Ultrasound guided percutaneous thrombin injection for the treatment of iatrogenic pseudoaneurysms

Iatrogenic aneurysms are usually postcatheterisation pseudoaneurysms of the femoral artery. Until recently, the treatment of choice was ultrasound guided compression repair. A case of pseudoaneurysm of the axillary artery, arising as a complication of pacemaker insertion in an 83 year old man is reported. Compression repair was not possible in this case, and so the aneurysm was occluded by percutaneous ultrasound guided thrombin injection directly into the aneurysm sac. Percutaneous ultrasound guided thrombin injection is a promising new minimally invasive technique for the treatment of iatrogenic pseudoaneurysms.


Keywords: pseudoaneurysm; ultrasound guided thrombin injection     

Sonographically guided thrombin injection for the treatment of femoral artery pseudoaneurysm

The formation of pseudoaneurysm in the femoral artery after cardiac catheterization is a well-recognized complication occurring in 1%-4% of cases. It is traditionally managed surgically and has a high morbidity. Prolonged ultrasound-guided compression of the neck of the pseudoaneurysm, and ultrasound-guided injection of thrombin into the aneurysm are newer modalities of treatment especially for small aneurysms. We describe the case of a giant pseudoaneurysm of the right femoral artery, post-arteriography, which was successfully managed with ultrasonographically guided percutaneous thrombin injection.     

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.     

Treatment of femoral artery pseudoaneurysm with percutaneous thrombin injection.

Pseudoaneurysm formation of the femoral artery is a well-known complication following catheter-based vascular procedures. Ultrasound-guided compression or surgical correction are commonly used for its repair. We describe a new method of treatment for femoral pseudoaneurysm. The pseudoaneurysm is visualized by contralateral angiography and thrombosed with a percutaneous thrombin injection while the distal vessel is isolated with a brief balloon inflation. Fluoroscopically guided percutaneous thrombin injection is a promising, minimally invasive technique for the treatment of iatrogenic pseudoaneurysm, especially in patients with compromised distal circulation.     

Percutaneous thrombin embolization of a ruptured peripancreatic pseudoaneurysm

Peripancreatic pseudoaneurysm formation is a recognized complication of pancreatitis. When associated with an acute episode of pancreatitis, surgical treatment is often difficult due to the inflammatory process that surrounds the pseudoaneurysm. In the stable patient, transcatheter embolization is the treatment of choice of this complication. However, this is not always technically feasible, as the aneurysm may be supplied by small inaccessible branch vessels. Recently, percutaneous thrombin injection has been described as a possible alternative for pseudoaneurysms. This is generally performed under computed tomography guidance in stable patients with non-ruptured pseudoaneurysms. We describe an acutely ruptured peripancreatic pseudoaneurysm in a critically ill patient, in whom percutaneous thrombin injection under computed tomography guidance resulted in immediate stabilization and cure of the pseudoaneurysm.     

Gastrointestinal hemorrhage caused by rupture of a pseudoaneurysm of the hepatic artery

Gastrointestinal bleeding secondary to rupture of a hepatic artery pseudoaneurysm is rare. We report the case of a 61-year-old woman, who was admitted to our institution with hematemesis and melena. Upper gastrointestinal endoscopy and flexible sigmoidoscopy failed to reveal any significant abnormality. Computed tomography scan showed an aneurysm arising from the hepatic artery. A selective angiography showed a ruptured pseudoaneurysm originating from the right hepatic artery with extravasation. It was decided to embolize the pseudoaneurysm, and the neck of the pseudoaneurysm was occluded successfully with two microcoils. While these investigations and interventions were being performed, disseminated intravascular coagulation and acute hepatic failure occurred due to the massive blood transfusion and gross intrahepatic hematoma. Consequently, the patient died 10 days after admission. In this case, we observed that delayed diagnosis of hepatic artery aneurysm rupture may lead to a life-threatening situation. Thus, computed tomography and selective angiography should be obtained immediately. The percutaneous super-selective angiographic embolization of intrahepatic aneurysms is a promising form of treatment, with low risk.     

