Postcatheterization pseudoaneurysm: results of US-guided percutaneous thrombin injection in 240 patients

Delayed ulnar artery pseudoaneurysm presentation after percutaneous cardiac intervention: A case report and review of the literature

PURPOSE

Here we present a case of a 62-year-old female with a delayed ulnar artery pseudoaneurysm presentation after cardiac catheterization.

CASE REPORT

A 62-year-old woman with multiple medical comorbidities including end-stage renal disease (ESRD) on hemodialysis (HD) and atrial fibrillation on tablet apixaban who presented 8 weeks after cardiac catheterization through right ulnar artery access with a pulsatile mass, pain, and tingling of her right-hand fingers. Ultrasound exam confirmed presence of ulnar artery pseudoaneurysm with >2 cm active chamber. This pseudoaneurysm was repaired via forearm exploration, evacuation of hematoma, and primary repair with non-absorbable sutures.

CONCLUSION

We report a case of delayed ulnar artery pseudoaneurysm presentation following cardiac catheterization through the right ulnar artery. Open surgical repair offers a definitive addressal of ulnar artery pseudoaneurysm and removes ulnar nerve compressive neuropathy with less risk of distal embolization in patients with delayed pseudoaneurysm presentation whenever ultrasound-guided thrombin injection (UGTI) is contraindicated.

Ultrasound-guided thrombin injection for cardiac catheterization pseudoaneurysms: efficacy, safety, and predictors

BACKGROUND

Percutaneous ultrasound-guided thrombin injection has become the gold standard treatment for pseudoaneurysms caused by cardiac catheterization. However, failure can occur in up to 25% of the procedures and little is known about its causes.

PURPOSE

To study the efficacy and safety of the technique and to determine possible risk factors responsible for the unsuccess.

MATERIAL AND METHODS

A cohort study was carried out based on data from medical records collected between December 2012 and June 2020 of 110 patients with the diagnosis of pseudoaneurysm, femoral or radial, secondary to cardiac catheterization. Clinical data, pseudoaneurysm morphological parameters, and technical factors related to catheterization were reviewed.

RESULTS

Primary and global technical success rates were 85.5% and 100%, respectively. Age, neck, and anteroposterior diameter variables were predictors of primary failure on multivariate analysis. The odds ratio (OR) for age was 0.960 (95% confidence interval [CI]=0.927-0.995; P = 0.025), for anteroposterior diameter, OR was 2.023 (95% CI=1.144-3.578; P = 0.015), and for neck diameter, it was 4.625 (95% CI=1.023-20.904; P = 0.047). The receiver operating characteristic (ROC) curve was performed for the multivariate analysis model and the three predictors of failure. The area under the curve for the multivariate analysis model was 0.695, for age it was 0.675, for anteroposterior diameter it was 0.679, and for neck diameter it was 0.676. No complications were observed.

CONCLUSIONS

Percutaneous ultrasound-guided thrombin injection is safe and effective for the treatment of pseudoaneurysms after cardiac catheterization. Largest anteroposterior diameter, largest neck diameter, and a younger age were independent predictors of primary failure with the technique.

A case of postgunshot deep femoral artery pseudo-aneurysm managed with coil embolization: A case report and literature review

In this case, the patient sustained a gunshot injury to the thigh and underwent surgery to treat a comminuted fracture. Six weeks after discharge, the patient presented with upper-thigh pain. Doppler ultrasound showed a deep femoral artery pseudoaneurysm, confirmed with computerized tomography (CT). We used coil embolization, a newly used method worldwide in recent years, to occlude the pseudoaneurysm. This reflects the complex, unknown mechanisms that contribute to such rare findings and draws attention to cases that require more extensive studies to understand potential pathological processes, leading to better management and improved outcomes. Furthermore, this case includes figures and images that illustrate the findings both pre- and postintervention, significantly enhancing the visual appeal of the procedure. Additionally, it provides a comprehensive review of other related cases, each with detailed presentations. Finally, this case illuminates the innovative application of embolization techniques in developing nations, which has resulted in lifesaving, cost-effectiveness, and a reduction in complications compared to other techniques.

Iatrogenic Carotid Artery Pseudoaneurym: Successful Treatment With Percutaneous Thrombin Injection

This report demonstrates the successful treatment of a carotid artery pseudoaneurysm using percutaneous thrombin injection. The patient, a 62-year-old woman with multiple comorbidities, experienced a pseudoaneurysm following an unintentional carotid artery puncture during a failed attempt to place a triple lumen catheter in the right jugular vein. Percutaneous thrombin injection was chosen as the treatment method, with Doppler ultrasound monitoring. Follow-up examinations showed no signs of recurrence, and the patient was discharged after nine days without complications.

Percutaneous balloon-assisted ultrasound-guided direct thrombin embolization of superficial femoral artery pseudoaneurysm: a case series and literature review

BACKGROUND

Superficial femoral artery (SFA) pseudoaneurysms, a rare but potentially life-threatening complication, that can arise after vascular interventions or trauma. This case series explores the efficacy and safety of a minimally invasive treatment modality, percutaneous ultrasound-guided thrombin injection (PUGTI) combined with balloon occlusion, in three patients with SFA pseudoaneurysms.

CASE PRESENTATION

Three patients (age: 71-82 years; 3 female) with SFA pseudoaneurysms underwent PUGTI with balloon occlusion. The procedure involved direct thrombin injection under ultrasound guidance while occluding the parent artery using a balloon catheter. Follow-up was conducted at 1 week and 1 month post-procedure to assess technical success, complications, and recurrence.

CONCLUSION

PUGTI combined with balloon occlusion appears to be a safe and effective treatment for SFA pseudoaneurysms, particularly for larger pseudoaneurysms. The procedure is associated with a high technical success rate. Balloon occlusion may offer a safer alternative to direct thrombin injection without occlusion, as it potentially minimizes the risk of complications such as distal thromboembolism.

Thrombin injection under B-flow and ultrasound guidance: A safe and effective treatment of pseudoaneurysms

PURPOSE

To evaluate the method of thrombin injection under B-flow and ultrasound guidance (BUGTI) for the treatment of pseudoaneurysms.

MATERIALS AND METHODS

Twenty-one patients suffering from pseudoaneurysm (PSA) were retrospectively reviewed at the First Affiliated Hospital of Nanjing Medical University in Nanjing, China, from January 2018 to August 2019. The patients were treated using an ultrasound-guided injection of thrombin (500 IU/mL) combined with B-mode blood flow imaging (B-flow). The information on the PSA, including the size of the arterial rupture and sac, flow rate, thrombin dose, and treatment outcome, was recorded during the procedure. Follow-up evaluation was performed at 1, 3, and 6 months after the treatment. Pearson's correlation analysis was performed among the characteristics of PSA and the dose of thrombin.

