Thrombin Injection Research Articles

Incidence of and predisposing factors for pseudoaneurysm formation in a high-volume cardiovascular center.

PurposeTo evaluate factors associated with pseudoaneurysm (PSA) development.MethodsBetween January 2016 and May 2020, 30,196 patients had invasive vascular radiological or cardiac endovascular procedures that required arterial puncture. All patients with PSA were identified. A matched (age, gender, and type of the procedure) control group of 134 patients was created to reveal predictors of PSA formation.ResultsSingle PSAs were found in 134 patients. Fifty-three PSAs developed after radiological procedures (53/6555 [0.8%]), 31 after coronary artery procedures (31/18038 [0.2%]), 25 after non-coronary artery cardiac procedures (25/5603 [0.4%]), and 25 due to procedures in which the arterial puncture was unintended. Thirty-four PSAs (25.4%) were localized to the upper extremity arteries (vascular closure device [VCD], N = 0), while 100 (74.6%) arose from the lower extremity arteries (VCD, N = 37). The PSA prevalence was 0.05% (10/20478) in the radial artery, 0.1% (2/1818) in the ulnar artery, 1.2% (22/1897) in the brachial artery, and 0.4% (99/22202) in the femoral artery. Treatments for upper and lower limb PSAs were as follows: bandage replacement (32.4% and 14%, respectively), ultrasound-guided compression (11.8% and 1%, respectively), ultrasound-guided thrombin injection (38.2% and 78%, respectively), and open surgery (17.6% and 12%, respectively). Reintervention was necessary in 19 patients (14.2%). The prevalence of PSA for the punctured artery with and without VCD use was 37/3555 (1%) and 97/27204 (0.4%), respectively (OR, 2.94; 95% CI, 1.95–4.34; P<0.001). The effect of red blood cell (RBC) count (P<0.001), hematocrit value (P<0.001), hemoglobin value (P<0.001), international normalized ratio (INR; P<0.001), RBC count—INR interaction (P = 0.003), and RBC count—VCD use interaction (P = 0.036) on PSA formation was significant.ConclusionPatients in whom the puncture site is closed with a VCD require increased observation. Preprocedural laboratory findings are useful for the identification of patients at high risk of PSA formation.

Choosing a treatment method for post-catheterization pseudoaneurysms guided by the late to early velocity index

Ultrasound-guided thrombin injection (UGTI) is often the first-line treatment for iatrogenic post-catheterization pseudoaneurysms (psA). There are also first reports of the use of biologically derived tissue glues (TG) instead of sole thrombin especially when UGTI was unsuccessful or in case of psA recurrence. Previously, we have established that a late to early velocity index (LEVI) < 0.2 could be a predictor of an increased risk of psA recurrence after standard UGTI. In this paper, we report our first experiences when the choice of the first-line treatment method was based on LEVI assessment. From May 2017 till January 2020 we included 36 patients with psA. Of them, 10 had LEVI < 0.2 and they underwent ultrasound-guided tissue glue injection (UGTGI) with biological TG and 26 had LEVI > 0.2 and they underwent UGTI. The injection set containing human thrombin and fibrinogen was used for UGTGI. Bovine thrombin was used for UGTI. The success rate was 100% and no psA recurrence was detected during a 2-week follow-up. It was significantly better when compared to the expected recurrence rates based on our previous 14 years of experience (0% vs. 13%, p = 0.01). All complications (10% in the UGTGI group and 15% in the UGTI group) were mild and transient and included clinical symptoms of paresthesia, numbness, tingling, or pain. Their rates were comparable to the rates we previously reported. No significant differences in other characteristics were observed. The approach to choose the first-line treatment method for iatrogenic psA based on LEVI is encouraging. It may increase the success rate and avoid unnecessary repetition of the procedure, without increasing complication rate while keeping costs of the procedure reasonable.

