Post-catheterization pseudoaneurysms treatment with ultrasound-guided thrombin injection

Transcription

1 Post-catheterization pseudoaneurysms treatment with ultrasound-guided thrombin injection Poster No.: C-2107 Congress: ECR 2010 Type: Topic: Scientific Exhibit Interventional Radiology Authors: A. Ladas, A. Tsikkini, E. Andipa, C. Zografou, E. Vrentzou, M. Tsouroulas; Athens/GR Keywords: DOI: thrombin injection, pseudoaneurysm, ultrasound-guided /ecr2010/C-2107 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 12

2 Purpose Iatrogenic pseudoaneurysm is one of the most common complications of diagnostic or interventional catheterization procedures with an overall incidence of up to 7,7%[1]. The incidence of pseudoaneurysm after cardiac catheterization ranges from 0,05%[2] up to 6,3%[3]. Ultrasound-guided compression is time consuming, painful and demonstrates lower success rates in patients on anticoagulants. Surgical repair, although still necessary in selected cases, requires anaesthesia and shows a high complication rate, including infection, neuralgia, prolonged hospital stay and death[4]. The purpose of this study is to assess the efficacy and safety of iatrogenic pseudoaneurysm treatment with ultrasound-guided thrombin injection. Methods and Materials Patients: This is a retrospective study of 26 iatrogenic pseudoaneurysms (PSA) in 25 consecutive patients that were treated with percutaneous ultrasound-guided thrombin injection in our institution during the period June 2006 to July Mean patient age was 65,3 years (range years). 6 patients were female. All patients had undergone diagnostic or interventional cardiac catheterizations. 21 patients were on anti-platelet and 4 on anticoagulation therapy. Procedure: A 4-7 MHz or 4-8 MHz linear array ultrasound transducer was used for the diagnosis and treatment of the pseudoaneurysms (Figure 1 on page 3). A 2-5 MHz convex array transducer was also used for better visualization of the larger pseudoaneurysms (Figure 2 on page 3). After local anaesthesia, the ultrasound transducer was placed over the pseudoaneurysm and under sterile conditions a 20G or 21G needle was inserted with the tip in the centre of the pseudoaneurysm sac. Using realtime gray-scale sonography, bovine thrombin solution (1000U/ml) was injected slowly into the pseudoaneurysm cavity without prior compression. Injections were administered in 0,1ml doses until thrombus formation was visible in the gray-scale image and colour signal was diminished, with an upper limit of 1700U (Figure3 on page 4). Page 2 of 12

3 Immediately after the procedure, the peripheral vessels were examined for complications such as arterial thrombosis using both colour and pulsed Doppler ultrasonography. Follow-up, consisting of clinical and sonographical examination, was performed one and four weeks after the procedure in all patients. Images for this section: Fig. 1: a) A simple pseudoaneurysm with a maximum diameter of 15mm originating from the common femoral artery. Typical Doppler signal from the pseudoaneurysm neck demonstrates "to and fro" flow. b) The same pseudoaneurysm after ultrasound-guided thrombin injection is completely thrombosed. There is no flow within the pseudoaneurysm chamber. Page 3 of 12

4 Fig. 2: A large pseudoaneurysm with a maximum diameter of 73,1mm in a 73-year old woman after cardiac catheterization. Large pseudoaneurysms are better visualized using a 5-2 MHz transducer. Page 4 of 12

5 Fig. 3: Thrombin injection into a simple pseudoaneurysm. The hyperechoic tip of the needle can be seen in the upper left side of the pseudoaneurysm sac. As thrombus starts to form, its echogenicity increases. Page 5 of 12

6 Results 12 pseudoaneurysms (46%) arose from the common femoral artery, 12 (46%) from the superficial femoral artery and 2 (8%) from the brachial artery (Figure1 on page 6). Mean pseudoaneurysm diameter was 35.9mm (range mm) and mean pseudoaneurysm neck length was 4.8mm (range mm) (Figure 2 on page 7). 1 pseudoaneurysm had an associated arteriovenous fistula (Figure 3 on page 8) and 3 were multilobulated (Figure 4 on page 8). 2 patients also had deep vein thrombosis. Mean thrombin dose was 803U (range U). 25 pseudoaneurysms (96.2%) were successfully thrombosed. 19 pseudoaneurysms (73.1%) with a mean diameter of 32.2mm (range mm) thrombosed on the first treatment (mean thrombin dose: 684U), whereas 6 pseudoaneurysms (23.1%) with a mean diameter of 46.3mm (range mm) required a second thrombin injection (mean thrombin dose: 900U) (Figure 5 on page 9). One patient with a pseudoaneurysm of 43.0mm in diameter, after two unsuccessful injections underwent surgical repair. No peri- or postprocedural complications such as artery thrombosis, infection or allergic reaction were noted in any patient. Moreover, there was no case with reperfusion of the pseudoaneurysm cavity at the first and second follow-up examinations. Images for this section: Page 6 of 12