Post-traumatic hepatic artery pseudoaneurysm treated with endovascular embolization and thrombin injection

Post-traumatic hepatic artery pseudoaneurysm is uncommon, appearing in approximately 1% of hepatic trauma cases. Most are extrahepatic (80%) and have a late onset. Although they are usually asymptomatic, they should always be treated becasue of the high risk of complications, especially breakage. Currently the treatment of choice is endovascular embolization with coils or the exclusion of the pseudoaneurysm using other intravascular devices. Recently there have been accounts of a treatment that combines embolization with coils and image-guided percutaneous human thrombin injection. We present a case of post-traumatic hepatic artery pseudoaneurysm that was successfully treated using this combined technique.     

超声波引导下压迫法与注射凝血酶法治疗心导管术后股动脉假性动脉瘤的比较

目的 :评价和比较超声引导下压迫法 (UGCR)和注射凝血酶法 (UGTI)治疗心导管术后股动脉假性动脉瘤 (PSA)的疗效和安全性。方法 :回顾性分析 2 1例心导管术后股动脉PSA的临床特征 ,以及序贯接受UGCR和UGTI法治疗的经过和结果。在彩色多普勒确定PSA后 ,UGCR法是用手压迫、加压包扎载瘤动脉近端和PSA颈部直至PSA瘤腔中血栓形成 ;UGTI法是超声波引导下将 18～ 2 0G针经皮穿刺使针头进入瘤腔内注射猪凝血酶。均于术后 2 4h、5～ 7d超声波复查。结果 :11例首次接受UGCR法治疗者中 4例成功 (首次成功率 36 .4 % ) ,5例接受重复压迫后有 1例成功 ,总成功率为 4 5 .5 % (5 / 11) ;UGCR治疗成功者的 5例中有 4例股动脉PSA最大直径 <2cm ,其中 2例接受抗凝剂治疗 ;在压迫中 10例有程度不等的局部不适、疼痛 ,有 8例在压迫中因局部疼痛而采用药物止痛 ,有 2例因出现血压增高、心绞痛发作而被迫放弃 ;UGCR治疗失败的 6例中 ,有 1例接受了外科手术治疗 ,5例改行UGTI治疗成功。采用UGTI治疗 15例股动脉PSA ,其中 10例首次接受UGTI治疗有 9例成功 (首次成功率 90 % ) ,6例为经重复UGTI治疗成功 ,UGTI总成功率为 10 0 %。单纯型PSA有 9例均一次性治疗成功 ,而 6例复杂型PSA需 2次或以上重复注射凝血酶。实际注射凝血酶剂     

Ruptured mycotic pseudoaneurysm of the gastroduodenal artery presenting with hemoperitoneum and subcapsular liver hematoma

Summary We report a case of a patient with mycotic pseudoaneurysm of the gastroduodenal artery who presented with hemoperitoneum and subcapsular hematoma of the liver. The diagnosis was established with contrasted abdominal CT scanning. Visceral angiography was not needed. Prompt recognition and surgical intervention led to a favorable outcome. Pseudoaneurysm of visceral vessels is an uncommon disease process, and to our knowledge, this is the first reported case that has presented with free blood in the peritoneal cavity and beneath the liver capsule. This case may also represent a rare complication of therapeutic ERCP procedures. Mycotic aneurysm or pseudoaneurysm of visceral vessels may develop from bacteremia and its dissection or rupture should be suspected in patients presenting with sepsis and abdominal pain.     