Impact of sex differences on thrombin-induced hydrocephalus and white matter injury: the role of neutrophils

BackgroundThrombin has been implicated in playing a role in hydrocephalus development following intraventricular hemorrhage (IVH). However, the mechanisms underlying the sex differences to the detrimental effects of thrombin post-IVH remain elusive.MethodThree-month old male and female Sprague-Dawley rats underwent unilateral intracerebroventricular (ICV) injections of 3U or 5U thrombin, or saline, to examine differences in thrombin-induced hydrocephalus and white matter injury. Mortality, and lateral ventricle volume and white matter injury were measured on magnetic resonance imaging evaluation at 24 h post-injection. In addition, male rats were pretreated with 17-β estradiol (E2, 5 mg/kg) or vehicle at 24 and 2 h prior to ICV injection of 3U thrombin. All rats were euthanized at 24 h post-injection for histology and immunohistochemistry.ResultsICV injection of 5U thrombin caused 100 and 0% mortality in female and male rats, respectively. 3U of thrombin resulted in significant ventricular dilation and white matter damage at 24 h in both male and female rats, but both were worse in females (p < 0.05). Furthermore, neutrophil infiltration into choroid plexus and periventricular white matter was enhanced in female rats and may play a critical role in the sex difference in brain injury. Pre-treating male rats with E2, increased thrombin (3U)-induced hydrocephalus, periventricular white matter injury and neutrophil infiltration into the choroid plexus and white matter.ConclusionsICV thrombin injection induced more severe ventricular dilation and white matter damage in female rats compared to males. Estrogen appears to contribute to this difference which may involve greater neutrophil infiltration in females. Understanding sex differences in thrombin-induced brain injury may shed light on future interventions for hemorrhagic stroke.

Secondary Femoral Access Hemostasis During Transcatheter Aortic Valve Replacement: Impact of Vascular Closure Devices.

Vascular and bleeding complications related to secondary femoral access site are frequent in patients undergoing transcatheter aortic valve replacement (TAVR), and their occurrence is associated to poorer outcomes. We aimed to evaluate the clinical impact of vascular closure devices (VCDs) for secondary femoral access hemostasis in TAVR procedures. This was a multicenter study including 4031 patients who underwent TAVR (mean age, 81 ± 8 years; mean Society of Thoracic Surgeons [STS] score, 4.9 [interquartile range, 3.3-7.6]), and had a secondary femoral access. The 30-day clinical outcomes were analyzed according to femoral access-site hemostasis (manual compression vs VCD), and according to the type of VCD (Perclose [Abbott Cardiovascular] vs Angio-Seal [Terumo Interventional Systems]) using a propensity-matched, multivariable, logistic regression model. Manual compression was used in 941 patients (23.3%) and VCDs were used in 3090 patients (76.7%; Perclose in 1549 patients [38.4%] and Angio-Seal in 1541 patients [38.2%]) for secondary femoral access hemostasis. Vascular complications related to secondary access site occurred in 162 patients (4%), and were more frequent in patients who underwent manual compression (7.2%) compared with VCD hemostasis (3%; adjusted P<.001). In the VCD group, the use of Angio-Seal (vs Perclose) was associated with a higher rate of vascular complications (3.7% vs 2.4%, respectively; adjusted P=.02), femoral artery pseudoaneurysm (1.3% vs 0.4%, respectively; adjusted P<.01), invasive treatment requirement for treating vascular complications (surgery: 0.8% vs 0.3%, respectively [adjusted P=.03]; and thrombin injection: 0.9% vs 0%, respectively [adjusted P<.001]). VCDs represented a safer and more effective alternative compared with manual compression for secondary femoral access-site hemostasis in patients undergoing TAVR procedures, and the Perclose VCD was associated with the lowest risk of vascular complications. Future randomized studies are warranted.

Traumatic Superficial Temporal Artery Pseudoaneurysm Treated With Thrombin Injection

Pseudoaneurysms of the superficial temporal artery are rare. They commonly occur after blunt trauma to the frontotemporal region of the head. There have been less than 400 cases of superficial temporal artery pseudoaneurysms reported. We present a case of a patient referred for a pulsatile head mass. Physical examination and color Doppler ultrasound confirmed the diagnosis of a superficial temporal artery pseudoaneurysm (STA PSA). This was treated with ultrasound guided thrombin injection with complete resolution. Anatomical distribution, diagnosis, and treatment of STA PSA are discussed.

