AJR 2000; 175:485-487
© American Roentgen Ray Society
Successful Sonographically Guided Thrombin Injection in an Infant with a Femoral Artery Pseudoaneurysm
Donald P. Frush1,
Erik K. Paulson1 and
Martin P. O'Laughlin2
1
Department of Radiology, Duke University Medical Center, Durham, NC
27710.
2
Department of Pediatrics, Division of Pediatric Cardiology, Duke University
Medical Center, Durham, NC 27710.
Received December 21, 1999;
accepted after revision January 17, 2000.
Address correspondence to D. P. Frush, Department of Radiology, Division of
Pediatric Radiology, Erwin Rd., Hospital North, Rm. 1508D, Durham, NC
27710.
Introduction
Posttraumatic pseudoaneurysms in children are rare
[1,2,3].
Because of this, there is little information regarding treatment
[1]. Therapy for these
pseudoaneurysms in adults includes surgical repair and, since Fellmeth et
al.'s [4] description in 1991,
sonographically guided compression repair
[5]. Recently, percutaneous
sonographically guided injection of thrombin into pseudoaneurysms has been
reported as a viable alternative to other techniques
[6,
7]. However, we are unaware of
any report of successful and uncomplicated use of this technique in neonates,
infants, or small children [3].
We describe the technique we used for sonographically guided percutaneous
thrombin injection that resulted in successful thrombosis of a pseudoaneurysm
in an infant.
Subject and Methods
An 8-month-old female infant with critical aortic stenosis underwent
valvuloplasty via a 4-French sheath in the left femoral artery. Femoral access
was uncomplicated, the platelet count was normal, and she was not
anticoagulated. Two hours after removal of the sheath with routine groin
compression, she developed progressive pain and swelling at the puncture site
and above the inguinal ligament. The hemoglobin level decreased from a
baseline of 10.4 to 7.0 mg/dL, necessitating a packed RBC transfusion. CT was
performed to evaluate for active extravasation (Figs.
1A and
1B). Based on the clinical
course and findings on CT, a compression dressing was applied and the patient
was monitored; she remained stable in the intensive care unit overnight. A
Doppler sonogram that was obtained the next morning showed a partially
thrombosed pseudoaneurysm of the left common femoral artery near the origin of
the epigastric artery. The flow lumen cavity was 1.5 cm in diameter. The neck
was 7.0 mm in length with a diameter of 3.0 mm
(Fig. 1C). Sonographically
guided compression was aborted when it appeared to transiently increase the
diameter of both the neck and flow lumen.
View larger version (112K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —Left femoral artery pseudoaneurysm in 8-month-old female infant who
had undergone cardiac catheterization. Contrast-enhanced axial CT scan at
level of upper pelvis shows large mass in pelvic wall. Note contrast-opacified
pseudoaneurysm flow lumen (arrows). Dense contrast material in
urinary bladder (B) resulted from recent cardiac catheterization.
|
|
View larger version (146K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —Left femoral artery pseudoaneurysm in 8-month-old female infant who
had undergone cardiac catheterization. Contrast-enhanced axial CT scan
obtained at slightly lower level in pelvis than A shows neck of
pseudoaneurysm (arrow).
|
|
View larger version (65K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1C. —Left femoral artery pseudoaneurysm in 8-month-old female infant who
had undergone cardiac catheterization. Color Doppler sonogram of left inguinal
region shows common iliac artery (thick straight arrows) and vein
(solid curved arrow). Note neck of pseudoaneurysm (open
arrow) and partially thrombosed pseudoaneurysm (thin straight
arrows).
|
|
After a discussion with members of cardiology and vascular surgical
services, sonographically guided percutaneous administration of thrombin was
planned. If this procedure was unsuccessful, surgical repair would follow.
Once signed informed consent was obtained from the parents, the infant was
taken to the operating room and anesthesia was administered. After sterile
preparation of the left groin was performed, the pseudoaneurysm was localized
sonographically (HDI 5000; Advance Technology Laboratories, Bothell, WA) using
a variable-bandwidth (8-5-MHz) sector transducer. A solution of bovine
thrombin (Johnson & Johnson, Middleton, WI) was prepared with sterile
water at a concentration of 1000 U/mL.
