Noninvasive technique of preventing thrombin escape into the systemic circulation during ultrasound-guided thrombin injection (UGTI) of the postcatheterization pseudoaneurysms
© Springer-Verlag 2011
Received: 27 June 2011
Accepted: 1 November 2011
Published: 10 November 2011
Iatrogenic, postcatheterization pseudoaneurysms (PSA) of the femoral artery are a common complication after diagnostic and interventional procedures, with up to 7.7% incidence. Treatment includes surgical repair, ultrasound-guided compression (USGC) repair of the tract of the PSA, or recently ultrasound-guided thrombin injection (UGTI). Large (>1.8 cm) PSA sac with short (<3 mm) and/or wide (>3 mm) tract has higher complication ratio such as thromboembolic events after UGTI. Those cases are considered for protective balloon inflation during thrombin injection. The aim of our study was to evaluate the success rate of preventing escape of the thrombin during UGTI with simultaneous manual compression on ipsilateral iliac artery.
Methods and results
We reported 46 patients, 17 males and 29 females, aged 53–74 years, with iatrogenic, postcatheterization femoral artery PSA. Out of 46 patients, 7 were successfully treated with USGC. The rest of the patients were treated with UGTI with simultaneous manual compression on ipsilateral iliac artery to stop the flow in PSA, and to avoid thrombin escape into the native circulation. Success rate of UGTI with manual compression of ipsilateral iliac artery was 97% with the complication rate of 2.6%.
Our study confirms that UGTI treatment of the PSA of the femoral artery combined with compression of the ipsilateral iliac artery could be a safe and reliable method of the thrombin escape prevention into the systemic circulation, as good as more invasive and demanding methods.
Iatrogenic, postcatheterization pseudoaneurysms (PSA) of the femoral artery are a common local complication after diagnostic and interventional procedures, with up to 7.7% incidence [1–3]. In many cases, postcatheterization PSA spontaneously thromboses in a few weeks, but PSA of 1.8 cm in diameter and larger, or PSA in patients on anticoagulant/antiplatelet therapy most commonly have to be treated . Treatment includes surgical repair, ultrasound-guided compression (USGC) repair of the tract of the PSA, or recently ultrasound-guided thrombin injection (UGTI) [1, 2, 5, 6]. UGTI is reserved for PSA sac larger than 1.8 cm in diameter and/or multisacular PSA, where ultrasound compression as a treatment failed . It is well described that patients with large (>1.8 cm) PSA sac, with short (<3 mm) and/or wide (>3 mm) tract have higher complications ratio such as thromboembolic events after thrombin injection. Those patients are considered for UGTI with protective balloon inflation during thrombin injection which is technically and resourcefully more demanding. The aim of this study was to evaluate success rate of preventing escape of the thrombin during UGTI with simultaneous manual compression on ipsilateral iliac artery.
Succes and complications of the UGTI (ultrasound-guided thrombin injection) technique with simultaneous manual compression on ipsilateral iliac artery regarding two different categories of the PSA (pseudoaneurysm)
No. of patients
Successful procedures (%)
Postcatheterization PSA of the femoral artery is a relatively common complication. The fact is that catheterization of the femoral artery is a more and more performed procedure in everyday clinical practice, and the incidence of the postcatheterization PSA becomes a clinically relevant concern [2, 3]. Treatment includes open surgical repair, USGC repair of the pseudoaneurysm, and UGTI . USGC repair and UGTI are proposed as first choice techniques . Clinical studies report high success, with very low complications rate. USGC repair technique has some disadvantages. Compression of the PSA is very painful and demands systemic analgesia and sedation of the patient. Sometimes is hard to maintain the ultrasound probe in the proper position during the period of 20 min. In patients on antiplatelet/anticoagulation therapy the success rate is significantly lower (63–70%). We assumed that very low success rate of the USGC repair method in our study (15%) is due to mandatory anticoagulation or/and antiplatelet therapy of our patients. In opposite, UGTI is a simple method with low complication rate and well tolerated by patients [1, 6, 10, 13, 14]. Therapeutic results of the UGTI are highly successful and complete thrombosis of the PSA is achieved in 93–100% of cases [2, 5]. Complications of the UGTI procedure (up to 4%) are most frequently due to escape of the thrombin into the systemic circulation and allergic reactions . Complications like distal embolisation require more invasive and active therapy, such as application of the activator of tissue plasminogen, intravenous heparin, or open surgical exploration [2, 11]. Two methods of UGTI are described: with protective balloon placement and without it. The aim of the protective balloon placement is to avoid thrombin escape from the pseudoaneurysm sac, usually through the wide or/and short tract of the PSA . Despite the fact that balloon protection is not suggested in routine use, in cases of short (<3 mm) or/and wide (>3 mm) PSA tract, numerous studies recommend it [2, 8–10, 12]. As a method to avoid thrombin escape into the circulation in this study, we used noninvasive manual compression on the ipsilateral iliac artery to stop the flow in PSA, 30 s before, 30 s during the procedure, and 60 s after the UGTI procedure. We performed this simple maneuver on all our patients regardless of the sizes of the PSA tract, but finally our aim was to protect those patients with short (<3 mm) and/or wide (>3 mm) pseudoaneurysm tract. There is a need for larger series of patients to confirm our results. Our study confirms that UGTI treatment of the PSA of the femoral artery combined with compression of the ipsilateral iliac artery could be a safe and reliable method of preventing thrombin escape into the systemic circulation, as effective as more invasive and demanding methods.
