Iatrogenic femoral pseudoaneurysms: thrombin injection after failed US-guided compression

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.

Percutaneous treatment of vascular access-site complications: a ten years' experience in two centres

Background

The spread of percutaneous arterial catheterization in diagnostic and therapeutic procedures has led to a parallel increase of vascular access site complications. The incidence of these events is between 0.2–1%. A detailed analysis of injuries by type of procedure shows a higher incidence of injuries after therapeutic procedures (3%) than those observed for diagnostic ones (1%), due to the greater size of the vascular devices used and the necessity to frequently administer anticoagulant and antiplatelet therapy during procedures. The iatrogenic arterial injuries requiring treatment are the pseudoaneurysm, arteriovenous fistula, arterial rupture and dissection. Less frequent complications include distal embolization of the limbs, nerve damage, abscess and lymphocele.

Moreover, the use of percutaneous vascular closure devices (VCD) has further expanded the types of complications, with an increased risk of stenosis, thrombosis, distal embolism and infection. Our work aims to bring the personal 10 years’ experience in the percutaneous treatment of vascular access-site complications.

Results

Ninety-two pseudoaneurysms (PSA), 12 arteriovenous fistulas (AVF), 15 retrograde dissections (RD) and 11 retroperitoneal bleedings (RB) have been selected and treated. In 120/130 cases there were no periprocedural complications with immediate technical success (92.3%). Nine femoral PSA, treated with percutaneous ultrasound-guided thrombin injection, showed a failure to close the sac and therefore they were treated by PTA balloon inflation with a contralateral approach and cross-over technique. Only one case of brachial dissection, in which the prolonged inflation of the balloon has not led to a full reimbursement of the dissection flap, was then surgically repaired. At the 7 days follow-up, complications were two abscesses in retroperitoneal bleedings, treated by percutaneous drainage. At 3 months, acute occlusion of 3 covered femoral stents occurred, then treated by loco-regional thrombolysis and PTA. A total of 18 major complications was recorded at 2 years, with a complication rate at 2 years of 13.8%.

Conclusions

The percutaneous treatment of vascular access-site complications is the first-choice treatment. It represents a safe and effective option, validated by a high technical success rate and a low long-term complication rate, that allows avoiding the surgical approach in most cases.

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.

Pseudoaneurysm of the Second Dorsal Metatarsal Artery: Case Report and Literature Review

Pseudoaneurysms are a rare complication of foot and ankle surgeries that can potentially lead to serious sequelae, especially when there is delay in the diagnosis. Due to the rarity of this occurrence, guidelines for management are limited for orthopedic surgeons. Once diagnosed, the surgeon has to decide quickly on many options for how to best manage the patient. In this case report, we present the occurrence of a dorsal second metatarsal artery pseudoaneurysm that occurred after removal of hardware. We also discuss the most current literature on the subject to help guide other surgeons in the diagnosis and management of this condition.

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.

Selective use of Duplex Ultrasound after Successful Thrombin Injection of Pseudoaneurysms

Introduction

Duplex-guided thrombin injection (DGTI) has been shown to be a safe and efficacious initial treatment of iatrogenic arterial pseudoaneurysms. Postinjection follow-up duplex ultrasound examination has become the accepted standard of care despite 1) the use of intraprocedural ultrasonography to monitor successful thrombosis, 2) a low post-DGTI recurrence rate, and 3) the relatively high cost of ultrasonography. A retrospective study of DGTI at our institution was conducted to examine the necessity of routine duplex ultrasound after successful DGTI, along with a review of the relevant literature.

Patient Population/Methods

A retrospective review was conducted of 82 patients with iatrogenic arterial pseudoaneurysms (12 complex; 25.6%) treated with DGTI after initial diagnostic duplex ultrasonography. Immediate routine follow-up duplex ultrasound was performed on 71 of 82 cases (86.6%), whereas 11 patients received only clinical follow-up at the surgeon's discretion. Patient demographics, pseudoaneurysm anatomy, procedural details, outcomes, and complications were retrospectively documented and analyzed.