Successful Transcatheter Arterial Embolization Using N-Butyl-2-Cyanoacrylate as a Treatment for Refractory Inferior Epigastric Artery Pseudoaneurysm Accompanied by an Enterocutaneous Fistula: A Case Report

: Inferior epigastric artery (IEA) pseudoaneurysms are well-known postoperative abdominal complications, which often require proper treatment. Treatment options include surgical ligation, transcatheter embolization, and thrombin injection. Here, we report a rare case of an IEA pseudoaneurysm, accompanied by a postsurgical enterocutaneous fistula. The pseudoaneurysm relapsed after transcatheter coil embolization and percutaneous thrombin injection; it was completely occluded by transcatheter arterial embolization using n-butyl-2-cyanoacrylate. The present case shows that a coexisting enterocutaneous fistula can affect the unresponsiveness of patients with IEA pseudoaneurysm to widely accepted treatments, such as coil embolization and thrombin injection, by creating an inflammatory environment. In such cases, repeated therapeutic trials may be required. Transcatheter arterial embolization using n-butyl-2-cyanoacrylate can be a feasible therapeutic option for patients with refractory IEA pseudoaneurysm, accompanied by an enterocutaneous fistula.

Efficacy and safety of position selection combined with intra-pleural thrombin injection in the treatment of postoperative persistent air leakage in bullous pulmonary-pleural diseases

Objective: To explore the efficacy and safety of position selection in combination with intra-pleural thrombin injection in the treatment of persistent air leakage (PAL) after medical thoracoscopic treatment of bullous pulmonary-pleural diseases (e.g. spontaneous pneumothorax or giant emphysematous bulla). Methods: This was a prospective study conducted in Rizhao Hospital of Traditional Chinese Medicine from August 2018 to November 2020. Twenty patients(19 males,1 female) with a mean age of (62.3±8.1) years met the diagnostic criteria for PAL which was defined as the air leak persisted more than 3 days despite of the closed thoracic drainage after medical thoracoscopic treatment of bullous pulmonary-pleural diseases.They received the following treatment procedures (referred to as "position plus"):①Pleural cavity injection (50% glucose 20 ml+thrombin 5 000 U).②Changing the patient's position under continuous negative pressure suction to find the position causing the complete stop or significant reduction of air leakage, and keeping in the position for 24-48 hours.③If the PAL wasn't stopped 48 hours later, the procedures above would be repeated.The duration of air leakage after "position plus", times of pleural cavity injection, condition of lung re-expansion, recurrence of air leakage and complications during hospitalization were recorded. Descriptive statistics were used to summarize the results:¯x±s or M(P25, P75) for continuous variables; frequency and percentages for categoric variables. Results: A total of 20 patients were included. The average duration of air leakage after"position plus" was (1.32±0.97) days. The times of pleural cavity injection required were 1.0(1.0, 1.0).All the patients showed good lung re-expansion in review of imaging after PAL was stopped. One patient had recurrent air leakage during hospitalization. No serious complications occurred. Conclusion: The comprehensive "position plus" intervention method is effective, safe and easily operating for the treatment of PAL after medical thoracoscopic treatment of bullous pulmonary-pleural diseases.

Neurokinin Receptor 1 (NK1R) Antagonist Aprepitant Enhances Hematoma Clearance by Regulating Microglial Polarization via PKC/p38MAPK/NFκB Pathway After Experimental Intracerebral Hemorrhage in Mice.

