence is increasing with increase in diagnostic and therapeutic angiography, and so, the less invasive percutaneous thrombin injection (PTI) is the most widely used treatment. Moreover, studies that minimize PTI complications and highlight therapeutic effects are lacking.

OBJECTIVES

This study performed in vitro thrombosis modeling of pseudoaneurysms and analyzed thrombosis within and thromboembolism outside the sac during thrombin injection.

METHODS

We evaluated PTI in terms of thrombin injection location (at the junction of the IFP sac and neck, the center, and the dome, located farthest from the neck of the sac), thrombin injection time (5 and 8 seconds), and blood flow rate (ranging from 210 mL/min to 300 mL/min). Porcine blood was used as the working fluid in this study.

RESULTS

Thrombin injection at the junction of the IFP sac and the pseudoaneurysm neck led to less thrombosis within the sac but substantial thrombi consistently outside the sac, whereas thrombin injected at the sac center mostly led to complete thrombosis within the sac, preventing further blood flow into the sac and reducing likelihood of thrombi outside the sac. A longer thrombin injection time enhanced the therapeutic effect and decreased the possibility of thromboembolism. Thromboembolism occurred more frequently at flow rates of >240 mL/min.

CONCLUSION

The thrombin injection site in a pseudoaneurysm significantly influences thrombogenesis within and thromboembolism outside the sac. Thus, slow and deliberate injection of thrombin into the center of the sac could potentially reduce complications and enhance treatment efficacy.

Ultrasound-guided percutaneous embolization of post renal biopsy gonadal artery pseudoaneurysm

Hemorrhage is the most frequently encountered post renal biopsy complication; reported in 12% to 14% of patients. Although the vast majority of these are due to renal artery injury, involvement of gonadal arteries is also rarely seen. These may be managed by the endovascular route, which has several limitations in this subset of patients. We report a case of a 69-year-old male with rapidly progressive glomerulonephritis, who underwent renal biopsy and developed a testicular artery pseudoaneurysm (PA). Successful embolization of this PA was performed under ultrasound guidance using a direct percutaneous approach. This is the first such case reported in the literature.

Massive Pulmonary Embolism due to Inferior Vena Cava Thrombosis Related to Compression by Lumbar Artery Pseudoaneurysm. A Case Report and Review of Literature

Lumbar artery pseudoaneurysm (LAPA) is a pathology infrequently described in the literature. The most frequent complications are the expansion and rupture of the pseudoaneurysm. Reports of association between PE with LAPA have not yet been described. We present a 53-year-old male patient with LAPA whose expansion caused compression of the inferior vena cava and subsequently PE. He underwent mechanical thrombectomy and inferior cava vein filter placement associated with embolization of the LAPA. Despite the severe clinical profile, the patient was discharged with a favorable postoperative course without complications. This case report also includes a review of the literature.

Lumbar artery aneurysm: A rare manifestation of vasculopathy in a patient with neurofibromatosis type 1

Lumbar artery aneurysms are rare but important to diagnose, since rupture can have serious consequences due to life-threatening hemorrhage. A 49-year-old male with Neurofibromatosis type 1 (NF-1) was admitted to the emergency room with abrupt onset of severe abdominal pain. Ultrasound examination was normal, noncontrast CT revealed a tapered retroperitoneal mass adjacent to the right psoas muscle. A multiphased contrast-enhanced CT scan raised suspicion of an arterial lumbar aneurysm and was confirmed by selective catheter based angiography. The patient underwent successful treatment with endovascular coiling and the patient was discharged within a few days after an uneventful course.

Lyophilizing thrombin powder-based treatment for hemostasis during coil embolization of ruptured cerebral aneurysm: Two case reports

BACKGROUND

Rupture of cerebral aneurysm is an inevitable complication during embolization, followed by subsequent acute subarachnoid hemorrhage or intracranial hematoma, and results in the aggravation of a patient's condition. In particular, for patients who have had a ruptured aneurysm, urgent treatment strategies are required during operation. The most common hemostatic methods seen in clinical practices are as follows: after lowering the blood pressure, we continue to embolize the aneurysms with detachable coils as soon as possible or inject with Glubran/Onyx embolization liquids, as well as use a balloon catheter to temporarily block the blood supply. If the conditions are permissible, a balloon guiding catheter may even be used to restrict the proximal blood flow. At times, due to limitations of these methods, neurosurgeons are requested to perform craniotomy to treat the hemostasis. However, the delayed transition often leads to rapid deterioration of the patient's condition and even death due to cerebral hernia.

CASE DESCRIPTION

We herein presented two cases of ruptured cerebral aneurysms to provide an alternative method for hemostasis and to save the lives of patients as much as possible. In an extremely urgent situation (conventional treatment is ineffective), we successfully saved the patient's life by injecting lyophilizing thrombin powder (LTP) solution into the aneurysmal sac and the parent artery through a microcatheter.

CONCLUSIONS

To our knowledge, this is the first report of successful hemostasis during coil embolization of ruptured cerebral aneurysm with LTP. Further prospective studies are needed to confirm the safety and efficacy of LTP in cerebrovascular interventional therapy.

Abdominal vascular emergencies: US and CT assessment

Acute vascular emergencies can arise from direct traumatic injury to the vessel or be spontaneous (non-traumatic).The vascular injuries can also be divided into two categories: arteial injury and venous injury.Most of them are life-treatening emergencies, sice they may cause an important ipovolemic shock or severe ischemia in their end organ and require prompt diagnosis and treatment.In the different clinical scenarios, the correct diagnostic approach to vascular injuries isn't firmly established and advantages of one imaging technique over the other are not obvious.Ultrasound (US) is an easy accessible, safe and non-invasive diagnostic modality but Computed Tomography (CT) with multiphasic imaging study is an accurate modality to evaluate the abdominal vascular injuries therefore can be considered the primary imaging modality in vascular emergencies.The aim of this review article is to illustrate the different imaging options for the diagnosis of abdominal vascular emergencies, including traumatic and non traumatic vessel injuries, focusing of US and CT modalities.

