Percutaneous injection of human thrombin to treat iatrogenic femoral pseudoaneurysms: short- and midterm ultrasound follow-up

Thrombin and Thrombin-Incorporated Biomaterials for Disease Treatments

Thrombin, a coagulation-inducing protease, has long been used in the hemostatic field. During the past decades, many other therapeutic uses of thrombin have been developed. For instance, burn treatment, pseudoaneurysm therapy, wound management, and tumor vascular infarction (or tumor vasculature blockade therapy) can all utilize the unique and powerful function of thrombin. Based on their therapeutic effects, many thrombin-associated products have been certificated by the Food and Drug Administration, including bovine thrombin, human thrombin, recombinant thrombin, fibrin glue, etc. Besides, several thrombin-based drugs are currently undergoing clinical trials. In this article, the therapeutic uses of thrombin (from the initial hemostasis to the latest cancer therapy), the commercially available drugs associated with thrombin, and the pros and cons of thrombin-based therapeutics (e.g., adverse immune responses related to bovine thrombin, thromboinflammation, and vasculogenic "rebounds") are summarized. Further, the current challenges and possible future research directions of thrombin-incorporated biomaterials and therapies are discussed. It is hoped that this review may provide a valuable reference for researchers in this field and help them to design safer and more effective thrombin-based drugs for fighting against various intractable diseases.

Usefulness of Balloon-Assisted Ultrasound-Guided Percutaneous Thrombin Injection to Femoral Artery Pseudoaneurysm by Transradial Artery Approach

Balloon-Assisted Ultrasound-Guided Percutaneous Thrombin Injection (BATI) is useful for iatrogenic pseudoaneurysm. In previous reports, BATI for pseudoaneurysm of the femoral artery was performed by contralateral transfemoral approach. It has been reported that patients with obesity, hypertension, and diabetes have more hemorrhagic complications at the puncture site of the femoral artery. We report a case in which BATI by transradial artery approach was useful for patients with obesity, hypertension, and diabetes who were expected to be at high risk of hemorrhagic complications of transfemoral artery approach.

Single ultrasound-guided local high-dose thrombin injection in the treatment of giant brachial artery pseudoaneurysm: A case report

RATIONALE

Pseudoaneurysm (PSA) is a common complication related to vascular intervention, and surgical therapy is the primary method. However, a giant brachial artery PSA over 2 weeks is rarely observed. Due to the adhesion of surrounding tissue, thrombus organization, the extensive injury, and the high expense of transluminal stent-graft placement, a single ultrasound-guided local high-dose thrombin injection can be a therapy option. Such cases are rarely reported.

PATIENT CONCERNS

A 71-year-old man with a history of left elbow fossa interventional puncture presented to our hospital with a pulsatile mass in the left elbow fossa. He had a history of cerebral infarction 32 years prior without sequelae, emphysema for more than 2 years, hyperlipidemia for 3 months, and prostatic hyperplasia for 8 months. After conservative therapy, the lumbar compression fracture produced by trauma 24 years ago healed, and the intracranial hematoma induced by trauma ten years ago was absorbed.

DIAGNOSIS

Ultrasound examination showed giant mixed echoes on the posterior medial side of the left brachial artery.

INTERVENTIONS

The patient underwent a single ultrasound-guided local high-dose thrombin injection to treat giant brachial artery PSA.

OUTCOMES

Following therapy, the ultrasonography revealed that extensive thrombosis immediately formed in the cavity, and the internal blood flow signals had completely vanished. A week later, a physical examination showed that the PSA had shrunk with no apparent tenderness and that the texture had hardened. Pulsation and vascular murmurs disappeared. Ultrasound showed that the PSA was reduced, and no blood flow signals were found.

LESSONS

A single ultrasound-guided local high-dose thrombin injection had a considerable effect in curing large iatrogenic PSA. However, when deciding on the best therapy, specificity must be taken into account.

Both in vitro T cell proliferation and telomere length are decreased, but CD25 expression and IL-2 production are not affected in aged men

INTRODUCTION

Aging is a natural process involving dysfunction of multiple organs and is characterized by increased susceptibility to infections, cancer and autoimmune diseases. The functionality of the immune system depends on the capacity of lymphocytes to proliferate in response to antigenic challenges, and telomere length has an important role regulating the number of cell divisions. The aim of this study was to determine the possible relationship between telomere length, interleukin 2 (IL-2) production, CD25 expression and proliferation of peripheral blood mononuclear cells (PBMCs) in aged men.

MATERIAL AND METHODS

Telomere length was measured by RT-PCR in PBMCs from young and aged men. IL-2 production and CD25 expression were determined by ELISA and flow cytometry, respectively. Cell proliferation was measured by CFSE dilution assays upon in vitro stimulation with concanavalin A (Con A).

RESULTS

PBMCs from aged men showed a shorter telomere length and a reduced capacity to proliferate in vitro, compared to young men. In contrast, no significant differences in the level of CD25 expression on T lymphocytes, and in vitro production of IL-2 were detected in both groups. In addition, no significant correlation was detected between levels of CD25 expression, IL-2 production, cell proliferation, and telomere length in aged men.

CONCLUSIONS

In aged men the telomere length shortening and the reduced T cell proliferation are not related to the capacity of IL-2 production and CD25 expression on T lymphocytes.

