Acute arterial occlusion after ultrasound-guided thrombin injection of a common femoral artery pseudoaneurysm with a wide, short neck

Ultrasound-guided thrombin injection (UGTI) has emerged as the preferred treatment modality for pseudoaneurysms occurring as a result of percutaneous femoral arterial interventions. UGTI is safe and effective, with few complications. Native arterial thrombosis has been rarely reported in the literature following UGTI and has usually been attributed to excessive thrombin injection. We report a case of femoral arteria thrombosis occurring following UGTI of a 4 cm postcatherization pseudoaneurysm with a wide, short neck successfully treated by surgical intervention. The large size of the neck of this pseudoaneurysm likely contributed to the development of this complication.     

Ultrasound-guided thrombin injection is a safe and durable treatment for femoral pseudoaneurysms

Ultrasound-guided percutaneous thrombin injection has recently been described as a treatment for postcatheterization femoral pseudoaneurysms. Although ultrasound guided compression offers another nonoperative treatment option, thrombin injection has shown superior initial success rates. Reports of follow-up for thrombin injection longer than 30 days are currently lacking. The authors reviewed their initial experience with thrombin injection and prospectively evaluated patients for occult late recurrences of pseudoaneurysm and for distal circulatory complications. Records and vascular laboratory data for all patients treated with ultrasound-guided thrombin injection were reviewed for an 18-month period. Tibial vessel Doppler waveforms and ankle/brachial indices were routinely obtained before and after thrombin injection. Follow-up duplex examinations were performed within 24 hours of initial treatment. In the prospective portion of the study, successfully treated patients underwent a repeat femoral duplex scan and lower extremity arterial examination for comparison with the pretreatment studies. Forty-nine of 52 femoral pseudoaneurysms (94%) were successfully treated with ultrasound guided thrombin injection. One immediate failure and 2 early recurrences were treated surgically. There was 1 thrombotic complication of the native circulation identified at the time of injection. Follow-up studies were obtained in 32 of 46 available patients with a mean length of follow-up of 9 months (range 3-17 months). No late recurrences of the pseudoaneurysms or arterial-venous fistulas were observed. No distal circulatory complications were detected by arterial waveform analysis. Three deaths occurred in the interim (cardiac related). Two patients were lost to follow-up. The remaining 12 patients reported no additional limb complications but declined to be restudied. Ultrasound-guided thrombin injection is a safe, effective, and durable treatment for iatrogenic pseudoaneurysms. Thrombin injection should be the therapy of choice for catheter-related femoral false aneurysms.     

Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms

PURPOSE: We previously reported preliminary data on a new procedure that we developed for the treatment of femoral pseudoaneurysms after catheterization. This study presents our current results of percutaneous ultrasound-guided thrombin injection for treating pseudoaneurysms that arise from various locations and causes. METHODS: Between February 1996 and May 1999, we performed thrombin injection of 83 pseudoaneurysms in 82 patients. There were 74 femoral pseudoaneurysms: 60 from cardiac catheterization (36 interventional), seven from peripheral arteriography (four interventional), five from intra-aortic balloon pumps, and two from dialysis catheters. There were nine other pseudoaneurysms: five brachial (two cardiac catheterization, two gunshot wounds, one after removal of an infected arteriovenous graft), one subclavian (central venous catheter insertion), one radial (arterial line), and one distal superficial femoral and one posterior tibial (both after blunt trauma). Twenty-nine pseudo-aneurysms were injected while on therapeutic anticoagulation. Patients underwent repeat ultrasound examination within 5 days and after 4 weeks. RESULTS: Eighty-two of 83 pseudoaneurysms had initial successful treatment by this technique, including 28 of 29 in patients who were undergoing anticoagulation therapy. The only complication was thrombosis of a distal brachial artery, which resolved spontaneously. There were early recurrences in seven patients: four patients underwent successful reinjection; reinjection failed in two patients, who underwent surgical repair; and one patient had spontaneous thrombosis on follow-up. After 4 weeks, ultrasound examinations were completely normal or showed some residual hematoma, and there were no recurrent pseudoaneurysms. CONCLUSION: Ultrasound-guided thrombin injection of pseudoaneurysms has excellent results, which support its widespread use as the primary treatment for this common problem.     

