Percutaneous Thrombin Injection Research Articles

Embolization of a ruptured cystic artery pseudoaneurysm by percutaneous injection.

Pseudoaneurysm of the cystic artery is very rare. It usually presents with rupture and hemorrhagic shock, which may be life-threatening. Ultrasonography and contrast-enhanced tomography can be used for the diagnosis. The mainstay of treatment for this disease is cholecystectomy. Here we present an 86-year-old man with known diabetes and Alzheimer's disease whose pseudoaneurysm was treated with percutaneous thrombin injection and highlight the technical aspect of the procedure. With ultrasonography guidance, a 21-gauge Chiba needle was passed through the liver and advanced into the pseudoaneurysm sac. A controlled, slow injection of 0.5-cc thrombin into the sac was performed with instant occlusion. Doppler imaging performed immediately following the procedure revealed that the pseudoaneurysm was not filled. Pseudoaneurysm of the gallbladder is extremely rare, and its diagnosis is difficult. If the condition is not treated right away, it can quickly become life-threatening. The majority of the pseudoaneurysms have already ruptured, and the patients are clinically septic, making surgery dangerous. Also, the use of contrast media in these patients may increase the risk of nephropathy, which is not an issue with percutaneous injection. Due to the obvious risk of rupture and bleeding, we propose injecting pseudoaneurysms only if they have a visible wall. Percutaneous injection of the gallbladder pseudoaneurysms can be an option when treating gallbladder pseudoaneurysms. More research on long-term success rates is required.

Ultrasound-guided percutaneous thrombin injection for the management of upper extremity pseudoaneurysms: 20 years of tertiary care center experience.

To evaluate the safety and efficacy of ultrasound-guided percutaneous thrombin injection for the treatment of upper extremity pseudoaneurysms. An institutional database containing 8,316,467 radiology reports was searched for suitable cases over a 241-month period. Fourteen female and 10 male patients, average age of 69.7 years (range 29-93) underwent a total of 26 procedures for the management of upper extremity pseudoaneurysms, involving the radial (n = 9), brachial (n = 9) or other upper extremity arteries (n = 6). Baseline demographic and pseudoaneurysm characteristics were documented, together with primary and secondary success, failures, and complications. All procedures were performed with real-time ultrasound guidance. The mean pseudoaneurysm volume was 9.93 cm3 (range 0.06-111.62 cm3). Twelve cases were related to central line placement or arterial access. Primary success was obtained in 50% (n = 12) after a single ultrasound-guided thrombin injection, and secondary success was achieved in an additional six (for a total success of 75%). Success was highest for the treatment of brachial artery pseudoaneurysms (87.5%), and in those who were diagnosed within 7 days of the inciting event, findings that were statistically significant (p-value 0.046 and 0.002, respectively). Ultrasound-guided percutaneous thrombin injection is safe and effective for managing upper extremity pseudoaneurysms.

Endovascular treatment of traumatic pseudoaneurysm of the ileal branch of the superior mesenteric artery in a 9-year-old girl: Case report and literature review.

Visceral artery aneurysm is a rare and potentially fatal vascular condition that typically affects the superior mesenteric or inferior mesenteric arteries, the splenic, hepatic, and celiac arteries, as well as their branches. Visceral artery aneurysms can usually be treated using endovascular intervention, open surgery, or percutaneous thrombin injection. A 9-year-old girl was admitted to our trauma center with abdominal and bilateral leg pain after a car accident involving a head-on collision. Abdominal computed tomography (CT) showed bowel herniation through a muscle defect in the left lateral abdominal wall. There was a small amount of fluid around the liver and spleen, mild thickening of the small bowel wall, and infiltration in the small bowel mesentery, indicating the possibility of small bowel injury. Emergent exploratory laparotomy was performed. After resection of the ischemic parts of the terminal ileum and sigmoid colon, intestinal continuity was reestablished. Primary repair was performed on a traumatic left lateral abdominal wall hernia. She recovered well postoperatively without any complications. A follow-up abdominal CT scan after 2 months showed a pseudoaneurysm of the ileal branch of the superior mesenteric artery. Despite the absence of any gastrointestinal symptoms, the pseudoaneurysm was treated by endovascular intervention using numerous coils because of the significant risk of delayed rupture or massive bleeding. Follow-up abdominal CT scan after 6 months showed complete occlusion and resorption of the pseudoaneurysm. Although it is technically challenging, endovascular coil embolization may be a feasible technique in children with traumatic visceral artery pseudoaneurysms without complications.