Ultrasound-Guided Fibrin Glue Injection for Treatment of Iatrogenic Femoral Pseudoaneurysms

Introduction:

Arterial pseudoaneurysms (PSAs) are the most common access site complication following transarterial catheter intervention. Ultrasound-guided injection of thrombogenic substances into perfused arterial PSAs followed by compression therapy is a well-established and less invasive treatment option than surgical repair. Different agents are available to induce thrombosis including thrombin and a fibrin-based tissue glue, which is used as first-line treatment at our institution. This paper deals with our experience using ultrasound-guided fibrin glue injection (UGFI).

Materials and Methods:

Retrospective data analysis: all patients (55) treated for iatrogenic femoral PSA following digital subtraction angiography of the lower extremities between January 1, 2010, and December 31, 2018, were included. Data on epidemiology, PSA location and size, vascular risk factors, fibrin glue injection (fibrin glue volume), primary success rate of UFGI, and complications related to the treatment were analyzed.

Results:

A total of 55 consecutive femoral iatrogenic PSAs were treated during the defined period and 32 (58.2%) of the patients were female. Imaging was performed using ultrasound in all cases. The most common PSA location (80.0%) was the common femoral artery, mean PSA size (± SD) was 2.7 ± 1.2 cm, and neck length was 1.6 ± 1.0 cm. The dose (mean ± SD) of fibrin glue was 2.6 mL (± 1.0; maximum: 6 mL). Primary UGFI success rate was 87.3% and conversion rate to open surgery was 12.7%. Two (4%) patients required embolectomy for peripheral embolization after UGFI.

Conclusion:

Early results achieved with UGFI for treatment of iatrogenic femoral PSA are promising. In our cohort, UGFI was a safe and effective first-line alternative to traditional open surgery, which then was unnecessary in the vast majority of PSA cases. Further prospective studies for comparison of ultrasound-guided techniques should be encouraged.

Percutaneous treatment of vascular access-site complications: a ten years' experience in two centres

Background

The spread of percutaneous arterial catheterization in diagnostic and therapeutic procedures has led to a parallel increase of vascular access site complications. The incidence of these events is between 0.2–1%. A detailed analysis of injuries by type of procedure shows a higher incidence of injuries after therapeutic procedures (3%) than those observed for diagnostic ones (1%), due to the greater size of the vascular devices used and the necessity to frequently administer anticoagulant and antiplatelet therapy during procedures. The iatrogenic arterial injuries requiring treatment are the pseudoaneurysm, arteriovenous fistula, arterial rupture and dissection. Less frequent complications include distal embolization of the limbs, nerve damage, abscess and lymphocele.

Moreover, the use of percutaneous vascular closure devices (VCD) has further expanded the types of complications, with an increased risk of stenosis, thrombosis, distal embolism and infection. Our work aims to bring the personal 10 years’ experience in the percutaneous treatment of vascular access-site complications.

Results

Ninety-two pseudoaneurysms (PSA), 12 arteriovenous fistulas (AVF), 15 retrograde dissections (RD) and 11 retroperitoneal bleedings (RB) have been selected and treated. In 120/130 cases there were no periprocedural complications with immediate technical success (92.3%). Nine femoral PSA, treated with percutaneous ultrasound-guided thrombin injection, showed a failure to close the sac and therefore they were treated by PTA balloon inflation with a contralateral approach and cross-over technique. Only one case of brachial dissection, in which the prolonged inflation of the balloon has not led to a full reimbursement of the dissection flap, was then surgically repaired. At the 7 days follow-up, complications were two abscesses in retroperitoneal bleedings, treated by percutaneous drainage. At 3 months, acute occlusion of 3 covered femoral stents occurred, then treated by loco-regional thrombolysis and PTA. A total of 18 major complications was recorded at 2 years, with a complication rate at 2 years of 13.8%.

Conclusions

The percutaneous treatment of vascular access-site complications is the first-choice treatment. It represents a safe and effective option, validated by a high technical success rate and a low long-term complication rate, that allows avoiding the surgical approach in most cases.

Das moderne befund- und patientenadaptierte Management von peripheren Pseudoaneurysmen nach arteriellem Zugang

Pseudoaneurysmen (PSA) zählen zusammen mit den Hämatomen zu den häufigsten Komplikationen nach kathetergestützten Eingriffen.

Ziel und Methode Die narrative kompakte Kurzübersicht umreißt sowohl die Entstehung und Charakteristika von Pseudoaneurysmen sowie die Optionen der Diagnostik und Therapie als auch deren mögliche Komplikationen.