Ultrasound-guided thrombin injection is the treatment of choice for femoral pseudoaneurysms

HYPOTHESIS: Ultrasound-guided injection of thrombin is the treatment of choice for femoral pseudoaneurysms. DESIGN: A prospective study of patients undergoing a single form of treatment for femoral pseudoaneurysms. SETTING: Patients were treated at 2 tertiary care, university-affiliated hospitals. PATIENTS: Forty consecutive patients with femoral pseudoaneurysms resulting from diagnostic and therapeutic catheterizations for peripheral arterial, coronary arterial, and cerebrovascular diseases were evaluated. INTERVENTION: Thrombin was injected directly into the pseudoaneurysms under ultrasonographic guidance. MAIN OUTCOME MEASURE: Thrombosis of the pseudoaneurysm following thrombin injection was the goal of treatment. RESULTS: All 40 patients had initial complete thrombosis of their femoral pseudoaneurysms. In each case, except for one, the aneurysm was noted to have thrombosed on follow-up duplex ultrasonogram. There was one complication. CONCLUSION: Ultrasound-guided thrombin injection is the treatment of choice for femoral pseudoaneurysms.     

Percutaneous Induced Thrombosis of Iatrogenic Femoral Pseudoaneurysms following Catheterization

Femoral pseudoaneurysms are one of the common iatrogenic complications following catheterization procedures done via the femoral approach. Their treatment has evolved over the last decade from operative repair to ultrasound-guided compression (USGC) and more recently to thrombin injection of the pseudoaneurysm. We report our experience with that technique and compare the results of thromboobliteration to those of the compression method. All consecutive iatrogenic femoral pseudoaneurysms diagnosed in the vascular laboratory of two large community hospitals were referred for the study. Under ultrasound guidance, percutaneous thromboobliteration (PTO) of the pseudoaneurysms was done by injecting thrombin solution (500-unit increments) into the pseudoaneurysm. Time to thrombosis, dose of thrombin, patient's discomfort, and ease of procedure were recorded and analyzed. Comparison with results of USGC reported in the literature was made. Percutaneous thromboobliteration may be a simple and very effective treatment of femoral pseudoaneurysms. The high success rate, ease of procedure, and cost benefit over USGC are noteworthy. A larger trial is currently under way. If results are duplicated, PTO will emerge as the preferred treatment for iatrogenic femoral pseudoaneurysms.     

Treatment of radial and ulnar artery pseudoaneurysms using percutaneous thrombin injection

Pseudoaneurysm formation is a recognized complication of arterial catheterization or traumatic arterial disruption, which may lead to considerable morbidity. Ultrasound-guided thrombin injection has been shown to be effective in the treatment of peripheral pseudoaneurysms; however, its application in the management of radial or ulnar artery pseudoaneurysms has not been well established. Arterial thrombosis and distal embolization are concerns when treating a pseudoaneurysm involving a small vessel. We performed successful ultrasound-guided thrombin injection of a 3-cm radial artery and a 2.5-cm ulnar artery pseudoaneurysm resulting from arterial catheterization and missed arterial trauma, respectively. Radial artery recannalization occurred 28 days after the procedure whereas the ulnar artery remained patent throughout the observation period.     

