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

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.

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.

The needle and the damage done: musculoskeletal and vascular complications associated with injected drug use

Injected drug use is associated with a wide range of medical complications which are predominantly musculoskeletal and vascular in nature. Illicit drug use is increasing worldwide. Patients with complications of injected drug use often present in a non-specific manner without a reliable clinical history. Musculoskeletal complications are typically infective in aetiology and may vary widely in severity from mild to life-threatening. A multimodal imaging approach is often required for both diagnostic imaging and image-guided sampling. Plain radiographs are often an important initial test, for example in identifying retained needles from injection. Ultrasound and CT play important roles in the assessment of complex soft tissue complications and MRI is the imaging modality of choice for bone and joint disorders. Vascular complications may be venous or arterial in nature and usually occur locally at the injection site. These complications may be related to direct injury to the vessel wall by a needle, or secondary to local infection and inflammation. A multimodal imaging strategy is also often required in the assessment of these vascular complications, typically involving a combination of ultrasound and CT. Familiarity with the multimodal imaging features of the complications related to injected drug use is crucially important as they may be rapidly progressive and life-threatening and require timely diagnosis.

Endovascular treatment of iliac artery rupture after septic embolization

A 56-year man with multiple comorbidities and recent septic embolization presented claudication intermittens (Rutherford3) at right lower limb and complaint in right lower quadrant at abdominal palpation. Duplex and computed tomography angiogram (CTA) showed a 64mm-pseudo-aneurysm (PA) originating from right common iliac artery, occlusion of external iliac and patency of hypogastric artery. An urgent endovascular approach was preferred. By left brachial percutaneous access, coil embolization (Balt SPI™ and Cook MReye™) of hypogastric and common iliac artery and deployment of Amplatzer Vascular PlugII™ into the common iliac artery were performed. Completion angiography showed exclusion of PA. One-day, 3-day and 1-month CTA proofed no vascularization of PA. No fever, no leukocytosis, no signs of infection occurred during follow-up and 10-month CTA showed the complete resolution of pseudoaneurysm. (www.actabiomedica.it)

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.

Clues to vascular disorders at non-contrast CT of the chest, abdomen, and pelvis

Non-contrast chest CT scans are commonly performed while CT scans of the abdomen and pelvis are performed in a select subset of patients; those with limited renal function, an allergy to iodinated contrast, in the setting of suspected renal calculus, retroperitoneal hematoma, common duct calculus, abdominal aortic aneurysm with or without rupture, and in patients undergoing a PET-CT scan. In the absence of intravenous contrast, vascular structures may prove challenging to evaluate, yet their assessment is an important component of every non-contrast CT examination. We describe the key imaging features of both arterial and venous pathology, and review clues and common associated non-vascular findings, which can help the radiologist identify vascular disorders at non-contrast CT. Briefly, alternative imaging options are discussed.