Hematoma clearance is an important therapeutic target to improve outcome following intracerebral hemorrhage (ICH). Recent studies showed that Neurokinin receptor-1 (NK1R) inhibition exerts protective effects in various neurological disease models, but its role in ICH has not been explored. The objective of this study was to investigate the role of NK1R and its relation to hematoma clearance after ICH using an autologous blood injection mouse model. A total of 332 adult male CD1 mice were used. We found that the expression levels of NK1R and its endogenous ligand, substance P (SP), were significantly upregulated after ICH. Intraperitoneal administration of the NK1R selective antagonist, Aprepitant, significantly improved neurobehavior, reduced hematoma volume and hemoglobin levels after ICH, and promoted microglia polarization towards M2 phenotype. Aprepitant decreased phosphorylated PKC, p38MAPK, and NFκB p65, and downregulated M1 markers while upregulating M2 markers after ICH. Intracerebroventricular administration of the NK1R agonist, GR73632 or PKC agonist, phorbol 12-myristate 13-acetate (PMA) reversed the effects of Aprepitant. To demonstrate the upstream mediator of NK1R activation, we performed thrombin injection and found that it increased SP. Inhibiting thrombin suppressed SP and decreased M1 markers while increasing M2 microglia polarization. Thus, NK1R inhibition promoted hematoma clearance after ICH by increasing M2 microglial polarization via downregulating PKC/p38MAPK/NFκB signaling pathway, and thrombin may be a key upstream mediator of NK1R activation. Therapeutic interventions inhibiting NK1R signaling may be a new target for the treatment of ICH.

Endovascular management of pelvic trauma.

Traumatic pelvic injuries are an important group of acquired pathologies given their frequent association with significant vascular compromise. Potentially fatal as a consequence of rapid hemorrhage, achievement of early hemostasis is a priority; endovascular management of traumatic pelvic arterial injuries is an important potential option for treatment. Precipitated by any number of mechanisms of trauma, pelvic vascular injury necessitates timely patient assessment. Variable patterns of arterial injury may result from blunt, penetrating or iatrogenic trauma. Selection of the most appropriate imaging modality is a priority, ensuring streamlined access to treatment. In the case of CT, this is complemented by acquisition of the most appropriate phase of imaging; review of both arterial and delayed phase imaging improves the accuracy of detection of low-flow hemorrhage. In cases where surgical intervention is not deemed appropriate, endovascular treatment provides an alternative means for cessation of hemorrhage associated with pelvic injuries. This may be achieved in a selective or nonselective manner depending on the patient’s clinical status and time constraints. Consequently, a detailed understanding of vascular anatomy is essential, including an appreciation of the normal variant anatomy between males and females. Additional consideration must be given to variant anatomy which may co-exist in both sexes. This review article aims to provide a synopsis of endovascular management of pelvic vascular injury. Through case examples, available treatment options will be discussed, including thrombin injection and transcatheter arterial embolization. Furthermore, potential adverse complications of pelvic arterial embolization will be highlighted. Finally, in view of the potential severity of these injuries, a brief overview of initial management of the hemodynamically unstable patient is provided.

Management of Visceral Artery Pseudoaneurysms by Combined Technique of Percutaneous Thrombin Injection and Endovascular Coiling

Abstract Purpose To describe our initial experience with percutaneous thrombin injection combined with endovascular coiling of high-flow visceral artery pseudoaneurysms. Materials and Methods Institutional review board approval was obtained. Between January 2019 and February 2020, 21 patients with nonvariceal upper gastrointestinal (GI) bleed underwent multidetector CT angiography. Four patients with acute pancreatitis and large pseudoaneurysms were selected for the combined technique. Human thrombin reconstituted with calcium chloride was injected percutaneously. Partially thrombosed aneurysms were treated up to three times. Simultaneously or within 15 days, coil embolization of the neck or patent part of pseudoaneurysm was performed. Patients were followed up to 1 month postprocedure. Results The size of the pseudoaneurysms ranged from 3 cm to 6 cm. All were accessed percutaneously by 22G Chiba needle under ultrasound guidance and 500 to 1500 units of thrombin was injected in one to three attempts. Subsequently, endovascular coiling of the neck of the pseudoaneurysm or of the feeding artery was performed. Technical success with cessation of flow was achieved in all four patients. One patient developed obstructive jaundice postprocedure and another continued to have GI bleeding despite thrombin injection. Conclusion Percutaneous thrombin injection is an easy to use and effective tool for treating visceral artery pseudoaneurysms and can be combined with endovascular coiling for successful occlusion of large pseudoaneurysms.

