Percutaneous Thrombin Injection Research Articles

Imaging-guided percutaneous thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms

To evaluate factors that may affect successful ultrasound-guided percutaneous thrombin injection of iatrogenic femoral artery pseudoaneurysms (PSA). This was an IRB-approved, HIPAA-compliant retrospective study of 326 consecutive subjects (138 males, 188 females; mean age 68years, range 18-95) who underwent thrombin injection for treatment of femoral PSA; follow-up ultrasound was available in 145 subjects. The number of PSA lobes and dimensions, pre-procedure laboratory values (international normalized ratio [INR], activated partial thromboplastin time [aPTT], platelet count), and concomitant anticoagulation therapy were recorded. Technical success was achieved in 98.2% (320/326) of subjects. Primary effectiveness (complete thrombosis at 24h) was achieved in 74.5% (108/145). Twenty-five subjects underwent repeat thrombin injection, successful in 21 subjects, for a total effectiveness rate of 97.0% (129/133). No imaging factor was associated with technique failure, including number of lobes (p = 0.898), largest dimension (p = 0.344), or volume (p = 0.697). No statistically significant difference in pre-procedure INR, aPTT, or platelet count was found between subjects with CT and those with IT (p > 0.138). Anticoagulation therapy was associated with incomplete thrombosis (35.5% [38/107] for CT vs. 63.9% [23/26] for IT; p = 0.002). Imaging-guided percutaneous thrombin injection has high technical success and effectiveness rates for the treatment of iatrogenic femoral artery PSA. Anticoagulation therapy was the only factor associated with incomplete thrombosis.

Safety evaluation of percutaneous ultrasound-guided thrombin injection into pseudoaneurysms.

common application of endovascular procedures is frequently connected with increased risk of pseudoaneurysm at the site of the artery puncture. The most frequent method of treatment of aneurysms is percutaneous ultrasound-guided thrombin injection. The aim of this research was the safety evaluation of treatment of pseudoaneurysm by thrombin injection based on own experience. 70 people (57% women, 43% men, average age 67,9 ± 10,5) with pseudoaneurysm and under ultrasound-guided thrombin injection treatment carried out between 2007 and 2018 in the Department of General and Vascular Surgery of Pirogow Hospital in Lodz were analyzed. Patients were qualified to treatment based on the aneurysm and channel morphology in ultrasound examination. Before application of medicine blood supply to the limb was clinically assessed and examined using sonography. The tip of the needle was imaged into the lumen of the aneurysm. In the research group, the average aneurysm diameter was 29,9 mm (± 17,2 mm) within a range from 10 mm to 96 mm. The multi-chamber aneurysm was detected in 21% of patients. Mean channel length was 12 mm (±7,7 mm), mean width 3,5 mm (±1,4 mm), mean thrombin injected 1,7 ml (±0,7 mm) within the range from 0,5 ml to 4 ml. The treatment was successful in 94% of cases. Complications after thrombin injection occurred in 7% of cases (1 patient suffered from shock, 1 from thrombus in the saphenous vein, 3 from thrombus moving from aneurysm neck to femoral artery). No deterioration of blood supply in a limb was detected after the obliteration of the aneurysm. No relevant differences in aneurysm and channel dimensions were detected between groups with and without complications (p >0,05). Obliteration of the pseudoaneurysm by percutaneous ultrasound-guided thrombin injection is a highly effective method. This method is considered safe, however, it requires experience. Its application may cause complications of which some are clinically significant and may lead to health and life-threatening situations. In some specific cases, surgical treatment of choice should be considered.

Interventional treatment of bleeding complications due to percutaneous cannulation for peripheral extracorporeal membrane oxygenation.