RESULT

The age of patients ranged from 34 to 80 years and averaged 62.8 years. The maximum cross-sectional area of PSA ranged from 208 to 1148 mm2. All patients were treated with thrombin injections. The dose of thrombin ranged from 300 to 1667 IU. No reperfusions were detected at follow-up 6 months, and the BUGTI treatment was successful in all 21 cases. Pearson's correlation analysis demonstrated that the dose of thrombin was positively correlated with the width (r = 0.449, p < .05) and maximum cross-sectional area (r = 0.504, p < .05) of PSA.

CONCLUSION

Thrombin injection under B-flow and ultrasound guidance is a rapid and effective treatment for PSA. Additionally, the sac size could be used to estimate the dose of thrombin.

A Case Report of Radial Artery Pseudoaneurysm After Repeated Radial Puncture for Arterial Blood Gas

Arterial blood gas, with subsequent radial arterial puncture as a simple access point, comprises a ubiquitous medical procedure in the diagnostic workup of patients admitted to the emergency department with dyspnea. Despite being a relatively safe and technically straightforward procedure, due to its considerable use, it is of vital importance to be able to promptly recognize its potential complications. We present the case of a 96-year-old female patient admitted to the emergency department with dyspnea and cough who underwent left radial arterial puncture for arterial blood gas. A total of three puncture attempts were performed until arterial blood was collected. Roughly two weeks upon observation, the patient was readmitted to the emergency department after the insidious appearance of a painful swelling in the left wrist, with progressive worsening since hospital discharge. On physical examination, a painful erythematous pulsatile swelling in the left wrist's volar aspect was observed, and further point-of-care ultrasound evaluation documented a cysticlike collection, communicating with the radial artery's lumen, and suggesting the probable diagnosis of iatrogenic radial pseudoaneurysm. The patient was hospitalized and underwent surgical resection of radial pseudoaneurysm, with subsequent arterial repair. Although severe complications from arterial blood gas have a low incidence rate, prompt diagnosis and management are required. Therefore, point-of-care ultrasound, as an additional diagnostic tool, may play a role in minimizing the risk of procedural complications.

Management for iatrogenic femoral pseudoaneurysms by embolisation of the aneurysmal neck from the contralateral femoral artery: A report of five cases

Femoral pseudoaneurysms are typically associated with femoral arterial catheterisation. Treating iatrogenic morbidity requires curing the disease, without causing any additional complications. Occlusion of the aneurysmal neck is ideal to seal post-catheterised pseudoaneurysms along with maintaining the femoral arterial flow. However, few reports have suggested neck embolisation for post-catheterised pseudoaneurysms. We describe five cases of iatrogenic femoral pseudoaneurysms in patients successfully treated with embolisation through the aneurysmal neck. This technique may be an alternative therapeutic option in managing femoral pseudoaneurysms.

Vascular Access Management in Complex Percutaneous Coronary Interventions

Vascular access is a crucial step, which every interventional cardiologist needs to be skilled with to consistently achieve excellent periprocedural outcomes. Some operators argue that it is the most important aspect of the entire intervention. Hence, careful planning of vascular access in an individualized fashion - based on the patient's clinical status, anatomy, and technical requirements of the intervention - is the first step in securing optimal procedural safety and successful results. We briefly review multiple aspects of vascular access and management including site selection, ultrasound guidance, micro-puncture techniques, sheathless techniques, limb perfusion, clinical monitoring, large bore closure, and management of complications. Approaching every vascular access in a systematic way, even in emergent situations, allows operators to minimize the risk of complications, especially in an often severely ill patient population.

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.

Microvascular tissue perfusion after postcatheterization pseudoaneurysm treatment

BACKGROUND

Femoral pseudoaneurysm (PSA) is a severe complication after endovascular procedures. Ultrasound-guided manual compression (MC) and percutaneous thrombin injection (TI) are frequently used treatments. MC is less effective, TI may cause thromboembolic events.

OBJECTIVE

Up to date, there is no data regarding impairment of microvascular tissue perfusion after PSA treatment.

METHODS

In this single-center, prospective study 22 patients with PSA were included. We compared macro- and microcirculatory perfusion in the treated and untreated leg at baseline before, after and one day after treatment. Leg perfusion was assessed with ultrasound and ankle-brachial index (ABI). Microcirculatory perfusion of the feet was measured with a near-infrared spectroscopy (NIRS) camera generating StO2-tissue-maps.

RESULTS

Successful PSA thrombosis was achieved in 16 (100%) patients in TI group and in 4 (66.7%) patients in MC group. There was no evidence of arterial thrombi on ultrasound and the ABI did not differ between groups. NIRS StO2-tissue-maps of the feet showed no significant difference in both groups concerning the treated (p = 0.121) or the untreated (p = 0.198) leg during follow up.

CONCLUSIONS

In this small exploratory study, there was no evidence of micro- and macrovascular tissue perfusion impairment after treatment of postcatheterization femoral pseudoaneurysm with thrombin injection underscoring the safety of this approach.

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.

Ruptured pseudoanuerysm of the posterial tibial artery after percutaneous Achilles tenotomy

Congenital talipes equinovarus (CTEV), or clubfoot, is the the most common encountered musculoskeletal defect encountered at birth. Most cases present as an isolated deformity, with up to half of them presenting with bilateral deformity. CTEV have also been reported to present as part of syndromic phenomena. Dr Igancio Ponseti proposed a serial casting programme to correct the foot's cavus, forefoot adduction, varus and equinus. Up to 90% of infants will require a tendo-achilles (TA) tenotomy for the persisting equinus deformity. TA tenotomy is deemed a relatively safe procedure, with the most authors citing bleeding as the most common complication. The Achilles tendon finds itself surrounded by rich network of blood vessels and nerves. We present a case of a ruptured pseudoaneurysm from the posterior tibial artery after percutaneous TA tenotomy was performed. This is a very rare complication and to our knowledge, only one other posterior tibial artery pseudoaneurysm has been reported.

Treatment of a Post-biopsy Pulmonary Artery Pseudoaneurysm

Peripheral pulmonary artery pseudoaneurysms (PPAP) following a lung biopsy are exceedingly rare but can lead to severe haemoptysis. Cases requiring treatment are usually managed using an endovascular approach. Nevertheless, successful percutaneous treatment has been described. Several embolic agents can be used to accomplish percutaneous embolization. We aim to report a successful percutaneous treatment of a post-biopsy PPAP using thrombin. Our patient developed a PPAP, with consequent large alveolar haemorrhage and haemoptysis, after a transthoracic lung biopsy. Because the patient had a mechanical mitral valve, she needed to be anticoagulated, impairing the spontaneous resolution of the pseudoaneurysm. Therefore, the PPAP had to be treated to safely anticoagulate the patient. A percutaneous approach was chosen given the very peripheric location of the PPAP. Treating PPAP with an endovascular approach can be challenging. With this report, we demonstrate that the percutaneous approach is a safe and efficient alternative method. We choose thrombin as an embolic agent given its safety profile and efficacy under anticoagulation. The good results of our intervention reinforce the applicability and efficacy of this kind of treatment approach to PPAP.