Feasibility, efficacy and safety of transbrachial access for interventional therapy on paravalvular leak post surgical valve replacement

Objective: To investigate the feasibility, efficacy and safety of transbrachial access for interventional therapy on prosthetic paravalvular leak (PVL) post surgical valve replacement. Methods: This is a retrospective study. Patients with PVL after surgical valve replacement who underwent interventional therapy via the brachial artery approach in Structural heart disease center of Fuwai hospital between August 2017 and October 2019, were included. All patients underwent puncture of the brachial artery under local anesthesia, angiography and transcatheter closure procedure were performed. The procedure was performed under transthoracic echocardiography (TTE) guidance. Baseline data, operation data and pre-and post-operative TTE examination results were collected and analyzed. Postoperative complications were recorded and operational adverse events were obtained during follow up in the outpatient department after discharge. The operation success rate was calculated, which was defined as the degree of perivalvular regurgitation decrease by 1 grade and above according to TTE without interfering the valve movement and coronary artery blood flow within 30 days after occluder placement. Results: A total of 10 patients were enrolled in this study, the mean age was (57.5±14.6) years, and 6 patients were males. There were 7 cases with aortic PVL, and 3 cases with mitral PVL. Except for one patient who was converted to the femoral vein-transseptal approach, the other 9 patients were successfully implanted with the devices via the brachial artery approach. The operation time was (103.3±34.0) minutes, and there was no need for rigorous bed rest after the operation. The median hospital stay was 7.5 (3.0, 9.8) days. The operation success rate was 9/10 via the brachial artery approach. The differences in the degree of perivalvular regurgitation, New York Heart Association (NYHA) classification, left ventricular end diastolic diameter and left atrial diameter before and after operation were statistically significant (all P<0.05). One case developed new hemolysis with renal insufficiency on the second day after procedure and discharged after successful dialysis. Another case experienced complication of brachial artery pseudoaneurysm after procedure and discharged after successful treatment with thrombin injection. The mean follow-up time was (14.3±7.9) months. During the follow-up, NYHA classification remained as Ⅰ/Ⅱ in 9 patients, no operational adverse events were observed. Conclusions: Transbrachial access for interventional therapy on PVL post surgical valve replacement is a feasible, effective, and safe procedure. It has the advantages of simplifying the operation process and reducing postoperative bed rest time.

Late to early velocity index as a predictor of iatrogenic femoral artery pseudoaneurysm recurrence in patients treated with ultrasound-guided thrombin injection.

IntroductionUltrasound-guided thrombin injection (UGTI) is the preferred treatment of pseudoaneurysms (psA). The potential risk of complications increases with the number of UGTI treatments needed for complete psA obliteration. Identification of risk factors for recurrent psA is needed.Material and methodsIn total, 508 patients with femoral artery psA underwent UGTI, followed by ultrasound examination repeated twice, at 1-week intervals, to assess UGTI effectiveness. In cases of psA recurrence, the procedure was repeated. Clinical and ultrasound data were prospectively collected.ResultsThe psA recurrence occurred in 76 (15%) patients. UGTI was repeated twice in 49 (64%), three times in 15 (20%) and more than three times in 12 (16%) patients. The median thrombin dose was 150 IU (80–250 IU), and was lower in initial procedures than repeated UGTI (p = 0.025). The median psA volume was 2.26 ml (0.86–5.47 ml). The median length of the communicating channel was 4 mm (0–12 mm). A time interval between vessel catheterization and UGTI greater than 7 days (p < 0.001), a late to early velocity index (LEVI) of < 0.2 identified during the outflow phase (p < 0.001), a psA volume > 5 ml (p = 0.032), and a short communicating channel between the psA and the artery (p = 0.037) predicted psA recurrence. Antiplatelet and anticoagulant agents did not increase the risk.ConclusionsThe LEVI and time interval between artery cannulation and UGTI treatment are strong parameters identifying patients at risk of psA recurrence. The psA volume and communicating channel length are less substantial risks, but still significant. Concomitant antiplatelet and anticoagulant therapy do not affect the success rate of UGTI.