This study aimed to evaluate the safety and effectiveness of interventional techniques as a treatment for bleeding complications secondary to percutaneous cannulation for peripheral extracorporeal membrane oxygenation (PECMO). Out of 1264 patients who underwent PECMO at our hospital between January 2009 and September 2018, we reviewed the clinical characteristics and outcomes of eight patients (4 men, 4 women; mean age, 54.9 years [range, 31-77 years]) who underwent percutaneous interventional treatment for bleeding complications secondary to percutaneous cannulation for PECMO. Both hemodynamic instability and coagulopathy were present in 7 patients who had direct injury during PECMO insertion and absent in one patient with pseudoaneurysm at the PECMO removal site. Percutaneous ultrasound-guided thrombin injection was performed in three patients with pseudoaneurysm of the common or superficial femoral artery, and adjunctive embolization was combined with microcoils or n-butyl 2-cyanoacrylate in two of them. Stent graft was inserted in four patients with contrast extravasation (n=3) from external iliac artery (n=1) or common femoral or iliac veins (n=2) ruptures or the fistula between the superficial femoral artery and vein (n=1). N-butyl 2-cyanoacrylate and coil embolization was performed for pseudoaneurysm from the internal pudendal artery branch in the remaining one patient. Technical success was achieved in all eight patients. There were no procedure-related complications. There was no rebleeding during the follow-up. Interventional treatment is a safe, technically feasible and therapeutically effective modality for treating bleeding complications secondary to a percutaneous cannulation for PECMO.

Percutaneous Thrombin Injection for the Treatment of Post-Procedural Iatrogenic Pseudoaneurysms

Percutaneous Thrombin Injection for the Treatment of Post-Procedural Iatrogenic Pseudoaneurysms

Arterial pseudoaneurysms in acute and chronic pancreatitis: Clinical profile and outcome.

ObjectiveTo evaluate the clinical profile and outcome of arterial pseudoaneurysms (PSA) associated with acute and chronic pancreatitis (CP).MethodsRecords of all patients of pancreatitis from 2010 to 2016 were analyzed retrospectively for the development PSAs; clinical profile and outcome parameters were compared between PSAs associated with acute and CP.ResultsOf the 980 patients, 46 (all males, age 39.70 ± 11.78 years) developed PSAs, including 19 of 600 of acute pancreatitis (AP) and 27 of 380 of CP. The most common clinical presentation was bleeding (37, 80.4%). The majority of patients was managed nonsurgically, with endovascular embolization in 31 (67.4%) and percutaneous thrombin injection in 9 (19.6%) patients. Pseudoaneurysms in patients with AP were associated more often with fluid collections (94.7% vs. 55.6%, P = 0.004) with more requirement of surgery compared to patients with CP (15.8% vs. 3.7%, P = 0.033). The pattern of arteries involved with PSAs and outcome was similar in AP and CP patients.ConclusionArterial PSAs were more commonly associated with CP compared to AP with similar presentations. Associated fluid collections and requirement of surgical intervention were higher in PSAs in patients with AP compared to patients with CP.

Repeated Percutaneous Thrombin Injections as Treatment of a Large Iatrogenic Pseudoaneurysm in the Artery Supplying a Haemodialysis Arteriovenous Fistula

Repeated Percutaneous Thrombin Injections as Treatment of a Large Iatrogenic Pseudoaneurysm in the Artery Supplying a Haemodialysis Arteriovenous Fistula

All That Bleeds! Visceral Artery Pseudo Aneurysm as a Rare Cause of Recurrent Fresh Gastrointestinal Bleeding

