10 YEARS OF EXPERIENCE IN ULTRASOUND-GUIDED THROMBIN INJECTION, A SAFE AND EFFECTIVE TECHNIQUE IN FEMORAL PSEUDOANEURYSM TREATMENT
Introduction: Increased percutaneous vascular procedures lead to a growth in access-related complications, the most common of which is pseudoaneurysm (PA). Nowadays, femoral PA first-line treatment is ultrasound-guided thrombin injection (UGTI).
Methods: An observational retrospective study was designed. Patients who underwent UGTI on a tertiary hospital, from 2008 to 2018 were included. Data were collected from medical records. Primary endpoint was UGTI success (primary PA occlusion and after US revaluation PA occlusion). Secondary endpoints were procedure-related complications, reinterventions, hospitalization duration and survival.
Results: 102 patients were included. 97% of PA had a confirmed iatrogenic etiology. 4% were diagnosed after a vascular procedure and 85% after cardiology procedure, 80% of which after coronary catheterization and 13% after TAVI (transcatheter aortic valve implantation). 58% of patients where on antiplatelets and 50% on anticoagulation therapy. 80% of PA was located on the right groin. 65% affected CFA and 35% affected SFA or PFA. PA mean diameter was 36,8mm. 29% of PA were lobulated (complex PA). Regarding PA neck, 58% had long neck (length ≥3mm) and 58% had narrow neck (width <3mm). Median time from iatrogenic trauma to UGTI was 6 days. 89% of PA showed primary occlusion after UGTI; this rate decreased to 73% after US revaluation. 16% of patients repeated UGTI, 5% more than once. We identified no procedure-related complications. Complex PA were associated with lower rates of PA occlusion on US revaluation (p=0,012). We found no association between occlusion rates and affected artery, antithrombotic medication, PA diameter, neck length or width. 6% of patients underwent femoral PA surgical procedure (most of them after more than 2 UGTI); one underwent an endovascular repair procedure. After UGTI, hospitalization median time was 3 days, longer after TAVI compared with coronary catheterization (p=0,006). Patients mean survival was 97±2% at 1 month, 86±4% at 1 year e 60±7% at 5 years, with no significant difference between different PA etiologies.
Conclusion: UGTI is a safe and effective modality for PA treatment. We can expect that 1/6 of patients will need more than one UGTI to achieve expected success; this risk is higher in complex PA. Despite good results, some patients will continue to require surgical procedures.
2. Siracuse JJ, Mckinsey JF. Local Endovascular Complications and Their Management, Rutherford's Vascular Surgery and Endovascular Therapy. 2019;
3. Kontopodis N, Tsetis D, Tavlas E et al. Ultrasound Guided Compression Versus Ultrasound Guided Thrombin Injection for the Treatment of Post-Catheterization Femoral Pseudoaneurysms: Systematic Review and Meta-Analysis of Comparative Studies, Eur J Vasc Endovasc Surg. 2016; 51, 815e823;
4. NICE, Thrombin injections for pseudoaneurysms, Interventional procedures guidance. 2004;
5. Valesano JC, Schmitz JJ, Kurup AN et al. Outcomes of Ultrasound-Guided Thrombin Injection of Nongroin Arterial Pseudoaneurysms, J Vasc Interv Radiol. 2017; 28:1156–1160;
6. Yoo T, Starr JE, Go MR et al. Ultrasound Guided Thrombin Injection is a Safe and Effective Treatment for Femoral Artery Pseudoaneurysm in the Morbidly Obese, Vasc Endovascular Surg. 2017; 51(6): 368–372;
7. Sizemore G, Ayubi F, Clark B et al. Ultrasound-guided percutaneous thrombin injection following iatrogenic femoral artery pseudoaneurysm: patient selection and perspectives, Journal of Vascular Diagnostics and Interventions. 2018; 6: 1–5;
8. Mishra A, Rao A, Pimpalwar Y. Ultrasound Guided Percutaneous Injection of Thrombin: Effective Technique for Treatment of Iatrogenic Femoral Pseudoaneurysms, Journal of Clinical and Diagnostic Research. 2017; Vol-11(4): TC04-TC06;
9. Toursarkissian B, Allen BT, Petrinec D, et al. Spontaneous closure of selected iatrogenic pseudoaneurysms and arteriovenous fistulae. J Vasc Surg. 1997;60(2):803–808
10. ElMahdy MF, Kassem HH, Ewis EB et al. Comparison Between Ultrasound-Guided Compression and Para-Aneurysmal Saline Injection in the Treatment of Postcatheterization Femoral Artery Pseudoaneurysms, Am J Cardiol. 2014; 113:871e876;
11. Yang EY, Tabbara MM, Sanchez PG et al. Comparison of Ultrasound-Guided Thrombin Injection of Iatrogenic Pseudoaneurysms Based on Neck Dimension, Ann Vasc Surg. 2018; 47: 121–127;
12. INFARMED, Resumo das características do medicamento: Tisseellyo, associação, pó e solvente para cola para tecidos;
13. Pająk M, Hasiura R, Stępień T. Safety evaluation of percutaneous ultrasound-guided thrombin injection into pseudoaneurysm, Pol Przegl Chir. 2019; 91 (2), 19-23.