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Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms
Journal of Vascular Surgery, 2000
Nonanastomotic pseudoaneurysms most commonly occur after iatrogenic trauma. Most of these aneurysms are located in the femoral arteries after catheterization. The standard mode of treatment for these aneurysms had been immediate surgical repair. Since its initial description by Fellmeth el al 1 in 1991, ultrasound-guided compression repair (UGCR) has allowed nonoperative treatment for most patients. In this procedure, pressure is applied with the ultrasound transducer over the center of the neck of the pseudoaneurysm until the flow through the neck is arrested. Pressure is maintained for 10 to 20 minutes and then slowly released. If flow is still present, compression is immediately resumed. This cycle is repeated until the flow in the pseudoaneurysm is eliminated. Dozens of reports have been published that verify the efficacy and overall safety of this procedure. The typical success rate is between 60% and 90%. 2-7 UGCR is a good alternative to surgical repair and has become the primary method of treatment in many institutions. However, the procedure is time-consuming and painful, has poor results with patients who are undergoing anticoagulation therapy, and cannot treat noncompressible pseudoaneurysms. Maywood, Ill 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 pseudoaneurysms 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. (J Vasc Surg 2000;31:289-98.)
Percutaneous Coil Embolization for the Treatment of a Giant Brachial Artery Pseudoaneurym in a Child
Annals of vascular surgery, 2017
Brachial artery pseudoaneurysm is a rare phenomenon. When a diagnosis of brachial artery pseudoaneurysm is established, early and appropriate treatment should be performed as soon as possible to prevent possible complications, such as hemorrhage, rupture, and upper limb and finger losses. Open surgical repair is usually the cornerstone of treatment; however, we here report a case of giant brachial pseudoaneurysm in a 2-year-old girl, which was successfully treated with percutaneous coil embolization.
Journal of the Medical Association of Thailand = Chotmaihet thangphaet, 2007
Report the successful treatment of iatrogenic pseudoaneurysm of the brachial artery with the percutaneous ultrasonographically guided thrombin injection (PUGTI). The pseudoaneurysm was caused by an accidental puncture into a native brachial artery instead of the venous side of an arteriovenous fistula during hemodialysis. The aneurysmal sac had a large size with a short neck, vulnerable to intra-arterial thrombosis and distal artery embolization during the thrombin glue injection. This procedure was secured by using color duplex ultrasonography (CDU) for the accurate positioning of the needle and the assessment of the optimal dosage of the injected bovine thrombin. After the procedure, an elastic compression was applied at the injection site to prevent the reentry of blood flow into the aneurysmal sac. The flow in the aneurysmal sac completely disappeared in seven days after the treatment. The 4-month follow-up demonstrated the complete resolution of the aneurysmal sac. Percutaneous...
Journal of Ultrasonography, 2018
The purpose of this paper was to evaluate the efficacy of ultrasound-guided percutaneous thrombin injection as a treatment method for arterial access site pseudoaneurysm. Materials and methods: A total of 148 patients with iatrogenic arterial access site pseudoaneurysms were treated in the Department of Interventional Radiology and Neuroradiology, Medical University of Lublin. Of those, 142 pseudoaneurysms were located in the common femoral artery, 3 in the brachial artery and the remaining 3 in the radial artery. The study included 77 woman and 71 men (mean age 64.5 ± 14 years). Patients were qualified for percutaneous thrombin injection after Doppler examination during which pseudoaneurysm size and morphology were assessed as well as the presence of arteriovenous fistula was excluded. Results: In the reported study, 94.8% (128/135) of patients were successfully treated during the initial thrombin injection. Additional 400 IU dose of thrombin after 24 hours was effective in 5 out of 7 patients with recanalization during the follow-up. A total of 98.5% (133/135) of patients were successfully treated with a percutaneous ultrasound-guided thrombin injection. Conclusions: The 10-year experience presented in this study as well as literature reports prove that percutaneous ultrasound-guided thrombin injection is an effective and safe treatment method for iatrogenic arterial access site pseudoaneurysm.
Journal of Ultrasound in Medicine, 2003
Objectives. To evaluate the effectiveness and safety of percutaneous ultrasonographically guided thrombin injection as treatment of unusually positioned and unusually large iatrogenic pseudoaneurysms. Methods. Five patients with iatrogenic pseudoaneurysms were evaluated by color duplex ultrasonography. Two patients had additional digital angiography, and 2 had additional computed tomographic angiography. In 3 of the patients, large, painful iatrogenic pseudoaneurysms located proximal (2 patients) and distal (1 patient) to the arteriovenous hemodialysis fistulas had developed, most likely due to erroneous puncture of the arterial side (brachial artery) or venous side (cephalic vein) of the fistulas. An iatrogenic pseudoaneurysm of the anterior tibial artery had developed in the fourth patient after osteotomy of the fibula, and an iatrogenic pseudoaneurysm of the superficial femoral artery had developed in the fifth patient after erroneous puncture during venous transfemoral angiography. With a sterile technique and color duplex ultrasonographic guidance, a diluted solution of bovine thrombin was slowly injected directly into the iatrogenic pseudoaneurysms until cessation of blood flow was seen. Follow-up color duplex ultrasonography was performed 24 to 48 hours after the ultrasonographically guided thrombin injection. Results. Four iatrogenic pseudoaneurysms were successfully thrombosed during 1 session. Two large iatrogenic pseudoaneurysms necessitated multiple repositions of the injecting needle and several injections of small amounts of thrombin into the residual patent lumen to induce complete thrombosis without an appreciable increase in the total thrombin dosage. Follow-up examinations revealed complete and persistent thrombosis without evidence of distal embolization. One iatrogenic pseudoaneurysm involving the cephalic vein, distal to an arteriovenous hemodialysis fistula, recurred after apparently successful initial thrombosis. Conclusions. Most iatrogenic pseudoaneurysms are amenable to ultrasonographically guided thrombin injection as long as they are imaged adequately by color duplex ultrasonography.