Ergebnisse Ätiopathogenese: Durch den nicht verschlossenen Stichkanal der Punktion kommt es zum kontinuierlichen Blutausstrom aus dem Gefäß, der im umliegenden Gewebe eine Pseudoaneurysmahöhle formt. Diese wird nicht wie beim wahren Aneurysma durch eine Gefäßwand begrenzt, sondern nur durch die umliegenden Gewebestrukturen eingedämmt. Dies ist aber meist nicht suffizient und es kommt zu einer raschen Ausbreitung und diffusen Einblutungen. Dadurch können umliegende Strukturen wie Nerven und Venen durch das expandierende Pseudoaneurysma komprimiert werden, woraus sich irreversible Schäden entwickeln können. Diagnostik: Die Duplexsonografie steht dominierend absolut im Vordergrund. Die CT-A, MR-A und DSA bleiben speziellen Fragestellungen oder klinischen Fallkonstellationen (z. B. Begleiterkrankungen etc.) vorbehalten – eine DSA ist stets mit Interventionsbereitschaft zu verbinden. Therapie: Mit der manuellen Kompression und der darauffolgenden Anlage eines Druckverbandes, einer ultraschallgestützten Kompression, der Thrombininjektion und der operativen Sanierung stehen mehrere Verfahren zur Auswahl. Die ultraschallgestützte Kompression sollte dabei immer sofort eingesetzt werden, da sie höchst effizient und ubiquitär verfügbar ist. Additiv zur Kompression kann die Thrombininjektion bei PSA ohne Nerven-/Gewebeirritation mit eingesetzt werden und bietet noch bessere Verschlussraten, ist jedoch anspruchsvoller in der Anwendung. Die operative Ausschaltung ist die effektivste Methode, bietet aber neben dem größten Aufwand die meisten Begleitkomplikationen wie Wundheilungsstörung bei mazeriertem Gewebe und den längsten Krankenhausaufenthalt. Alternative Verfahren zu den genannten haben sich bisher nicht durchsetzen können.

Schlussfolgerung Das diagnostische und therapeutische Management von Pseudoaneurysmen stellt eine Herausforderung im interdisziplinären befund- und patientenadaptierten Vorgehen dar, das den erfahren Gefäßmediziner erfordert.

Ultrasound-guided thrombin injections for arterial pseudoaneurysms: a 14-year study conducted at King Khalid University Hospital Vascular Lab

BACKGROUND

Arterial pseudoaneurysms are a well-known complication resulting from procedures requiring arterial wall puncture. Previously, surgical repair was the definitive treatment option for arterial pseudoaneurysms despite being relatively invasive and time-consuming. Ultrasound-guided thrombin injection (UGTI) has become the standard of care since its initial description back in 1997. We aimed to evaluate the safety and efficacy of UGTI for the treatment of arterial pseudoaneurysms at the King Khalid University Hospital Vascular Lab.

METHODS

A retrospective analysis of prospectively maintained data was conducted on all patients diagnosed with arterial pseudoaneurysms by Doppler ultrasound between 2006 and 2019. Patients with large arterial pseudoaneurysms (>1.5 cm) qualified for thrombin injections. Individuals with a known hypersensitive to thrombin were excluded. All included patients were treated with UGTI until resolution and were followed at postoperative days 7 and 30.

RESULTS

In all, 35 patients qualified for thrombin injections. The mean age of the included patient population was 56.5 (range, 24-81) years. The majority of them were hypertensive (N.=26, 74.3%), and a quarter of them were on anticoagulant treatment (N.=9, 25%). The mean thrombin injection dose was 1000 U (range, 500-1500 U). In 34 of 35 (97.1%) patients, a thrombin injection resulted in complete thrombosis of the pseudoaneurysm lumen within a few seconds. There were no complications or recurrence of pseudoaneurysm after UGTI during the follow-up period.

CONCLUSIONS

Throughout the study period of 14 years, we did not encounter any procedural complications or arterial pseudoaneurysm recurrence. This is attributed to a safe procedural technique and proper patient selection. UGTI for arterial pseudoaneurysms is a safe, successful, and convenient treatment for both patients and surgeons.

Comparison of the Efficacy and Safety of Two Dosing Protocols for Ultrasound Guided Thrombin Injection in Patients with Iatrogenic Femoral Pseudoaneurysms

OBJECTIVE

Ultrasound guided thrombin injection (UGTI) is a minimally invasive method of treatment for iatrogenic post-catheterisation femoral pseudoaneurysms (psAs). The optimal dosing protocol for UGTI has not been established. The aim of the study was to compare the success and complication rates between two different dosing protocols (the most commonly used "standard dose protocol" and the "low dose protocol," which is the fractionated administration of smaller thrombin doses of up to 40 IU every 15 s) in patients with a psA with sac volume of ≥1 mL.

METHODS

This was a retrospective cohort study, and the analysis was performed using a case matching approach based on propensity score. From June 2004 to August 2018, 384 patients who underwent femoral puncture for transcatheter procedures were diagnosed with femoral psA with a sac volume of ≥1 mL and qualified for UGTI. The patients' mean age was 68 (±10.6) years and there were 217 (56.5%) women. To compare protocols, 124 patients treated according to the low dose protocol were nearest neighbour matched according to their propensity score to 124 patients treated according to the standard dose protocol.

RESULTS

The overall success rate (99.2% vs. 98.4%; p = 1) and success rate of the first UGTI attempt (87.1% vs. 86.3%; p = .85) did not differ between the low dose and standard dose groups. Complications were less common in the low dose group (7.3% vs. 16.1%; p = .03) and the median total amount of thrombin used for procedures was smaller in the low dose group (120 IU vs. 195 IU; p = .01).

CONCLUSIONS

In patients with femoral psA with sac volume of ≥1 mL, the use of the low dose protocol seemed to be equally effective as the standard dose protocol and was associated with a lower complication rate and reduced thrombin dose.

Pseudoaneurysm

Pseudoaneurysms (PSAs) are commonly known as complications associated with invasive interventions. Because of the pulsatile in- and outflow of blood through the neck of PSAs, they tend to grow and, in the worse cases, can rupture. Therapeutic options are compression therapy, using a compression bandage and ultrasound-guided compression, and thrombin injection. Manual ultrasound-guided compression is widely performed and is successful in most cases. In general, it is combined with a subsequently applied compression bandage. Thrombin injection is a more difficult technique, but it has a higher success rate. This article gives an overview of the characteristics of PSAs, their diagnostic characteristics and the therapeutic methods used to treat them. Complications associated with compression or thrombin injection are also explained in detail.