Results

From January 2002 to November 2003, 82 patients (59.8% women) underwent DGTI for pseudoaneurysm, with the majority located in the common femoral artery (48 of 82; 58.5%). Eighty pseudoaneurysms (97.6%) were treated with DGTI, with 78 (95.1%) being initially successful. Four of 78 (5%) follow-up examinations were judged to be of clinical significance: 2 of 78 patients (2.6%) became symptomatic and experienced pseudoaneurysm recurrence, whereas 2 of 78 patients were found to have an additional, previously undocumented, pseudoaneurysm. Three of these four resolved with a second injection, whereas one resolved without additional treatment. No thromboembolic, allergic, or infectious complications related to DGTI occurred.

Conclusions

In concert with the available literature, this cohort confirms that DGTI is a safe and effective treatment of iatrogenic arterial pseudoaneurysms with a low rate of recurrence, complication, and need for conversion to surgical intervention. DGTI should undoubtedly be the initial treatment of choice for pseudoaneurysms; however, follow-up duplex ultrasonography can be reserved for the clinically symptomatic patient.

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.

Femoral Pseudoaneurysms

Iatrogenic pseudoaneurysms will continue to be a problem associated with arterial cannulation procedures. With the increasing trend toward minimally invasive procedures, vascular surgeons, as well as interventionalists will be performing more cannulation procedures; hence we will be more involved in the management of this complication more frequently. Treatment trends and efforts aimed at preventing iatrogenic pseudoaneurysms have evolved over the past decade. This article reviews the history and available literature on the subject, in conjunction with the experience of a center that performs over 10,000 cannulation procedures annually.

"To-and-fro" waveform in the diagnosis of arterial pseudoaneurysms

Medical ultrasound imaging with Doppler plays an essential role in the diagnosis of vascular disease. This study intended to review the clinical use of “to-and-fro” waveform at duplex Doppler ultrasonography (DDU) in the diagnosis of pseudoaneurysms in the arterial vessels of upper and lower extremities, abdominal aorta, carotid and vertebral arteries as well as to review our personal experiences of “to-and-fro” waveform at DDU also. After receiving institutional review board approval, an inclusive literature review was carried out in order to review the scientific foundation of “to-and-fro” waveform at DDU and its clinical use in the diagnosis of pseudoaneurysms in various arterial vessels. Articles published in the English language between 2000 and 2013 were evaluated in this review study. Pseudoaneurysms in arterial vessels of the upper and lower extremities, abdominal aorta, carotid and vertebral arteries characterized by an extraluminal pattern of blood flow, which shows variable echogenicity, interval complexity, and “to-and-fro” flow pattern on color Doppler ultrasonography. In these arterial vessels, Duplex ultrasonography can demonstrate the degree of clotting, pseudoaneurysm communication, the blood flow patterns and velocities. Spectral Doppler applied to pseudoaneurysms lumen revealed systolic and diastolic turbulent blood flow with traditional “to-and-fro” waveform in the communicating channel. Accurate diagnosis of pseudoaneurysm by spectral Doppler is based on the documentation of the “to-and-fro” waveform. The size of pseudoaneurysm determines the appropriate treatment approach as surgical or conservative.

Radial artery pseudoaneurysm: a simplified treatment method

A radial artery pseudoaneurysm represents a rare, potentially catastrophic complication of arterial cannulation that has been reported after cardiac catheterization. Treatment options are limited to chemical, mechanical, and combined approaches to obliterate the radial artery pseudoaneurysm and tract. Manual compression protocols using the TR Band (Terumo Medical Corporation, Somerset, NJ) have been variable and anecdotal, without objective measurements of adequate compression, making this technique prone to failure. In this report, we present an efficient, safe, and noninvasive management protocol using a pulse oximeter and the TR Band for treatment of radial artery pseudoaneurysms that is cost-effective and efficient and ensures correction without occlusion of the radial artery.

