Iatrogenic Femoral Pseudoaneurysms That Are Unresponsive to Percutaneous Thrombin Injection: Potential Causes

Abstract

We sought to determine whether any quantitative selection criteria can be established to predict which pseudoaneurysms of the common femoral artery will fail to respond to thrombin. SUBJECTS AND METHODS. Under sonographic guidance, we injected thrombin into 54 consecutive iatrogenic pseudoaneurysms of the common femoral artery. We statistically compared the volume, maximum dimension, and neck diameter of the pseudoaneurysms and thrombin doses injected into the successfully treated (persistent thrombosis on a follow-up duplex sonogram obtained 7-10 days after thrombin injection) and unresponsive (sonographically documented recurrence within 24 hr) pseudoaneuryms to determine whether any of these factors could help to predict a failure to respond to thrombin. For all patients in whom treatment failed, findings at surgical repair were noted and sonograms were reviewed to confirm the dimensions and appearance of the pseudoaneurysm and the absence of an associated arteriovenous fistula. Complete and persistent thrombosis was achieved in 49 (91%) of the 54 common femoral artery pseudoaneurysms. In comparing the 49 successfully treated patients and the five patients in whom treatment failed, we identified no significant differences in the volume, maximum dimension, or neck diameter of the pseudoaneurysm (two-sample t test) or in the thrombin dose (Wilcoxon's rank sum test). In all five patients with failed treatment, an arteriotomy site laceration measuring at least 8.0 mm (n = 4) or infection (n = 1) was identified at surgical repair, none of which were identifiable even in retrospect on duplex and color Doppler sonography. Failure of an iatrogenic pseudoaneurysm of the common femoral artery to respond to thrombin may indicate an occult vascular injury. In these patients, surgical repair, rather than reinjection of thrombin, should be considered.