Ultrasound-Guided Percutaneous Thrombin Injection in Iatrogenic Femoral Artery Pseudoaneurysms: A Single Center Experience

Öz

Objective: The aim of this study is to share our experience of ultrasound-guided percutaneus thrombin injection in the treatment in iatrogenic femoral artery pseudoaneurysms and discuss about the safety and efficacy of this minimally invasive treatment.

Material and Methods: Fourty-two patients (26 female, 16 male) with iatrogenic femoral artery pseudoaneurysms treated with percutaneous ultrasound-guided thrombin injection between June 2012 and August 2017 were retrospectively evaluated. The diameter and the number of the pseudoaneurysm sac, artery of origin, pseudoaneurysm shape and structure were identified by Doppler ultrasound and thrombin was injected via a 21 G needle. Control with Doppler ultrasound was performed on the first day and one weekafter the procedure.

Results: The mean age of the patients included in the study was 66 years (range: 46-88 years). Thirty-three percent of pseudoaneurysm sacs had originated from the superficial femoral artery and 67%from the common femoral artery. Mean pseudoaneurysm diameter was 36.7 mm (range: 19-55 mm), mean neck lenght was 21 mm and mean neck diameter was 3.2 mm. Pseudoaneurysm in 50%of the patients was partially thrombosed, while 8 patients had two or more synchronous pseudoaneurysms and 8 patients had multilobulated pseudoaneurysm sacs.

Pseudoaneurysms were completely thrombosed with a single injection in 83%of patients. In two patients, pseudoaneurysms were thrombosed with mild compression in addition to thrombin injection during the first procedure. Four patients’ pseudoaneurysms were thrombosed after a second injection within the first week because of recurrence. In one patient, the pseudoaneurysm sac enlarged after procedure and required stent-graft owing to superficial femoral artery compression and occlusion. Technical, primary and secondary success rates were 100%, 93% and 98% respectively. No complications occured during the procedure.

Conclusion: Ultrasound-guided percutaneus thrombin injection is a reliable and effective method that can be easily applied even in numerous and multilobulated pseudoaneurysms.

Anahtar Kelimeler

• Pseudoaneurysm,thrombin,ultrasound

İYATROJENİK FEMORAL ARTER PSÖDOANEVRİZMALARINDA ULTRASON EŞLİĞİNDE PERKÜTAN TROMBİN ENJEKSİYONU: TEK MERKEZ DENEYİMİ

Öz

Amaç: Bu çalışmada, iyatrojenik femoral arter psödoanevrizmalarında ultrason eşliğinde perkütan trombin enjeksiyonu tedavisi hakkında tecrübemizi aktarmak ve bu minimal invaziv tedavinin etkinliği ile güvenilirliğinin sunulması amaçlandı.

Gereç ve Yöntemler: Bu çalışmada Haziran 2012 ile Ağustos 2017 arasında ultrason eşliğinde perkütan trombin enjeksiyonu ile tedavi edilmiş iyatrojenik femoral arter psödoanevrizmalı 42 hasta (26 kadın, 16 erkek) retrospektif olarak değerlendirildi. Doppler ultrason ile psödoanevrizma kesesi sayısı, çapı, psödoanevrizma şekli ve yapısı, orijin aldığı arter tanımlandı ve sonrasında 21 G iğne ile trombin enjeksiyonu gerçekleştirildi. İşlem sonrası kontrol, ilk gün ve birinci hafta sonrası Doppler ultrason ile yapıldı.

Bulgular: Çalışmaya dahil edilen hastların ortalama yaşı 66 idi (46-88 yaş). Psödoanevrizmalar hastaların %33’ünde yüzeyel femoral arterden, %67’sinde ana femoral arterden köken almaktaydı. Ortalama psödoanevrizma çapı 36.7 mm (19-55 mm), ortalama psödoanevrizma uzunluğu 21 mm, ortalama boyun çapı 3.2 mm olarak ölçüldü. Psödoanevrizmalar hastaların %50’sinde parsiyel tromboze, 8 hastada aynı zamanda iki veya daha fazla sayıda ve 8 hastada multilobuleydi. Hastaların %83’ünde psödoanevrizma kesesi tek enjeksiyonda total tromboze oldu. İki hastanın psödoanevrizma kesesi ilk prosedür esnasında trombin enjeksiyonuna ek olarak hafif kompresyon ile tromboze edildi. Dört hastada ilk hafta içinde gelişen rekürrens nedeniyle ikinci bir enjeksiyon ile total tromboz sağlandı. Bir hastada psödoanevrizma boyutunun artması sonucu yüzeyel femoral artere bası yapması ve akımı engellemesi nedeniyle psödoanevrizma stent-greft ile tedavi edildi. Teknik, primer ve sekonder başarı oranları ise sırasıyla %100, %93 ve %98 olarak hesaplandı. İşlemler esnasında komplikasyon gelişmedi.

Sonuç: İyatrojenik femoral arter psödoanevrizmalarının tedavisinde uygulanan ultrason eşliğinde perkütan trombin enjeksiyonu; güvenilir, etkin ve çok sayıda, multilobule psödoanevrizmalarda bile kolay uygulanabilir bir yöntemdir.