Obliteration of femoral artery pseudoaneurysm by thrombin injection

BACKGROUND: Femoral artery pseudyoaneurysms are a common complication after femoral access for transcatheter procedures, frequently requiring operative repair. We review the safety and efficacy of a novel nonsurgical method of pseudoaneurysm treatment METHODS: From June 1998 to November 2001, a total of 47 femoral artery pseudoaneurysms in 46 patients were treated by bedside ultrasound-guided injection of dilute topical thrombin. All pseudoaneurysms occurred after femoral access for transcatheter procedures, and were diagnosed clinically and confirmed with ultrasound imaging. Clinical follow-up was performed and included ultrasound (2 hours to 1 month) in 64.4% of patients, including any patient with a symptomatic or clinical change. RESULTS: Pseudoaneurysms ranged in size from 1.5 to 4.5 cm. Of 47 pseudoaneurysms, 45 were successfully obliterated on the initial injection. After successful obliteration of pseudoaneurysm, 1 patient sustained thrombosis of the tibioperoneal trunk that required surgical embolectomy, yielding a complication rate of 2%. Four pseudoaneurysms recurred after initially successful obliteration. In 1 of these cases, the patient was taken directly to surgery, and 3 were successfully treated with repeat injection, for an overall success rate of 93.6%. CONCLUSIONS: Obliteration of femoral artery pseudoaneurysm by injection is safe and effective, and may be associated with decreased morbidity. Recurrent pseudoaneurysms may be safely reinjected, with a high success rate.     

Combined endovascular intervention and percutaneous thrombin injection in the treatment of iatrogenic pseudoaneurysm. Case report

One of the basic techniques of treatment of iatrogenic pseudoaneurysms is percutaneous thrombin injection. Unfortunately, success rate of this treatment can be limited in cases associated with extensive damage to arterial wall. Our paper presents one case of combined treatment involving endovascular occlusion of the entry to the false aneurysm and percutaneous thrombin injection into the pseudoaneurysm chamber. In our opinion this technique can be successfully applied in patients with contraindications for compression therapy, surgical intervention or failure of traditional injection due to large entry, multiple arterial wall damage or accompanying arteriovenous fistula.     

US-guided percutaneous management of femoral artery pseudoaneurysms by thrombin injection: personal experience and review of the literature

Treatment of femoral artery pseudoaneurysms includes US-guided compression, endovascular coil embolisation or stenting, thrombin injection and open surgical repair. Thrombin injection is currently the standard approach to all non-complicated pseudoaneurysms of the peripheral arteries. Between January 2001 and December 2004, 59 pseudoaneurysms of the femoral artery were submitted to percutaneous US-guided thrombin injection in our surgery division. Complicated pseudoaneurysms, patients in whom percutaneous treatment failed, and chronic pseudoaneurysms with large necks were excluded from this kind of treatment and underwent surgical repair. Eighteen patients were on therapeutic anticoagulation (30.5%) and none of the pseudoaneurysms had an associated arteriovenous fistula. All patients were submitted to clinical and ultrasound follow-up at 24 hours and at 1, 6 and 12 months, and thereafter at yearly intervals for evaluation of recurrences. The thrombin injection was successful in 57/59 patients (96.6%) while two patients (3.4%) were submitted to surgical treatment after failure of the procedure. In 1 patient (1.7%) an additional injection was necessary to achieve complete thrombosis of the pseudoaneurysm. No complications occurred; none of the patients reported discomfort and there was no request for sedation. No recurrences were seen at follow-up. Nowadays US-guided percutaneous thrombin injection is the treatment of choice for femoral artery pseudoaneurysms. Surgical treatment is reserved to rare selected cases. More studies are necessary to evaluate further indications for treatment of visceral or small distal artery pseudoaneurysms.     

Ultrasound-guided thrombin injection of iatrogenic femoral pseudoaneurysms: a prospective analysis