Ultrasound (US)-guided percutaneous thrombin injection for stoma-site bleeding after PEG tube insertion: a case series and review of the literature.

Post-gastrostomy bleeding sequelae are acknowledged, with reported approaches focusing on conservative measures or surgical repair. Nonetheless, Percutaneous Thrombin Injections (PTI) role in PEG-site-related bleeding remains underexplored. PTI under ultrasound guidance is an advocated management strategy for stoma-site bleeding following gastrostomy in high-risk patients, particularly those on direct oral anticoagulants. This study presents three cases with multiple comorbidities who underwent PTI. Resulting in immediate resolution of bleeding, no systemic\local effect, and no reported complications or rebleeding after a 3-6-month follow-up. The findings highlight the safety, direct complete resolution, and absence of sequelae associated with PTI, suggesting its potential as a promising technique in managing PEG stoma-related bleeding.

Percutaneous balloon-assisted ultrasound-guided direct thrombin embolization of superficial femoral artery pseudoaneurysm: a case series and literature review

BackgroundSuperficial femoral artery (SFA) pseudoaneurysms, a rare but potentially life-threatening complication, that can arise after vascular interventions or trauma. This case series explores the efficacy and safety of a minimally invasive treatment modality, percutaneous ultrasound-guided thrombin injection (PUGTI) combined with balloon occlusion, in three patients with SFA pseudoaneurysms.Case presentationThree patients (age: 71–82 years; 3 female) with SFA pseudoaneurysms underwent PUGTI with balloon occlusion. The procedure involved direct thrombin injection under ultrasound guidance while occluding the parent artery using a balloon catheter. Follow-up was conducted at 1 week and 1 month post-procedure to assess technical success, complications, and recurrence.ConclusionPUGTI combined with balloon occlusion appears to be a safe and effective treatment for SFA pseudoaneurysms, particularly for larger pseudoaneurysms. The procedure is associated with a high technical success rate. Balloon occlusion may offer a safer alternative to direct thrombin injection without occlusion, as it potentially minimizes the risk of complications such as distal thromboembolism.

Balloon-assisted Percutaneous Thrombin Injection for Brachial Artery Pseudoaneurysm after AV Fistula Cannulation

Balloon-assisted Percutaneous Thrombin Injection for Brachial Artery Pseudoaneurysm after AV Fistula Cannulation

CT-Guided Percutaneous Thrombin Injection of Posttraumatic Aortic Branch Pseudoaneurysm

AbstractA pseudoaneurysm of an aortic branch artery is a potentially life-threatening uncommon occurrence, which may result in retroperitoneal hemorrhage. Imaging-guided percutaneous thrombin injection has a high technical success and effectiveness rate for treating pseudoaneurysms of the femoral, iliac, and popliteal arteries. We present a case of a retroperitoneal hemorrhage in a patient with a periaortic branch pseudoaneurysm, potentially from an avulsed lumbar artery. Anatomy prevented fixation with a covered stent; the comorbidities eliminated safe surgical repair, and endovascular embolization was not an option due to the avulsion. Computed tomography (CT) fluoroscopy-guided thrombin injection provided a safe, successful embolization with no postprocedural complications.

Ulnar artery thrombosis after percutaneous thrombin injection of a pseudoaneurysm with a concomitant radial artery occlusion: Three complications after percutaneous coronary intervention.

Ulnar artery thrombosis after percutaneous thrombin injection of a pseudoaneurysm with a concomitant radial artery occlusion: Three complications after percutaneous coronary intervention.

Percutaneous thrombin injection under contrast-enhanced ultrasound guidance to control active extravasation not associated with pseudoaneurysm.

