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Sonographically Guided Thrombin Injection of latrogenic Femoral Pseudoaneurysms

Further Experience of a Single Institution

Erik K. Paulson1, Rendon C. Nelson1, Charles E. Mayes2, Douglas H. Sheafor1, Michael H. Sketch, Jr.2 and Mark A. Kliewer1

1 Department of Radiology, Duke University Medical Center, Box 3808, Durham, NC 27710.
2 Department of Cardiology, Duke University Medical Center, Durham, NC.



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  		Fig. 1. —Drawing illustrates percutaneous injection of thrombin directly into pseudoaneurysm lumen. Using attachable biopsy guide, 22-gauge spinal needle is advanced into lumen, carefully avoiding pseudoaneurysm neck and underlying artery. Once needle is in position, thrombin is slowly injected. Flow in lumen is monitored with color or power Doppler sonography. Formation of thrombus generally occurs within seconds. (Reprinted with permission from [22])

 


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  		Fig. 2A. —65-year-old woman with pulsatile groin mass identified 2 days after coronary angioplasty. Transverse color Doppler sonogram at groin puncture site shows 1.5 x 2.2 cm pseudoaneurysm. Pseudoaneurysm neck and femoral artery are not shown on this image.

 


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  		Fig. 2B. —65-year-old woman with pulsatile groin mass identified 2 days after coronary angioplasty. Using gray-scale sonographic technique, 22-gauge needle is passed into lumen. Note echogenic needle tip (arrow). Particular care is taken to avoid underlying artery and pseudoaneurysm neck.

 


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  		Fig. 2C. —65-year-old woman with pulsatile groin mass identified 2 days after coronary angioplasty. Transverse color Doppler sonogram obtained 12 sec after injection of 650 U of thrombin shows complete thrombosis of lumen. Echogenic material (arrows) represents fresh thrombus.

 


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  		Fig. 3. —66-year-old woman with persistent pseudoaneurysm flow after injection of 300 U of thrombin. Power Doppler sonogram shows thin crescent of flow (arrow) about peripheral aspect of partially thrombosed pseudoaneurysm (arrowheads). Sonographically guided compression was performed for 1 min and resulted in complete thrombosis. Second injection of thrombin was not performed. Follow-up color Doppler sonogram (not shown) showed complete pseudoaneurysm thrombosis.

 


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  		Fig. 4A. —80-year-old man with groin pseudoaneurysm after coronary angioplasty. Transverse color Doppler sonogram shows 3 x 3 cm pseudoaneurysm. Two white lines (arrows) represent anticipated path of needle (using attachable biopsy guide).

 


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  		Fig. 4B. —80-year-old man with groin pseudoaneurysm after coronary angioplasty. Transverse color Doppler sonogram obtained immediately after injection of 600 U of thrombin shows that pseudoaneurysm thrombosed completely. However, persistent flow was identified in pseudoaneurysm neck (arrow). This persistent flow was not treated with second injection of thrombin.

 


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  		Fig. 4C. —80-year-old man with groin pseudoaneurysm after coronary angioplasty. Transverse color Doppler sonogram of groin obtained 1 day after thrombin injection shows thrombosis of pseudoaneurysm neck (arrow).

 


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  		Fig. 5A. —72-year-old woman with pulsatile mass at right groin puncture site. Color Doppler sonogram shows right groin pseudoaneurysm that was subsequently successfully treated with 100 U of thrombin. Two white lines represent anticipated path of needle.

 


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  		Fig. 5B. —72-year-old woman with pulsatile mass at right groin puncture site. Color Doppler sonogram obtained after patient returned to clinic 7 days later with pain, erythema, and tenderness at puncture site shows fluid collection (arrows) at site of treated pseudoaneurysm. Subsequent incision and drainage revealed purulent material containing Staphylococcus aureus.

 

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