Low-dose thrombin injection to treat iatrogenic femoral artery pseudoaneurysms

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.

New Techniques in Iatrogenic Coronary Artery Perforation Management Including Umbrella Technique, Case Report

This case report presents a patient with iatrogenic coronary artery perforation during coronary angioplasty, complicated with a life-threatening cardiac tamponade. Tamponade decompression was achieved via timely pericardiocentesis with direct autotransfusion. The coronary artery perforation itself was initially closed by using the umbrella technique, which involves distal vessel occlusion with angioplasty balloon fragments. To control further blood extravasation into the pericardial sac, the perforation site was injected with thrombin, ensuring the leak closure. If performed with caution, these relatively rarely used, management techniques are effective in dealing with percutaneous coronary intervention complications.

Traumatic Pseudoaneurysm of Anterior Tibial Artery Treated by Thrombin Injection

Traumatic pseudoaneurysm of limb arteries are relatively rare. A 70-year-old gentleman, with history of mechanical aortic valve implantation on warfarin, presented to the emergency department with pain and swelling in the right leg. He had sustained blunt injury to the leg, a week prior to presentation. On examination, the lateral compartment of the leg was swollen, ecchymotic, and tense. Distal pulses were well palpable. An ultrasound Doppler evaluation revealed a large intramuscular hematoma in the lateral compartment with a pseudoaneurysm of a muscular branch of the anterior tibial artery. An ultrasound-guided compression of the pseudoaneurysm was initially attempted for 24 hours, which failed in closing off the pseudoaneurysm. He was subsequently taken up for thrombin injection into the pseudoaneurysm, which resulted in instant thrombosis of the pseudoaneurysm, with an uneventful clinical course thereafter. Thrombin injection is an effective and safe modality to treat pseudoaneurysms of limb arteries.

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.

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.

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.

Ultrasound-guided percutaneous periarterial thrombin injection for paracentesis-related hemoperitoneum

Paracentesis is a common procedure used in the diagnostic evaluation of peritoneal fluid as well as the therapeutic removal of high-volume ascites. Although generally regarded as a safe procedure, complications may arise from arterial injury, including hematomas and pseudoaneurysms. Transcatheter embolization and surgery are first-line interventions for injuries refractory to conservative management. We present a case where a patient failed conventional therapies for hemoperitoneum following a paracentesis which resolved after thrombin injection into the subcutaneous tissues, a novel use for thrombin. Using a linear 12-3 MHz transducer, approximately 3000-3500 U of thrombin was injected through connecting tubing and a 25-gauge needle by the interventional radiologist into the subcutaneous tissues around the origin of the arterial hemorrhage. The bleeding ceased and the patient's hemoglobin and hemodynamics stabilized.

Stent-assisted coiling of large common femoral artery pseudoaneurysm following coronary artery catheterization: an uncommon and novel approach

The femoral artery pseudoaneurysm is a disturbing groin complication associated with the femoral arterial access site used for invasive cardiovascular interventions. We present a 39 year old man who developed a huge right common femoral artery pseudoaneurysm, following diagnostic coronary artery catheterization, which was successfully managed with stent-assisted coiling, an emerging and narrative option in invasive percutaneous approaches to femoral artery pseudoaneurysm.

Percutaneous instillation of physiological saline solution for the treatment of femoral pseudoaneuryms

OBJECTIVE

To investigate the efficacy of para-aneurysmal saline injection for closure of postcatheterization pseudo-aneurysm (PA) at the vascular access site.

METHODS

Fifty-one consecutive patients with postcatheterization PA at the vascular access site were included to undergo percutaneous para-aneurysmal saline injection. In case of technical failure the day after, PA were treated by bovine thrombin injection. Anatomical properties of the PA were recorded as were details to injection.

RESULTS

Initially all patients exhibited success which was reduced to 43 % at day one. A saline volume of median 7 ml (interquartile range 6-8 ml) has been injected. The amount of injected saline was not different in patients with and without treatment success at day one (P = 0.6). Several anatomical properties of the PA exhibited marked differences in patients with or without success. The length (10.3 mm (7.8-12.0) vs. 12.5 mm (10.3-15.0); P = 0.009) and the angulation (110° (100-118) vs. 140° (129-146); P < 0.001) of the fistula/vessel axis was statistically different between groups. The peak systolic velocity failed to show significance with a tendency to higher values in the ineffective study group (P = 0.07). No peripheral complications occurred.

CONCLUSION

Para-aneurysmal saline injection may be a therapeutic alternative to percutaneous thrombin injection in patients exhibiting favorable anatomical properties.

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 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.

Iatrogenic femoral artery pseudoaneurysms--a review of current methods of diagnosis and treatment

The common femoral artery is commonly used as arterial access for a wide range of radiological and cardiological procedures. Pseudoaneurysm formation is the most common arterial complication of femoral artery catheterization, and is diagnosed using colour Doppler ultrasound. Ultrasound-guided thrombin injection has replaced ultrasound-guided compression as the first-line treatment. The practicalities of thrombin injection (technique and types of thrombin available) and other treatment options are discussed. Awareness of pseudoaneurysm formation and the treatment options allows prompt diagnosis and successful treatment.