The technique of percutaneous thrombin injection (PTI) under contrast-enhanced ultrasound (CEUS) guidance for control of acute hemorrhage-active extravasation not associated with pseudoaneurysm is demonstrated in three cases: 1) Massive spontaneous retroperitoneal hematoma in a patient with multiple comorbidities. Contrast-enhanced computed tomography (CT) showed extensive active extravasation, which was only partially controlled by transarterial embolization. CEUS was performed in the angiography suite. Contrary to unenhanced US and colour Doppler US (CDUS), CEUS confirmed persistent extravasation; CEUS-guided PTI was performed immediately thereafter. 2) Large rectus sheath hematoma in a patient on anticoagulant therapy. Contrast-enhanced CT and unenhanced US/CD could not definitely diagnose extravasation. CEUS clearly showed extravasation and was used for guidance of PTI. 3) Chest wall hematoma complicating central venous catheter placement in a patient with coronavirus on anticoagulant therapy. CDUS was inconclusive. CEUS was performed at the bedside, clearly showed active extravasation, and was used for guidance of PTI. In all three cases, post-PTI CEUS confirmed the absence of residual enhancement of the hematomas, and the hemodynamic status of the patients improved. PTI appears to be effective in selected cases of hematomas associated with active extravasation. In this context, CEUS may be the most suitable modality for guidance and for an immediate evaluation of the treatment effect.

Safety and Effectiveness of a Sequential Suture and Plug Vascular Closure Devices Technique for Large-Bore Access Closure after Percutaneous Endovascular Aneurysm Repair

PurposeTo evaluate the safety and effectiveness of sequential sutures and plugged vascular closure devices (VCDs) for large-bore access closure during percutaneous access endovascular aneurysm repair (PEVAR). Materials and MethodsData on 16 patients who underwent PEVAR at the authors’ center from January 2022 to May 2022 were retrospectively reviewed. The median age was 72 years (interquartile range [IQR], 59–75 years), with a male-to-female ratio of 3:1. All patients received sequential suture and plug VCDs using dual Exoseal after 1 Proglide for access closure. Success was defined as the ability to achieve complete hemostasis and was confirmed by ultrasonography. The patients were followed up for access-related adverse events at 30 and 90 days after the procedure, and the severity was graded according to the Society of Interventional Radiology (SIR) classification. ResultsOverall, 24 access sites were included. The median sheath size was 21 F (IQR, 18–23 F). The median hemostasis time was 11.0 minutes (IQR, 9.3–13.0 minutes), the median procedural time was 133.5 minutes (IQR, 102.5–151.0 minutes), and the median length of stay was 5 days (IQR, 4.0–6.8 days). The success rate was 95.8%, and a pseudoaneurysm (SIR Grade 2) developed in 1 patient, which was treated by a percutaneous injection of thrombin. No other access-related adverse events occurred, and the total adverse event rate was 4.2%. ConclusionsPlacement of sequential suture and plug VCDs using 1 Proglide and dual Exoseal is a safe and effective method and may be an option for access closure during PEVAR.

A130 ENDOSCOPIC ULTRASOUND GUIDED THROMBIN INJECTION: A NOVEL TECHNIQUE IN THE MANAGEMENT OF RECURRENT UPPER GASTROINTESTINAL BLEEDING CAUSED BY GASTRODUODENAL ARTERY PSEUDOANEURYSMS

Abstract Background Gastroduodenal artery (GDA) aneurysm is a rare vascular condition that is potentially life-threatening. It is associated with significant morbidity and mortality and most often encountered in patients with chronic pancreatitis. Other etiologies including atherosclerosis, peptic ulcer disease, alcohol abuse, cholecystectomy and absence of celiac axis, have been reported. False and true GDA aneurysms account for about 1.5% of all visceral artery aneurysms however are associated with a risk of rupturing and hemorrhage up to 75%. Mainstay of GDA aneurysm management involves aneurysm repair with open surgery with vessel ligation or endovascular repair with coil embolization or stent placement, depending on the patient’s comorbidities and overall hemodynamic stability. The use of percutaneous thrombin injection via computed tomography (CT) and ultrasound has also been described in the literature and is being increasingly used to promote clot formation and pseudoaneurysm occlusion as a less invasive option. Purpose To present a case of endoscopic ultrasound guided thrombin injection as an effective and safe management strategy for GDA pseudoaneurysms. Method At this time, there are limited data in the literature on endoscopic ultrasound guided thrombin injection for pseudoaneurysms. To our knowledge, this is the first case report describing a patient with recurrent gastrointestinal bleeding from a duodenal ulcer, who had undergone multiple endoscopic and angiographic procedures, with subsequent development of a gastroduodenal pseudoaneurysm unrelated to pancreatitis which was successfully managed by occluding the pseudoaneurysm with thrombin injection under endoscopic ultrasound guidance. EUS guided thrombin injection is a viable alternative to traditional interventional radiology guided thrombin injection for management of pseudoaneurysms. Result(s) In clinic follow-up three weeks after thrombin injection, our patient continued to do clinically well, without abdominal pain or symptoms. Repeat CT angiogram demonstrated the GDA pseudoaneurysm had remained thrombosed, indicating successful endoscopic obliteration. He had no further signs of gastrointestinal bleeding. Conclusion(s) EUS guided thrombin injection is a novel approach that has been presented as an option in the management of bleeding gastroduodenal pseudoaneurysms, especially when radiology guided or surgical options are higher risk or have previously failed. The paucity of available data highlights the need for ongoing clinical studies comparing the different therapeutic strategies that can effectively and safely manage these rare but life-threatening vascular entities. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Treatment of iatrogenic pseudo-aneurysms with ultrasonography-guided percutaneous thrombin injection and compression