An adverse consequence of the use of the femoral artery for the endovascular evaluation and treatment of arterial disease is the increased incidence of iatrogenic femoral pseudoaneurysms. Although surgical repair has traditionally been used to treat such aneurysms, less invasive modalities have emerged. The purpose of this study is to prospectively evaluate ultrasound-guided thrombin injection (UGTI) for the treatment of iatrogenic femoral pseudoaneurysms. A treatment protocol was approved and 30 stable patients (21 female; age range 43-85 years; mean 67 years) were prospectively enrolled from December 1997 through June 1999 to undergo UGTI on 30 iatrogenic femoral pseudoaneurysms. Pseudoaneurysms occurred after cardiac intervention (n = 22, 73%), peripheral intervention (n = 7, 23%), and after a femoral line placement (n = 1, 3%). They ranged in size from one to 5 cm with a time interval from intervention until UGTI of one to 132 days (median 3 days). Eleven patients (37%) were systematically anticoagulated at the time of UGTI. All pseudoaneurysms were treated using sterile technique and local anesthesia with ultrasound-guided injection via a 20-gauge spinal needle of 0.1 to 2 cm3 (median 0.6 cm3) of 1000 units/cm3 topical thrombin solution administered by one of six physicians. A period of bedrest for 4 to 6 hours after injection was followed by repeat groin duplex scan at 24 hours and a clinical follow-up at 30 days. There were no procedural deaths or nonvascular complications. Twenty-seven (90%) UGTIs resulted in successful pseudoaneurysm ablation with no recurrences at 24 hours or 30 days. Two (7%) UGTIs failed and one (3%) femoral artery embolic complication occurred; all were successfully treated with surgery. Success appeared to be independent of anticoagulation status, pseudoaneurysm age, size, or operator experience. We conclude that UGTI is a safe, easy, well-tolerated and effective noninvasive method for treatment of iatrogenic femoral pseudoaneurysms and should be considered in all stable patients before operative repair.     

Hepatic artery pseudoaneurysm after liver transplantation: treatment with percutaneous thrombin injection

Pseudoaneurysms of the hepatic artery are a rare complication of liver transplantation. Early diagnosis and treatment are essential to avoid life-threatening hemorrhage. Conventional treatment consists of surgical resection and vascular reconstruction or transarterial coil embolization. More recently, percutaneous thrombin injection has been successfully used in the treatment of femoral artery pseudoaneurysms. We describe a 70-year-old woman who had a hepatic artery pseudoaneurysm after orthotopic liver transplantation, which was successfully treated by percutaneous thrombin injection.     

Iatrogenic femoral artery pseudoaneurysm: Studies relating to the current treatment strategies including observation,ultrasound-guided compression,and duplex-directed thrombin injection

These articles demonstrate 3 “conservative” management strategies for postcatheterization femoral artery pseudoaneurysms. The continuum of watchful waiting in selected patients to ultrasound-guided compression, to ultrasound-guided thrombin injection mirrors many of the changes in the surgical treatment of myriad disease states. Operative repair of these lesions, such as open cholecystectomy, is not going to be of historical importance because many of these lesions will still require open repair. However, with the ever-increasing use of catheter-based therapies, minimally invasive techniques that demonstrate similar efficacy and safety are needed.The most frequent complication of femoral artery catheterization is the development of a femoral artery pseudoaneurysm. Approximately 500,000 interventional cardiologic procedures are performed in the United States every year. This does not take into account the interventional radiologic and other (femoral arterial line placement) procedures used to gain access to the central arterial system via the femoral artery. The reported incidence of complications after femoral artery catheterization ranges from 0.2%–9%. Pseudoaneurysm formation has been reported as a complication in 0.05%–5% of all femoral artery catheterizations.Obviously, with the large number of procedures being performed each year, femoral artery pseudoaneurysm formation is not an uncommon lesion referred to general and vascular surgeons.The first article reviewed explores the conservative management of femoral artery pseudoaneurysms. This article is important in that it documents the benign natural history of a large number of these lesions. Although the conservatively managed patients were a relatively select group, they were not so select that the findings of the study become uninterpretable. This study demonstrates that many of these lesions can in fact be observed with frequent spontaneous resolution.The second article discusses another “conservative” management strategy for the treatment of femoral artery pseudoaneurysms, involving ultrasound-guided compression of the lesion. Ultrasound-guided compression has been adopted in many centers and has shown very good results. Success rates of 70%–100% have been reported. Unfortunately, a recurrence rate of 20% is still seen, especially in patients undergoing anticoagulant therapy. Also, a large number of patients fail this therapeutic method secondary to intolerance of the pain associated with compression. Still, it is clear that ultrasound-guided compression is a highly effective choice in many patients.The third article addresses duplex-directed thrombin injection, a novel technique that is being employed in certain centers. This technique appears to be quite effective and safe. Although this study included only 11 patients, this paper is one of a series of papers that have documented the efficacy and safety of the technique. Duplex-directed thrombin injection is also very expeditious with thrombosis, occurring in only 30 seconds in most patients.Surgical repair of femoral artery pseudoaneurysms will always be necessary for a number of these lesions. However, many can be observed with spontaneous thrombosis. Other techniques have been and are being designed to treat this common condition. With the economic pressure for decreased in-patient treatment, the conservative strategies that have been reviewed will continue to occupy a central role in the management of these lesions.     