Percutaneous cyanoacrylate glue embolization for peripheral pseudoaneurysms: an alternative treatment

Post-traumatic pseudoaneurysms are rare in the peripheral arteries and usually occur as a late sequel of trauma. Surgery has traditionally been considered as the gold standard of therapy for traumatic peripheral pseudoaneurysms. We report 2 cases of post traumatic pseudoaneurysms successfully treated by percutaneous cyanoacrylate glue (N-Butyl 2 cyanoacrylate) embolization. This method offers complete exclusion of the pseudoaneurysm, at the same time avoiding the morbidity of open surgery.

Ultrasound-guided thrombin injection for treatment of iatrogenic femoral pseudo-aneurysm: a nursing protocol

Femoral pseudo-aneurysm (FPA) is a pulsatile hematoma (false aneurysm) of the femoral artery that communicates with an artery through a disruption in the arterial wall. Most often, FPA develops after an injury or angiographic access to the femoral artery with bleeding into the adjacent tissue. FPA is an uncommon complication, but a very significant one, that can have serious consequences. FPA can initially present as a new thrill or bruit, a pulsatile hematoma, or marked pain and tenderness near the site of arterial puncture. Doppler flow imaging has been the mainstay of diagnosis. Ultrasound (US)-guided compression was the treatment of choice. However, it carries drawbacks including length of time to compress for adequate closure of the artery, discomfort to patients, high recurrence rate in patients receiving anticoagulation, femoral artery thrombosis, and a success rate of only 75% overall. An alternative to compression is US-guided thrombin injection (UGTI) of the FPA. This is a safe procedure that can be done as an outpatient or in an office setting. This paper will provide nursing guidelines and rationale as well as a nursing protocol for the management of patients who undergo UGTI for FPA.

Complications from catheter ablation of atrial fibrillation: a systematic review

Atrial fibrillation (AF) is the most common arrhythmia requiring treatment that is encountered in clinical practice. Recent advances in the understanding of underlying mechanisms of AF have led to the increased use of catheter ablation (CA) as a treatment modality for paroxysmal, persistent, or long-standing persistent AF in patients with symptomatic AF despite treatment with antiarrhythmic medications. Because of the complexity in technique and anatomic location of the ablation sites, it is not surprising that CA of AF is associated with a greater risk of procedural complications compared with simpler cardiac ablation procedures. Major and minor complications, including life-threatening complications, have been described and quantified. This systematic review describes the potential risks of CA that have been reported over a period and provides insights into the evolving strategies to minimize these complications, thus making CA techniques safer and potentially more efficacious for AF.

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

PURPOSE

To evaluate the safety and efficacy of n-butyl cyanoacrylate (NBCA) injection under fluoroscopy for iatrogenic femoral artery pseudoaneurysms under temporary balloon occlusion.

MATERIALS AND METHODS

This treatment was approved by the Ethics Committee of our institute, and informed consent was obtained from the patients. Three male patients aged 82, 77, and 51 years developed femoral arterial pseudoaneurysms after catheterization. The pseudoaneurysms (diameter: 30, 12, and 15 mm; neck diameter: 1.8, 5.2, and 1.4 mm) were treated with percutaneous NBCA injection under fluoroscopy after failed ultrasound (US)-guided compression. First, a 4-Fr balloon catheter was inserted into the responsible femoral artery via the contralateral approach. An 18-gauge needle was placed in the pseudoaneurysm under US guidance, and a test injection of contrast medium was performed under fluoroscopic guidance to evaluate the extent of the pseudoaneurysm. NBCA-lipiodol (Lp) (ratio, 1:3) was then injected under balloon inflation. The balloon catheter was deflated and withdrawn after treatment.

RESULTS

The total volume of the injected NBCA-Lp was 0.4-1.5 ml. In each case, angiography immediately after NBCA-Lp injection showed eradication of the pseudoaneurysm, and color Doppler US revealed no blood flow signal. No complications were observed. Color Doppler US showed no recurrence in the three patients at their last follow-ups at 6, 12, and 12 months.

CONCLUSION

Percutaneous NBCA injection under fluoroscopy with the support of balloon inflation was safe, feasible, and useful for eradicating iatrogenic femoral artery pseudoaneurysms in three cases following failed US compression.