Background/Aim: Recently, endovascular interventional procedures have become prevalent. Thus, complications due to arterial catheterization are frequent. The most common access site complications are pseudo-aneurysms (PSAs). The present study aimed to treat iatrogenic pseudo-aneurysm (PSA) with ultrasonography (US)-guided compression and percutaneous thrombin injection and to report these methods’ effectiveness and short-term outcomes. Methods: The study was designed as a retrospective cohort study. Two treatment techniques were performed. Forty-eight of 54 patients were included in the study. Forty patients were treated with US-guided percutaneous thrombin injection, and eight were treated with US-guided compression. Six of the 54 patients were excluded from the study. Two of these patients needed further surgical treatment. The other four patients needed no further intervention due to spontaneous thrombosis of PSA. The patient demographics, history of AC/AA drug use, indication for performing arterial catheterization, localization and size of PSAs, treatment method applied, the effectiveness of treatment, early outcomes, and the treatment complications were evaluated. Results: In eight patients treated with US-guided compression, recurrent filling was not observed at the 24-h and first-month post-treatment follow-ups, and 100% success was achieved. Among the 40 patients treated with percutaneous thrombin injection for whom a second session was applied, recurrent filling was observed in six PSAs at the 24-h post-treatment follow-up. While the treatment success rate was 85% in the first session, it increased to 97.5% after the second session. A first-month follow-up could be made in 84.6% of the treated patients, and recurrence was observed in no patients. Conclusion: US-guided thrombin injection for PSAs has a high success rate. It is practical, relatively rapid to perform, has low complication rates, and may be selected as the first treatment choice for PSA.

Thyroid fine needle aspiration biopsy complicated by a Pseudoaneurysm: Treatment with percutaneous thrombin injection

Fine-needle aspiration biopsy (FNAB) is a cheap and effective diagnostic procedure that can be applied directly or with imaging guidance. Complications are rare and mostly insignificant. Here, we report a rare but serious complication related to thyroid FNAB: hematoma and a pseudoaneurysm (PSA) that was managed with percutaneous US-guided thrombin injection.

Microvascular tissue perfusion after postcatheterization pseudoaneurysm treatment.

Femoral pseudoaneurysm (PSA) is a severe complication after endovascular procedures. Ultrasound-guided manual compression (MC) and percutaneous thrombin injection (TI) are frequently used treatments. MC is less effective, TI may cause thromboembolic events. Up to date, there is no data regarding impairment of microvascular tissue perfusion after PSA treatment. In this single-center, prospective study 22 patients with PSA were included. We compared macro- and microcirculatory perfusion in the treated and untreated leg at baseline before, after and one day after treatment. Leg perfusion was assessed with ultrasound and ankle-brachial index (ABI). Microcirculatory perfusion of the feet was measured with a near-infrared spectroscopy (NIRS) camera generating StO2-tissue-maps. Successful PSA thrombosis was achieved in 16 (100%) patients in TI group and in 4 (66.7%) patients in MC group. There was no evidence of arterial thrombi on ultrasound and the ABI did not differ between groups. NIRS StO2-tissue-maps of the feet showed no significant difference in both groups concerning the treated (p = 0.121) or the untreated (p = 0.198) leg during follow up. In this small exploratory study, there was no evidence of micro- and macrovascular tissue perfusion impairment after treatment of postcatheterization femoral pseudoaneurysm with thrombin injection underscoring the safety of this approach.