Do not underestimate the femoral pseudoaneurysm

Abstract. In addition to haematoma and arteriovenous fistula, the iatrogenic pseudoaneurysm is a common complication of vascular access that is caused by a perforation in the arterial wall. Iatrogenic pseudoaneurysms can progress in size and lead to rupture and active bleeding. Over the previous few decades, therapeutic methods have evolved from surgical repair to less invasive options, such as ultrasound-guided compression therapy (UGCT) and ultrasound-guided thrombin injection (UGTI). This paper presents an overview of the diagnostic and treatment modalities used in femoral pseudoaneurysms as well as a comprehensive summary of previous studies that analysed the success and complication rates of UGCT and UGTI.

[Treatment of post-catheterization pseudoaneurysms by ultrasound-guided thrombin injection: A single-center experience and practical guideline]

Ultrasound-guided thrombin injection has been shown to be a safe and effective treatment for iatrogenic post-catheterization pseudoaneurysms, but still is underused in France. We report our single-center experience and propose a technical guideline for ultrasound-guided thrombin injection. Ultrasound-guided thrombin injection should be considered to be the first-line treatment of iatrogenic pseudoaneurysms.

Complications of percutaneous thrombin injection in patients with postcatheterization femoral pseudoaneurysm

PURPOSE

To study the complications of ultrasound-guided thrombin injection of pseudo-aneurysms occurring after interventional cardiovascular procedures.

METHOD

We prospectively studied 353 patients who developed post-catheterization femoral artery pseudo-aneurysms and were treated with ultrasound-guided thrombin injection.

RESULTS

Arterial micro-embolization occurred in 53 patients (15%) and pulmonary embolism in 1 patient (0.3%). None of the patients developed significant peripheral arterial embolism. The length of the communicating channel between the arterial lumen and the pseudo-aneurysm was inversely correlated with the risk of embolization (p < 0.0001). A 4.6 mm increase in channel length decreased the odds of embolization by 14%, and patients with a channel less than 2 mm long were at greater risk. Repeated thrombin injection also increased the risk of embolization (p = 0.02).

CONCLUSION

Thrombin injection for the treatment of post-catheterization femoral pseudo-aneurysm is feasible and safe, but it must be performed with caution, especially when the sac is directly communicating with the artery, or when success cannot be achieved with a single injection.

Cardiologist operated ultrasound guided thrombin injection as a safe and efficacious first line treatment for iatrogenic femoral artery pseudoaneurysms

OBJECTIVES

To assess the efficacy and safety of ultrasound guided thrombin injection (UGTI) as a first line treatment for post arterial cannulation iatrogenic femoral artery pseudoaneurysms (IFAP).

BACKGROUND

IFAPs complicate up to 1% of diagnostic and 8% of interventional cardiac catheterisation procedures. UGTI remains a second line or non-attempted treatment after ultrasound guided manual compression (UGMC) and surgical repair in many centres.

METHODS

A retrospective review was undertaken of 121 consecutive patients who received UGTI as a first line treatment for IFAPs following cardiac diagnostic, interventional or catheter ablation procedures between 1999 and 2011 at our centre. The mean patient age was 70.7 years and 63% were male. At the time of injection, 89% were on at least one antiplatelet or anticoagulant. Pseudoaneurysms had a mean maximum dimension of 26.7mm (range 10-122mm) and 25% were multilobed. UGTI was performed by an interventional cardiologist with a mean bovine thrombin dose of 648 IU (range 50-5000 IU).

RESULTS

Primary success, defined as immediate IFAP thrombosis with UGTI, was achieved in 111 (92%) patients. Recurrence occurred in seven patients, three of whom required surgical repair. Multilobed IFAPs had significantly lower primary success rates than unilobed IFAPs (80% vs. 96%, p=0.016). Antiplatelet and anticoagulant use and IFAP size did not significantly affect outcomes. UGTI was not associated with any serious complications (such as thromboembolism, aneurysm rupture, venous thrombosis or abscess formation).

CONCLUSION

Interventional cardiologist operated UGTI should be considered as a first line therapy for uncomplicated IFAPs following interventional and diagnostic cardiac procedures. Despite high rates of concomitant antiplatelet and antithrombotic therapy, initial thrombosis rates exceeded 90% and we did not experience serious complications.

Treatment for femoral pseudoaneurysms

BACKGROUND

Femoral pseudoaneurysms may complicate up to 8% of vascular interventional procedures. Small pseudoaneurysms can spontaneously clot, but sometimes definitive treatment is needed. Surgery has traditionally been considered the 'gold standard' treatment, although it is not without risk in patients with severe cardiovascular disease. Less invasive treatment options such as Duplex ultrasound-guided compression and percutaneous thrombin injection are available, however, evidence of their efficacy is limited. This is an update of a Cochrane review first published in 2006.

OBJECTIVES

To assess the effects of different treatments for femoral pseudoaneurysms resulting from endovascular procedures, specifically assessing less invasive treatment options such as blind manual or mechanical compression, ultrasound-guided compression, or percutaneous thrombin injection.