Ultrasound evaluation of access complications: Thrombosis, aneurysms, pseudoaneurysms and infections

Arteriovenous fistula (AVF) complications are classified based on fistula outcomes. This review aims to update colour Doppler (CD) and pulse wave Doppler (PWD) roles in managing early and late complications of the native and prosthetic AVF. Vascular access (VA) failure occurs because inflow or outflow stenosis activates Wirchow's triad inducing thrombosis. Therefore, the diagnosis of the tributary artery and outgoing vein stenosis will be the first topic considered. Post-implantation complications occur from the inability to achieve AVF maturation and dialysis suitability due to inflow/outflow stenosis. Late stenosis is usually a sequence of early defects repaired to maintain patency. Less frequently, in the mature AVF or graft, complications are acquired 'de novo'. They derive either from incorrect management of vascular access (haematoma, pseudoaneurysm, prosthesis infection) or wall pathologies (aneurysm, myxoid valve degeneration, kinking, coiling, abnormal dilation from defects of elastic structures). High-resolution transducers (10-20 MHz) allow the characterization of the wall damage, haemodynamic dysfunctions, early and late complications even if phlebography remains the gold standard for the diagnosis for its sensitivity and specificity.

Percutaneous Thrombin Injection Based on Computational Fluid Dynamics of Femoral Artery Pseudoaneurysms

Objective

To analyze the computational fluid dynamics (CFD) of femoral artery pseudoaneurysm (FAP), identify a suitable location and timing for percutaneous thrombin injection (PTI) based on this analysis, and report our clinical experience with the procedure.

Materials and Methods

CFD can be used to analyze the hemodynamics of the human body. An analysis using CFD recommended that the suitable location of the needle tip for PTI is at the center of the aneurysm sac and the optimal timing for starting PTI is during the early inflow phase of blood into the sac. Since 2011, seven patients (three male and four female; median age, 60 years [range, 43–75 years]) with FAP were treated with PTI based on the devised suitable location and time. Prior to the procedure, color Doppler ultrasonography was performed to determine the location and timing of the thrombin injection.

Results

The technical success rate of the PTI was 100%. The amount of thrombin used for the procedure ranged from 200 IU to 1000 IU (median, 500 IU). None of the patients experienced any symptoms or signs of embolic complications during the procedure. Follow-up CT images did not reveal any embolism in the lower extremities and showed complete thrombosis of the pseudoaneurysm.

Conclusion

Based on our study of CFD, PTI administered centrally in the FAP during early inflow, as seen on color Doppler, can be an effective technique.

Ultrasound-Guided Percutaneous Thrombin Injection of Femoral Artery Pseudoaneurysms Caused by Vascular Access

Purpose

To analyze the success and complication rates and factors associated with technical failure of the ultrasound (US)-guided percutaneous thrombin injection of femoral artery pseudoaneurysms caused by vascular access.

Materials and Methods

Records of 30 patients with post-catheterization femoral artery pseudoaneurysms who had been treated with US-guided percutaneous thrombin injections in the department of radiology between March 2009 and June 2019 were retrospectively analyzed. The lesion was diagnosed based on US or contrast-enhanced CT. The characteristics of the patients and their lesions were analyzed.

Results

The mean patient age was 67.8 years. The mean diameter of the pseudoaneurysmal sac was 20.88 mm (5-40 mm). Twenty patients (66.6%) obtained complete thrombosis after the primary injection, while 10 patients (33.3%) obtained partial thrombosis. The number of patients with a low platelet count (< 130 k/µL) was significantly higher in the partial thrombosis group than in the complete thrombosis group (p = 0.02). No substantial procedure-related complications were found in any patient.

Conclusion

The US-guided percutaneous thrombin injection is considered an initial treatment option for pseudoaneurysms caused by vascular access because of its safety and efficacy.

[Surgical treatment of giant false aneurysm of the axillary artery]

Vascular damage is an important aspect in the structure of injuries. Untimely medical care in patients with peripheral artery damage is often followed by development of false aneurysm. This event may be complicated by aneurysm rupture and bleeding, peripheral arterial thromboembolism, hematoma infection and neuropathy following adjacent nerved compression. We report surgical treatment of a patient with giant false aneurysm of the left axillary artery following a knife wound 1 year ago. The patient did not appeal for qualified medical care and ensured haemostasis at home. The patient underwent surgery under endotracheal anaesthesia. Debridement of hematoma, closure of arterial wall defect and wound drainage were carried out through an approach in the upper and middle third of the left shoulder.

Both in vitro T cell proliferation and telomere length are decreased, but CD25 expression and IL-2 production are not affected in aged men

INTRODUCTION

Aging is a natural process involving dysfunction of multiple organs and is characterized by increased susceptibility to infections, cancer and autoimmune diseases. The functionality of the immune system depends on the capacity of lymphocytes to proliferate in response to antigenic challenges, and telomere length has an important role regulating the number of cell divisions. The aim of this study was to determine the possible relationship between telomere length, interleukin 2 (IL-2) production, CD25 expression and proliferation of peripheral blood mononuclear cells (PBMCs) in aged men.

MATERIAL AND METHODS

Telomere length was measured by RT-PCR in PBMCs from young and aged men. IL-2 production and CD25 expression were determined by ELISA and flow cytometry, respectively. Cell proliferation was measured by CFSE dilution assays upon in vitro stimulation with concanavalin A (Con A).

RESULTS

PBMCs from aged men showed a shorter telomere length and a reduced capacity to proliferate in vitro, compared to young men. In contrast, no significant differences in the level of CD25 expression on T lymphocytes, and in vitro production of IL-2 were detected in both groups. In addition, no significant correlation was detected between levels of CD25 expression, IL-2 production, cell proliferation, and telomere length in aged men.

CONCLUSIONS

In aged men the telomere length shortening and the reduced T cell proliferation are not related to the capacity of IL-2 production and CD25 expression on T lymphocytes.

Successful Treatment of Radial Artery Pseudoaneurysm After Transradial Cardiac Catheterization With Continuous Compression Therapy by a TR Band® Radial Compression Device

Arterial pseudoaneurysm formation after transradial cardiac catheterization is a rare post-procedural complication occurring in less than 0.1% of radial arterial access. While the data on the management of femoral pseudoaneurysms is extensive, few studies have evaluated how these techniques apply for small vessel arterial pseudoaneurysms. We present the case of an octogenarian man with a radial artery pseudoaneurysm after transradial coronary intervention that failed initial compression therapy, and surgical intervention was avoided by applying continuous compression therapy with a TR Band® radial compression device.