Noninvasive technique of preventing thrombin escape into the systemic circulation during ultrasound-guided thrombin injection (UGTI) of the postcatheterization pseudoaneurysms

Introduction

Iatrogenic, postcatheterization pseudoaneurysms (PSA) of the femoral artery are a common complication after diagnostic and interventional procedures, with up to 7.7% incidence. Treatment includes surgical repair, ultrasound-guided compression (USGC) repair of the tract of the PSA, or recently ultrasound-guided thrombin injection (UGTI). Large (>1.8 cm) PSA sac with short (<3 mm) and/or wide (>3 mm) tract has higher complication ratio such as thromboembolic events after UGTI. Those cases are considered for protective balloon inflation during thrombin injection. The aim of our study was to evaluate the success rate of preventing escape of the thrombin during UGTI with simultaneous manual compression on ipsilateral iliac artery.

Methods and results

We reported 46 patients, 17 males and 29 females, aged 53–74 years, with iatrogenic, postcatheterization femoral artery PSA. Out of 46 patients, 7 were successfully treated with USGC. The rest of the patients were treated with UGTI with simultaneous manual compression on ipsilateral iliac artery to stop the flow in PSA, and to avoid thrombin escape into the native circulation. Success rate of UGTI with manual compression of ipsilateral iliac artery was 97% with the complication rate of 2.6%.

Conclusion

Our study confirms that UGTI treatment of the PSA of the femoral artery combined with compression of the ipsilateral iliac artery could be a safe and reliable method of the thrombin escape prevention into the systemic circulation, as good as more invasive and demanding methods.

Radial artery pseudoaneurysm in the intensive care unit

Pseudoaneurysms may occur at the wrist after catheterization of the radial artery but may also occur after arteriovenous shunting for dialysis or after direct trauma to an artery. Radial artery pseudoaneurysms are being increasingly reported because of widespread use of invasive monitoring. We report a case of radial artery pseudoaneurysm at the wrist related to catheterization. The pseudoaneurysm thrombosed after 6 days of external compression. In selected cases, extended external compression is a useful therapeutic option, especially in patients who are medically unfit to undergo general anesthesia or operative treatment.

Percutaneous ultrasound-guided thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms

PURPOSE

To audit our experience with ultrasound-guided thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms.

METHODS

A retrospective study of 85 consecutive patients undergoing percutaneous ultrasound-guided thrombin injection of post-catheterization femoral pseudoaneurysms during the period January 2002 to May 2007.

RESULTS

Pseudoaneurysms had a mean maximum diameter of 3.3 cm (range 1.0-7.6 cm) and a mean neck width of 3.4mm (range 1.0-7.0mm). No statistically significant correlation existed between maximum diameter and neck width (Kendall's rank correlation tau b=-0.09, p=0.5). The median dose of thrombin injected was 425 U (range 100-1500 U). The procedure resulted in complete sac thrombosis in 81 (95%) patients. Seventy-nine pseudoaneurysms thrombosed immediately after one injection, whereas two required a second thrombin injection. There were no procedural complications. The maximum diameter of the pseudoaneurysm was predictive of procedural success (Wilcoxon's rank sum test, p=0.001) and of the 5 patients with a pseudoaneurysm measuring ≥6 cm, ultrasound-guided thrombin injection was unsuccessful in 4 (4/5 versus 0/80, p<0.0001, Fisher's exact test). Three of these necessitated implantation of a stent-graft, whereas one required repeated thrombin injection and coil placement. In contrast, the pseudoaneurysm neck width did not seem to relate to the success of the procedure.

CONCLUSION

Percutaneous ultrasound-guided thrombin injection of is a quick, effective and safe treatment for iatrogenic femoral pseudoaneurysms. For larger pseudoaneurysms, although it is worth attempting more than one thrombin injection, endovascular repair may eventually be required.

