ARTERİYEL PSÖDOANEVRİZMALARIN ULTRASONOGRAFİ KILAVUZLUĞUNDA TROMBİN ENJEKSİYONU İLE TEDAVİSİ

Öz

Amaç: Bu çalışma ile amacımız, anjiyografik tetkik ve tedaviler sonrasında, artere giriş yerini kapatma işleminin başarısız olması sebebiyle ortaya çıkan iyatrojenik arteriyel psödoanevrizmaların, ultrasonografi kılavuzluğunda, trombin enjeksiyonu ile tedavisi hakkındaki tecrübelerimizi paylaşmaktır.

Gereç ve Yöntemler: Periferik anjiyografi, koroner anjiyografi ve diyaliz sonrası aksiller, brakial ve femoral arterlerinde psödoanevrizma meydana gelen 59 kadın, 59 erkek olmak üzere toplam 118 hastadaki 121 psödoanevrizmaya 131 enjeksiyon yapıldı. Hastaların yaş ortalaması 63.11±15.8 olup en küçük hasta 3, en büyüğü ise 94 asyndeta. Yüz otuz bir seansta yapılan trombin enjeksiyonu ile ilgili bulgular, psödoanevrizma büyüklüğü, tam oklüzyon için gereken trombin miktarı ve tedavi sonrası nüks gelişimi retrospektif olarak değerlendirildi.

Bulgular: Çapları 2 cm -10 cm arasındaki 121 psödoanevrizmaya 0.2-2 cc arasında trombin enjeksiyonu yapıldı. Takip esnasında nüks izlenen 10 hastanın 2 tanesinde anevrizma periferik anjiyografi, 8 tanesinde ise koroner anjiyografi işlemlerinden sonra meydana gelmişti. Nüks meydana gelen psödoanevrizmaların en büyüğü 50x45 mm, en küçüğü 20x17 mm boyutlarındaydı. Nüks meydana gelen anevrizmalardan 3 tanesi, işlem sonrası anjiyoseal ile hemostaz sağlanan hastalardı. İşlem sonrası başarı oranı %100 olup major komplikasyon izlenmedi.

Sonuç: İyatrojenik psödoanevrizmaların tedavisinde uygulanan ultrasonografi kılavuzluğunda trombin enjeksiyonu tedavisi, psödoanevrizmaya bası ve cerrahi tedavi seçeneklerine göre, daha hızlı, güvenli, konforlu ve başarılı bir metod olup kullanımı giderek yaygınlaşmaktadır.

Anahtar Kelimeler

• psödoanevrizma
• trombin
• ultrason klavuzluğu

Ultrasound-Guided Thrombin Injection for the Treatment of Arterial Pseudoaneurysms

Öz

Objective: In this study, we aim to share our experience on treating iatrogenic arterial pseudoaneurysms, which has occurred after angiographic examinations and treatments, with ultrasound-guided thrombin injection.

Material and Methods: One hundred and thirty-one injections were administered to 121 pseudoaneurysms in a total of 118 patients, consisting of 59 women and 59 men, who developed pseudoaneurysm in the axillary, brachial and femoral arteries after peripheral, coronary angiography and dialysis. The mean age of the patients was 63.11±15.8, The youngest patient was 3 years old, and the oldest was 94 years old. Findings, related to thrombin injection, performed in 131 sessions were analyzed. The size of the pseudoaneurysm, the amount of thrombin required for complete occlusion and the development of recurrence after treatment were evaluated retrospectively.

Results: Thrombin injection of 0.2 to 2 cc was applied to 121 pseudoaneurysms with a size of 2 cm to 10 cm. Of the 10 patients who had recurrence during follow-up, 2 occurred after peripheral angiography and 8 after coronary angiography procedures. The largest of the recurrent pseudoaneurysms was 50x45 mm and the smallest was 20x17 mm in size. Three of the relapses were detected in the patients in whom hemostasis was achieved with angioseal after the procedure. The success rate after the procedure was 100%, and no major complications were observed.

Conclusion: Ultrasound-guided thrombin injection treatment is a more rapid, safe, comfortable and successful method than compression or surgery options for the treatment of iatrogenic pseudoaneurysms, and it is gaining more widespread use.