SEARCH METHODS

For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched October 2013) and CENTRAL (2013, Issue 9).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing two treatments for femoral pseudoaneurysms following vascular interventional procedures were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Four studies were included in the analyses comparing: manual compression versus ultrasound-guided compression; ultrasound-guided application of a mechanical device (FemoStop) versus blind application; and ultrasound-guided compression versus percutaneous thrombin injection (two studies). There were no studies with a surgical intervention arm. Data were extracted independently by both authors.

MAIN RESULTS

Compression (manual or FemoStop) was effective in achieving pseudoaneurysm thrombosis although ultrasound-guided application failed to confer any benefit (risk ratio (RR) 0.96; 95% confidence interval (CI) 0.88 to 1.04).Percutaneous thrombin injection was more effective than a single session of ultrasound-guided compression in achieving primary pseudoaneurysm thrombosis within individual RCTs but merged data failed to show statistical significance (RR 2.81; 95% CI 0.44 to 18.13). There was no statistically significant difference in the length of hospital stay between the two groups and no complications were reported apart from one deep vein thrombosis in the compression group.

AUTHORS' CONCLUSIONS

The limited evidence base appears to support the use of thrombin injection as an effective treatment for femoral pseudoaneurysm. A pragmatic approach may be to use compression (blind or ultrasound-guided) as first-line treatment, reserving thrombin injection for those in whom the compression procedure fails.

Value of percutaneous embolotherapy for the management of traumatic vascular limb injury

BACKGROUND

Arterial injuries to the extremities may result in severe hemorrhagic complications. Open surgical repair has been the standard of care for these patients, but endovascular management may be a valuable, less invasive alternative.

PURPOSE

To evaluate the safety, efficacy and long-term durability of embolotherapy for the management of hemorrhagic, traumatic vascular injuries in upper and lower limbs.

MATERIAL AND METHODS

Patients with traumatic or iatrogenic hemorrhagic vascular injuries to the extremities and managed with endovascular embolotherapy in the authors' institution between 1998 and 2010 were included in this retrospective study. Embolization was performed with different embolic materials; technical and long-term clinical outcome was assessed by review of the medical records or by telephone interviews of the referring physicians.

RESULTS

Embolization was performed in 31 patients. In six patients the vascular lesion was traumatic, in the remaining 25 patients the lesion was of iatrogenic origin. Angiographic vascular lesions identified were: contrast extravasation (n = 19, 61%), pseudoaneurysm (n = 8, 26%), and pseudoaneurysm with arteriovenous fistula (n = 3, 10%). Primary and secondary clinical success was obtained in 84% and 97% of cases, respectively. Procedure-related complications occurred in five patients (16%). Most of them were mild. One patient expired 34 days after the procedure due to amputation-stump infection, septicaemia, and multiple organ failure. Long-term outcome showed no recurrent bleeding or other embolization-related complications.

CONCLUSION

Embolotherapy for the management of hemorrhagic, traumatic vascular injuries in upper and lower limbs is relatively safe, very effective without recurrence or other embolization-related symptoms.

Results of a New Human Recombinant Thrombin for the Treatment of Arterial Pseudoaneurysm

Objective: To evaluate the results of a new thrombin sealant (Recothrom) for the treatment of arterial pseudoaneurysms (PDAs). Methods: We reviewed 47 consecutive patients prospectively entered in a dedicated data set who underwent ultrasound-guided percutaneous thrombin injection to treat PDA. End points were PDA recurrence, need for reintervention, and related complications such as limb ischemia or allergic reactions. Results: Twenty-six patients were females (55%) and the median age of the entire group was 71 years (range, 45-87). The mean size of the PDA was 2.3 ± 0.9 cm. The mean injected volume was 2.4 ± 1.4 mL containing 500 ± 320 units. Recurrence of the PDA occurred in 4 (8.5%) patients and was not related to anticoagulation status, body habitus, platelets levels, or use of antiplatelets. All recurred PDAs were successfully sealed with a second (n = 3) and a third injection (n = 1). There was no distal embolization or allergic reactions and no surgical intervention was required. Conclusion: The new human recombinant thrombin (Recothrom) is a safer nonimmunogenic option with similar success rates of other fibrin glue sealants.

Off label use of devices and drugs in interventional radiology

AIM

To establish how often off-label device and drug use occurs in interventional radiology (IR) in a UK tertiary referral hospital and consider the wider implications for the interventional radiologist.

MATERIALS AND METHODS

Prospective data were collected during interventional procedures for 1 working week in a university hospital. Out-of-hours procedures and procedures outside the department were excluded. Operators were asked to record the drugs and devices used, the indication, and method of use. The instructions for use/summary of product characteristics were then studied for each device/drug used to assess if the use was on or off-label.

RESULTS

During the study period 52 cases were performed and data were available on 26 cases (50%). In 22 of the 26 cases (84%) there was evidence of off-label use of devices or drugs. Off-label use of drugs included treatment of venous malformations with Fibrovein(©) (sodium tetradecyl sulphate), which is licensed for the treatment of varicose veins in the leg, and intra-arterial injection of heparin, which is licensed for intravenous and subcutaneous use. Off-label device use included placing vascular sheaths in the urinary tract, using angiographic catheters to guide wires in the urinary tract, using sheaths for thrombosuction, reshaping of the tip of most guidewires, and using angioplasty balloons to dislodge the arterial plug at fistula thrombectomy.

CONCLUSION

Off-label device and drugs use is common in a UK tertiary hospital IR department and literature suggests this is common in the wider IR community. There are important clinical and legal implications for off-label use for patients and physicians.

