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Ann Thorac Surg 2002;74:S1413-S1415
© 2002 The Society of Thoracic Surgeons
a Cardiopulmonary Research Science and Technology Institute (CRSTI), Dallas, Texas, USA
* Address reprint requests to Dr Edgerton, 7777 Forest Lane, Suite A323, Dallas TX 75230, USA.
e-mail: edgertonjr{at}aol.com
Presented at the Eighth Annual Cardiothoracic Techniques and Technologies Meeting 2002, Miami Beach, FL, Jan 23–26, 2002.
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Abstract |
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METHODS: From June 1998 to November 2001, a total of 47 femoral artery pseudoaneurysms in 46 patients were treated by bedside ultrasound-guided injection of dilute topical thrombin. All pseudoaneurysms occurred after femoral access for transcatheter procedures, and were diagnosed clinically and confirmed with ultrasound imaging. Clinical follow-up was performed and included ultrasound (2 hours to 1 month) in 64.4% of patients, including any patient with a symptomatic or clinical change.
RESULTS: Pseudoaneurysms ranged in size from 1.5 to 4.5 cm. Of 47 pseudoaneurysms, 45 were successfully obliterated on the initial injection. After successful obliteration of pseudoaneurysm, 1 patient sustained thrombosis of the tibioperoneal trunk that required surgical embolectomy, yielding a complication rate of 2%. Four pseudoaneurysms recurred after initially successful obliteration. In 1 of these cases, the patient was taken directly to surgery, and 3 were successfully treated with repeat injection, for an overall success rate of 93.6%.
CONCLUSIONS: Obliteration of femoral artery pseudoaneurysm by injection is safe and effective, and may be associated with decreased morbidity. Recurrent pseudoaneurysms may be safely reinjected, with a high success rate.
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Introduction |
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Seeking a treatment associated with less morbidity, Fellmeth [8] introduced ultrasound-guided compression repair in 1991. With this treatment, flow into the pseudoaneurysm is halted by applying pressure with the ultrasound probe to the pseudoaneurysm neck, and maintaining such pressure until spontaneous thrombosis of the pseudoaneurysm cavity occurs. This therapy, however, has its own set of associated morbidities. Compression is painful and frequently requires conscious sedation. It is time consuming, with mean compression times ranging from 30 to 104 minutes [5, 9–16]. The overall success rate for ultrasound-guided compression repair ranges from 47% to 100% [5, 9], with recurrence rates as high as 30% in the patients receiving anticoagulation treatment [17, 18].
To obviate the problems of ultrasound-guided compression repair, a new technique of pseudoaneurysm obliteration was developed. In 1986, Cope and Zeit [19] reported percutaneous injection of thrombin to thrombose an iliac, femoral, and peroneal pseudoaneurysm as well as a true hepatic aneurysm. In 1987, Walker and colleagues [20] described transcatheter injection of thrombin into a femoral artery pseudoaneurysm. Based on this precedent work, both Kuay and colleagues [21] in 1997, and Kang and associates [22] in 1998, described percutaneous thrombin injection for obliteration of postcatheterization femoral artery pseudoaneurysms. We adopted this technique in 1998. Here we review our series to evaluate the safety and efficacy of this new procedure.
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Material and methods |
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Technique
Fully informed consent was obtained from each patient; this included discussion of the relatively recent development of the technique of thrombin injection and of the long experience with more traditional surgical therapy. A thorough examination of the arterial vasculature of the affected extremity is performed, including an assessment of the ankle pulses and a Doppler assessment of the patency of the popliteal artery and the trifurcation. Bedside preparation and draping of the groin is performed, and the echo probe within a sterile pouch is positioned directly over the pseudoaneurysm. Obtaining a small area of cutaneous local anesthesia with 1% lidocaine facilitates the procedure, as sometimes several approaches are attempted before the successfully locating the pseudoaneurysm with a longer needle. With the color mode turned off, a 21- or 22-gauge spinal needle is passed obliquely from caudad to cephalad and the tip positioned within the pseudoaneurysm cavity. Although it is sometimes difficult to visualize the shaft of the needle, the tip becomes echo dense as soon as a small thrombus forms upon it. In addition, confirmation of successful cannulation of the pseudoaneurysm is obtained when red blood drips freely from the hub of the needle. It is important not to have previously flushed this needle with thrombin solution or it will promptly occlude with thrombus. The tip of the needle is positioned within the center of the pseudoaneurysm, attempting to keep it away from the neck. A small syringe containing several milliliters of bovine thrombin at 1,000 U/mL dilution is now attached to the spinal needle. A quanity of 0.5 to 1 mL is injected into the pseudoaneurysm cavity. The echogenicity should immediately increase, and absence of flow is confirmed by switching back to color flow mode. Large pseudoaneurysms and multiloculated pseudoaneurysms will sometimes require repeated injections.
When absence of flow within the pseudoaneurysm is confirmed, the needle is withdrawn and the drapes are removed from the groin. An immediate assessment of the ankle pulses is performed and an echocardiographic examination of the superficial femoral, popliteal artery, and trifurcation is performed to confirm their patency. As a precaution, we maintain the patient on bed rest for 2 hours, reasoning that any small nonthrombosed lobulations will proceed to clot off during this period. The patient is then encouraged to ambulate, and is allowed to be discharged in several hours if otherwise clinically appropriate.
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Results |
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The three recurrent pseudoaneurysms that underwent repeat injection all had an enduring result, with no further occurrence on follow-up. Of interest, two of these pseudoaneurysms were in 1 patient who was on both aspirin and IIb IIIa platelet inhibition and sustained bilateral recurrences at 2 weeks after successful bilateral obliteration. Success bilateral reinjections were performed after discontinuation of the IIb IIIa platelet inhibitor. All patients were given aspirin. Although almost three quarters of the patients were also given IIb IIa platelet inhibitors, only in this 1 patient did the pseudoaneurysms recur during IIb IIa therapy.
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Comment |
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Taylor and colleagues [24] argue for using a more dilute preparation of thrombin (100 U/mL), believing that a lower dose of thrombin is safer. However, in their series, injection volumes ranged from 1 to 6 mL, with the average volume of thrombin injected being 3 mL. Although he did not observe any instances of native vessel thrombosis, we are concerned that the larger volume of injection necessary with this more dilute preparation may overfill smaller aneurysms and risk washout of thrombin into the native vasculature.
Our single episode of native vessel thrombosis occurred in a patient who had a short and relatively wide pseudoaneurysm neck. Accordingly, we try to avoid thrombin injection therapy in patients with a very short or very wide flow channel leading from the femoral artery to the pseudoaneurysm cavity. We believe that these patients are at an increased risk for thrombin solution washing out of the pseudoaneurysm cavity and into the native vasculature.
Although we did not witness any arteriovenous fistulae in our series, there is a reported case of massive pulmonary embolism after injection of a pseudoaneurysm with an associated arteriovenous fistula [25]. Caution is advised when treating a pseudoaneurysm with an associated arteriovenous fistula.
Finally, there are several reported cases of hypersensitivity reaction after exposure to bovine thrombin. The most common reaction is that of hypotension and bradycardia [26], although anaphylaxis has been reported [27]. In addition, there are several reported cases of immune complex reaction to bovine thrombin resulting in antibody formation, which may cross-react with the coagulation cascade, resulting in factor inhibition and clinical coagulopathy [28–32]. We witnessed no such reactions in our series.
In summary, we believe that obliteration of an iatrogenic pseudoaneurysm by thrombin injection is safe, effective, and accompanied by low morbidity, allowing an early return to activity.
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