Iatrogenic femoral artery pseudoaneurysm

Opinion statement A small (< 6 cm³ in volume or 1.8 cm in diameter), uncomplicated iatrogenic femoral artery pseudoaneurysm in a reliable patient not requiring anticoagulation can be safely observed with weekly physical examinations and ultrasound evaluations until full thrombosis is documented. The patient should be informed that any symptoms or complications should be reported to a physician immediately. A pseudoaneurysm associated with limb ischemia, severe infection, neurologic deficit, skin necrosis, rapid expansion, or hemorrhage should be treated surgically. Also, surgery is recommended if less invasive treatment strategies have failed, or if a planned surgical procedure involving the groin is anticipated. Given its high success rate, low complication rate, and cost-effectiveness, ultrasound-guided thrombin injection should be considered as first-line treatment for uncomplicated iatrogenic femoral pseudoaneurysm. Ultrasound-guided compression repair is an effective alternative to thrombin injection, especially in institutions that have little or no experience with thrombin injection. Alternative treatment strategies, such as percutaneous endovascular stenting and perfusion ballooning, are generally not recommended as first-line treatment options, because they have not been studied as extensively as ultrasound-guided compression repair or thrombin injection. If no other options are available, however, these alternative approaches may be appropriate in certain clinical situations.     

Ultrasound guided percutaneous thrombin injection of iatrogenic femoral artery pseudoaneurysms after coronary angiography and intervention

Ultrasound guided percutaneous thrombin injection has recently been described for the treatment of iatrogenic femoral pseudoaneurysms. Patient selection and technical aspects of this technique are still evolving and safety data, particularly after coronary intervention, remains limited. The percutaneous thrombin injection of femoral artery pseudoaneurysms in 13 consecutive patients, most of whom were receiving antiplatelet/anticoagulant treatment (aspirin 11, heparin 4, clopidogrel 6), is reported. Thrombin (1000 U/ml) was injected over several seconds until Doppler colour flow within the cavity ceased. The median dose of thrombin injected was 800 U (range 200-1000 U) and the treatment was successful in all cases without complication. In one case, thrombus was visualised within the arterial lumen immediately after thrombin injection, but this dissolved spontaneously within five minutes without evidence of embolisation. In contrast to ultrasound guided compression, percutaneous thrombin injection of femoral pseudoaneurysms is a rapid, well tolerated, and successful technique even in patients receiving antiplatelet/anticoagulant treatment.


Keywords: ultrasound guided percutaneous thrombin injection; iatrogenic femoral artery pseudoaneurysm     

Die perkutane Kontrast-ultraschallgesteuerte Thrombin-Injektion zur minimal-invasiven Therapie des iatrogen entstandenen Pseudoaneurysma

BACKGROUND: Complicating femoral artery puncture aneurysms may occur resulting in the need for surgical or newer, non- or minimal-invasive therapy: A new minimal-invasive method is the percutaneous occlusion injecting bovine thrombin. The high thrombogenous potential of thrombin bears the risk of iatrogenic artery occlusion by artificial intravascular instillation. AIM: Is the contrast-ultrasound guided thrombin injection safe and effective in occluding femoral aneurysms? METHODS: During 1/99 to 12/00, 33 femoral artery aneurysms as a complication coronary catheterization were diagnosed. In 32 patients the aneurysm (mean dimensions 32 x 35 x 24 mm) was punctured during ultrasound guidance. By injecting ultrasound contrast medium, the flow pattern perfusing the aneurysm was documented. In the canula position where no contrast medium exited the aneurysm thrombin was injected. RESULTS: Complete occlusion of the aneurysm was achieved in 96.9% (31 out of 32) of the patients by contrast-ultrasound guided thrombin occlusion. Follow-up for up to 3 months after the procedure revealed complete occlusion and no clinical or sonographical complications. In one case, a large aneurysm (50 mm x 62 mm x 27 mm) had already led to skin alterations and was only partly occluded by thrombin injection. CONCLUSIONS: Contrast-ultrasound guided thrombin occlusion of femoral artery aneurysms is safe and highly effective.     