Direct percutaneous embolization of an iatrogenic lumbar artery pseudoaneurysm following unsuccessful coil embolization

A 56-year-old man with acute myeloleukemia was hospitalized for lumbar pain. Treatment with antibiotics failed to improve the symptoms. For the diagnosis of infiltration by leukemia we performed CT-guided percutaneous needle biopsy of the L2-L3 disc and the L3 vertebral body using a left posterolateral approach. His symptoms were improved by treatment with antibiotics and he was discharged 4 days later. He again experienced lumbar pain 4 days post-discharge and was readmitted. Unenhanced CT scans of the abdomen and pelvis revealed a giant hematoma in the left psoas muscle and we suspected lumbar arterial injury. A preoperative aortography and transcatheter arterial coil embolization was then performed for the diagnosis and treatment of a lumbar artery pseudoaneurysm. On the preoperative angiography, pseudoaneurysm arising from the left lumbar artery was shown. All feeders were shown by the selective catheterization of the lumbar arteries and they were completely embolized using coils. However, contrast-enhanced CT obtained on the next day still demonstrated a pseudoaneurysm in the left psoas muscle. Thus, additional percutaneous embolization using N-butyl-2-cyanoacrylate was performed. After this procedure, complete embolization of the pseudoaneurysm was obtained and his lumbar pain was relieved.

Treatment of spontaneous lumbar artery pseudoaneurysm by computed tomography--guided thrombin injection

A case of spontaneous pseudoaneurysm of a lumbar artery that was treated with computed tomography- guided thrombin injection is reported in this study. To the authors' knowledge, pseudoaneurysm of lumbar artery without any predisposing factors has been reported only twice in the literature previously. The aims of this case report are to discuss the differential diagnosis and management of this difficult problem.

Pseudoaneurysm following vertebral biopsy and treatment with percutaneous thrombin injection

We present a case of a pseudoaneurysm within the lumbar musculature. This occurred following a computed tomography (CT)-guided vertebral biopsy in a 79-year-old male patient and was successfully treated with percutaneous ultrasound-guided thrombin injection. The patient initially presented with severe back pain. The plain radiographs and Magnetic resonance imaging (MRI) showed destruction of the L1 and L2 end plates, with marked narrowing of the disc space, suggestive of infective discitis. CT-guided biopsy was performed by the right paravertebral approach. Methicillin-resistant Staphylococcus aureus (MRSA) was grown, following culture of the specimen. Twenty days later, the patient developed a palpable swelling in the right lumbar region, with worsening of the back pain. MRI and ultrasound imaging showed a 3 cm pseudoaneurysm within the right lumbar musculature. The pseudoaneurysm was successfully treated following percutaneous ultrasound-guided injection of thrombin.

Lower extremity arterial thrombosis following sonographically guided thrombin injection of a femoral pseudoaneurysm

Sonographically guided percutaneous thrombin injection is a minimally invasive and highly successful treatment of arterial pseudoaneurysms. Despite a very low complication rate, several severe arterial thrombotic events have been reported following thrombin injection of pseudoaneurysms. Native arterial thrombosis, though recognized as a severe complication of thrombin injection, has not been well described in the literature. We report a case of successful surgical management of arterial thrombosis after percutaneous thrombin injection of a femoral artery pseudoaneurysm in a 69-year-old woman. The pathophysiology, risk factors, diagnosis, and treatment options for this complication are discussed.

Lumbar false aneurysms following image-guided interventive procedures for spondylodiskitic abscesses

Pseudoaneurysms of the lumbar arteries are infrequent, and are most often found incidentally after trauma to the lumbar spine. More rarely, they are an iatrogenic complication from diagnostic or therapeutic procedures, particularly of the kidney. Their rupture can cause rapid clinical deterioration by retroperitoneal hemorrhage, and therefore their diagnosis and treatment must be rapid. We report two cases of lumbar artery false aneurysms arising as a complication during the treatment of infectious disciitis. The diagnoses were established via CT and immediately followed by expeditious treatment by selective arterial embolization.

Nontraumatic Rupture of Lumbar Artery Causing an Intravertebral Body Pseudoaneurysm: Treatment by Transcatheter Embolization

We report a case of nontraumatic rupture of the lumbar artery that led to a pseudoaneurysm in the vertebral body and massive retroperitoneal to retropleural hematoma. The pseudoaneurysm was successfully treated by endovascular embolization. To our knowledge, idiopathic rupture of the lumbar artery has been reported in a limited number of cases and pseudoaneurysm formation in the vertebral body has not been presented in the literature. The etiology of hemorrhage has been discussed based on CT, MRI, and three-dimensional rotational angiography.

Paravertebral Pseudoaneurysm Thrombosed after Percutaneous Thrombin Injection

We present a case of a lumbar pseudoaneurysm in a 62-year-old patient with myelofibrosis (agnogenic myeloid metaplasia). The patient was submitted to two anesthetic infiltrations for lumbar pain and one biopsy of a suspected hematopoietic site. Subsequently, a 4.5 cm lumbar pseudoaneurysm was diagnosed. The pseudoaneurysm was thrombosed with 1 ml (500 IU) thrombin injection with a successful clinical result. We discuss different treatment options along with several issues related to the most frequent complication of this technique, namely, native artery thrombosis.