A prospective study of ultrasound scan-guided thrombin injection of femoral pseudoaneurysm: a trend toward minimal medication

BACKGROUND: Catheterizations and endovascular procedures in which the femoral artery is cannulated are sometimes complicated by iatrogenic pseudoaneuryms. Surgical repair of pseudoaneurysms was the treatment of choice until 1991 when compression was used in those that were small. A less uncomfortable technique involving the ultrasound scan-guided injection of thrombin (UGTI) has been used more recently. The purpose of this study was to prospectively evaluate the effectiveness of ultrasound scan-guided thrombin injection (UGTI) as a treatment of iatrogenic femoral pseudoaneurysms. METHODS: From December 1998 to December 2000, 3734 femoral artery catheterizations were performed, and from those, 32 consecutive patients with 33 femoral pseudoaneurysms (0.88%) of less than 8 cm were prospectively enrolled for UGTI. With sterile technique, a 21-gauge or 22-gauge spinal needle was used to access the pseudoaneurysm and thrombin (100 to 6000 international units [IU]) was slowly injected until thrombosis occurred. RESULTS: The initial success rate was 100%. Thirty-one cases (93.9%) remained successfully thrombosed with a single injection at day 30. Recurrence of two pseudoaneurysms (6.1%) was seen at day 1 and day 8. One patient had groin cellulitis develop, and the other had a bleed into the thigh after discharge; both were treated with open surgical repair. Fifteen patients underwent UGTI on an outpatient basis with 100% successful ablation. More than half of the patients were on an inpatient basis (53.1%). Hospital stay was 1 to 9 days, with 88.2% of the patients released on day 1 or 2. However, two patients had a prolonged stay: one from open repair (day 9) and the other from a gastrointestinal bleed (day 8). Pseudoaneurysms ranged from 1.7 to 7.5 cm and lasted 1 to 17 days before UGTI. Twenty-one of the patients (65.7%) continued undergoing anticoagulant therapy at the time of injection. Ten of the last 11 cases needed less than 800 IU, and nearly half of the pseudoaneurysms (49%) successfully thrombosed with less than 600 IU. No procedural complications or mortality were noted. No statistical significance was found between occurrence of the pseudoaneurysm and sheath size (with chi(2) test, P value =.05) or between the size of the pseudoaneurysm and successful thrombosis (with chi(2) test: degrees of freedom, 6 - 1 = 5; P value =.227426). A mean follow-up period of 11.8 months was documented (range, 71 to 24 months). Seven patients were lost to follow-up at less than 30 days. CONCLUSION: Percutaneous thrombin injection of iatrogenic pseudoaneurysms is an effective treatment. Not only is it minimally painful, but it can be done as an outpatient procedure and anticoagulation therapy does not hinder the success. Minimal thrombin seems necessary to successfully treat pseudoaneurysms that may further limit procedure-related complications.     

