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Technical Innovation |
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.
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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.
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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.
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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.
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  S. G. Friedman, J. S. Pellerito, L. Scher, G. Faust, B. Burke, and T. Safa Ultrasound-Guided Thrombin Injection Is the Treatment of Choice for Femoral Pseudoaneurysms Arch Surg, April 1, 2002; 137(4): 462 - 464. [Abstract] [Full Text] [PDF]
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 J. A. Pezzullo and M. T. Wallach Successful Percutaneous Thrombin Injection of a Brachial Artery Pseudoaneurysm in a Neonate Am. J. Roentgenol., January 1, 2002; 178(1): 244 - 245. [Full Text] [PDF]
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