Treatment for femoral pseudoaneurysms

BACKGROUND

Femoral pseudoaneurysms may complicate up to 8% of vascular interventional procedures. Small pseudoaneurysms can spontaneously clot, but sometimes definitive treatment is needed. Surgery has traditionally been considered the 'gold standard' treatment, although it is not without risk in patients with severe cardiovascular disease. Less invasive treatment options such as Duplex ultrasound-guided compression and percutaneous thrombin injection are available, however, evidence of their efficacy is limited. This is an update of a Cochrane review first published in 2006.

OBJECTIVES

To assess the effects of different treatments for femoral pseudoaneurysms resulting from endovascular procedures, specifically assessing less invasive treatment options such as blind manual or mechanical compression, ultrasound-guided compression, or percutaneous thrombin injection.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases Group searched their Specialised Register (last searched December 2008) and the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 4). Additional searches were also made of the bibliographies of papers found through the electronic searches, and by handsearching relevant journals.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing two treatments for femoral pseudoaneurysms following vascular interventional procedures were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Four studies were included in the analyses comparing: manual compression versus ultrasound-guided compression; ultrasound-guided application of a mechanical device (FemoStop) versus blind application; and ultrasound-guided compression versus percutaneous thrombin injection (two studies). There were no studies with a surgical intervention arm. Data were extracted independently by both authors.

MAIN RESULTS

Compression (manual or FemoStop) was effective in achieving pseudoaneurysm thrombosis although ultrasound-guided application failed to confer any benefit (risk ratio (RR) 0.96; 95% confidence interval (CI) 0.88 to 1.04).Percutaneous thrombin injection was more effective than a single session of ultrasound-guided compression in achieving primary pseudoaneurysm thrombosis within individual RCTs but merged data failed to show statistical significance (RR 2.81; 95% CI 0.44 to 18.13). There was no statistically significant difference in the length of hospital stay between the two groups and no complications were reported apart from one deep vein thrombosis in the compression group.

AUTHORS' CONCLUSIONS

The limited evidence base appears to support the use of thrombin injection as an effective treatment for femoral pseudoaneurysm. A pragmatic approach may be to use compression (blind or ultrasound-guided) as first-line treatment, reserving thrombin injection for those in whom the compression procedure fails.

Popliteal pseudoaneurysm after total knee arthroplasty secondary to intraoperative arterial injury with a surgical pin: review of the literature

Pseudoaneurysms of the popliteal artery after total knee arthroplasty are rare. Although many possible explanations are proposed in the literature, no intimate mechanism of injury to the artery is previously described. We report on a case of popliteal pseudoaneurysm after a total knee arthroplasty that presented clinically on the second postoperative day. Open vascular surgery with resection of the pseudoaneurysm and end-to-end bypass of contralateral saphena vein graft was successfully performed. At the time of the surgery, a hole was clearly identified on the anterior wall of the popliteal artery due to a perforation with a pin used during the knee arthroplasty. The patient had no further complications.

Interventional radiology in the diagnosis, management, and follow-up of pseudoaneurysms

Arterial wall disruption, as a consequence of inflammation/infection, trauma (penetrating or blunt), or iatrogenic causes, may result in pseudoaneurysm formation. Currently, iatrogenic causes are increasing as a result of the growth of endovascular intervention. The frequency of other causes also seems to be increasing, but this may simply be the result of increased diagnosis by better imaging techniques, such as multidetector contrast-enhanced computed tomography. Clinically, pseudoaneurysms may be silent, may present with local or systemic signs, or can rupture with catastrophic consequences. Open surgical repair, previously the mainstay of treatment, has largely been replaced by image-guided occlusion methods. On the basis of an experience of over 100 pseudoaneurysms, treatments at various anatomical sites, imaging modalities used for accurate diagnosis, current changing therapeutic options for pseudoaneurysm management, approved embolization agents, and clinical follow-up requirements to ensure adequate treatment will be discussed. Image-guided direct percutaneous and endovascular embolization of pseudoaneurysms are established treatment options with favorable success rates and minimal morbidity. The pendulum has now swung from invasive surgical repair of pseudoaneurysms to that of image-guided interventional radiology.

Ultrasound-guided thrombin injection of iatrogenic groin pseudoaneurysm: Doppler features and technical tips

The practice of angiographic procedures is increasing and, concomitantly, there has been an increase in the incidence of iatrogenic femoral pseudoaneurysms (PA). Ultrasound-guided thrombin injection is becoming the accepted gold standard in the treatment of PA. It is a cost-effective, safe and efficacious treatment that requires a short learning curve. The aim of this pictorial review is to demonstrate the Doppler and ultrasound features used to diagnose PA and those that help differentiate it from alternative diagnoses, and to describe the procedure of thrombin injection, highlighting technical tips and ways to avoid potential complications.

Reducing duplex examinations in patients with iatrogenic pseudoaneurysms

OBJECTIVE

Ultrasound-guided thrombin injection has become the initial treatment of choice for femoral access-related pseudoaneurysms. Patients typically undergo serial duplex examinations to assess for spontaneous resolution of small iatrogenic pseudoaneurysms (IPSAs) (<2.5 cm), or may require repeated diagnostic, therapeutic, and follow-up studies for larger IPSAs (>2.5 cm). We evaluated the impact of a revised treatment algorithm that includes primary treatment of both small (<2.5 cm) and larger pseudoaneurysms (>2.5 cm), rather than observation of smaller ones, and attempts to establish a single duplex examination via a point-of-care treatment strategy.