Ultrasound-guided percutaneous thrombin injection for femoral artery pseudoaneurysms

We reviewed 13 cases of ultrasound-guided thrombin injection of femoral pseudoaneurysms. All cases occurred within a 17-month period from January 1998 through May 1999 and were complications of femoral artery puncture. Immediate total thrombosis occurred in nine of 13 patients. Twenty-four-hour follow-up ultrasound in seven patients revealed no recurrence of pseudoaneurysm. Two of 13 patients required operative repair. One pseudoaneurysm thrombosed with 15 minutes of compression after injection and one case required a second injection. No cases of arterial thrombosis were noted. Ultrasound-guided thrombin injection for femoral artery pseudoaneurysm represents a safe and effective alternative to operative repair.     

Percutaneous ultrasound guided thrombin injection: A new method for treating postcatheterization femoral pseudoaneurysms

Purpose: Since its introduction in 1991, ultrasound guided compression repair of postcatheterization femoral artery pseudoaneurysms has been shown to be effective. Disadvantages of ultrasound guided compression repair include patient discomfort during compression, inability to treat noncompressible pseudoaneurysms, prolonged use of ultrasound equipment and personnel, limited success with patients being treated with anticoagulants, and some early recurrences. We conducted a prospective study to evaluate a new method of treating femoral pseudoaneurysms, percutaneous ultrasound guided thrombin injection. Methods: Under duplex ultrasound guidance, a 22- or 25-gauge needle was percutaneously positioned within the pseudoaneurysm. Without compressing the pseudoaneurysm, 0.5 to 1 ml thrombin solution (1000 U/ml) was injected to induce thrombosis. Early in the study, the procedure was modified to allow more than one injection. After successful thrombosis, the patients were kept at rest in bed for at least 1 hour. Duplex ultrasound examination was repeated in 1 to 4 days. Distal pulses and ankle-brachial indexes were measured before and after the procedure. Results: Twenty of 21 consecutive pseudoaneurysms were successfully treated with thrombin injection. Fifteen pseudoaneurysms thrombosed immediately (<20 seconds) after one injection. The other five had partial thrombosis after one injection and complete thrombosis immediately after a second injection. The one failure occurred in a patient who had only one injection and then underwent subsequent ultrasound guided compression repair, which failed. No patient required sedation or analgesia during thrombin injection. There were no procedure-related complications and no recurrences. Conclusions: Percutaneous ultrasound guided thrombin injection appears to be a safe and expeditious method for treating postcatheterization femoral pseudoaneurysms. It has significant advantages with respect to ultrasound guided compression repair or surgical repair. (J Vasc Surg 1998;27:1032-8.)     

Thrombin injection versus compression of femoral artery pseudoaneurysms

OBJECTIVE: The compression of femoral artery pseudoaneurysms is a time consuming, painful, and sometimes unsuccessful procedure. Thrombin injection has been advocated as a superior alternative. In this study, we compare our experiences with both techniques. METHODS: All the records of femoral artery false aneurysms that were treated in the vascular laboratory from January 1996 to April 1999 were retrospectively reviewed. Treatment with ultrasound scan-guided compression was compared with treatment with dilute thrombin injection (100 U/mL). RESULTS: Both groups had similar demographics and aneurysm sizes (P >.2). Of the pseudoaneursyms, 88% were caused by cardiac catheterization and the others were the results of femoral artery access for cardiac surgery (6%), arteriography (5%), and renal dialysis (1%). Compression was successful in 25 of 40 patients (63%). Nine persistent aneurysms necessitated operation, and six were treated successfully with thrombin injection. Primary thrombin injection successfully obliterated 21 pseudoaneurysms in 23 patients. Overall, 27 of 29 pseudoaneurysms were treated successfully with thrombin injection (93%). Thrombosis occurred within seconds of the thrombin injection and required, on average, 300 units of thrombin (100 to 600 units). The patients who underwent successful compression required an average of 37 minutes of compression (range, 5 to 70 minutes) and required analgesia on several occasions. No patients in the thrombin group required analgesia or sedation. Neither group had complications. A cost analysis shows that thrombin treatment results in considerable savings in vascular laboratory resource use but not in overall hospital expenditures. CONCLUSION: Ultrasound scan-guided thrombin injection is a safe, fast, and painless procedure that completely obliterates femoral artery pseudoaneurysms. The shift from compressive therapy to thrombin injection reduces vascular laboratory use and is less expensive, although it does not significantly impact hospital costs.     