US-guided percutaneous thrombin injection to treat non-femoral artery pseudoaneurysms: preliminary experience and review of the literature.

To evaluate the clinical outcome of US-guided percutaneous thrombin injection in the treatment of non-femoral artery pseudoaneurysms (NFAP). Among all pseudoaneurysms treated in our institution, we retrospectively collected NFAP embolized with percutaneous thrombin injections from January 1, 2015, to December 31, 2021. The embolization was prompted for an ongoing antiaggregating/anticoagulation therapy, NFAP optimal US visibility, or high surgery-related risks. Causes, location, size and neck of NFAP, complications, number of repeated treatments, clinical success and patients clinical conditions at discharge were annotated. The endpoint for clinical success was the resolution of NFAP at postprocedural imaging, with no resort to surgery. Eight consecutive patients (5 females, median age 73years, range 46-84) underwent 16 procedures. Arterial damage was due to catheterization (3), CVC mispositioning (2), trauma, hemorrhagic diathesis and endoprosthesis endoleak. We treated humeral (2), subclavian (2), thyrocervical, anterior tibial, radial and pancreaticoduodenal arteries. Median pseudoaneurysm size was 530 mm2 (range 32-2400 mm2), with a thin (7/8) or non-visible (1/8) neck. No complications occurred. Clinical success was obtained in 7/8 patients (88%), with a single treatment in 4, multiple in 3 cases (4 embolizations, 3 and 2, respectively). One patient underwent surgical suture after the second failed attempt of percutaneous embolization. Seven patients were discharged in good clinical conditions; one died during hospitalization, due to the worsening of the underlying cardiac disease. Percutaneous US-guided thrombin injection to treat NFAP is feasible in selected cases, with rare complications. Clinical success is often reached, also by repeated injections.

S2569 Bleeding From Peg Tube Insertion Site due to a Gastroepiploic Artery Pseudoaneurysm

Introduction: Percutaneous endoscopic gastrostomy (PEG) is generally regarded as a safe procedure with rare complications. Gastroepiploic artery aneurysms (GEAAs) are extremely rare with only 22 cases reported in the literature and constituting 3-4% of all splanchnic artery aneurysms. GEAAs carry a mortality rate of 70% due to a 90% rate of rupture and can lead to complications like hemorrhagic shock. Therefore, early detection and management is necessary for survival. Case Description/Methods: A 55-year-old male with PEG tube placed for ALS-associated dysphagia presented with bleeding around the PEG tube site 10 days after placement. He was admitted twice for the complaint. On his first admission, EGD was normal and it was suspected that he had bleeding subcutaneously around the PEG site that self-resolved. He was discharged but promptly returned the next day with profuse bleeding around PEG tube. Emergent repeat EGD was again negative. This time, the diagnosis was confirmed with CTA of the abdomen that demonstrated a branch of the gastroepiploic artery that had an 8mm pseudoaneurysm. Interventional radiology successfully performed US-guided thrombin injection with successful thrombosis of the pseudoaneurysm. The patient’s PEG site bleeding stopped, and patient successfully discharged. Discussion: Gastric bleeding following PEG tube placement is rare and usually occurs secondary to injury of the small gastric vessels. Due to the rotated configuration of stomach, caution should be exercised when penetrating during the PEG insertion. The gastroepiploic artery (GEA) runs along the greater curvature and may be injured during PEG tube placement although this is rare. The bleeding in our patient was due to a pseudoaneurysm of the GEA as evident from CT scan. GEA peudoaneurysms are a very rare complication that occur due to iatrogenic injury to the artery. GEA pseudoaneurysms can present as abdominal pain, bleeding, and even shock due to intraperitoneal hemorrhage. Due to the risk of fatal bleeding by GEA pseudoaneurysms, early detection and management is needed. Our patient was treated with percutaneous thrombin injection leading to resolution of bleeding. Other treatment options include trans arterial embolization and more invasive including surgical repair. Systemic embolization is the main complication of thrombin injection and can be prevented by placing the needle tip away from the neck of the pseudoaneurysm. (Figure).Figure 1.: A (axial) and B (sagittal): Arrows represent a small 8 mm pseudoaneurysm off of the gastroepiploic artery at the level of the gastrostomy tube insertion site.