Anahtar Kelimeler

• pseudoaneurysm
• thrombin
• ultrasound-guided

Kaynakça

1. 1. Harman A, Boyvat F. Psödoanevrizma Kapatılması. Türk Kardiyoli Derneği Arşivi. 2013;41(1):84-6.
2. 2. Vlachou PA, Karkos CD, Bains S, McCarthy MJ, Fishwick G, Bolia A. Percutaneous ultrasound-guided thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms. Eur J Radiol. 2011;77(1):172-4.
3. 3. Kang SS, Labropoulos N, Mansour MA, Baker WH. Percutaneous ultrasound-guided thrombin injection: a new method for treating post catheterization femoral pseudoaneurysms. J Vasc Surg. 1998;27(6):1032-8.
4. 4. Katzenschlager R, Ugurluoglu A, Ahmadi A, Hülsmann M, Koppensteiner R, Larch E et al. Incidence of pseudoaneurysm after diagnostic and therapeutic angiography. Radiology. 1995;195(2):463-6.
5. 5. Lenartova M, Tak T. Iatrogenic pseudoaneurysm of femoral artery: case report and literature review. Clin Med Res. 2003;1(3):243-7.
6. 6. Cox GS, Young JR, Gray BR, Grubb MW, Hertzer NR. Ultrasound-guided compression repair of post catheterization pseudoaneurysms: results of treatment in one hundred cases. J Vasc Surg. 1994;19(4):683-6.
7. 7. Fellmeth BD, Roberts AC, Bookstein JJ, Freischlag A, Forsythe JR, Buckner NK et all. Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression. Radiology. 1991;178(3):671-5.
8. 8. Paschalidis M, Theiss W, Kölling K, Busch R, Schömig A. Randomised comparison of manual compression repair versus ultrasound-guided compression repair of post catheterization femoral pseudoaneurysms. Heart. 2006;92(2):251-2.

9. 9. Taylor BS, Rhee RY, Muluk S, Trachtenberg J, Walters D, Steed DL et al. Thrombin injection versus compression of femoral artery pseudoaneurysms. J Vasc Surg. 1999;30(6):1052-9.
10. 10. Brophy DP, Sheiman RG, Amatulle P, Akbari CM. Iatrogenic femoral pseudoaneurysms: thrombin injection after failed US-guided compression. Radiology. 2000;214(1):278-82.
11. 11. Ferguson JD, Whatling PJ, Martin V, Walton J, Banning AP. Ultrasound-guided percutaneous thrombin injection of iatrogenic femoral artery pseudoaneurysms after coronary angiography and intervention. Heart. 2001;85(4):E5.
12. 12. D'Ayala M, Smith R, Zanieski G, Fahoum B, Tortólani AJ. Acute arterial occlusion after ultrasound-guided thrombin injection of a common femoral artery pseudoaneurysm with a wide, short neck. Ann Vasc Surg. 2008;22(3):473-5.
13. 13. Sheldon PJ, Oglevie SB, Kaplan LA. Prolonged generalized urticarial reaction after percutaneous thrombin injection for the treatment of a femoral artery pseudoaneurysm. J Vasc Interv Radiol. 2000;11(6):759-61.
14. 14. O'Sullivan GJ, Ray SA, Lewis JS, Lopez AJ, Powell BW, Moss AH et al. A review of alternative approaches in the management of iatrogenic femoral pseudoaneurysms. Ann R Coll Surg Engl. 1999;81(4):226-34.
15. 15. Hanson JM, Atri M, Power N. Ultrasound-guided thrombin injection of iatrogenic groin pseudoaneurysm: Doppler features and technical tips. Br J Radiol. 2008;81(962):154-63.
16. 16. Morgan R, Belli AM. Current treatment methods for post catheterization pseudoaneurysms. J Vasc Interv Radiol. 2003;14(6):697-710. 17. Agarwal R, Agrawal SK, Roubin GS, Lincolc B, Cox DA, Iyer SS et al. Clinically guided closure of femoral arterial pseudoaneurysms complicating cardiac catheterization and coronary angioplasty. Cathet Cardiovasc Diagn. 1993;30(2):96-100.
17. 18. Pezzullo JA, Dupuy DE, Cronan JJ. Percutaneous injection of thrombin for the treatment of pseudoaneurysms after catheterization: an alternative to sonographically guided compression. AJR. Am J Roentgenol. 2000;175(4):1035-40.
18. 19. Coley BD, Roberts AC, Fellmeth BD, Valji K, Bookstein JJ, Hye RJ. Postangiographic femoral artery pseudoaneurysms: further experience with US-guided compression repair. Radiology. 1995;194(2):307-11.
19. 20. Feld R, Patton GM, Carabasi RA, Alexander A, Merton D, Needleman L. Treatment of iatrogenic femoral artery injuries with ultrasound-guided compression. J Vasc Surg. 1992;16(6):832-40.
20. 21. Schaub F, Theiss W, Heinz M, Zagel M, Schömig A. New aspects in ultrasound-guided compression repair of postcatheterization femoral artery injuries. Circulation. 1994;90(4):1861-5.
21. 22. Cope C, Zeit R. Coagulation of aneurysms by direct percutaneous thrombin injection. Am J Roentgenol. 1986;147(2):383-7.
22. 23. Walker TG, Geller SC, Brewster DC. Transcatheter occlusion of a profunda femoral artery pseudoaneurysm using thrombin. Am J Roentgenol. 1987;149(1):185-6.
23. 24. Liau CS, Ho FM, Chen MF, Lee YT. Treatment of iatrogenic femoral artery pseudoaneurysm with percutaneous thrombin injection. J Vasc Surg. 1997;26(1):18-23.
24. 25. Lumsden AB, Miller JM, Kosinski AS, Allen RC, Dodson TF, Salam AA et al. A prospective evaluation of surgically treated groin complications following percutaneous cardiac procedures. Am Surgeon. 1994;60(2):132-7.
25. 26. 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.