Angiography-guided percutaneous thrombin injection for haemostasis of active bleeding complicated by femoral access: a case report

Active bleeding from a small branch of the femoral artery can occur after catheterisation and may be difficult to treat. Stent-graft placement or embolisation after catheterisation can be a useful solution. However, stent-graft placement is often challenging for the treatment of bleeding around bifurcations, and it may be limited by available stent-graft sizes during emergencies. Embolisation can also be difficult if the vessel diameter is too small to catheterise or if the branching angle is too acute. Thrombin injection is accepted as a safe and effective treatment for iatrogenic or traumatic pseudoaneurysm. However, large haematomas can deter ultrasonographic guidance. We herein report the successful treatment of active bleeding from a small branch of the superficial femoral artery after femoral access by percutaneous direct puncture under angiographic guidance and thrombin injection at the bleeding focus.

Ultrasound-guided thrombin injection versus ultrasound-guided compression therapy of iatrogenic femoral false aneurysms: Single center experience

Background

Iatrogenic femoral pseudoaneurysm (false aneurysm) due to arterial access following cardiovascular procedures is becoming common because of the increase in number and complexity of the procedures. Recently, percutaneous thrombin injection is becoming a popular treatment of these false aneurysms.The aim of this study was to assess the efficacy and safety of femoral pseudoaneurysm closure using ultrasound-guided thrombin injection in comparison to ultrasound-guided compression.

Methods

A retrospective analysis was undertaken of 65 patients who presented to our vascular department with iatrogenic femoral pseudoaneurysm between January 2015 and March 2019. Twenty-five patients underwent ultrasound-guided thrombin injection, and 40 were treated using ultrasound-guided compression therapy. The primary outcome measured was efficacy, while other outcomes examined were safety, procedure duration, and cost.

Results

A total of 65 patients (45 males, 20 female) were identified with a mean age of 62 years. Out of the 65, 40 patients (28 males, 12 female) underwent ultrasound-guided compression therapy (group A) with a mean aneurysm size of 2.9 cm, and 25 (17 male, 8 female) underwent ultrasound-guided thrombin injection (group B) with a mean pseudoaneurysm sac size of 3.7 cm. The success rate of thrombosis in group A was 70% and in group B was 92%. No significant complications were reported in both groups.

Conclusions

Ultrasound-guided thrombin injection should be considered as the first line of treatment for uncomplicated femoral pseudoaneurysms because it has a higher thrombosis and lower recurrence rates, when compared with ultrasound-guided compression treatment.

Interventional Radiology Management of Renal Pseudoaneurysms: Experience at a Tertiary Care Hospital

Objectives Renal pseudoaneurysms are multifactorial in origin, and angioembolization remains the mainstay of treatment. Few case reports have also described percutaneous embolization using glue or thrombin. Our study aimed to evaluate the predictors of active bleed by analyzing their etiology, morphology, imaging features, and treatment adopted. To the best of our knowledge, this is the largest such study done in India.

Methods This was a retrospective study of patients treated for renal pseudoaneurysms between 2014 and 2019. We reviewed their clinical data, treatment modalities used, and clinical outcomes. We also assessed computed tomography angiography (CTA) and conventional angiography images.

Results A total of 79 patients (54 males and 25 females) were included in the study. The mean age was 39.5 years (range 15–83 years). The most common cause was renal biopsy, followed by surgery. Of these, three patients (3.9%) had more than one lesion and 57% of pseudoaneurysms were seen in lower polar arteries. Active contrast extravasation was seen in 15.2% (n = 12) of the patients and 21.5% (n = 17) showed lobulations in CT and digital substraction angiography. The mean size of the pseudoaneurysms was 1.17 cm (SD 0.7); 22.8% of pseudoaneurysms were wide necked. The embolization was approached by endovascular (89.9%), percutaneous (10.1%), or both (1.3%) routes. Embolization was performed using microcoils (78.5%), gel foam (12.7%), N-butyl cyanoacrylate glue (8.9%), polyvinyl alcohol (8.9%), and thrombin (5.1%) either as a single agent or in combination. The technical success was achieved in all cases after the first procedure. Pseudoaneurysms with a wide neck (p = 0.03) and lobulations (p = 0.002) were associated with active contrast extravasation. Episodes of rebleeding were seen at a younger age (p-value = 0.02).

Conclusion Minimally invasive methods remain the cornerstone in the management of renal pseudoaneurysms with high success rates. The morphology of pseudoaneurysms can help predict the risk of active bleeding and decide the type of intervention. Direct percutaneous injection into the aneurysm sac is an alternate technique and should be considered when an endovascular approach is challenging.

Ultrasound-Guided Fibrin Glue Injection for Treatment of Iatrogenic Femoral Pseudoaneurysms

Introduction:

Arterial pseudoaneurysms (PSAs) are the most common access site complication following transarterial catheter intervention. Ultrasound-guided injection of thrombogenic substances into perfused arterial PSAs followed by compression therapy is a well-established and less invasive treatment option than surgical repair. Different agents are available to induce thrombosis including thrombin and a fibrin-based tissue glue, which is used as first-line treatment at our institution. This paper deals with our experience using ultrasound-guided fibrin glue injection (UGFI).

Materials and Methods:

Retrospective data analysis: all patients (55) treated for iatrogenic femoral PSA following digital subtraction angiography of the lower extremities between January 1, 2010, and December 31, 2018, were included. Data on epidemiology, PSA location and size, vascular risk factors, fibrin glue injection (fibrin glue volume), primary success rate of UFGI, and complications related to the treatment were analyzed.

Results:

A total of 55 consecutive femoral iatrogenic PSAs were treated during the defined period and 32 (58.2%) of the patients were female. Imaging was performed using ultrasound in all cases. The most common PSA location (80.0%) was the common femoral artery, mean PSA size (± SD) was 2.7 ± 1.2 cm, and neck length was 1.6 ± 1.0 cm. The dose (mean ± SD) of fibrin glue was 2.6 mL (± 1.0; maximum: 6 mL). Primary UGFI success rate was 87.3% and conversion rate to open surgery was 12.7%. Two (4%) patients required embolectomy for peripheral embolization after UGFI.

Conclusion:

Early results achieved with UGFI for treatment of iatrogenic femoral PSA are promising. In our cohort, UGFI was a safe and effective first-line alternative to traditional open surgery, which then was unnecessary in the vast majority of PSA cases. Further prospective studies for comparison of ultrasound-guided techniques should be encouraged.

Das moderne befund- und patientenadaptierte Management von peripheren Pseudoaneurysmen nach arteriellem Zugang

Pseudoaneurysmen (PSA) zählen zusammen mit den Hämatomen zu den häufigsten Komplikationen nach kathetergestützten Eingriffen.

Ziel und Methode Die narrative kompakte Kurzübersicht umreißt sowohl die Entstehung und Charakteristika von Pseudoaneurysmen sowie die Optionen der Diagnostik und Therapie als auch deren mögliche Komplikationen.