701 Combined Endovascular and Percutaneous Treatment of Traumatic Pseudoaneurysm of Profunda Femoris Artery: A Case Report

Abstract Pseudoaneurysms of the profunda femoris artery are rare complications of femoral fractures, seen especially after orthopaedic interventions for the same. We present a case of an 89-year-old Caucasian male with a left neck of femur fracture, repaired with a dynamic hip screw. He presented to us a month later with a painful swollen thigh and deep vein thrombosis. The patient underwent arterial duplex and CT angiogram scans and was found to have a pseudoaneurysm in his left profunda femoris artery, measuring 3x3x4.5cm. This was treated with balloon angioplasty and stenting. However, his stent surveillance duplex scan, a month later, showed that the pseudoaneurysm was largely thrombosed with a patent core that was being fed by a communicating vessel from the superficial femoral artery. A subsequent angiogram showed no obvious feeding vessel. The patent pseudoaneurysm was then treated by percutaneous injection of thrombin. Exclusion of the pseudoaneurysm was confirmed by a follow-up duplex scan. It is essential to treat all feeding vessels of pseudoaneurysms in the presence of a rich collateral supply. Profunda femoris false aneurysms can thus be treated entirely by endovascular/percutaneous methods and so, potentially avoid open surgery.

Persisterende zwelling na enkelartroscopie: pseudoaneurysma van de arteria tibialis anterior als zeldzame complicatie

Persistent swelling after ankle arthroscopy: pseudoaneurysm of the anterior tibial artery as a rare complication A patient was admitted to a geriatric rehabilitation ward following a septic arthritis for which she received an antibiotic treatment and arthroscopic irrigation. She had a normal kidney function and received a prophylactic dose of enoxaparin for the prevention of a deep venous thrombosis (DVT). During the hospitalization, a progressive, painless swelling of the ankle was seen. The ultrasonography showed a pseudoaneurysm of the anterior tibial artery measuring 4.2 cm by 4 cm by 1.7 cm. Following the surgical consultation, compression therapy was started. The follow-up ultrasonography after 4 weeks showed absence of flow in the pseudoaneurysm. A pseudoaneurysm is a rare complication (0.008%) of foot and ankle surgery. Risk factors are malnutrition, immunosuppression, diabetes mellitus and trauma or infection. Abnormal coagulation may contribute to the development of a pseudoaneurysm. The diagnosis is mostly based on clinical clues, confirmed by means of color-flow Doppler imaging. The treatment options include non-surgical methods (external compression, ultrasound-guided compression and ultrasound-guided thrombin injections), percutaneous endovascular therapy (coil, stenting) or surgical ligation with an aneurysmectomy and an arterial reconstruction. Although pseudoaneurysms are a rare complication, their possibility should be considered in the period following the commencement of mobilization and weight-bearing after ankle surgery, especially if risk factors are present.

Ozanimod Preserves Endothelial Health by Attenuating Cerebrovascular MMP‐9 Activity Following Acute Ischemic Injury