The forgotten bomb: Ramussens’s aneurysm

IntroductionRasmussen’s aneurysm is an inflammatory pseudoaneurysmal dilatation of a branch of the pulmonary artery adjacent to the tuberculous cavity. It often presents with hemoptysis resulting from its rupture. Massive hemoptysis seen in giant aneurysms is a rare but life-threatening complication of cavitary tuberculosis.AimIn this case, we aimed to present a case of giant rasmussen aneurysm that did not bleed and was diagnosed incidentally.Case studyIn this article, we present a female patient who was surprisingly diagnosed with Rasmussen’s aneurysm during her follow-up after having been admitted to our emergency department due to diabetic ketoacidosis, fever, and shortness of breath and not responding to tuberculosis treatment. She was diagnosed using multi-detector computed tomography angiography and underwent embolization with a percutaneous thrombin injection. On the day after the procedure, thoracotomy had to be performed because the pseudoaneurysm continued to show contrast enhancement on imaging. She was successfully treated with surgery.Results and discussionAlthough pulmonary artery aneurysms are rare, it should be kept in mind that they may be related to tuberculosis. Pulmonary artery aneurysms are large asymptomatic and can reach gigantic dimensions as in this case. Rupture of an aneurysm of this size can be predicted to be mortal. Percutaneous thrombin injection can be used for treatment. However, percutaneous treatment may recur in large aneurysms, in which case surgical treatment is curative.ConclusionsRasmussen aneurysm is very rare, and when it is asymptomatic, its diagnosis may be delayed until it reaches gigantic dimensions. Contrast-enhanced thorax computed tomography and especially multi-detector computed tomography angiography are helpful in diagnosis.

Peripartum hemorrhage: Two cases of ruptured ovarian artery aneurysms with additional multifocal intact aneurysms.

We report two cases of peripartum ruptured ovarian artery aneurysms (OAA). One patient was treated through endovascular embolization and the other with percutaneous thrombin injection. Multiple additional unruptured OAAs were incidentally discovered in each patient. We describe the pathophysiologic basis for OAA rupture, approaches to treatment, and suggest management strategies for incidentally discovered ovarian aneurysms.

Dilemmas in the Management of Pseudoaneurysms, Treatment Approaches, and Clinical Outcomes

Gurjeet Dulku, Ross Vander Wal A review was conducted of all patients who were investigated for pseudoaneurysms, including those who were treated with ultrasound guided percutaneous thrombin injection(s) – (UGTI) in the medical imaging department since 2014.

Balloon assisted, ultrasound guided percutaneous thrombin injection of a large radial artery pseudoaneurysm using a trans-venous approach via an Ipsilateral Arteriovenous Fistula

BackgroundPseudoaneurysm formation is known to complicate arteriovenous haemodialysis access. Ultrasound guided thrombin injection is a recognised treatment option, but is not possible in pseudoaneurysms with no measurable neck. Balloon assisted techniques have been described in such cases, which transiently obstruct flow out of the pseudoaneurysm and thereby prevent non-target embolization during ultrasound guided percutaneous thrombin injection. We describe a balloon assisted technique for the treatment of a radial artery pseudoaneurysm, via retrograde access from the draining cephalic vein of an arteriovenous fistula.MethodA 61-year-old male with a radio-cephalic fistula was found on duplex ultrasound to have a large radial artery pseudoaneurysm with no measurable neck, as well as a juxta-anastomotic cephalic vein stenosis. Endovascular treatment was selected over open surgery. Retrograde cephalic venous access was established, which allowed for concurrent treatment of both the venous stenosis and the arterial pseudoaneurysm. After balloon dilation of the juxta-anastomotic stenosis, a percutaneous transluminal angioplasty balloon catheter was advanced across the arteriovenous anastomosis and inflated across the neck of the radial artery pseudoaneurysm, to transiently obstruct blood flow. This allowed for safe injection of thrombin into the pseudoaneurysm by direct ultrasound guided sac puncture; thereby achieving thrombosis.ConclusionsBalloon assisted ultrasound guided thrombin injection is an endovascular treatment option that can obviate the need for open surgery in cases involving pseudoaneurysms with no measurable neck. The technique described allowed both concurrent treatment of a juxta-anastomotic venous stenosis and treatment of an arterial pseudoaneurysm from a single venous puncture. This technique avoided arterial access and its inherent complications.