Duplex scanning-guided thrombin injection for the treatment of iatrogenic pseudoaneurysms

Purpose: This study presents our current results with duplex scanning-guided thrombin injection (DGTI) for the treatment of lower-extremity iatrogenic pseudoaneurysms (PAs). These results were compared with the results from our patient population that was treated with duplex scanning-guided compression (DGC). Methods. This was a prospective evaluation of an institutional review board-approved protocol for ultrasound scanning-guided thrombin injection for the treatment of iatrogenic lower-extremity PAs. The maneuver was performed with continuous real-time color ultrasound scanning imaging to guide a needle into a PA sac. Then 0.5 to 1.0 mL of a thrombin solution (1000 U/mL) was injected, and thrombosis of the sac was monitored. Ail patients underwent an arterial evaluation of the involved extremity before and after thrombin injection. In addition, the size of the PA and its parent artery were documented by means of pre-injection imaging. After thrombosis of the PA, the patient was kept on bed rest for 4 hours, and activity was Limited that day (bathroom privileges for inpatients). Follow-up imaging was performed after 24 hours, and attempts were made to obtain imaging I week and I month after injection. Results. In the 31 months of the study, 131 iatrogenic PAs of the lower extremity were initially treated with DGTI, and thrombosis was achieved in 126 of these cases (96%). Thrombosis of the PA sac was accomplished within seconds of thrombin injection. Five cases failed, three of which resulted from complications of the procedures, with two intra-arterial thrombin injections and one PA rupture after thrombosis. Conclusion: Our experience indicates that DGTI is more effective than DGC (96% vs; 75%) in the treatment of iatrogenic lower-extremity PAs. The DGTI procedure is completed in minutes, compared with a mean compression time of 44 minutes with DGC, which leads to increased patient and operator acceptance. Intra-arterial thrombin injection was seen in 4% of PAs that were 2.6 cm or smaller and resulted in limb-threatening ischemia requiring surgical intervention. Finally, the use of a biopsy guide attached to the ultrasound scanning transducer head simplifies the visualization of the needle, reducing the number of needle punctures and needle manipulation.