Ultrasound-guided thrombin injection of iatrogenic groin pseudoaneurysm: Doppler features and technical tips

The practice of angiographic procedures is increasing and, concomitantly, there has been an increase in the incidence of iatrogenic femoral pseudoaneurysms (PA). Ultrasound-guided thrombin injection is becoming the accepted gold standard in the treatment of PA. It is a cost-effective, safe and efficacious treatment that requires a short learning curve. The aim of this pictorial review is to demonstrate the Doppler and ultrasound features used to diagnose PA and those that help differentiate it from alternative diagnoses, and to describe the procedure of thrombin injection, highlighting technical tips and ways to avoid potential complications.

Sonographic evaluation of vascular injuries

OBJECTIVE

The purpose of this presentation is to highlight the color Doppler duplex sonographic features of procedure-related and blunt or penetrating trauma-related vascular injuries.

METHODS

Different kinds of vascular complications such as pseudoaneurysms, arteriovenous fistulas, dissection, and thrombosis are discussed. Cases of vascular injuries in the extremities, neck, and abdomen are presented to illustrate the spectrum of sonographic appearances.

RESULTS

Color Doppler duplex sonography is valuable in the diagnosis and monitoring of most vessel injuries and in the treatment of pseudoaneurysms. It is useful for flow analysis and for follow-up after treatment. However, because of limitations inherent to sonography, such as bones, air, casts, skin burns, and relatively slow performance of the test, magnetic resonance imaging, computed tomography, and angiography are necessary for further evaluation in selected cases.

CONCLUSIONS

Color Doppler duplex sonography is a widely available, noninvasive, and accurate technique for evaluating vascular injuries and should be the first-line imaging modality in most patients.

Ultrasound-Guided Breast Interventions: Accuracy of Biopsy Techniques and Applications in Patient Management

Ultrasound (US) provides a versatile approach for guiding biopsies and other breast interventions. The wide availability, real-time capability, technical improvements, and increasing user experience have greatly expanded the role of US-guided interventions in the diagnosis and management of breast disease. This article reviews the accuracy of US-guided fine-needle aspiration biopsy, automated core biopsy, and vacuum-assisted biopsy. Some of the more specialized procedures that reflect the growing role of US-guided interventions in patient management will also be discussed.

Iatrogenic Brachial and Femoral Artery Complications Following Venipuncture in Children

INTRODUCTION

Catheter- or noncatheter-related peripheral arterial complications such as arterial pseudoaneurysm, embolus, or arteriovenous fistula may be seen in the pediatric age group. The most common etiologies defined for arterial complications are peripheral arterial puncture performed for a routine arterial blood gas analysis, arterial catheters placed for invasive monitorization of children, or catheterization performed for diagnostic purposes through the peripheral arterial system, most commonly the femoral artery.

MATERIALS AND METHODS

Nine children with peripheral arterial complications, whose ages varied between 2 months and 2.5 years, were enrolled in this study. All patients were treated surgically. Following physical examination, Doppler ultrasonography, computed tomography angiography, magnetic resonance angiography, or digital subtraction angiography were used as diagnostic tools. We studied thrombophilic panels preoperatively. Six patients had brachial artery pseudoaneurysms that developed accidentally during venipuncture, I had a brachial arteriovenous fistula that developed after an accidental brachial artery puncture during routine peripheral blood analysis. In the remaining 2 patients, peripheral arterial embolic events were detected. One had a left brachial arterial embolus and the other had a sudden onset right femoral artery embolus that was detected via diagnostic interventions.

RESULTS

No morbidity such as amputation, extremity loss, or mortality occurred due to the arterial events or surgery. All patients were discharged from the hospital in good clinical condition. In all patients, follow-up at 3 or 6 months revealed palpable peripheral artery pulsations of the ulnar and radial arteries at wrist level.

CONCLUSION

Because the incidence of peripheral arterial complications is relatively low in children compared to adults, the diagnostic and therapeutic approaches are extrapolated from the adult guidelines. We proposed that early diagnosis and surgical approach prevented the complications from further developing in the affected extremity in these particular cases.