Anahtar Kelimeler

• Psödoanevrizma,trombin,ultrason

Kaynakça

1. 1. Tsetis D. Endovascular treatment of complications of femoral arterial access. Cardiovasc Intervent Radiol. 2010;33(3):457-68.
2. 2. Webber GW, Jang J, Gustavson S, Olin JW. Contemporary management of postcatheterization pseudoaneurysms. Circulation. 2007;115(20):2666-74.
3. 3. Morgan R, Belli AM. Current treatment methods for post catheterization pseudoaneurysms. J Vasc Interv Radiol. 2003;14(6):697-710.
4. 4. Rapoport S, Sniderman KW, Morse SS, Proto MH, Ross GR. Pseudoaneurysm: a complication of faulty technique in femoral arterial puncture. Radiology. 1985;154(2):529-30.
5. 5. Coughlin BF, Paushter DM. Peripheral pseudoaneurysms: Evaluation with duplex US. Radiology. 1988;168(2):339-42.
6. 6. Eisenberg L, Paulson EK, Kliewer MA, Hudson MP, DeLong DM, Carroll BA. Sonographically guided compression repair of pseudoaneurysms: further experience from a single institution. AJR Am J Roentgenol. 1999;173(2):1567-73.
7. 7. Toursarkissian B, Allen BT, Petrinec D, Thompson RW, Rubin BG, Reilly JM et al. Spontaneous closure of selected iatrogenic pseudoaneurysms and arteriovenous fistulae. J Vasc Surg. 1997;25(5):803-9.
8. 8. Cox GS, Young JR, Gray BR, Grubb MW, Hertzer NR. Ultrasound guided compression repair of postcatheterization pseudoaneurysms: results of treatment in one hundred cases. J Vasc Surg. 1994;19(4):683-6.

9. 9. Kang SS, Labropoulos N, Mansour MA, Michelini M, Filliung D, Baubly MP et al. Expanded indications forultrasound-guided thrombin injection of pseudoaneurysms. J Vasc Surg. 2000;31(2):289-98.
10. 10. Krueger K, Zaehringer M, Strohe D, Stuetzer H, Boecker J, Lackner K. Postcatheterization pseudoaneurysm: Results of US-guided percutaneous thrombin injection in 240 patients. Radiology. 2005;236(3):1104-10.
11. 11. Schneider C, Malisius R, Küchler R, Lampe F, Krause K, Bahlmann E et al. A prospective study on ultrasound-guided percutaneous thrombin injection for treatment of iatrogenic post-catheterization femoral pseudoaneurysms. Int J Cardiol. 2009;131(3):356-61.
12. 12. Kresowik TF, Khoury MD, Miller BV, Winniford MD, Shamma AR, Sharp WJ et al. A prospective study of the incidence and natural history of femoral vascular complications after percutaneous transluminal coronary angioplasty. J Vasc Surg. 1991;13(2):328-33.
13. 13. Middleton WD, Dasyam A, Teefey SA. Diagnosis and treatment of iatrogenic femoral artery pseudoaneurysms. Ultrasound Q. 2005;21(1):3-17.
14. 14. Olsen DM, Rodriguez JA, Vranic M, Ramaiah V, Ravi R, Diethrich EB. A prospective study of ultrasound scan-guided thrombin injection of femoral pseudoaneurysm: a trend toward minimal medication. J Vasc Surg. 2002;36(4):779-82.
15. 15. Cope C, Zeit R. Coagulation of aneurysms by direct percutaneous thrombin injection. AJR Am J Roentgenol. 1986;147(2):383-7.
16. 16. Paschalidis M, Theiss W, Kölling K, Busch R, Schömig A. Randomised comparison of manual compression repair versus ultrasound guided compression repair of postcatheterization femoral pseudoaneurysms. Heart. 2006;92(2):251-2.
17. 17. Paulson EK, Nelson RC, Mayes CE, Sheafor DH, Sketch MH Jr, Kliewer MA. Sonographically guided thrombin injection of iatrogenic femoral pseudoaneurysms: further experience of a single institution. Am J Roentgenol. 2001;177(2):309-16.
18. 18. Scheiman RG, Brophy DP. Treatment of iatrogenic femoral pseudoaneurysms with percutanous thrombin injection: Experience in 54 patients. Radiology. 2001;219(1):123-7.
19. 19. Gurel K, Gur S, Ozkan U, Tekbas G, Onder H, Oguzkurt L. Us-guided percutanous thrombin injection of postcatheterization. Diagn Intern Radiol. 2012;18(3):319-25.
20. 20. Loose HW, Haslam PJ. The managementof peripheral artery aneurysms using percutaneous injection of fibrin adhesive. Br J Radiol. 1998;71(852):1255-9.
21. 21. Ergun O, Çeltikçi P, Güneş Tatar İ, Yılmaz M, Hekimoğlu B. Percutaneous thrombin injection treatment of a femoral artery pseudoaneurysm with simultaneous arterial balloon occlusion: Case report and review of the literature. Turk Kardiyol Dern Ars. 2016;44(8):684-9.