Ergebnisse Ätiopathogenese: Durch den nicht verschlossenen Stichkanal der Punktion kommt es zum kontinuierlichen Blutausstrom aus dem Gefäß, der im umliegenden Gewebe eine Pseudoaneurysmahöhle formt. Diese wird nicht wie beim wahren Aneurysma durch eine Gefäßwand begrenzt, sondern nur durch die umliegenden Gewebestrukturen eingedämmt. Dies ist aber meist nicht suffizient und es kommt zu einer raschen Ausbreitung und diffusen Einblutungen. Dadurch können umliegende Strukturen wie Nerven und Venen durch das expandierende Pseudoaneurysma komprimiert werden, woraus sich irreversible Schäden entwickeln können. Diagnostik: Die Duplexsonografie steht dominierend absolut im Vordergrund. Die CT-A, MR-A und DSA bleiben speziellen Fragestellungen oder klinischen Fallkonstellationen (z. B. Begleiterkrankungen etc.) vorbehalten – eine DSA ist stets mit Interventionsbereitschaft zu verbinden. Therapie: Mit der manuellen Kompression und der darauffolgenden Anlage eines Druckverbandes, einer ultraschallgestützten Kompression, der Thrombininjektion und der operativen Sanierung stehen mehrere Verfahren zur Auswahl. Die ultraschallgestützte Kompression sollte dabei immer sofort eingesetzt werden, da sie höchst effizient und ubiquitär verfügbar ist. Additiv zur Kompression kann die Thrombininjektion bei PSA ohne Nerven-/Gewebeirritation mit eingesetzt werden und bietet noch bessere Verschlussraten, ist jedoch anspruchsvoller in der Anwendung. Die operative Ausschaltung ist die effektivste Methode, bietet aber neben dem größten Aufwand die meisten Begleitkomplikationen wie Wundheilungsstörung bei mazeriertem Gewebe und den längsten Krankenhausaufenthalt. Alternative Verfahren zu den genannten haben sich bisher nicht durchsetzen können.

Schlussfolgerung Das diagnostische und therapeutische Management von Pseudoaneurysmen stellt eine Herausforderung im interdisziplinären befund- und patientenadaptierten Vorgehen dar, das den erfahren Gefäßmediziner erfordert.

Ultrasound-guided thrombin injections for arterial pseudoaneurysms: a 14-year study conducted at King Khalid University Hospital Vascular Lab

BACKGROUND

Arterial pseudoaneurysms are a well-known complication resulting from procedures requiring arterial wall puncture. Previously, surgical repair was the definitive treatment option for arterial pseudoaneurysms despite being relatively invasive and time-consuming. Ultrasound-guided thrombin injection (UGTI) has become the standard of care since its initial description back in 1997. We aimed to evaluate the safety and efficacy of UGTI for the treatment of arterial pseudoaneurysms at the King Khalid University Hospital Vascular Lab.

METHODS

A retrospective analysis of prospectively maintained data was conducted on all patients diagnosed with arterial pseudoaneurysms by Doppler ultrasound between 2006 and 2019. Patients with large arterial pseudoaneurysms (>1.5 cm) qualified for thrombin injections. Individuals with a known hypersensitive to thrombin were excluded. All included patients were treated with UGTI until resolution and were followed at postoperative days 7 and 30.

RESULTS

In all, 35 patients qualified for thrombin injections. The mean age of the included patient population was 56.5 (range, 24-81) years. The majority of them were hypertensive (N.=26, 74.3%), and a quarter of them were on anticoagulant treatment (N.=9, 25%). The mean thrombin injection dose was 1000 U (range, 500-1500 U). In 34 of 35 (97.1%) patients, a thrombin injection resulted in complete thrombosis of the pseudoaneurysm lumen within a few seconds. There were no complications or recurrence of pseudoaneurysm after UGTI during the follow-up period.

CONCLUSIONS

Throughout the study period of 14 years, we did not encounter any procedural complications or arterial pseudoaneurysm recurrence. This is attributed to a safe procedural technique and proper patient selection. UGTI for arterial pseudoaneurysms is a safe, successful, and convenient treatment for both patients and surgeons.

Comparison of the Efficacy and Safety of Two Dosing Protocols for Ultrasound Guided Thrombin Injection in Patients with Iatrogenic Femoral Pseudoaneurysms

OBJECTIVE

Ultrasound guided thrombin injection (UGTI) is a minimally invasive method of treatment for iatrogenic post-catheterisation femoral pseudoaneurysms (psAs). The optimal dosing protocol for UGTI has not been established. The aim of the study was to compare the success and complication rates between two different dosing protocols (the most commonly used "standard dose protocol" and the "low dose protocol," which is the fractionated administration of smaller thrombin doses of up to 40 IU every 15 s) in patients with a psA with sac volume of ≥1 mL.

METHODS

This was a retrospective cohort study, and the analysis was performed using a case matching approach based on propensity score. From June 2004 to August 2018, 384 patients who underwent femoral puncture for transcatheter procedures were diagnosed with femoral psA with a sac volume of ≥1 mL and qualified for UGTI. The patients' mean age was 68 (±10.6) years and there were 217 (56.5%) women. To compare protocols, 124 patients treated according to the low dose protocol were nearest neighbour matched according to their propensity score to 124 patients treated according to the standard dose protocol.

RESULTS

The overall success rate (99.2% vs. 98.4%; p = 1) and success rate of the first UGTI attempt (87.1% vs. 86.3%; p = .85) did not differ between the low dose and standard dose groups. Complications were less common in the low dose group (7.3% vs. 16.1%; p = .03) and the median total amount of thrombin used for procedures was smaller in the low dose group (120 IU vs. 195 IU; p = .01).

CONCLUSIONS

In patients with femoral psA with sac volume of ≥1 mL, the use of the low dose protocol seemed to be equally effective as the standard dose protocol and was associated with a lower complication rate and reduced thrombin dose.

Safety and Effectiveness of Percutaneous Low-Dose Thrombin Injection for Femoral Puncture Site Pseudoaneurysms in Neurointervention: Single-Center Experience

PURPOSE

We present ultrasound-guided percutaneous low-dose thrombin (200-250 IU) injection for the treatment of iatrogenic femoral pseudoaneurysms. Second, we compared patient and procedure factors between subcutaneous hematoma and pseudoaneurysm groups.

MATERIALS AND METHODS

From April 2012 to May 2018, 8425 patients underwent neurointervention. Among these patients, 18 had small subcutaneous hematomas and 6 had pseudoaneurysms. Pseudoaneurysms in the neck and entire sac were visualized, and low-dose thrombins were injected while visualizing a "whirlpool" hyperechoic core in the pseudoaneurysm sac. Subcutaneous hematomas were treated with simple compression. We compared the following parameters between the subcutaneous hematoma group and pseudoaneurysm group: sex, age, body mass index (BMI), type of procedure, heparin usage, sheath size, procedure time, and number of previous neurointervention procedures with the Mann-Whitney U test.