7 Fig. 1: Colour duplex US image obtained in longitudinal direction in a patient with a simple pseudoaneurysm (arrow) originating from the brachial artery. Page 7 of 12

8 Fig. 2: Longitudinal colour Doppler US image obtained in a 61-year-old man demonstrates a simple pseudoaneurysm with a long neck (40mm)(arrow). There is hypoechoic thrombus in the periphery of the pseudoaneurysm sac. Fig. 3: a) Colour Doppler US image shows a pseudoaneurysm with a short neck associated with an arteriovenous fistula. b) After injection of 600U of thrombin the pseudoaneurysm thrombosed completely. Page 8 of 12

9 Fig. 4: a) A two-chamber pseudoaneurysm originating from the superficial femoral artery. b) Thrombin injection into the deeper chamber (Chamber 2) was not successful. A second trombin injection into the superficial Chamber (Chamber 1) resulted in complete pseudoaneurysm thrombosis. Page 9 of 12

10 Fig. 5: a,b) Colour Doppler US image obtained in a 78-year-old man demonstrates a simple pseudoaneurysm with a short neck originating from the superficial femoral artery. Thrombin injection resulted in partial thrombosis of the pseudoaneurysm sac. c) After a second thrombin injection, the pseudoaneurysm was occluded. Page 10 of 12

11 Conclusion Ultrasound guided thrombin injection is currently the treatment of choice for iatrogenic pseudoaneurysms in many centers, with reported success rates ranging from 91% to 100%[4-10]. In our series, complete thrombosis was achieved in 96.2% of cases. According to literature, the thrombin dose required for successful treatment is influenced by the type of the pseudoaneurysm lumen (simple vs complex) and not by the pseudoaneurysm size, patient's sex or age[9]. In a series of 54 patients, the maximum dimension, volume and neck size of the pseudoaneurysms that did not respond to treatment were similar with those that were successfully thrombosed. It is suggested that failure of thrombin injection may be the result of vessel injury (i.e. laceration) or infection[5]. In another study, however, the pseudoaneurysm size was predictive of the treatment's success[6]. In our study, pseudoaneurysms that required a second thrombin injection had a larger mean diameter (46.3mm) than those that were occluded with a single injection (mean diameter: 32.2mm); mean thrombin dose was 900U and 684U respectively. For multilobulated pseudoaneurysms, the chamber directly communicating with the feeding vessel was injected first, followed by a separate thrombin injection of the most superficial chamber if necessary. Complications of the procedure include reperfusion of previously occluded pseudoaneurysms, thromboembolic events, allergic reactions and groin pain[9]. None of these occurred in our series. In conclusion, percutaneous ultrasound-guided thrombin injection is an effective and safe method for the treatment of post-catheterization pseudoaneurysms, regardless of anticoagulation or anti-platelet therapy. Even for larger pseudoaneurysms a second thrombin injection proves to be safe, significantly reducing the need for surgical repair. References 1. Katzenschlager, R., et al., Incidence of pseudoaneurysm after diagnostic and therapeutic angiography. Radiology, (2): p Heintzen, M.P. and B.E. Strauer, [Peripheral arterial complications after heart catheterization]. Herz, (1): p Kresowik, T.F., et al., A prospective study of the incidence and natural history of femoral vascular complications after percutaneous transluminal coronary angioplasty. J Vasc Surg, (2): p ; discussion Page 11 of 12

12 4. Webber, G.W., et al., Contemporary management of postcatheterization pseudoaneurysms. Circulation, (20): p Sheiman, R.G. and M. Mastromatteo, Iatrogenic femoral pseudoaneurysms that are unresponsive to percutaneous thrombin injection: potential causes. AJR Am J Roentgenol, (5): p Vlachou, P.A., et al., Percutaneous ultrasound-guided thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms. Eur J Radiol, Schneider, C., et al., A prospective study on ultrasound-guided percutaneous thrombin injection for treatment of iatrogenic post-catheterisation femoral pseudoaneurysms. Int J Cardiol, (3): p Mohler, E.R., 3rd, et al., Therapeutic thrombin injection of pseudoaneurysms: a multicenter experience. Vasc Med, (4): p Krueger, K., et al., Postcatheterization pseudoaneurysm: results of US-guided percutaneous thrombin injection in 240 patients. Radiology, (3): p Etemad-Rezai, R. and D.J. Peck, Ultrasound-guided thrombin injection of femoral artery pseudoaneurysms. Can Assoc Radiol J, (2): p Personal Information Ladas Andreas. Ultrasound Department, GENERAL HOSPITAL of ATHENS G.GENNIMATAS, Athens, GREECE Page 12 of 12