Journal of Ultrasound in Medicine
Objectives-Ultrasound-guided thrombin injection has become standard treatment for extremity pseudoaneurysms. Our specific aims were to determine the procedural success rate, the procedural complication rate, and the factors associated with pseudoaneurysm recurrence. Methods-A total of 262 consecutive cases of ultrasound-guided thrombin repair of pseudoaneurysms were identified between January 1, 2006, and March 20, 2016. The procedural and follow-up ultrasound studies were reviewed. Outcomes of interest included procedural success (defined as complete thrombosis at the time of injection and on a follow-up examination), incomplete pseudoaneurysm thrombosis, and postprocedural recurrence. Postprocedural pseudoaneurysm recurrences were compared to procedural successes with regard to patient demographics, pseudoaneurysm characteristics, amount of thrombin injected, and periprocedural laboratory values. Results-Procedural success occurred in 85.7% of cases. Complications occurred in 3.0% of cases. The mean patient age 6 SD was 72.3 6 11.3 years. The median amount of thrombin injected was 500 U (interquartile range, 400 U). The median follow-up time was 1 day (interquartile range, 0 days). A pseudoaneurysm size of 2 cm or larger and thrombocytopenia were significant independent predictors of pseudoaneurysm recurrence (P 5 .003 and .03, respectively). The odds ratios for pseudoaneurysm recurrence were 2.29 for pseudoaneurysm size of 2 cm or larger (P 5 .03) and 1.04 for thrombocytopenia (P 5 .04). Conclusions-Thrombin injection of pseudoaneurysms is an off-label procedure with few complications and a high success rate. Follow-up imaging is recommended in all pseudoaneurysms that are 2 cm or larger and in patients with thrombocytopenia.
Ultrasonography guided percutaneous thrombin injection of postcatheterization pseudoaneurysms
Diagnostic and Interventional Radiology, 2011
F emoral 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).
Duplex scanning–guided thrombin injection for the treatment of iatrogenic pseudoaneurysms
Journal of Vascular Surgery, 2002
Purpose: This study presents our current results with duplex scanning-guided thrombin injection (DGTI) for the treatment of lower-extremity iatrogenic pseudoarteurysms (PAs). These results were compared with the results from our patient population that was treated with duplex scanning-guided compression (DGC). Methods: This was a prospective evaluation of an institutional review board-approved protocol for ultrasound scanningguided thrombin injection for the treatment of iatrogenic lower-extremity PAs. The maneuver was performed with continuous real-time color ultrasound scanning imaging to guide a needle into a PA sac. Then 0.5 to 1.0 mL ofa thrombin solution (1000 U/mL) was injected, and thrombosis of the sac was monitored. All patients underwent an arterial evaluation of the involved extremity before and after thrombin injection. In addition, the size of the PA and its parent artery were documented by means of pre-injection imaging. After thrombosis of the PA, the patient was kept on bed rest for 4 hours, and activity was limited that day (bathroom privileges for inpatients). Follow-up imaging was performed after 24 hours, and attempts were made to obtain imaging 1 week and 1 month after injection. Results: In the 31 months o£ the study, 131 iatrogenic PAs of the lower extremity were initially treated with DGTI, and thrombosis was achieved in 126 of these cases (96%). Thrombosis of the PA sac was accomplished within seconds of thrombin injection. Five cases failed, three of which resulted from complications of the procedures, with two intra-arterial thrombin injections and one PA rupture after thrombosis. Conclusion: Our experience indicates that DGTI is more effective than DGC (96% vs 75%) in the treatment of iatrogenic lower-extremity PAs. The DGTI procedure is completed in minutes, compared with a mean compression time of 44 minutes with DGC, which leads to increased patient and operator acceptance. Intra-arterial thrombin injection was seen in 4% of PAs that were 2.6 cm or smaller and resulted in limb-threatening ischemia requiring surgical intervention. Finally, the use of a biopsy guide attached to the ultrasound scanning transducer head simplifies the visualization of the needle, reducing the number of needle punctures and needle manipulation. (J Vasc Surg 2002;35:517-21.)