RESULTS

Most of the pseudoaneurysms were successfully occluded with 200 IU of thrombin (n=5). Only 1 pseudoaneurysm required a slightly higher thrombin concentration (250 IU, n=1). During the short-term follow-up, no residual sac was observed and no surgical repair was necessary. Pain in the groin region was alleviated. During the 1-month follow-up, no evidence of pseudoaneurysm recurrence nor subcutaneous hematoma was noted. Patient factors (sex, age, and BMI) and procedure factors (heparin usage, sheath size, procedure time, number of previous procedures) were not statistically different between the subcutaneous hematoma and pseudoaneurysm groups.

CONCLUSION

Ultrasound-guided percutaneous low-dose thrombin injection (200-250 IU) is safe, effective, and less invasive for treating iatrogenic femoral pseudoaneurysm in neurointervention.

Factors associated with pseudoaneurysm development and necessity for reintervention: a single centre study

OBJECTIVE

Evaluate the factors associated with pseudoaneurysm development and morphology. Measure ultrasound-guided thrombin injection (UGTI) and surgical treatment outcomes for pseudoaneurysms, and the necessity for post-primary intervention (reintervention).

METHODS

Retrospective analysis of ultrasound scans and CT angiography of peripheral pseudoaneurysm interventions from February 2011 to April 2017. 99 patients (61.6% female) were identified; median age 72 years (range 12-89). Multivariate analysis of patient demographics, including pre-intervention anticoagulant and antiplatelet medication was performed.

RESULTS

Primary intervention for peripheral pseudoaneurysms (62.6% common femoral artery) included 93 UGTI and 6 surgical repairs; with 12 reinterventions (9 UGTI and 3 surgical). Pseudoaneurysm incidence for vascular interventional radiology (VIR) was 0.48% (31/6451) and cardiology was 0.24% (60/25,229). Rates for primary success, immediate complications, 30-day mortality and reintervention were measured respectively for UGTI (98.9%, 3.0%, 2.0%, and 11.8%) and surgical repair (100%, 0.0%, 22.2% and 16.7%). Reintervention risk factors included pre-intervention thrombocytopaenia (<150 × 10⁹/L) ( p = 0.025) and pseudoaneurysms following vascular surgery (p = 0.033). Other positive associations for reintervention (non-significant) included use of a sheath size > 6 Fr ( p = 0.108) or arterial closure device ( p = 0.111) during the pseudoaneurysm causative procedure. The pre-intervention warfarin subgroup developed a larger mean pseudoaneurysm sac size (4.21 cm, range 0.9-7.6), compared to no treatment (p = 0.003), aspirin (p = 0.005) and clopidogrel (p = 0.026) subgroups. UGTI dosage for thrombosis had a positive correlation with incremental sac size increase (p < 0.001).

CONCLUSION

The main reintervention risk factor was pre-intervention thrombocytopaenia, with additional positive associations including pseudoaneurysms caused by surgery, increased sheath size and arterial closure devices. Warfarinized patients developed larger sac-sized pseudoaneurysms compared with other pre-intervention regimens, with positive correlation of higher UGTI dosage required for thrombosis.

ADVANCES IN KNOWLEDGE

Patients with pre-intervention thrombocytopaenia and pseudoaneurysms attributed to vascular surgery are subgroups that may benefit from post-intervention imaging surveillance due to significant reintervention risk.

Imaging-guided percutaneous thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms

PURPOSE

To evaluate factors that may affect successful ultrasound-guided percutaneous thrombin injection of iatrogenic femoral artery pseudoaneurysms (PSA).

MATERIALS AND METHODS

This was an IRB-approved, HIPAA-compliant retrospective study of 326 consecutive subjects (138 males, 188 females; mean age 68 years, range 18-95) who underwent thrombin injection for treatment of femoral PSA; follow-up ultrasound was available in 145 subjects. The number of PSA lobes and dimensions, pre-procedure laboratory values (international normalized ratio [INR], activated partial thromboplastin time [aPTT], platelet count), and concomitant anticoagulation therapy were recorded.

RESULTS

Technical success was achieved in 98.2% (320/326) of subjects. Primary effectiveness (complete thrombosis at 24 h) was achieved in 74.5% (108/145). Twenty-five subjects underwent repeat thrombin injection, successful in 21 subjects, for a total effectiveness rate of 97.0% (129/133). No imaging factor was associated with technique failure, including number of lobes (p = 0.898), largest dimension (p = 0.344), or volume (p = 0.697). No statistically significant difference in pre-procedure INR, aPTT, or platelet count was found between subjects with CT and those with IT (p > 0.138). Anticoagulation therapy was associated with incomplete thrombosis (35.5% [38/107] for CT vs. 63.9% [23/26] for IT; p = 0.002).

CONCLUSION

Imaging-guided percutaneous thrombin injection has high technical success and effectiveness rates for the treatment of iatrogenic femoral artery PSA. Anticoagulation therapy was the only factor associated with incomplete thrombosis.

Pseudoaneurysm

Pseudoaneurysms (PSAs) are commonly known as complications associated with invasive interventions. Because of the pulsatile in- and outflow of blood through the neck of PSAs, they tend to grow and, in the worse cases, can rupture. Therapeutic options are compression therapy, using a compression bandage and ultrasound-guided compression, and thrombin injection. Manual ultrasound-guided compression is widely performed and is successful in most cases. In general, it is combined with a subsequently applied compression bandage. Thrombin injection is a more difficult technique, but it has a higher success rate. This article gives an overview of the characteristics of PSAs, their diagnostic characteristics and the therapeutic methods used to treat them. Complications associated with compression or thrombin injection are also explained in detail.

Femoral pseudoaneurysm closure by direct access: To stick or not to stick?

Femoral artery pseudoaneurysms are usually the result of femoral artery cannulation for percutaneous cardiac or endovascular procedures. It causes compression of surrounding structures, may cause distal embolization, arteriovenous fistula formation, or might rupture. Most close spontaneously by thrombosis, and the remainder need intervention, either percutaneous or surgical repair. We describe a unique case of femoral pseudoaneurysm that was repaired percutaneously by excluding it via stenting and simultaneous closure of residual aneurysm by direct access and coil embolization.

Do not underestimate the femoral pseudoaneurysm

Abstract. In addition to haematoma and arteriovenous fistula, the iatrogenic pseudoaneurysm is a common complication of vascular access that is caused by a perforation in the arterial wall. Iatrogenic pseudoaneurysms can progress in size and lead to rupture and active bleeding. Over the previous few decades, therapeutic methods have evolved from surgical repair to less invasive options, such as ultrasound-guided compression therapy (UGCT) and ultrasound-guided thrombin injection (UGTI). This paper presents an overview of the diagnostic and treatment modalities used in femoral pseudoaneurysms as well as a comprehensive summary of previous studies that analysed the success and complication rates of UGCT and UGTI.