The technique for injection of thrombin was similar to that of Kang et al.
[6]. The solution was drawn
into a 1.0-mL syringe. Using gray-scale sonographic guidance, a 22-gauge
spinal needle was positioned (no needle guide was used) so that the tip was
visualized in the pseudoaneurysm flow lumen but was directed away from the
neck. Subsequently, color Doppler sonography was used while slowly injecting
the thrombin solution (Figs.
1D,1E,1F).
Ten seconds after initiation of the injection of a total volume of 0.2 mL of
solution, there was complete cessation of flow within the flow lumen and neck.
No thrombus was identified within the lumen of the artery.
View larger version (46K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1D. —Left femoral artery pseudoaneurysm in 8-month-old female infant who
had undergone cardiac catheterization. Longitudinal color Doppler sonogram
obtained just before sonographically guided injection of thrombin shows
external common femoral artery (thick straight arrow), region of neck
(curved arrow), and flow in cavity (thin straight
arrows).
|
|
View larger version (39K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1E. —Left femoral artery pseudoaneurysm in 8-month-old female infant who
had undergone cardiac catheterization. Longitudinal color Doppler sonogram
obtained at approximately 5 sec after initiation of sonographically guided
injection of thrombin shows decreased amount of flow within cavity
(arrow).
|
|
View larger version (64K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1F. —Left femoral artery pseudoaneurysm in 8-month-old female infant who
had undergone cardiac catheterization. Longitudinal color Doppler sonogram
obtained at 10 sec after initiation of sonographically guided injection of
thrombin shows no flow in pseudoaneurysm cavity.
|
|
The patient required no further transfusion, and the lower extremity pulses
and blood pressures remained normal and symmetric. A 24-hr follow-up Doppler
sonogram showed persistent pseudoaneurysm thrombosis and a patent femoral
artery. The patient was discharged that afternoon. A Doppler sonogram obtained
1 week later revealed a decrease in the size of the abdominal wall hematoma,
normal common and superficial femoral arteries, and no recurrence of the
pseudoaneurysm.
Discussion
Thrombin is an enzyme that converts fibrinogen to fibrin, a critical step
in coagulation. Recent reports in adults indicate that sonographically guided
injection of thrombin into femoral pseudoaneurysms is an excellent alternative
to surgery or sonographically guided compression repair
[6,
7]. Compared with
sonographically guided compression repair, the advantages of thrombin
injection include minimal pain, decreased reliance on sedation, substantially
more rapid thrombosis (with decreased need for radiology resources), and
higher success rates [7].
Although all these advantages are compelling justifications for using
thrombin, the method has received little attention in infants and
children.
To our knowledge, only one report of thrombin injection into a
pseudoaneurysm in an infant has been reported
[3]. In this case, thrombin was
administered into a brachial artery pseudoaneurysm with a neck diameter of 3.0
mm (the length was not specified). Thrombin injection caused an acute brachial
artery thrombosis, requiring emergent thrombectomy. The authors advised
against percutaneous thrombin administration in infants and small children and
suggested the risk of thrombosis is higher in children than in adults because
of the relatively small size of the underlying artery
[3]. However, several important
technical considerations that could affect the success of the procedure were
not specified. These include transducer selection and use of a guide, the
potential risk of antecedent sonographically guided compression repair, the
orientation of the needle tip with respect to the neck, the size of the
syringe, and the duration of injection
[3]. Although we agree that the
technique is potentially more problematic in children, we have shown that
sonographically guided thrombin injection in an infant can be successful.
Because of the risk of arterial thrombosis, we administered general
anesthesia and performed this procedure in the operating room. General
anesthesia provided optimal control by preventing unexpected movements during
injection. The setting was chosen because an emergent thrombectomy with repair
of the vessel could be quickly performed. In adults, minimal or no sedation is
necessary and the procedure can be performed in an outpatient setting
[7]. It may be shown that
similar technique can be used in the pediatric population after increased
experience with thrombin injection.