METHODS

We reviewed 105 consecutive patients treated with ultrasound-guided thrombin injection from July 2001 through September 2004. Patient, IPSAs, characteristics, and treatment methods were examined. The number of duplex examinations per patient was evaluated over the treatment interval. Also, published cost data were used to compare primary treatment of small ISPAs vs observation with serial duplex examinations.

RESULTS

Successful thrombosis occurred in 103 (98.1%) of 105 treated pseudoaneurysms. No minor or major complications occurred after thrombin injection in either small or large ISPAs, and both failures requiring operation were in the large aneurysm group. The recurrence rate for the series was 1.9% (2/105), and both recurrences were successfully treated with an additional thrombin injection. A single injection was successful in treating 43 (97.7%) of 44 small (<2.5 cm) IPSAs, and one required a second injection. Patients had an average of 3.3 duplex examinations in our first year of treatment experience, which declined to 1.5 by our third year with the institution of a point-of-care service model for all pseudoaneurysms. Based on this decreased use of duplex examination and an average treatment cohort of 35 IPSA patients per year our institution, we determined this results in a reduction of 35 hours of laboratory time and nearly 70 ultrasounds per year. Similarly for small pseudoaneurysms, a point-of-service primary treatment program rather than observation results in an estimated cost savings of $12,000, based on treating 15 small IPSAs per year.

CONCLUSIONS

Ultrasound-guided thrombin injection is safe and effective for the treatment of nearly all iatrogenic pseudoaneurysms. We recommend primary treatment of small pseudoaneurysms by ultrasound-guided thrombin injection rather than observation with serial duplex scans. A point-of-care treatment algorithm can result in cost savings by reducing the number of necessary duplex examinations.

True and false aneurysms of the femoral artery

True aneurysms of the femoral artery are uncommon. They are most often identified in elderly males and are frequently associated with aneurysms at other locations. Femoral artery aneurysms that are symptomatic or larger than 2.5 cm should be repaired in order to prevent limb-threatening complications, such as rupture, thrombosis, or embolization. Open repair is the standard method of treatment and should be preceded by evaluation for coexisting aortoiliac or popliteal aneurysms, assessment of superficial femoral artery patency, and determination of the point of origin of the deep femoral artery relative to the aneurysm sac. Femoral artery pseudoaneurysms are most often seen in the setting of previous femoral artery catheterization but may also be associated with trauma, anastomotic leakage, or infection. The majority of femoral pseudoaneurysms less than 3 cm in diameter will spontaneously thrombose and may be observed with serial duplex ultrasound exams in asymptomatic patients. Symptomatic pseudoaneurysms, pseudoaneurysms with a diameter greater than 3 cm, and those found in patients who are anticoagulated should usually be treated. Ultrasound-guided thrombin injection is our preferred method for treating femoral pseudoaneurysm because of its low risk, high success rate, and efficacy in the setting of anticoagulation. Ultrasound-guided compression is an alternative method that may be considered when thrombin products are contraindicated. Open pseudoaneurysm repair should be undertaken in the setting of infection, rapid expansion, or if less-invasive methods are not technically feasible.

Surgery versus non-surgical treatment for femoral pseudoaneurysms

BACKGROUND

Femoral pseudoaneurysms may complicate up to 8% of vascular interventional procedures. Small pseudoaneurysms can spontaneously clot, while others need definitive treatment. Surgery is considered the gold-standard treatment, although is not without risk in patients with severe cardiovascular disease. Less invasive treatment options, such as Duplex ultrasound-guided compression and percutaneous thrombin injection are available, however, evidence of their efficacy is limited.

OBJECTIVES

To assess the effects of different treatments for femoral pseudoaneurysms resulting from endovascular procedures, specifically assessing less invasive treatment options such as ultrasound-guided compression or percutaneous thrombin injection.

SEARCH STRATEGY

We searched the Cochrane Peripheral Vascular Diseases Review Group's Specialised Register and the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library Issue 3, 2005 (last searched October 12, 2005). Additional searches were also made of bibliographies of papers found through these searches and by handsearching relevant journals.

SELECTION CRITERIA

Randomised controlled trials comparing two treatments for femoral pseudoaneurysms following vascular interventional procedures were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two studies were included in the analysis: ultrasound-guided application of a mechanical device (FemoStop) versus blind application; ultrasound-guided compression versus percutaneous thrombin injection. Data were extracted independently by both authors.

MAIN RESULTS

Mechanical compression with a FemoStop was effective in achieving thrombosis of the pseudoaneurysm although ultrasound-guided application of this failed to confer any benefit (relative risk (RR) 1.07; 95% confidence intervals (CI) 0.75 to 1.53, P = 0.7). Percutaneous thrombin injection was more effective than ultrasound-guided compression in achieving thrombosis of a pseudoaneurysm (RR 7.50; 95% CI 2.06 to 27.25, P = 0.002 at 24 hours after treatment; RR 2.50; 95% CI 1.35 to 4.65, P = 0.004 at 48 hours after treatment). There was no statistically significant difference in the length of hospital stay between the two groups and no complications were reported.

AUTHORS' CONCLUSIONS

The limited evidence base appears to support the use of thrombin injection as an effective treatment for femoral pseudoaneurysm. A pragmatic approach may be to use ultrasound-guided compression as first-line treatment, reserving thrombin injection for those in whom the procedure fails.