Comparison of Ultrasound-Guided Thrombin Injection of Iatrogenic Pseudoaneurysms Based on Neck Dimension

BACKGROUND

Ultrasound-guided thrombin injection (UGTI) of femoral artery pseudoaneurysms after endovascular procedures is an effective therapy. There is controversy in the literature regarding injecting pseudoaneurysms with short and/or wide necks. This article reports our experience in UGTI of pseudoaneurysms in 1 hospital regarding the efficacy of this treatment in all pseudoaneurysms regardless of the size of the necks.

METHODS

A retrospective review of 46 patients diagnosed between 2011 and 2016 with groin pseudoaneurysms using established duplex ultrasound criteria. Mean age was 68 years (range 27-87). Ten pseudoaneurysms thrombosed spontaneously, 5 were thrombosed by ultrasound-guided compression, and 2 were treated surgically due to disqualifying criteria. In this retrospective review, we analyzed the remaining 29 pseudoaneurysms regarding the dimensions of their neck lengths and outcomes after attempting thrombin injection.

RESULTS

The mean aneurysm neck length and width were 1.03 ± 0.9 cm and 0.30 ± 0.1 cm, respectively. All 29 patients were evaluated with respect to pseudoaneurysm size, neck length, neck width, and complexity. Successful treatment of 29 pseudoaneurysms (2 external iliac, 20 common femoral, 2 deep femoral, and 5 superficial femoral) with UGTI was achieved without complications in 100% of the cases, regardless of pseudoaneurysm size, neck dimensions, or complexity. Anticoagulation status did not affect the efficacy of the procedure. Nine of the 29 pseudoaneurysms (31.0%) had neck length less than 0.5 cm.

CONCLUSIONS

This study demonstrates the safety and efficacy of UGTI in treating iatrogenic pseudoaneurysm in 29 of 29 patients, even in patients with pseudoaneurysm with short neck lengths. Our experiences support injecting all pseudoaneurysms irrespective of dimension.

Recurrence of Thrombin-Injected Pseudoaneurysms Under Ultrasound Guidance: A 10-Year Retrospective Analysis

OBJECTIVES

Ultrasound-guided thrombin injection has become standard treatment for extremity pseudoaneurysms. Our specific aims were to determine the procedural success rate, the procedural complication rate, and the factors associated with pseudoaneurysm recurrence.

METHODS

A total of 262 consecutive cases of ultrasound-guided thrombin repair of pseudoaneurysms were identified between January 1, 2006, and March 20, 2016. The procedural and follow-up ultrasound studies were reviewed. Outcomes of interest included procedural success (defined as complete thrombosis at the time of injection and on a follow-up examination), incomplete pseudoaneurysm thrombosis, and postprocedural recurrence. Postprocedural pseudoaneurysm recurrences were compared to procedural successes with regard to patient demographics, pseudoaneurysm characteristics, amount of thrombin injected, and periprocedural laboratory values.

RESULTS

Procedural success occurred in 85.7% of cases. Complications occurred in 3.0% of cases. The mean patient age ± SD was 72.3 ± 11.3 years. The median amount of thrombin injected was 500 U (interquartile range, 400 U). The median follow-up time was 1 day (interquartile range, 0 days). A pseudoaneurysm size of 2 cm or larger and thrombocytopenia were significant independent predictors of pseudoaneurysm recurrence (P = .003 and .03, respectively). The odds ratios for pseudoaneurysm recurrence were 2.29 for pseudoaneurysm size of 2 cm or larger (P = .03) and 1.04 for thrombocytopenia (P = .04).

CONCLUSIONS

Thrombin injection of pseudoaneurysms is an off-label procedure with few complications and a high success rate. Follow-up imaging is recommended in all pseudoaneurysms that are 2 cm or larger and in patients with thrombocytopenia.

Outcomes of Ultrasound-Guided Thrombin Injection of Nongroin Arterial Pseudoaneurysms

PURPOSE

To evaluate success and complication rates of percutaneous ultrasound-guided thrombin injection of nongroin pseudoaneurysms (PSAs).

MATERIALS AND METHODS

Retrospective review of a prospectively maintained institutional database yielded 39 cases of arterial PSAs occurring at nongroin sites that were treated with percutaneous ultrasound-guided thrombin injection between 2000 and 2016 (average patient age 69.2 y ± 14.0). Of PSAs, 74.4% (29/39) arose in the upper extremities, and 92.3% (36/39) were iatrogenic. The brachial artery was the most commonly affected vessel (51.3% [20/39]), and arterial access was the most common cause (56.4% [22/39]). Average overall PSA size was 2.4 cm (range, 0.5-7.2 cm); average amount of thrombin injected was 320 IU (range, 50-2,000 IU). Technical success was defined as absence of flow within the PSA immediately after thrombin injection. Treatment success was defined as sustained thrombosis on follow-up imaging obtained at 1-3 days after treatment.

RESULTS

Technical and treatment success rates of thrombin injections were 100% (39/39) and 84.8% (28/33), respectively. Longer term follow-up imaging (average 71 d; range, 12-201 d) was available for 7 of the treatment successes with 100% (7/7) showing sustained thrombosis. Comparing treatment successes and failures, there was no significant difference in average PSA size (2.3 cm vs 2.0 cm, P = .51) or average amount of thrombin injected (360 IU vs 180 IU, P = .14). There were no complications.

CONCLUSIONS

Ultrasound-guided thrombin injection is a safe, efficacious treatment option for PSAs arising in nongroin locations.

Ultrasound Guided Percutaneous Injection of Thrombin: Effective Technique for Treatment of Iatrogenic Femoral Pseudoaneurysms

INTRODUCTION

Arterial pseudoaneurysms are well known iatrogenic complication of percutaneous angiographic or interventional vascular procedures. In the past, the definitive treatment option was open surgical repair which is a relatively invasive procedure. In the last few years, Ultrasound (US) guided percutaneous thrombin injection has been gaining popularity as definitive treatment of pseudoaneurysms.

AIM

To evaluate efficacy and safety of US guided percutaneous injection of thrombin for treatment of iatrogenic femoral pseudoanurysms at a tertiary care interventional radiological and cardiology centre.

MATERIALS AND METHODS

A retrospective analysis was conducted on 38 consecutive patients, diagnosed to have iatrogenic femoral artery pseudoaneurysms by Doppler study, in the period from Jan 2013 to Jun 2016. All these patients were treated by US guided percutaneous injection of thrombin solution inside the pseudoaneurysm sac till contents became echogenic and flow inside the pseudoaneurysm stopped completely. One month further follow up in all these patients was done.

RESULTS

The dose of thrombin injected varied from 200-1000 IU (mean 300 IU). Immediate thrombosis was seen in all the pseusdoaneurysms. Follow up at 24-48 hours showed complete thrombosis and regression of pseudoaneurysm in all the patients except one in whom a small residual sac was seen which thrombosed completely on second thrombin injection. Further follow up at one month showed regression of aneurysms in all the cases. No significant post procedural clinically significant complications were seen in any of the patients.