Visceral artery aneurysm and pseudoaneurysm are rare with incidence of 0.1-2%.We report a case of pancreato-duodenal artery pseudoaneurysm presenting as recurrent upper and lower GIB. CASE PRESENTATION: A 57 year old male with past history of COPD, hypertension, GERD, chronic hepatitis C,and alcohol abuse, presented with diffuse abdominal pain.His symptoms started nearly two weeks prior with hematemesis and lower GIB. An upper endoscopy and colonoscopy failed to identify source of bleeding.Two days later he had another episode of fresh upper and lower GI bleeding. Repeat endoscopy revealed no source.On third occassion patient reported diffuse abdominal pain, followed by mild nausea,vomiting and large amount of fresh blood hematemesis and bleeding per rectum. Abdominal CT angiogram revealed acute on chronic pancreatitis, atrophy of pancreatic body and multiple pseudocysts.A 4.6x3.2 cm pseudoaneurysm anterior to splenic artery anatomically was located in close proximity to posterior gastric wall with possible erosion. During endovascular repair a small branch of gastro-duodenal artery was identified as vessel of origin. Multiple micro-catheter coils were used to fill and obliterate the sac and feeding vessel. At six month follow up pseudoaneursym was stable on imaging. DISCUSSION ETIOLOGY: True aneurysms are caused by hypertension, atherosclerosis,and connective tissue disease.Two-thirds of VAPA are secondary to pancreatitis and leaking of proteolytic enzymes.PRESENTATION:Most cases present with vague abdominal symptoms.If ruptured, patients present with anemia and hemodynamic instability.DIAGNOSIS:Color Doppler can display inflow and outflow of blood in sac, known as “yin-yang sign”.Transcatheter angiography remains gold-standard for diagnosis as it can provide definitive diagnosis, has highest sensitivity (100%) and therapeutic potential.TREATMENT: Treatment is indicated if a visceral aneurysm size is >2cm. Women of child bearing age or pregnant should also undergo treatment.A pseudoaneurysm must be treated immediately as rate of expansion is much rapid(76.3% vs 3.1%). Treatment options include endovascular(stent,embolization),percutaneous thrombin injection,and surgery(vessel ligation,arterial bypass,sac exclusion). CONCLUSION:This case reports highlights importance of including VAA and VAPA in differential diagnosis of GI bleeding and use of alternative diagnostic modalities when endoscopy and colonoscopy fail to reveal a source of bleeding.1954_A Figure 1. Non contrast CT Abdomen showing extensive pancreatic destruction1954_B Figure 2. Contrast enhanced CT showing a large pseudoaneurysm in proximity of posterior gastric wall1954_C Figure 3. Intra operative angiogram before and after the endovascular repair.

Post-Pancreatitis Gastrointestinal Bleed: A Key Association for a Difficult Diagnosis

Hemosuccus pancreaticus (HP) is defined as bleeding from the pancreatic duct into the duodenum through the ampulla of Vater and is a rare cause of gastrointestinal bleeding. We present a 37-year-old man with history of alcohol induced recurrent pancreatitis with recent hospitalization for acute pancreatitis with a stable pseudocyst. He presents with periumbilical abdominal pain for 4 days, bright red blood per rectum and melanotic stools. Physical examination was significant for guarding and diffuse abdominal tenderness, with rectal exam notable for melena. He was hemodynamically stable. Labs were consistent with hemoglobin of 10.2 g/dl with a baseline of 12 g/dl, lipase of 305 U/L, and negative autoimmune pancreatitis workup. EGD showed active bleeding from the ampulla of Vater with no intraprocedural intervention (Fig. 1). He was managed conservatively and discharged with a stable hemoglobin level. Five days later, he was readmitted with ongoing abdominal pain and melena. Hemoglobin decreased to 6.9 g/dl, and lipase was 2205 U/L. Patient received 2 units of packed RBC. Abdominal CT angiogram showed arterial blushing along the anterior aspect of the pancreatic head consistent with pseudoaneurysm posterior to the gastroduodenal artery (Fig. 2&3). Celiac and SMA angiography were performed with successful direct percutaneous puncture and thrombin injection into pseudoaneurysm with resolution of the latter on repeat CTA. The patient was closely monitored for 2 days and discharged with a stable hemoglobin with instructions to follow up in 3 weeks.1259_A.tif Figure 1: Esophagogastroduodenoscopy showing active bleeding from the ampulla of Vater1259_B.tif Figure 2: Cross-sectional view of CT Abdomen showing arterial blushing along the anterior aspect of pancreatic head, consistent with aneurysm/pseudoaneursym1259_C.tif Figure 3: Coronal view of CT Abdomen showing arterial blushing along the anterior aspect of pancreatic head, consistent with aneurysm/pseudoaneursymHP is a rare cause of gastrointestinal bleeding with an incidence of 1 in 1500 patients. It should be included in the differential diagnosis of acute, intermittent GI bleeding in patients with a history of chronic pancreatitis and pseudocysts. The presence of lytic enzymes in the cyst may lead to corrosion and rupture of the peripheral vascular wall leading to HP. The most common arteries affected are the splenic (45%), gastroduodenal (17%), and pancreaticoduodenal (16%) arteries. Pseudocysts occur in approximately 10% of all cases of acute pancreatitis, of which 10% can develop HP. Prompt diagnosis with EGD and/or angiography can help prevent life threatening complications, however, early diagnosis is difficult because the bleeding is intermittent and often missed on EGD. If seen, it presents as blood oozing from the ampulla of Vater in 30% of cases, thus making arterial embolization the gold standard treatment.