Reducing duplex examinations in patients with iatrogenic pseudoaneurysms

OBJECTIVE

Ultrasound-guided thrombin injection has become the initial treatment of choice for femoral access-related pseudoaneurysms. Patients typically undergo serial duplex examinations to assess for spontaneous resolution of small iatrogenic pseudoaneurysms (IPSAs) (<2.5 cm), or may require repeated diagnostic, therapeutic, and follow-up studies for larger IPSAs (>2.5 cm). We evaluated the impact of a revised treatment algorithm that includes primary treatment of both small (<2.5 cm) and larger pseudoaneurysms (>2.5 cm), rather than observation of smaller ones, and attempts to establish a single duplex examination via a point-of-care treatment strategy.

METHODS

We reviewed 105 consecutive patients treated with ultrasound-guided thrombin injection from July 2001 through September 2004. Patient, IPSAs, characteristics, and treatment methods were examined. The number of duplex examinations per patient was evaluated over the treatment interval. Also, published cost data were used to compare primary treatment of small ISPAs vs observation with serial duplex examinations.

RESULTS

Successful thrombosis occurred in 103 (98.1%) of 105 treated pseudoaneurysms. No minor or major complications occurred after thrombin injection in either small or large ISPAs, and both failures requiring operation were in the large aneurysm group. The recurrence rate for the series was 1.9% (2/105), and both recurrences were successfully treated with an additional thrombin injection. A single injection was successful in treating 43 (97.7%) of 44 small (<2.5 cm) IPSAs, and one required a second injection. Patients had an average of 3.3 duplex examinations in our first year of treatment experience, which declined to 1.5 by our third year with the institution of a point-of-care service model for all pseudoaneurysms. Based on this decreased use of duplex examination and an average treatment cohort of 35 IPSA patients per year our institution, we determined this results in a reduction of 35 hours of laboratory time and nearly 70 ultrasounds per year. Similarly for small pseudoaneurysms, a point-of-service primary treatment program rather than observation results in an estimated cost savings of $12,000, based on treating 15 small IPSAs per year.

CONCLUSIONS

Ultrasound-guided thrombin injection is safe and effective for the treatment of nearly all iatrogenic pseudoaneurysms. We recommend primary treatment of small pseudoaneurysms by ultrasound-guided thrombin injection rather than observation with serial duplex scans. A point-of-care treatment algorithm can result in cost savings by reducing the number of necessary duplex examinations.

Pseudoaneurysms and the role of minimally invasive techniques in their management

Pseudoaneurysms are common vascular abnormalities that represent a disruption in arterial wall continuity. Some complications associated with pseudoaneurysms develop unpredictably and carry high morbidity and mortality rates. The advent of new radiologic techniques with a greater sensitivity for asymptomatic disease has allowed more frequent diagnosis of pseudoaneurysms. Conventional angiography remains the standard of reference for diagnosis but is an invasive procedure, and noninvasive diagnostic modalities (eg, ultrasonography [US], computed tomographic angiography, magnetic resonance angiography) should be included in the initial work-up if possible. A complete work-up will help in determining the cause, location, morphologic features, rupture risk, and clinical setting of the pseudoaneurysm; identifying any patient comorbidities; and evaluating surrounding structures and relevant vascular anatomy, information that is essential for treatment planning. Therapeutic options have evolved in recent years from the traditional surgical option toward a less invasive approach and include radiologic procedures such as US-guided compression, US-guided percutaneous thrombin injection, and endovascular management (embolization, stent-graft placement). The use of noninvasive treatment has led to a marked decrease in the morbidity and mortality rates for pseudoaneurysms.