The loss of vascular integrity at the level of the blood brain barrier leads to a vicious cascade of secondary injuries following acute ischemic stroke (AIS). Elevated MMP-9 activity within the cerebral vasculature has been implicated with severe degradation of the vascular basement membrane leading to abnormal cerebrovascular permeability and detrimental stroke outcome. Sphingosine-1-phosphate receptor (S1PR) modulation improves stroke outcome in AIS patients, however the influence of selective S1PR1ligands, such as ozanimod, on brain endothelial health and MMP-9 activity following AIS has not been investigated. Thus, the aim of this study was to determine the impact of acute ischemic injury on MMP-9 activity in both the rat and the human cerebrovasculature as well as the vascular specific role of ozanimod on human endothelial health and MMP-9 activity. Using an in vivo thromboembolic stroke model, cerebral vessels were isolated from male Wistar rats that underwent a right middle cerebral artery (MCA) thrombin injection. Sham-operated animals underwent the same surgical procedure; however, nothing was injected. Vascular MMP-9 enzymatic activity of was evaluated at 3, 6 and 24h post injury using zymography. Using an in vitro ischemic injury model (HGD; hypoxia plus glucose deprivation), male human brain microvascular endothelial cells (HBMECs; P7) were treated with ozanimod (0.5nM) or vehicle (DMSO) and then exposed to normoxia (21% O2) or HGD (1% O2). In some experiments, W146 (a selective antagonist), verified S1PR1 dependence. Morphology and vacuole formations were assessed using crystal violet staining. Enzymatic activity of MMP-9 was evaluated via zymography and the extracellular H2O2 concentration, inducer of MMP-9 activity, was measured using a colorimetric assay. Following in vivo thromboembolic occlusion, ipsilateral MMP-9 activity increased at 6h post injury and returned to baseline when compared to sham. In comparison to the contralateral side, thromboembolic occlusion induced a time dependent modulation of ipsilateral MMP-9 activity compared to the contralateral side with the highest activity peaking at 6h. In our in vitro HBMEC stroke model, MMP-9 enzymatic activity was increased following 3h HGD exposure, and this response was attenuated by ozanimod. Concomitantly, during HGD, H2O2 production, a partial inducer of MMP-9 activity, was increased in a time dependent manner when compared to normoxic controls. Furthermore, HGD induced an increase in HBMEC vacuole formations and a decrease in cell viability at 3h. Loss of cell viability was rescued with ozanimod. In conclusion, increased MMP-9 activity, in part due to H2O2, is an acute response to ischemic injury in the cerebrovasculature. Specifically, ozanimod's ability to attenuate endothelial MMP-9 activity may play an important beneficial role in mitigating blood brain barrier integrity loss following an acute ischemic injury.

Abstract No. 161 Trends in percutaneous injection and surgical procedures for the treatment of extremity pseudoaneurysms among radiologists and other specialties

Percutaneous thrombin injection has been shown to be a safe and effective alternative to surgical treatment of extremity pseudoaneurysms. We sought to evaluate utilization trends in percutaneous injection compared to surgical procedures to treat extremity pseudoaneurysms among radiologists and nonradiologist providers.

Closure device use for common femoral artery antegrade access is higher risk than retrograde access

Although the use of closure devices (CD) for femoral artery antegrade access (AA) is not in the instructions for use (IFU) for many devices, AA has been reported to be associated with a lower incidence of access site complications compared to manual compression alone. We hypothesized that CD use for AA would not be associated with a clinically significant increased odds of access site complications compared to CD use for retrograde access (RA). This was a retrospective review of the Vascular Quality Initiative from 2010 to 2019 for infrainguinal peripheral vascular interventions with common femoral artery access closed with a CD. Patients who had a cutdown or multiple access sites were excluded. Cases were then stratified into whether access was antegrade or retrograde. Hierarchical multivariable logistic regressions controlling for hospital level variation were used to examine the independent association between AA and access site complications. The primary outcomes were access site hematoma, stenosis, or occlusion as defined in the VQI. The secondary outcome was the development of an access site hematoma requiring an intervention, which was defined as transfusion, thrombin injection, or surgery. Sensitivity analyses after coarsened exact matching were performed to reduce residual bias. Overall, 72,463 cases were identified and 6,070 (8.4%) had AA. Patients with AA were less likely to be smokers (27.2% vs 33.0%) or obese (31.5% vs 35.6%; all P<0.05). Patients with AA were more likely to be on dialysis (12.8% vs 10.1%) and have ultrasound-guided access (76.4% vs 66.2%; P<0.05 for all). Compared to RA, patients with AA were more likely to develop any access site hematoma (2.5% vs 1.8%; P<0.01) and a hematoma requiring intervention (0.7% vs 0.5%; P=0.03), but had no difference in access site stenosis or occlusion (0.3% vs 0.2%; P=0.21). On multivariable analyses, AA had increased odds of developing any access site hematoma (OR=1.46; 95% CI=1.22-1.76) and a hematoma requiring intervention (OR=1.48; 95% CI=1.10-1.98). Sensitivity analyses after coarsened exact matching confirmed these findings. In this nationally representative sample, the use of CDs for femoral access was associated with an overall low rate of access site complications. However, there was an increased odds of access site hematomas with AA. Patient selection for AA remains important and ultrasound guided access should be the standard of care for this approach.