CONCLUSION

US guided percutaneous thrombin injection is a highly successful and safe procedure for the treatment of iatrogenic femoral pseudoaneurysms.

Hemobilia

Hemobilia is a rare source of upper gastrointestinal bleeding, though the incidence is increasing along with the rise in minimally invasive biliary interventions. Prompt diagnosis and treatment rests on having appropriate clinical suspicion which should be based on the patient's presenting signs and symptoms, as well as history including recent instrumentation. Endoscopy should be reserved for cases of upper gastrointestinal bleeding with low suspicion for hemobilia. Interventional radiology may be the first-line diagnostic and therapeutic option for patients with a high suspicion of hemobilia. While embolization is the mainstay of therapy, other options include thrombin injection, stent placement, and/or placement of a percutaneous biliary drain. Surgery should be reserved for failed treatment by interventional radiology.

Successful Treatment of Iatrogenic Subclavian Artery Pseudoaneurysm by Ultrasound-Guided Thrombin Injection

Ultrasound-guided thrombin injection has been well described as a safe and effective treatment for pseudoaneurysms of the femoral artery. However, cases for subclavian artery pseudoaneurysm are rare. An 82-year-old man developed an iatrogenic right subclavian artery pseudoaneurysm. The pseudoaneurysm, which was partially thrombosed, was successfully treated by ultrasound-guided percutaneous thrombin injection. A trial injection with saline under color Doppler ultrasonography was helpful for confirming that the tip of the needle was in the sac with blood flow in the partially thrombosed pseudoaneurysm. Ultrasound-guided thrombin injection can be the first treatment of choice to treat subclavian artery pseudoaneurysm.

Complications of percutaneous thrombin injection in patients with postcatheterization femoral pseudoaneurysm

PURPOSE

To study the complications of ultrasound-guided thrombin injection of pseudo-aneurysms occurring after interventional cardiovascular procedures.

METHOD

We prospectively studied 353 patients who developed post-catheterization femoral artery pseudo-aneurysms and were treated with ultrasound-guided thrombin injection.

RESULTS

Arterial micro-embolization occurred in 53 patients (15%) and pulmonary embolism in 1 patient (0.3%). None of the patients developed significant peripheral arterial embolism. The length of the communicating channel between the arterial lumen and the pseudo-aneurysm was inversely correlated with the risk of embolization (p < 0.0001). A 4.6 mm increase in channel length decreased the odds of embolization by 14%, and patients with a channel less than 2 mm long were at greater risk. Repeated thrombin injection also increased the risk of embolization (p = 0.02).

CONCLUSION

Thrombin injection for the treatment of post-catheterization femoral pseudo-aneurysm is feasible and safe, but it must be performed with caution, especially when the sac is directly communicating with the artery, or when success cannot be achieved with a single injection.

Pseudoaneurysm of the internal maxillary artery: A case report of facial trauma and recurrent bleeding

INTRODUCTION

Pseudoaneurysms occur when there is a partial disruption in the wall of a blood vessel, causing a hematoma that is either contained by the vessel adventitia or the perivascular soft tissue.

PRESENTATION OF CASE

A 32-year-old male presented to the emergency department presented with comminuted fractures in the left zygoma, ethmoids, and the right ramus of the mandible following a gunshot wound. The patient underwent open reduction of his fractures and the patient was discharged on the eighth day after the trauma. Thirteen days after the discharge and 21 days after the gunshot wound, the patient returned to the ER due to heavy nasopharyngeal bleeding that compromised the patency of the patient's airways and caused hemodynamic instability. Arteriography of the facial blood vessels revealed a pseudoaneurysm of the maxillary artery. Endovascular embolization with a synthetic embolic agent resulted in adequate hemostasis, and nine days after embolization the patient was discharged.

DISCUSSION

The diagnosis of pseudoaneurysm is suggested by history and physical examination, and confirmed by one of several imaging methods, such as CT scan with contrast. Progressive enlargement of the lesion may lead to several complications, including rupture of the aneurysm and hemorrhage, compression of adjacent nerves, or release of embolic thrombi.

CONCLUSION

This case reports the long-term follow up and natural history of a patient with a post-traumatic pseudoaneurysm of the internal maxillary artery and the successful use of endovascular embolization to treat the lesion.

Hybrid Treatment of Large Brachial Artery Pseudoaneurysms

BACKGROUND

Conventional surgical treatment of brachial artery pseudoaneurysms (BAPs) includes aneurysm excision/opening and subsequent arterial reconstruction with different options depending on the extent of the arterial deficit. Endovascular repair of BAPs with stent grafting has also been reported but published experience remains limited. In this report, we present our experience with a novel hybrid approach consisting of primary endovascular aneurysm exclusion with a stent graft and subsequent open surgical evacuation of pseudoaneurysm content for decompression of adjacent structures.

METHODS

This study included all patients who underwent hybrid repair of a BAP within the period 2005-2014 in our institution. Data were collected retrospectively.

RESULTS

During the study period a total of 5 patients with iatrogenic BAPs were treated. Mean BAP diameter was 58 ± 4.9 mm. Technical success was 100%. Thirty-day mortality was null. No major perioperative complications were noted. Hand ischemia and neurological symptoms were reversed in all patients after the procedure. During follow-up (median 24 months, range 6-60 months) all stent grafts remained patent and no aneurysm relapse was noticed. No signs of stent-graft infection were noticed in any of the patients and no reintervention was needed.

CONCLUSIONS

Primary endovascular exclusion of BAPs with a stent graft followed by surgical evacuation of pseudoaneurysm sac content is associated with good early and mid-term results in this limited experience. Larger patient cohorts are required for further evaluation of this technique.

Unsuspected Traumatic Pseudoaneurysm of the Internal Carotid Artery

Peripheral arterial aneurysms may be true aneurysms, a dilation of the lumen lined by the remnants of the stretched arterial wall, or a false aneurysm (pseudoaneurysm), a penetration of the luminal wall with contained flow external to the vessel. Pseudoaneurysms are typically a result of blunt or penetrating arterial trauma, which includes a variety of iatrogenic injuries. This case report describes a traumatic psuedoaneurysm of the left internal carotid artery that occurred after a fall resulting in hyperextension of the neck. The psuedoaneurysm was undetected for three months until a sonographic examination for persistent neck pain showed the lesion. Endovascular repair of the pseudoaneurysm was done without complications.

Successful treatment of a radial artery pseudoaneurysm in an octogenarian

The transradial approach for coronary catheterisation has gained rising popularity owing to its fewer access site complications compared with the transfemoral approach. A rare but recognisable complication of the procedure is radial artery pseudoaneurysm (PSA). We report a case of radial PSA occurring 2 h following percutaneous coronary intervention in an 85-year-old woman, which was successfully treated by ultrasound-guided thrombin injection. This non-surgical technique has recently gained rising popularity as a relatively novel modality of managing radial PSA.