Conflict of interest
- Ahmad F, Turner SA, Torrie P, Gibson M (2008) Iatrogenic femoral artery pseudoaneurysms—a review of current methods of diagnosis and treatment. Clin Radiol 63:1310–1316PubMedView ArticleGoogle Scholar
- Morgan R, Belli AM (2003) Current treatment methods for postcatheterization pseudoaneurysms. J Vasc Interv Radiol 14:697–710PubMedView ArticleGoogle Scholar
- San Norberto García EM, González-Fajardo JA, Gutiérrez V, Carrera S, Vaquero C (2009) Femoral pseudoaneurysms post-cardiac catheterization surgically treated: evolution and prognosis. Interact Cardiovasc Thorac Surg 8:353–357PubMedView ArticleGoogle Scholar
- Webber GW, Jang J, Gustavson S, Olin JW (2007) Contemporary management of postcatheterization pseudoaneurysms. Circulation 115:2666–2674PubMedView ArticleGoogle Scholar
- La Perna L, Olin JW, Goines D, Childs MB, Ouriel K (2000) Ultrasound-guided thrombin injection for the treatment of poscatheterization pseudoaneurysms. Circulation 102:2391–2395PubMedView ArticleGoogle Scholar
- Paschalidis M, Theiss W, Kölling K, Busch R, Schömig A (2006) Randomised comparison of manual compression repair versus ultrasound guided compression repair of postcatheterisation femoral pseudoaneurysms. Heart 92:251–252PubMedPubMed CentralView ArticleGoogle Scholar
- Luedde M, Krumsdorf U, Zehelein J, Ivandic B, Dengler T, Katus HA, Tiefenbacher C (2007) Treatment of iatrogenic femoral pseudoaneurysm by ultrasound-guided compression therapy and thrombin injection. Angiology 58:435–439PubMedView ArticleGoogle Scholar
- Matson MB, Morgan RA, Belli AM (2001) Percutaneous treatment of pseudoaneurysms using fibrin adhesive. Br J Radiol 74:690–694PubMedView ArticleGoogle Scholar
- D’Ayala M, Smith R, Zanieski G, Fahoum B, Tortólani AJ (2008) Acute arterial occlusion after ultrasound-guided thrombin injection of a common femoral artery pseudoaneurysm with a wide, short neck. Ann Vasc Surg 22:473–475PubMedView ArticleGoogle Scholar
- Elford J, Burrell C, Freeman S, Roobottom C (2002) Human thrombin injection for the percutaneous treatment of iatrogenic pseudoaneurysms. Cardiovasc Interv Radiol 25:115–118View ArticleGoogle Scholar
- Sadiq S, Ibrahim W (2001) Thromboembolism complicating thrombin injection of femoral artery pseudoaneurysm: management with intraarterial thrombolysis. J Vasc Interv Radiol 12:633–636PubMedView ArticleGoogle Scholar
- Kruger K, Zaehringer M (2005) Postcatheterization pseudoaneurysm: results of US-guided percutaneous thrombin injection in 240 patients. Radiology 236:1104–1110View ArticleGoogle Scholar
- Paulson EK et al (2001) Sonographically guided thrombin injection of iatrogenic femoral pseudoaneurysms. AJR 177:309–316PubMedView ArticleGoogle Scholar
- Brophy DP et al (2000) Iatrogenic femoral pseudoaneurysms: thrombin injection after failed US-guided compression. Radiology 214:278–282PubMedView ArticleGoogle Scholar