Spontaneous Intra-Abdominal Hemorrhage Due to Rupture of Jejunal Artery Aneurysm in Behcet Disease: Case Report and Literature Review

Rupture of jejunal artery aneurysm is a very rare event resulting in life-threatening hemorrhage in Behcet disease (BD). We report a case of ruptured jejunal artery aneurysm in a 35-year-old patient with BD. The patient had a 1-year history of intermittent abdominal pain caused by superior mesenteric artery aneurysm with thrombosis. Anticoagulation treatment showed a good response. Past surgical history included stenting for aortic pseudoaneurysm. On admission, the patient underwent an urgent operation due to sudden hemorrhagic shock. Resection was performed for jejunal artery aneurysm and partial ischemia of intestine. The patient was diagnosed with BD, based on a history of recurrent oral and skin lesions over the past 6 years. Treatment with anti-inflammatory medications showed a good response during the 8-month follow-up.An increased awareness of BD and its vascular complications is essential. Aneurysms in BD involving jejunal artery are rare, neglected and require proper management to prevent rupture and death. To our knowledge, this is the first reported case of jejunal artery aneurysm caused by BD.     

Compression repair versus low-dose thrombin injection for the treatment of iatrogenic femoral pseudoaneurysm: a retrospective case-control study.

BACKGROUND: It has been shown that thrombin injection is a safe and effective technique for the treatment of iatrogenic femoral pseudoaneurysm. The aim of this study was to evaluate and compare the use of ultrasound-guided low-dose thrombin injections with ultrasonographically-guided compression repair in the treatment of iatrogenic femoral arterial pseudoaneurysm. METHODS: We compared two cohorts of patients treated for iatrogenic femoral pseudoaneurysm: the first included 38 patients who underwent ultrasonographically-guided compression repair as a first-step approach between January 1998 and November 2002; the second included 21 patients treated with ultrasound-guided low-dose thrombin injection between December 2002 and December 2003. RESULTS: Both groups had similar demographic characteristics and aneurysm sizes (p = 0.72). Compression was successful in 24/38 patients (63%); the 14 persistent aneurysms were surgically repaired (37%). The primary thrombin injection of a mean dose of 185+/-95 U/ml (range 100-400 U/ml) successfully obliterated all of the 21 pseudoaneurysms (success rate 100 vs 63% in the compression group, p = 0.004). Thrombosis occurred within an average of 12+/-15 s of thrombin injection. Sedation was used in 42% of the patients undergoing compression and in none of those receiving thrombin (p = 0.001). The duration of hospitalization was significantly longer in patients undergoing compression therapy (9.8+/-5.6 vs 5.6+/-1.4 days, p = 0.001). CONCLUSIONS: Ultrasound-guided low-dose thrombin injection appears to be more effective in reducing the need for surgical repair when used to treat iatrogenic femoral pseudoaneurysm, is better tolerated by the patients, and requires a shorter hospital stay.     

Ultrasound guided thrombin injection of pseudoaneurysm of the radial artery after percutaneous coronary intervention

Thrombin injection is frequently used to occlude iatrogenic pseudoaneurysms in larger vessels, but has never successfully been used in the radial artery location. Here we report the use of this treatment in a patient with radial artery pseudoaneurysm following coronary intervention. After Doppler sonographic visualization of the pseudoaneurysm cavity and its neck, an ultrasound-guided transcutaneous injection of thrombin was carried out. Immediately after the injection, the pseudoaneurysm was completely clotted and Doppler measurement confirmed the stop of blood flow. The result suggests that ultrasound-guided injection of thrombin into a radial artery pseudoaneurysm following coronary intervention is a feasible alternative to surgical intervention.     

Percutaneous occlusion of posttraumatic aortic arch pseudoaneurysm by catheter-based delivery of thrombin.

PURPOSE: To report a patient in whom a posttraumatic pseudoaneurysm of the aortic arch was successfully treated by catheter-based delivery of thrombin with balloon occlusion of the entry tear. CASE REPORT: A 63-year-old male presented with pseudoaneurysm of the aortic arch after blunt chest trauma which was detected incidentally during routine chest X-ray. Using a percutaneous transfemoral approach, a 5 French Swan-Ganz catheter could be positioned into the aneurysm sac. Under balloon occlusion of the entry tear in order to prevent systemic embolization, 1,000 units of bovine thrombin were injected into the aneurysm sac resulting in complete occlusion of the aneurysm. Contrast-enhanced computed tomographic control showed complete thrombosis of the aneurysm over a follow-up period of 12 months. CONCLUSION: Percutaneous catheter-based delivery of thrombin is a feasible and effective minimally-invasive treatment alternative for patients with thoracic aortic pseudoaneurysms.     