Careful selection of appropriate transducers is also critical. Needle
guides are generally used for adult injections
[7]. However, freehand needle
placement may be used in young children. Many attachable needle guides cannot
be used with the small-foot-plate transducers necessary for superficial
vascular sonography in children. In addition, some needle-guide systems may be
more difficult to use considering the superficial nature of pseudoaneurysms in
children who have little subcutaneous fat.
It has been suggested that thrombin injection is more difficult to perform
in adults after failed sonographically guided compression repair
[7]. In our patient, we noted a
transient distortion of the pseudoaneurysm neck with increased flow during a
brief trial of direct compression. In children, it is possible that a longer
period of sonographically guided compression repair could result in a more
persistent distortion of the pseudoaneurysm with an increase risk of thrombin
entering the native artery.
The amount of thrombin required to thrombose a pseudoaneurysm in children
is unknown but is likely less than that required in adults, as suggested by
our total volume of 0.2 mL. In adults, Paulson et al.
[7] used volumes ranging from
0.1 to 0.6 mL (mean, 0.35 mL). Thrombin is an extremely potent thrombogen.
Therefore, the rate of injection should be slow, over 10-20 sec or until
thrombosis occurs. Careful real-time monitoring of the pseudoaneurysm flow
during injection should decrease the possibility of excess thrombin
administration, which would place the patient at risk for downstream
embolization. Before thrombin injection, it is critical to delineate the
anatomy of the pseudoaneurysm with particular attention to the relationship of
the flow lumen and neck to the underlying artery. Thrombin should be injected
away from the neck to decrease the possibility of thrombin escaping the flow
lumen. Finally, we recommend the use of a small syringe, such as a tuberculin
syringe, to decrease the possibility of inadvertent overinjection of
thrombin.
The long-term success and the complications of this procedure are unknown.
Until more extensive evaluation is available in children, we recommend
follow-up sonographic examination 24-48 hr after the injection unless clinical
features warrant earlier evaluation.
In conclusion, sonographically guided thrombin injection, a viable method
of treatment for pseudoaneurysms in adults, can also be successful in infants.
This new technique obviates sonographically guided compression repair or
surgical intervention [1].
Meticulous technique is critical because this procedure can be even more
challenging to perform in infants than in adults.
References
-
Nehler MR, Taylor LM, Porter JM. Iatrogenic vascular trauma.
Semin Vasc Surg
1998;11:283
-293[Medline]
-
Vitiello R, McCrindle BW, Nykanen D, et al. Complications
associated with pediatric cardiac catheterization. J Am Coll
Cardiol 1998;32:1433
-1440[Abstract/Free Full Text]
-
Lennox A, Griffin M, Nicolaides A, Mansfield A. Regarding
"percutaneous sonogram guided thrombin injection: a new method for
treating postcatheterization femoral pseudoaneurysms" (letter).
J Vasc Surg
1998;28:1120
-1121[Medline]
-
Fellmeth BD, Roberts AC, Bookstein JJ, et al. Post-angiographic
femoral artery injuries: nonsurgical repair with US-guided compression.
Radiology
1991;178:629
-630[Free Full Text]
-
Coley BD, Roberts AC, Fellmeth BD, Valji K, Bookstein JJ, Hye RJ.
Postangiographic femoral artery pseudoaneurysms: further experience with
US-guided compression repair. Radiology
1995;194:307
-311[Abstract/Free Full Text]
-
Kang SS, Labropoulos N, Mansour MA, et al. Percutaneous sonogram
guided thrombin injection: a new method for treating postcatheterization
femoral pseudoaneurysms. J Vasc Surg
1998;27:1032
-1038[Medline]
-
Paulson EK, Sheafor DH, Kliewer MA, et al. Treatment of iatrogenic
femoral pseudoaneurysms: comparison of US-guided thrombin injection with
compression repair. Radiology
2000;215:403
-408[Abstract/Free Full Text]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Introduction
Subject and Methods