Treatment of arterial pseudoaneurysms with percutaneous ultrasound-guided thrombin injection

Background: The pseudoaneurysms or false aneurysms are one of the most common complications after arterial invasive manipulation. Different methods of treatment have been described, such as surgical repair, ultrasound-guided compression and endovascular procedures. Ultrasound-guided thrombin injection has shown efficacy, safety and low cost, and, in some cases, the procedure is considered the treatment of choice. Preliminary results are presented. Methods: Design: Case series. We studied adult patients with iatrogenic arterial pseudoaneurysms demonstrated clinically and corroborated with ultrasound. We describe the technique used for the management of the arterial pseudoaneurysms by ultrasound-guided thrombin application, as well as complications and follow-up. Results: Twelve patients were included with a mean age of 63 years (SD 12.4), 33% were male and 67% female. Associated comorbid states were hypertension 83%, 50% diabetes, obesity 66%. All pseudoaneurysms were located in the femoral artery (2:1 right/left ratio). The mean size of the pseudoaneurysm was 48.2 mm SD 11.9, (range of 30 to 65 mm) by 44.3 mm SD 9.3, (range 20 to 53 mm). The average neck diameter was 2.2 mm SD 0.54 (range of 1.5 to 3 mm). Eleven cases were unilobulated (87.5%), and one bilobulated (12.5%). All reported arterial integrity with complete occlusion after one thrombin application without recurrence and morbidity after 90 days of follow up. Conclusions: In our study we obtained a 100% of thrombosis without pseudoaneurysm recurrence or complications. However a longer follow-up time and more number of cases are required to confirm these results.     

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.     

Endovascular repair of giant iatrogenic femoral artery pseudoaneurysm: case report and literature review

Femoral Artery Pseudoaneurysm (FAP) is one of the most troublesome complications after various invasive cardiovascular procedures related to the femoral arterial access site. It occurs in 0.8% to 2.2% post Intra Aortic Balloon Pump (IABP) removal Messina et al. (J Vasc Surg 13:593–600, 1991). Doppler flow mapping confirms the diagnosis. Angiography provides information regarding native vessel morphology and the relation of the pseudoaneurysm to major branches. Ultrasound-Guided Compression Repair (UGCR) has been a successful modality of FAP management while minimally invasive percutaneous treatments include thrombin injection, coil embolization and insertion of covered stents. We report a case of iatrogenic FAP who was a high risk candidate for UGCR or surgical repair. She was successfully managed by percutaneous implantation of endovascular covered stent with a rapid return to ambulatory activity and minimised hospital stay. This treatment method may be a safe and effective alternative to surgery in selected patients.     

Ipsilateral femoral vein compression: a contraindication to thrombin injection of femoral pseudoaneurysms

Development of a femoral artery pseudoaneurysm occurs in 0.6% to 3.2% of interventional procedures. Nonsurgical treatment has consisted of ultrasound scan-directed compression and, more recently, direct thrombin injection into the pseudoaneurysm cavity to achieve thrombosis. Reported complications after thrombin injection are rare. We report two cases of femoral venous compression associated with pseudoaneurysm injection and review the literature. A 76-year-old man and an 86-year-old man both underwent thrombin injection of pseudoaneurysms compressing the ipsilateral common femoral vein. Both patients were diagnosed with deep venous thrombosis and subsequently needed surgical exploration for repair of the pseudoaneurysm and release of the venous compression. At exploration, both were found to have significant inflammation surrounding the femoral vessels, which made vessel exposure challenging. Because of the venous outflow obstruction involved in femoral pseudoaneurysms with secondary venous compression and the surgical difficulty caused by surrounding inflammation, avoidance of thrombin injection in favor of early surgical intervention is suggested.