Ultrasound-guided percutaneous thrombin injection following iatrogenic femoral artery pseudoaneurysm: patient selection and perspectives

Ultrasound-guided percutaneous thrombin injection following iatrogenic femoral artery pseudoaneurysm: patient selection and perspectives

Ultrasound-guided thrombin injection in the management of pseudoaneurysm after percutaneous arterial access.

Aim: 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.

A Rare Case of Axillary Artery Pseudoaneurysm Due to Shoulder Dislocation Treated With Percutaneous Thrombin Injection

The incidence of combined neurovascular injuries among patients with high-energy shoulder trauma ranges from 27% to 44%. However, the presentation of an axillary artery pseudoaneurysm (PSA) due to shoulder dislocation without an associated osseous fracture is a very rare condition. Moreover, treatment of combined neurologic and vascular injuries of the shoulder remains controversial. Additionally, minimally invasive treatments such as thrombin injection have been mainly evaluated in patients with iatrogenic femoral artery PSAs. Therefore, we aim to report a rare case of axillary artery PSA associated with brachial plexus injury after shoulder dislocation treated with percutaneous thrombin injection.

Tratamento de Aneurisma da Aorta Abdominal por PEVAR Complicado de Pseudo-Aneurisma Femoral

O aneurisma da aorta abdominal constitui uma patologia comum e silenciosa, com desfechos potencialmente trágicos em situação de rutura. Se no passado a sua correção requeria abordagens cirúrgicas abdominais complexas, com grande morbi-mortalidade associada, o advento da correção endovascular do aneurisma da aorta abdominal (EVAR) e a sua generalização como procedimento gold-standard para o tratamento desta patologia vieram revolucionar o estado da arte, com possibilidade de tratamento de pacientes progressivamente mais velhos ou de risco cirúrgico previamente considerado proibitivo. Este é um caso clínico de um doente de 86 anos de idade, com múltiplos fatores de risco cardiovascular, submetido a EVAR sob anestesia local com acesso por via percutânea para correção de um aneurisma da aorta abdominal, o qual se complicou de pseudo-aneurisma femoral esquerdo, corrigido de forma minimamente invasiva e com sucesso por injeção percutânea ecoguiada de trombina.
 Recebido 25/05/2016 - Aceite 06/06/2016

Pseudoaneurysm of superior epigastric artery branch: A rare complication following renal allograft biopsy treated by percutaneous thrombin injection

Renal biopsy is often needed to diagnose posttransplant graft dysfunction. Although it is very safe due to availability of real-time imaging, complications do occur. We report a rare case of anterior abdominal wall vessel injury during allograft biopsy resulting in a large perigraft hematoma. It mimics a subcapsular hematoma due to intrarenal vessel injury leading to diagnostic confusion. We detected a partially thrombosed pseudoaneurysm 3 weeks after the biopsy which had feeders from superior and inferior epigastric artery confirmed by injecting contrast into the pseudoaneurysm. The pseudoaneurysm is due to injury to small branch of these arteries. We used a novel and a cost-effective therapeutic intervention to treat this pseudoaneurysm. We injected thrombin percutaneously into pseudoaneurysm which enables thrombosis of the feeder vessels preventing recurrence.