Experiência inicial com o uso de adesivo tissular contendo trombina para tratamento do pseudo-aneurisma femoral

O pseudo-aneurisma (PSA) após cateterização femoral tem sido diagnosticado com regularidade em serviços com grande movimento de intervenções percutâneas, com incidência variando de 0,05 a 6%. PSA femorais pequenos podem ser acompanhados até a resolução espontânea. As opções de tratamento são: compressão guiada por ultra-som, injeção de trombina para trombose do PSA e tratamento cirúrgico. A injeção percutânea de trombina tem a vantagem de ser um procedimento indolor e rápido. Podem ser utilizados trombina isolada ou preparados contendo trombina associada a fibrinogênio e fatores de coagulação. A experiência inicial dos autores de cinco casos tratados com injeção de adesivo tissular contendo trombina mostrou resultado satisfatório em quatro; um caso necessitou tratamento cirúrgico. Não houve sucesso com uso isolado de trombina humana, porém, ocorreu trombose imediata após injeção de preparado de trombina associada a fibrinogênio/fator XIII. Neste artigo, são discutidas as opções de tratamento dos PSA femorais e a técnica do uso de trombina percutânea.

Development of Nonobstructive Intraarterial Thrombi After Injection of Thrombin into Pseudoaneurysms

OBJECTIVE

Our objective was to describe the development of nonobstructive, localized intraarterial thrombi after percutaneous injection of thrombin into femoral pseudoaneurysms.

CONCLUSION

Partial extension of thrombi into the arterial lumen may occur after injection of thrombin into small pseudoaneurysms with short necks. In our experience, this is an asymptomatic and self-limited complication of the procedure.

[Treatment of iatrogenic femoral pseudoaneurysms by ultrasound-guided percutaneous thrombin injection: effectiveness and complications]

AIM

We retrospectively assessed the effectiveness of ultrasound-guided percutaneous thrombin injection in the treatment of iatrogenic femoral pseudoaneurysms and registered the occurrence of complications in the systemic circulation.

METHODS

We performed ultrasound-guided thrombin injection in 26 iatrogenic femoral pseudoaneurysms: 24 were classified as single en 2 as complex. We registered the volume and the pseudoaneurysm neck measurements, as well as the complication rate.

RESULTS

Ultrasound-guided percutaneous thrombin injection led to a successful obliteration of pseudoaneurysm in 25 out of 26 cases (96.2%). The thrombin amount varied between 250 and 1000 IU. A thrombosis of the common femoral artery after the thrombin injection occurred only in one patient.

CONCLUSION

Ultrasound-guided percutaneous thrombin injection is effective and safe in the treatment of iatrogenic femoral pseudoaneurysms provided the exclusion criteria are respected. Complications are rare.

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

PURPOSE

To prospectively evaluate ultrasonographically (US) guided percutaneous thrombin injection for treatment of femoral artery and brachial artery pseudoaneurysms.

MATERIALS AND METHODS

The university institutional review board approved the study. Informed consent was obtained from all patients. Two hundred forty patients with postcatheterization femoral artery (n = 132) or brachial artery (n = 8) pseudoaneurysms were treated with US-guided bovine thrombin (1.000 IU/mL) injection. At diagnosis, 107 (44.6%) patients received anticoagulation therapy; 159 (66.2%), antiplatelet therapy; and 76 (31.7%), both therapies. Pseudoaneurysm size, length and width of pseudoaneurysm neck, thrombin dose, therapy outcome, and complications were documented. The peak blood flow in peripheral arteries was determined before and after thrombin injection. Follow-up duplex US was performed 12-24 hours, 5-7 days, and 21-25 days after treatment. A nonpaired t test was used to compare differences in age between the male and female patients. Two-way analysis of covariance was performed to analyze the influences of factors that may have been related to the amount of thrombin used.

RESULTS

Mean pseudoaneurysm volume was 4.69 cm3 +/- 5.49 (standard deviation). Simple and complex pseudoaneurysms were treated in 165 and 75 patients, respectively. A total of 260 thrombin injections were performed: 1.04 injections per patient with a simple pseudoaneurysm and 1.17 injections per patient with a complex pseudoaneurysm. The mean injected thrombin dose was 425.31 IU +/- 341.75 for all pseudoaneurysms, 382.12 IU +/- 281.00 for simple pseudoaneurysms only, and 520.33 IU +/- 434.64 for complex pseudoaneurysms only. There was only a computational correlation between pseudoaneurysm size and thrombin dose (r2 = 0.07). The primary success rate was 93.8% overall, 95.8% for simple pseudoaneurysms, and 89% for complex pseudoaneurysms. The secondary success rate was 99.6% overall, 100% for simple pseudoaneurysms, and 99% for complex pseudoaneurysms. Early (at < or =24 hours) reperfusion occurred in one simple and five complex pseudoaneurysms. Four late reperfusions-two in simple and two in complex pseudoaneurysms-were detected at 1-week follow-up; no late reperfusions were detected at 3 weeks. Thromboembolic complications occurred in two patients and resolved spontaneously. One mild allergic reaction and no infections occurred.