Treatment of post-catheterization femoral artery pseudo-aneurysm with para-aneurysmal saline injection

Femoral artery pseudoaneurysm is a common complication associated with cardiac catheterization procedures. Ultrasound-based techniques (e.g., mechanical compression, thrombin injection) and open surgical intervention are frequently used in the management of pseudoaneurysm. The investigators report their prospective experience with a novel method for the treatment of pseudoaneurysm after cardiac catheterization using ultrasound-guided, para-aneurysmal injection of physiologic saline. Sixty-four consecutive patients with pseudoaneurysms after cardiac catheterization were treated using normal saline (0.9% sodium chloride 25 to 60 ml) injected into the tissue surrounding the tract connecting the pseudoaneurysm with the femoral artery, followed by manual pressure of short duration. In none of the patients was concomitant antithrombotic therapy (aspirin [n = 63], clopidogrel [n = 45], unfractionated or low-molecular-weight heparin [n = 23], and warfarin [n = 5]) discontinued during the closure attempt. Fifty-nine of the 64 pseudoaneurysms (92%) were successfully occluded using saline injection. In 5 patients in whom saline injection failed, the pseudoaneurysms were successfully treated with thrombin injection (n = 4) or ultrasound-guided compression (n = 1). In all 64 patients, pseudoaneurysm closure was confirmed by ultrasound at 24 hours. The procedure was very well tolerated by the patients, and no side effects or complications were noted. In conclusion, ultrasound-guided saline injection affords a simple, safe, and effective alternative treatment for the closure of postcatheterization pseudoaneurysms.

Percutaneous Thrombin Injection for Treatment of Iatrogenic Femoral Artery Pseudoaneurysms: A Case for Caution

The case of a patient who developed a femoral artery pseudoaneurysm following cardiac catheterization is described. After 2 failed attempts of ultrasound-guided compression repair, the patient underwent percutaneous thrombin injection with, beside of complete closure of the pseudoaneurysm, a severe limb ischemia due to distal thrombin migration with consecutive clot formation finally resulting in thigh amputation of the affected leg. Indications, advantages, and disadvantages of various options for the treatment of iatrogenic femoral artery pseudoaneurysms (vascular surgery, ultrasound-guided compression, percutaneous thrombin injection, and other nonsurgical treatment modalities), as well as risk factors for distal migration of liquid thrombin after percutaneous injection, are discussed in this report.

True and false aneurysms of the femoral artery

True aneurysms of the femoral artery are uncommon. They are most often identified in elderly males and are frequently associated with aneurysms at other locations. Femoral artery aneurysms that are symptomatic or larger than 2.5 cm should be repaired in order to prevent limb-threatening complications, such as rupture, thrombosis, or embolization. Open repair is the standard method of treatment and should be preceded by evaluation for coexisting aortoiliac or popliteal aneurysms, assessment of superficial femoral artery patency, and determination of the point of origin of the deep femoral artery relative to the aneurysm sac. Femoral artery pseudoaneurysms are most often seen in the setting of previous femoral artery catheterization but may also be associated with trauma, anastomotic leakage, or infection. The majority of femoral pseudoaneurysms less than 3 cm in diameter will spontaneously thrombose and may be observed with serial duplex ultrasound exams in asymptomatic patients. Symptomatic pseudoaneurysms, pseudoaneurysms with a diameter greater than 3 cm, and those found in patients who are anticoagulated should usually be treated. Ultrasound-guided thrombin injection is our preferred method for treating femoral pseudoaneurysm because of its low risk, high success rate, and efficacy in the setting of anticoagulation. Ultrasound-guided compression is an alternative method that may be considered when thrombin products are contraindicated. Open pseudoaneurysm repair should be undertaken in the setting of infection, rapid expansion, or if less-invasive methods are not technically feasible.

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.

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.

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.

Iatrogenic pseudoaneurysm of femoral artery: case report and literature review

The case of a patient who developed a femoral artery pseudoaneurysm (FAP) following cardiac catheterization is described. It is one of the most troublesome complications after various invasive cardiovascular procedures related to the femoral arterial access site. Iatrogenic pseudoaneurysms (IPA) form when an arterial puncture site fails to seal, allowing arterial blood to ooze into the surrounding tissues and form a pulsatile hematoma. The FAP occurs in 0.8% to 2.2% after interventional procedures. This problem has become more significant due to the exponential growth of interventional cardiology. Doppler flow mapping has been the mainstay of diagnosis. Diagnostic criteria include: swirling color flow in a mass separate from the affected artery, and a typical "to-and-fro" Doppler waveform in the pseudoaneurysm neck. Ultrasound-guided compression repair has replaced the need for surgical repair of FAP. It has been shown to be a safe and cost-effective method for achieving pseudoaneurysm thrombosis. However, it carries considerable drawbacks including long procedure times, discomfort to patients, high recurrence rate in patients receiving anticoagulant therapy and an overall 3.6% complication rate. Recently, percutaneous thrombin injection in the FAP has gained popularity despite complications associated with the initial use of high dose thrombin (average dose of 1,100 IU). The technique was refined when low-dose thrombin injections were studied and proved to have the same efficacy and consistently high success rates (average dose used 192 IU). However, there is a theoretical risk of developing type I IgE-mediated allergic reaction to bovine thrombin. The indications, advantages, disadvantages, and complications of the various treatment modalities are discussed in this report and review of the literature. Other treatments with collagen injection are also discussed in detail.

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.

Thrombin injection for failed stent graft repair of perforated atherosclerotic aortic ulcer

We used direct thrombin injection to occlude a pseudoaneurysm that formed from a contained rupture of a penetrating atherosclerotic ulcer at the junction of the thoracic and abdominal aorta after we failed to seal the perforation with an endovascular stent graft. The principles of thrombin injection and the technical modifications specific for use in a false aneurysm of aortic origin are described. An evolving role for thrombin in endovascular therapy is suggested.