Delayed Pseudoaneurysm after PCI Treated by Ultrasound-Guided Manual Radial Artery Compression: A Case Report

Although uncommon, radial artery access site complications are likely to become more frequent with the increased adoption of transradial cardiac catheterization, the incidence of radial artery pseudoaneurysm (PSA) has also increased. The treatments for radial artery PSA include ultrasound-guided radial artery compression, ultrasound-guided percutaneous thrombin injection, and surgical repair. This report is about a delayed radial artery PSA patient after percutaneous coronary intervention (PCI), treated by manual radial artery compression under the real-time monitoring of color Doppler ultrasound (CDU); the effect was significant.

Primary Management of Large Pancreatic Pseudoaneurysm by Ultrasound-Guided Percutaneous Thrombin Injection after Failure of Transarterial Pseudoaneurysm Embolization

AbstractPancreatic pseudoaneurysm is a rare but life-threatening complication secondary to pancreatitis, surgery, trauma, or infection. Early treatment is advocated due to high risk of rupture and bleeding. Surgical treatment has traditionally been the first line but is associated with high morbidity. Transarterial embolization or exclusion is the treatment of choice; however, in cases with failure of endovascular treatment, percutaneous thrombin injection can be used successfully. We present a case of a large pancreatic pseudoaneurysm managed successfully with percutaneous ultrasound-guided thrombin injection after failure of transarterial management.

Outcomes of Ultrasound-Guided Thrombin Injection of Nongroin Arterial Pseudoaneurysms

PurposeTo evaluate success and complication rates of percutaneous ultrasound-guided thrombin injection of nongroin pseudoaneurysms (PSAs). Materials and MethodsRetrospective review of a prospectively maintained institutional database yielded 39 cases of arterial PSAs occurring at nongroin sites that were treated with percutaneous ultrasound-guided thrombin injection between 2000 and 2016 (average patient age 69.2 y ± 14.0). Of PSAs, 74.4% (29/39) arose in the upper extremities, and 92.3% (36/39) were iatrogenic. The brachial artery was the most commonly affected vessel (51.3% [20/39]), and arterial access was the most common cause (56.4% [22/39]). Average overall PSA size was 2.4 cm (range, 0.5–7.2 cm); average amount of thrombin injected was 320 IU (range, 50–2,000 IU). Technical success was defined as absence of flow within the PSA immediately after thrombin injection. Treatment success was defined as sustained thrombosis on follow-up imaging obtained at 1–3 days after treatment. ResultsTechnical and treatment success rates of thrombin injections were 100% (39/39) and 84.8% (28/33), respectively. Longer term follow-up imaging (average 71 d; range, 12–201 d) was available for 7 of the treatment successes with 100% (7/7) showing sustained thrombosis. Comparing treatment successes and failures, there was no significant difference in average PSA size (2.3 cm vs 2.0 cm, P = .51) or average amount of thrombin injected (360 IU vs 180 IU, P = .14). There were no complications. ConclusionsUltrasound-guided thrombin injection is a safe, efficacious treatment option for PSAs arising in nongroin locations.

Ultrasound Guided Percutaneous Injection of Thrombin: Effective Technique for Treatment of Iatrogenic Femoral Pseudoaneurysms.

Arterial pseudoaneurysms are well known iatrogenic complication of percutaneous angiographic or interventional vascular procedures. In the past, the definitive treatment option was open surgical repair which is a relatively invasive procedure. In the last few years, Ultrasound (US) guided percutaneous thrombin injection has been gaining popularity as definitive treatment of pseudoaneurysms. To evaluate efficacy and safety of US guided percutaneous injection of thrombin for treatment of iatrogenic femoral pseudoanurysms at a tertiary care interventional radiological and cardiology centre. A retrospective analysis was conducted on 38 consecutive patients, diagnosed to have iatrogenic femoral artery pseudoaneurysms by Doppler study, in the period from Jan 2013 to Jun 2016. All these patients were treated by US guided percutaneous injection of thrombin solution inside the pseudoaneurysm sac till contents became echogenic and flow inside the pseudoaneurysm stopped completely. One month further follow up in all these patients was done. The dose of thrombin injected varied from 200-1000 IU (mean 300 IU). Immediate thrombosis was seen in all the pseusdoaneurysms. Follow up at 24-48 hours showed complete thrombosis and regression of pseudoaneurysm in all the patients except one in whom a small residual sac was seen which thrombosed completely on second thrombin injection. Further follow up at one month showed regression of aneurysms in all the cases. No significant post procedural clinically significant complications were seen in any of the patients. US guided percutaneous thrombin injection is a highly successful and safe procedure for the treatment of iatrogenic femoral pseudoaneurysms.

