Ultrasonography guided percutaneous thrombin injection of postcatheterization pseudoaneurysms

Abstract

Femoral artery pseudoaneurysms are among the most frequent complications of angiography. Factors that predispose a patient to pseudoaneurysm formation are inadequate compression, simultaneous artery and vein catheterization, hypertension, obesity, hemodialysis, heavily calcified arteries, and low femoral puncture. The risk of pseudoaneurysm formation also increases when large-bore sheaths, postprocedural anticoagulation therapy, and/or antiplatelet therapy are used as interventions (1, 2). The incidence of femoral pseudoaneurysms ranges from 0.05% to 4% (2). Color Doppler scanning reveals a prevalence of 7.7% in all postcatheterization patients regardless of symptoms, but the prevalence may increase up to 16% with more complex procedures that necessitate larger sheaths (2, 3).Open surgical repair was the gold standard for iatrogenic pseudoaneurysms till the development of percutaneous therapeutic options. One prominent disadvantage of the surgical repair of pseudoaneurysms is the remarkably high complication rate. Ultrasonography-guided (US-guided) compression repair is relatively safe and effective, but it has considerable limitations. Specifically, the duration of compression is lengthy, the procedure is painful and may require conscious sedation, and the success rate is approximately 75%. The US-guided injection of thrombin has emerged as an alternative to US-guided compression repair with success rates of 91% to 100%. The complication rate is approximately 2% (2, 4). The USguided injection of thrombin has become the first-line treatment for pseudoaneurysms, and it is increasingly popular for the treatment of iatrogenic pseudoaneurysms in many institutions. This study reports our experience with the use of US-guided percutaneous thrombin injection for the treatment of iatrogenic femoral artery and brachial artery pseudoaneurysms. Materials and methodsAll of the procedures on humans were performed in accordance with the ethical standards of the World Medical Association. Written consent was obtained from all patients following instructions on the nature and risks of the intervention. In this retrospective study, 55 consecutive patients with a mean age of 60.1±12.7 years (26 men, aged 35 to 79 years [mean, 58.2 years]; 29 women, aged 32 to 85 years [mean, 61.9 years]) who were treated from December 2006 to June 2010 and who received a diagnosis of pseudoaneurysm of the femoral or brachial artery with the guidance of color Doppler US (CDUS) were included in this analysis. Patients with any of the following criteria were excluded from this study: a rapid expansion of the pseudoaneurysm, especially in unstable patients, distal ischemia due to femoral artery compression, infection of the pseudoaneurysm, neuropathy, overlying soft tissue or skin ischemia, or impending compartment syndrome. No patients were excluded for these reasons during the study period. The morphology INTERVENTIONAL RADIOLOGY ORIGINAL ARTICLE US-guided percutaneous thrombin injection of postcatheterization pseudoaneurysmsKamil Gürel, Serkan Gür,...

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

“…The complication rate, considered separately, was 3.0%. These results are concordant with those in prior studies, which suggest that ultrasound‐guided thrombin injection is a relatively effective and safe treatment . It is noteworthy that no immediate complications were identified in the 32 patients who were excluded from this study for loss to follow‐up.…”

“…Although a number of additional studies have demonstrated ultrasound-guided thrombin injection to be both safe and efficacious, [7][8][9][10][11][12][13][14][15][16][17][18][19] most have been conducted with relatively small sample sizes, and few have focused on the need for follow-up imaging or described the factors associated with pseudoaneurysm recurrence. The purpose of this study was to review cases of ultrasoundguided thrombin injection of pseudoaneurysms performed over a 10-year period to determine the procedural success rate, the procedural complication rate, the rate of pseudoaneurysm recurrence, and the factors associated with failure of complete and sustained pseudoaneurysm thrombosis to be able to recommend appropriate follow-up imaging.…”

Iliac artery pseudoaneurysm presenting as a paravertebral collection: a potentially fatal mimic

“…Thromboembolic events arise from thrombin flow beyond site of the aneurysm into the arterial system 3. Some studies have shown this method is more successful in acute pseudoaneurysms within the first few weeks of their development 9. Many authors also consider this method unsuitable for treating aneurysms with a wide neck as they have a slightly higher risk of embolisation.…”

“…However, the presence of infection is not an absolute contraindication to minimally invasive techniques, and management should be tailored to the individual case. Careful evaluation of the imaging studies, particularly CT angiography, is essential to determine the proper treatment and hence reduce the risk of complications in order to achieve the best possible results 1–3 9Learning points

Aneurysms can masquerade as a mass or an abscess, so careful evaluation of imaging studies is essential to rule out a vascular origin prior to lesion intervention.

Vascular lesions may be discovered incidentally during routine investigation of non-specific symptoms such as pain in a particular location, and so radiologists must be familiar with their imaging findings, particularly on MRI.

Contrast-enhanced CT is the gold standard for the investigation of lesions suspected of having a vascular origin.

Although minimally invasive procedures, such as percutaneous thrombin injection, are considered to be safe in comparison to open surgery, they may still result in serious complications, so careful evaluation is required to determine optimal treatment.

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Rupture of an inferior epigastric artery pseudo-aneurysm following laparoscopic port insertion

“…This had a high success rate, but with the possibility of complications at the entry puncture site, usually a femoral vessel. Percutaneous injection of thrombin for IEA pseudo-aneurysm was first described in 20026 and this method has been established in treating pseudo-aneurysms at other sites, with a success rate of around 91–100% 7. The simplicity of percutaneous injection with no significant complications, except for the theoretical risk of thrombin migration into the patent artery, makes this procedure the first choice.…”