A prospective study of ultrasound scan-guided thrombin injection of femoral pseudoaneurysm: a trend toward minimal medication.

BACKGROUND: Catheterizations and endovascular procedures in which the femoral artery is cannulated are sometimes complicated by iatrogenic pseudoaneuryms. Surgical repair of pseudoaneurysms was the treatment of choice until 1991 when compression was used in those that were small. A less uncomfortable technique involving the ultrasound scan-guided injection of thrombin (UGTI) has been used more recently. The purpose of this study was to prospectively evaluate the effectiveness of ultrasound scan-guided thrombin injection (UGTI) as a treatment of iatrogenic femoral pseudoaneurysms.
METHODS: From December 1998 to December 2000, 3734 femoral artery catheterizations were performed, and from those, 32 consecutive patients with 33 femoral pseudoaneurysms (0.88%) of less than 8 cm were prospectively enrolled for UGTI. With sterile technique, a 21-gauge or 22-gauge spinal needle was used to access the pseudoaneurysm and thrombin (100 to 6000 international units [IU]) was slowly injected until thrombosis occurred.
RESULTS: The initial success rate was 100%. Thirty-one cases (93.9%) remained successfully thrombosed with a single injection at day 30. Recurrence of two pseudoaneurysms (6.1%) was seen at day 1 and day 8. One patient had groin cellulitis develop, and the other had a bleed into the thigh after discharge; both were treated with open surgical repair. Fifteen patients underwent UGTI on an outpatient basis with 100% successful ablation. More than half of the patients were on an inpatient basis (53.1%). Hospital stay was 1 to 9 days, with 88.2% of the patients released on day 1 or 2. However, two patients had a prolonged stay: one from open repair (day 9) and the other from a gastrointestinal bleed (day 8). Pseudoaneurysms ranged from 1.7 to 7.5 cm and lasted 1 to 17 days before UGTI. Twenty-one of the patients (65.7%) continued undergoing anticoagulant therapy at the time of injection. Ten of the last 11 cases needed less than 800 IU, and nearly half of the pseudoaneurysms (49%) successfully thrombosed with less than 600 IU. No procedural complications or mortality were noted. No statistical significance was found between occurrence of the pseudoaneurysm and sheath size (with chi(2) test, P value =.05) or between the size of the pseudoaneurysm and successful thrombosis (with chi(2) test: degrees of freedom, 6 - 1 = 5; P value =.227426). A mean follow-up period of 11.8 months was documented (range, 71 to 24 months). Seven patients were lost to follow-up at less than 30 days.
CONCLUSION: Percutaneous thrombin injection of iatrogenic pseudoaneurysms is an effective treatment. Not only is it minimally painful, but it can be done as an outpatient procedure and anticoagulation therapy does not hinder the success. Minimal thrombin seems necessary to successfully treat pseudoaneurysms that may further limit procedure-related complications.