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St. Francis Hospital and Medical Center Hartford, CT 06105
In their recent article, Eisenberg et al. [1] review the results of their 306 consecutive attempts to accomplish sonographically guided compression repair of groin pseudoaneurysms after catheterization and conclude that this technique is an effective alternative to surgery. Nevertheless, they believe that the failure rate is higher than initially reported and that the recently described nonsurgical approach of sonographically directed thrombin injection may be an attractive alternative.
Sonographically guided thrombin injection should replace compression repair as the front-line treatment of pseudoaneurysms after catheterization.
First, several reports [2,3,4] show that thrombin injection succeeds in close to 100% of patients, even in patients undergoing anticoagulation therapy who, the authors in these studies found, were among the most likely to fail sonographically guided compression repair.
Second, overcoming the drawbacks Eisenberg et al. [1] ascribe to the compression method, thrombin injection can be done safely, quickly, and painlessly with a lasting effect.
Third, in my own practice, in which most femoral pseudoaneurysm patients are referred by cardiologists days to weeks after cardiac catheterization and coronary stenting, I have found that the compression technique is painful and labor intensive and that it fails in 80% of patients. Now, with thrombin injection, we have successfully treated 21 consecutive patients presenting as late as 2 weeks after catheterization and with pseudoaneurysms as large as 6 cm. All injection procedures were completed in less than 15 min. Many patients reported immediate pain relief as the pulsatile component of their hematoma was occluded.
Further, although I understand that the exclusive purpose of Eisenberg et al. [1] was to evaluate their experience with sonographically guided compression and that most of their patients were treated before publication of the literature describing the use of thrombin, I would ask whether they too have replaced compression with injection.
References
Duke University Medical Center Durham, NC 27710
Dr. Feld submits that sonographically guided thrombin injection should replace compression repair as the first line of therapy for iatrogenic pseudoaneurysms. We agree.
Although compression repair is relatively safe and effective, it has considerable limitations [1]. The procedures are lengthy, painful for patients, exhausting for physicians, and require conscious sedation. The success rate is only approximately 75% and even lower if patients are receiving anticoagulation therapy. Finally, compression repair rarely causes pseudoaneurysm rupture.
We have also adopted sonographically guided thrombin injection as the first line of therapy for iatrogenic pseudoaneurysms [2]. Like Feld, we have found these procedures to be effective and quick to perform. Based on our experience with 80 consecutive patients (Paulson et al., to be presented at the American Roentgen Ray Society annual meeting, May 2000), the success rate was 76 (95%) of 80 patients, mean thrombosis time was 10 sec (compared with approximately 45 min for compression), and only two (3%) of 80 patients required conscious sedation. Two complications occurred. Fifteen hours after thrombin injection, one patient developed a "blue toe" that resolved spontaneously. The second patient developed a groin abscess 2 weeks after thrombin injection. Additional advantages of thrombin injection include its effectiveness in pseudoaneurysms not amenable to compression, including those located above the inguinal ligament, those that are tender, those in patients receiving anticoagulation therapy, and those in which flow cannot be arrested despite extreme effort.
However with any new technique, particularly a gratifying one in which the results are quick and dramatic, it is prudent to proceed with caution. Thrombin is an extremely potent promoter of thrombosis: "a little dab will do you." Accordingly, to reduce the possibility of inadvertently injecting enough thrombin to cause a downstream embolic complication, we use a 1-ml tuberculin syringe to better control delivery. During injection, it is necessary to monitor the pseudoaneurysm flow with color sonography to identify the development of a thrombus that usually occurs in seconds. It is also critical to understand the anatomy of the pseudoaneurysm lest one inadvertently inject thrombin into the underlying femoral artery. Some pseudoaneurysms that are small or deeply located may be difficult to accurately puncture with a needle. Patients with such pseudoaneurysms may be better served by compression repair or by waiting for spontaneous thrombosis. Finally, patients exposed to bovine thrombin may rarely develop abnormalities in hemostasis related to the formation of antibodies to bovine factor V that may cross-react with human factor V (package insert; Johnson & Johnson, Middleton, WI). Second applications of this product may increase the likelihood of such an allergic response. The Food and Drug Administration recently approved a thrombin (Thrombin-JMI; Johnson & Johnson) product derived from pooled human plasma. Use of the human product should decrease the possibility of an allergic reaction. Physicians should be aware that neither the bovine nor the human products have been approved for IV injection.
Reported experience based on relatively small patient numbers indicates sonographically guided thrombin injection is effective. Large patient numbers will be required to refine the indications, limitations, and true complications of this technique. We agree: stop compressing, start injecting. However, we are obliged to continue to critically analyze this technique as we gain experience.
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  K. Krueger, M. Zaehringer, D. Strohe, H. Stuetzer, J. Boecker, and K. Lackner Postcatheterization Pseudoaneurysm: Results of US-guided Percutaneous Thrombin Injection in 240 Patients Radiology, September 1, 2005; 236(3): 1104 - 1110. [Abstract] [Full Text] [PDF]
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K. Kruger, M. Zahringer, F.-D. Sohngen, A. Gossmann, O. Schulte, C. Feldmann, D. Strohe, and K. Lackner Femoral Pseudoaneurysms: Management with Percutaneous Thrombin Injections--Success Rates and Effects on Systemic Coagulation Radiology, February 1, 2003; 226(2): 452 - 458. [Abstract] [Full Text] [PDF]
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