High incidence of deep vein thrombosis during the treatment of pseudoaneurysms - a retrospective nonrandomized study.

Background: Pseudoaneurysms (PSAs) are concerning complications after arterial invasive interventions. Therapeutic options include manual ultrasound-assisted compression, pressure dressings, surgical intervention and thrombin injection. Compression of neighboring veins is obvious. However, the incidence of deep vein thrombosis (DVT) in patients with PSA has not previously been investigated. Patients and methods: In this retrospective, nonrandomized study 238 patients with PSA were analyzed from 2013 to 2018. In 149 patients, all of the parameters were complete for participating. PSAs were treated according to the local standard therapy with either ultrasound-guided compression followed by compression bandage or thrombin injection. Treatment success was evaluated 24 hours later, and the venous system was examined for the presence of DVT. Results: Peripheral DVT was found in 25.4% patients after ultrasound-assisted compression and subsequent pressure bandages, but only 6.4% of patients had DVT after thrombin injection (p = 0.013). Lower leg veins, particularly veins of the crural muscles, were primarily affected. Significantly more PSAs were successfully treated without the occurrence of DVT in the thrombin injection group compared to the compression group (93.6 vs. 69.0%; p = 0.001). Conclusions: Our study revealed that the use of thrombin injections resulted in a significantly lower rate of postinterventional DVT and a higher total number of successfully treated PSAs compared to compression therapy.

Endobronchial blood patch with thrombin injection

Abstract Introduction: Persistent pulmonary air leaks present a challenging clinical problem, often requiring surgical intervention that not all patients can withstand. Patient concerns: An elderly female with severe emphysematous Chronic Obstructive Pulmonary Disease and dependent on continuous home oxygen supplementation developed recurrent pneumothoraces. On evaluation, the patient was considered a poor surgical candidate for Video assisted thoracoscopic surgery, and therefore a less invasive approach to treat the recurrent pneumothoraces was required. Diagnosis: A diagnosis of recurrent right pneumothorax due to Pulmonary-parenchymal fistula (either alveolo-pleural fistula or broncho-pleural fistula) was made Interventions: Due to the fragile overall condition of the patient, the peri-procedure risk of video assisted thoracoscopic surgery was not acceptable. Hence bronchoscopic evaluation with an endobronchial blood patch with thrombin injection was performed using a swan-ganz catheter. Outcomes: The patient had significant reduction in air leak post procedure and achieved complete resolution on day 3. She was successfully discharged home later. Conclusion: In patients with significant comorbidities that preclude standard interventions for persistent pulmonary-pleural fistulas, endobronchial blood patch repair with thrombin injection can be safely performed utilizing a swan-ganz catheter.

Ultrasound-Guided Thrombin Injection for the Treatment of Bleeding Following Kidney and Liver Biopsies.

The purpose of this study was to describe the technique and outcomes of percutaneous thrombin injection into the superficial aspect of actively bleeding liver and kidney biopsy tracks identified with color Doppler ultrasound with the aim of hemorrhage termination. After percutaneous thrombin injection, 15/16 (94%) patients did not require further intervention. Ultrasound-guided thrombin injection into the superficial site of active bleeding is an effective technique for terminating bleeding in the immediate post-procedure period following kidney and liver biopsies and should be considered if active bleeding persists on color Doppler after ≥30 minutes of compression and observation.