CONCLUSION

US-guided percutaneous thrombin injection enables successful, safe management of postcatheterization pseudoaneurysms.

Human thrombin for treatment of pseudoaneurysms: comparison of bovine and human thrombin sonogram-guided injection

OBJECTIVE

The purpose of this research was to review our experience and determine the success rate of percutaneous sonogram-guided human thrombin injection to treat iatrogenic femoral pseudoaneurysms and compare this with the results obtained with bovine thrombin injection.

CONCLUSION

In our experience, the use of human thrombin for the treatment of iatrogenic femoral pseudoaneurysms is highly efficient (100%), the administered dose is significantly less than with bovine thrombin, and the risk for allergy is potentially lower. At our hospital, human thrombin has replaced bovine thrombin and is the first line of treatment for an iatrogenic pseudoaneurysm.

Ultrasound-Guided Glue Injection as Alternative Treatment of Femoral Pseudoaneurysms

The interventional angiographic techniques using the percutaneous femoral approach for endovascular revascularization are becoming increasingly more popular. These methods usually require larger sheaths, and most patients need postprocedural anticoagulation or antiplatelet therapy. As a consequence, the interventional procedure is associated with a higher rate of complications at the arterial entry site compared to diagnostic angiography. The reported incidence of iatrogenic pseudoaneurysm formation after coronary artery interventions ranges from 3.2% to 7.7%, and the rates noted after diagnostic angiography range from 0.2% to 1%.

[Treatment of postcatheterization femoral false aneurysms]

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

Arterial injuries: a sonographic approach

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

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

OBJECTIVE

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

RESULTS

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

CONCLUSION

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

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

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

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

BACKGROUND AND OBJECTIVE

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

PATIENTS AND METHOD

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

RESULTS

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

CONCLUSION

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

Treatment of femoral artery pseudoaneurysms using ultrasound-guided thrombin injection

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

Current treatment methods for postcatheterization pseudoaneurysms

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

Thrombin injection for treatment of false aneurysms after failed compression therapy in patients on full-dose antiplatelet and heparin therapy

The aim of this study was to gauge the effectiveness of thrombin injection after failed manual compression in patients with false aneurysms receiving full-dose antiplatelet and heparin therapy. In consecutive patients with failed manual compression therapy (ultrasound-guided manual compression, compression bandage, or both), thrombin was injected under ultrasound guidance. In 23 patients, thrombin was injected into the false aneurysm (100-2,000 units; mean, 895 +/- 520 units). All patients were on aspirin (median dose, 100 mg/day), clopidogrel (median dose, 75 mg/day), and either heparin (n = 3) with a partial thromboplastin time (PTT) > 55 sec or weight-adjusted enoxaparine (0.1 ml per 10 kg; maximum, 1 ml/b.i.d.). Twelve patients had received an i.v. GB IIIb/IIa antagonist 11-72 hr prior to diagnosis of the aneurysm. The mean width of the false aneurysms was 20.8 +/- 3.2 mm (range, 8.0-52.0 mm), length 29.7 +/- 32.6 mm (range, 9.0-147 mm), and depth 19 +/- 9.1 mm (range, 5.1-35.5 mm). Thrombosis after thrombin injection occurred in 21 patients within seconds. One patient required a second injection the next day, one patient underwent surgery. Overall success rate was 96%. No in-hospital complications occurred. In patients with false aneurysms and failed compression therapy under full-dose aspirin, clopidogrel, and heparin, selective thrombin injection is highly effective and safe.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Percutaneous management of access site complications

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

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

PURPOSE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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