股动脉假性动脉瘤超声引导下凝血酶注射与压迫法的护理比较

目的：比较经股动脉行冠状动脉介入诊疗操作后假性动脉瘤（PSA）超声引导下凝血酶注射（UGTI）与超声引导下压迫（UGCR）治疗的护理效果。方法：选取我院2000年6月～2006年6月经股动脉行冠状动脉介入诊疗操作后出现假性动脉瘤患者共37例。其中，UGTI组：有接受UGTI治疗患者21例，UGCR组：有采用UGCR治疗的患者16例。比较两组的治疗成功率、平均治疗时间、术后卧床时间等护理指标。结果：UGTI组的各种护理指标均优于UGCR组（P〈0．05～0．01）；但PSA直径〈4cm的假性动脉瘤，UGTI组与UGCR组成功率无显著差异（P〉0．05）。结论：若动脉瘤直径≥4cm，UGTI的疗效明显优于UGCR。     

Pseudoaneurysm of the cystic artery associated with upper gastrointestinal bleeding

Pseudoaneurysm of the cystic artery is a cause of hemobilia, and is extremely rare, with only eight cases having been reported in the world literature. We report a case of pseudoaneurysm of the cystic artery in a 72-year-old Japanese man. The patient experienced epigastric pain and melena, and was found to have jaundice and liver dysfunction. Repeated gastroendoscopy did not reveal the cause of the alimentary tract bleeding; however, color-Doppler ultrasonography detected an aneurysm of the cystic artery in the gallbladder. Selective hepatic arteriography demonstrated that the posterior branch of the cystic artery was markedly dilated and that an aneurysm had formed in the midst of the artery. We diagnosed hemobilia due to the pseudoaneurysm of the cystic artery, and associated gastrointestinal bleeding. Cholecystectomy was performed immediately. Pathologically, the gallbladder showed acute calculous cholecystitis. This case emphasizes the importance of including hemobilia in the differential diagnosis whenever gastrointestinal bleeding is associated with signs of biliary disorder; color-Doppler imaging is a favorable modality for the diagnosis of pseudoaneurysm of the cystic artery.     

Pseudoaneurysm of coronary artery following rupture of coronary artery during coronary angioplasty.

Rupture of the coronary artery is a rare complication of percutaneous transluminal coronary angioplasty (PTCA). We describe a case of coronary artery rupture during PTCA resulting in the formation of a coronary artery pseudoaneurysm. The pseudoaneurysm was successfully treated by percutaneous spring-coil embolization of the coronary artery.     

超声引导下凝血酶栓塞法治疗股动脉假性动脉瘤的疗效分析

目的探讨瘤腔内注射凝血酶治疗股动脉假性动脉瘤的疗效和安全性。方法78例股动脉假性动脉瘤的患者分别首选床边指压法（50例）和凝血酶注射法（28例）治疗。所有患者均使用GE LOGIQ9彩色多普勒超声仪确诊,凝血酶注射法组在超声引导下进行瘤腔内注射凝血酶栓塞治疗。结果指压法组50例患者中41例通过持续手指压迫治疗有效消除血管杂音和动脉瘤搏动,6例出现迷走神经反射,4例因不耐受再次压迫改用彩色多普勒引导下凝血酶注射法治愈,5例股动脉压迫治疗无效后改用凝血酶注射法治疗。凝血酶注射法组28例首选超声引导下瘤腔内注射凝血酶栓塞治疗的患者全部治愈,其中25例一次栓塞成功,2例经两次栓塞成功,1例出现血管迷走性晕厥;12例患者注射凝血酶后有体温轻度升高,自行好转;无动脉栓塞及静脉血栓形成、无凝血酶过敏表现、感染、出血等并发症。结论与指压法比较,超声引导下瘤腔内注射凝血酶的治疗方法有效性显著提高而不耐受性显著降低,是一种安全有效的方法。