Postcatheterization pseudoaneurysm: results of US-guided percutaneous thrombin injection in 240 patients

PURPOSE

To prospectively evaluate ultrasonographically (US) guided percutaneous thrombin injection for treatment of femoral artery and brachial artery pseudoaneurysms.

MATERIALS AND METHODS

The university institutional review board approved the study. Informed consent was obtained from all patients. Two hundred forty patients with postcatheterization femoral artery (n = 132) or brachial artery (n = 8) pseudoaneurysms were treated with US-guided bovine thrombin (1.000 IU/mL) injection. At diagnosis, 107 (44.6%) patients received anticoagulation therapy; 159 (66.2%), antiplatelet therapy; and 76 (31.7%), both therapies. Pseudoaneurysm size, length and width of pseudoaneurysm neck, thrombin dose, therapy outcome, and complications were documented. The peak blood flow in peripheral arteries was determined before and after thrombin injection. Follow-up duplex US was performed 12-24 hours, 5-7 days, and 21-25 days after treatment. A nonpaired t test was used to compare differences in age between the male and female patients. Two-way analysis of covariance was performed to analyze the influences of factors that may have been related to the amount of thrombin used.

RESULTS

Mean pseudoaneurysm volume was 4.69 cm3 +/- 5.49 (standard deviation). Simple and complex pseudoaneurysms were treated in 165 and 75 patients, respectively. A total of 260 thrombin injections were performed: 1.04 injections per patient with a simple pseudoaneurysm and 1.17 injections per patient with a complex pseudoaneurysm. The mean injected thrombin dose was 425.31 IU +/- 341.75 for all pseudoaneurysms, 382.12 IU +/- 281.00 for simple pseudoaneurysms only, and 520.33 IU +/- 434.64 for complex pseudoaneurysms only. There was only a computational correlation between pseudoaneurysm size and thrombin dose (r2 = 0.07). The primary success rate was 93.8% overall, 95.8% for simple pseudoaneurysms, and 89% for complex pseudoaneurysms. The secondary success rate was 99.6% overall, 100% for simple pseudoaneurysms, and 99% for complex pseudoaneurysms. Early (at < or =24 hours) reperfusion occurred in one simple and five complex pseudoaneurysms. Four late reperfusions-two in simple and two in complex pseudoaneurysms-were detected at 1-week follow-up; no late reperfusions were detected at 3 weeks. Thromboembolic complications occurred in two patients and resolved spontaneously. One mild allergic reaction and no infections occurred.

CONCLUSION

US-guided percutaneous thrombin injection enables successful, safe management of postcatheterization pseudoaneurysms.

Translumbar thrombin embolization of an aortic pseudoaneurysm complicating lumbar disk surgery

We report a case of translumbar embolization of an aortic pseudoaneurysm complicating lumbar disk surgery. The iatrogenic pseudoaneurysm was initially treated by open repair, but due to failure of this treatment, we opted for direct translumbar thrombin injection under computed tomography (CT) guidance. The patient recovered completely, and follow-up CT scans showed progressive shrinkage of the residual retroperitoneal hematoma. This minimally invasive treatment should be considered in selected cases as a valuable treatment option for pseudoaneurysms that arise from the aorta.

Prospective randomized study comparing ultrasound-guided thrombin injection to compression in the treatment of femoral pseudoaneurysms

PURPOSE

To compare in a randomized prospective study the treatment of femoral pseudoaneurysms with ultrasound-guided thrombin injection versus ultrasound-guided compression.

METHODS

Thirty consecutive patients (22 men; mean age 67+/-8 years, range 53-82) with iatrogenic femoral pseudoaneurysms were randomized to treatment with either ultrasound-guided compression (n=15) or injection of bovine thrombin (n=15). The primary outcome measure was thrombosis of the pseudoaneurysm within 24 hours. Secondary outcome measures were complications and hospitalization time (LOS).

RESULTS

Thrombosis within 24 hours was achieved in 15 (100%) patients given thrombin versus 2 (13%) in the compression group (p<0.001). Of 13 pseudoaneurysms failing the initial compression treatment, 7 were retreated, 4 successfully. Thus, only 6 (40%) lesions were thrombosed within 48 hours after 1 or 2 compression sessions. The other 9 cases were successfully treated with thrombin injection. LOS was 2.8+/-1.5 days and 3.5+/-2.4 days in the thrombin and compression groups, respectively (p>0.05). No complications were noted in either group.

CONCLUSIONS

Ultrasound-guided thrombin injection induces a fast, effective, and safe thrombosis of postcatheterization pseudoaneurysms. The technique is clearly superior to compression treatment and is recommended as the therapy of choice.

Embolization of traumatic pseudoaneurysms after total knee arthroplasty

We report on 2 cases of traumatic pseudoaneurysm after total knee arthroplasty. In one patient, a hemarthrosis and a pulsatile antecubital mass developed 1 month after arthroplasty, prompting angiography. In the second patient, evacuation of a large hemarthrosis was performed before angiography and embolization. In both patients, the pseudoaneurysm was successfully treated without the need for surgical repair, using percutaneous thrombin injection or transcatheter embolization. No recurrence of hemarthrosis was seen in either patient at up to 24 months of follow-up evaluation. These cases show the use of angiography in reconstructed joints when acute or delayed hemarthrosis occurs, and the role of embolization techniques in this setting.