Ulnar pseudoaneurysm after transulnar coronary angiogram treated with percutaneous ultrasound-guided thrombin injection

Ulnar pseudoaneurysm after transulnar coronary angiogram treated with percutaneous ultrasound-guided thrombin injection

Post-procedural pseudoaneurysms: Single-center experience.

Objectives Pseudoaneurysms are a well-recognized complication of percutaneous angiographic procedures. Ultrasound-guided thrombin injection is currently the preferred treatment modality. This study was undertaken to evaluate our experience with the management of post-procedure pseudoaneurysms. Methods A retrospective study was undertaken of all patients who developed a post-procedure pseudoaneurysm between March 2004 and January 2013. Data were obtained from our prospectively maintained non-invasive vascular laboratory data base. Results Overall, 167 patients (80 men) with post-procedure pseudoaneurysms were identified. The mean age was 66 years. Post-procedure pseudoaneurysms developed following diagnostic coronary angiography (38%), coronary angioplasty (37%), peripheral vascular interventions (14.7%), or other access procedures (7.6%). Mean post-procedure pseudoaneurysm diameter was 2.8 ± 1.8 cm. One hundred forty-two post-procedure pseudoaneurysms were injected with thrombin under ultrasound guidance. Primary success rate was 93.5%. There were 12 (8.5%) procedural failures of which seven (58%) responded to reinjection, three (25%) required operative management, one was treated with ultrasound-guided compression, and one (8.3%) was simply observed. On multivariate analysis, failures were associated with increased aneurysm diameter ( p = 0.006; odds ratio 2.23, 95% CI 1.25 to 3.96), end-stage renal disease ( p = 0.013; odds ratio 1.15, 95% CI 1.09 to 1.78) and superficial femoral artery aneurysm origin ( p = 0.031; odds ratio 0.20, 95% CI 0.04 to 0.86). There were two episodes of thrombus formation in the femoral artery; one resolved with anticoagulation alone, and the other required thrombectomy. Conclusions Percutaneous ultrasound-guided thrombin injection is an effective and safe method for managing post-procedure pseudoaneurysms. Failure rates are low and associated with large aneurysm size, superficial femoral artery origin and end-stage renal disease.

Percutaneous Endovascular Aortic Repair with Local Anesthesia - One Day Surgery

To evaluate the results of the abdominal aortic aneurism endovascular treatment (EVAR), percutaneously and with local anesthesia, according to the concept of one day surgery. Unicentric, retrospective analysis of patients with aorto-iliac aneurysmal disease, consecutively treated by EVAR with percutaneous access trough the Preclose technique (pEVAR), according to the outpatient criteria, with one overnight stay in the hospital. The technical success, exclusion of the aneurysmal sac, endoleak, re-intervention and mortality were evaluated. Twenty consecutive patients (all male; mean age 74.65 years) were treated by EVAR with percutaneous access and local anesthesia, from which 95% (19) presented with abdominal aortic aneurysm and 5% (1) common iliac aneurysm. All implants were sucessfully performed, with an initial endoleak rate of 10% (2), determined by one type 1a endoleak successfully corrected intra-operatively and one type 2a endoleak diagnosed in the first imaging control, which sealed spontaneously on the second control. Initial technical success for percutaneous closure was 97.5%, with one case reported of femoral pseudo-aneurism, posteriorly treated by percutaneous thrombin injection. Median length of stay was one day [1-10], with a mean follow-up of 11.4 months [1-36]. Both the re-intervention and mortality rate are 0% for the selected period. Our one day surgery model for the outpatient treatment of abdominal aortic aneurysm by the pEVAR technique is innovative, safe and effective, as long as the selection criteria are respected.