| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Technical Innovation |
1
Department of Diagnostic Imaging, Dalhousie University and Queen Elizabeth II
Health Sciences Centre, 1796 Summer St., Halifax, N. S., B3H 2Y9 Canada.
2
Present address: Department of Radiology, Hospital of the University of
Pennsylvania, 3400 Spruce St., Philadelphia, PA 19104.
Received March 7, 2000;
accepted after revision August 1, 2000.
Presented at the annual meeting of the American Roentgen Ray Society,
Washington, DC, May 2000.
Introduction
 Top Introduction Materials and MethodsResultsDiscussionReferences |
|---|
|
TopIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
The procedure for sonographically guided thrombin injection was as follows. After informed consent was obtained, limited sonography was repeated to confirm the dimensions and orientation of the femoral pseudoaneurysm and to localize the neck (Figs. 1A,1B,1C,1D and 2A,2B,2C,2D). All sonographic examinations were performed with an HDI 3000 scanner (Advanced Technology Laboratories, Bothell, WA) using a high-frequency (7 MHz) linear array transducer. After localization, an assistant applied suprasystolic manual pressure to the neck using sonographic guidance. The transducer was next repositioned, if necessary, to optimize visualization of the pseudoaneurysm lumen. Using local anesthesia and sterile technique, a 25-gauge needle was advanced into the lumen of the pseudoaneurysm with real-time sonographic guidance. A solution of thrombin (Thrombostat; Parke-Davis, Scarborough, Ontario, Canada [1000 U in 1.0 mL]) was injected until an end point of thrombosis was reached, requiring 600-1000 U of thrombin. Thrombosis was associated with the immediate formation of a heterogeneous, solid echotexture to the lumen. The needle was removed and color Doppler sonography of the groin was performed with color gain set to maximum sensitivity to confirm complete thrombosis of the pseudoaneurysm. Pedal pulses were monitored before and after injection of thrombin. Patients remained on bed rest for 2 hr after thrombin injection. Patients were followed up clinically for recurrence, and Doppler sonographic examinations were performed 24 hr after the procedure.
|
|
|
|
|
|
|
|
A retrospective chart review of the sonographically guided compression group was performed. In those patients, sonographically guided compression was performed using standard technique as previously described [3]. Medical and procedural records and sonographic images were reviewed for determination of outcomes.
For both groups, patient demographics, catheterization procedure, sheath size, coagulation status at the time of thrombin injection or compression, maximum diameter of the pseudoaneurysm, successful thrombosis, and time to thrombosis were recorded.
Patient age, pseudoaneurysm diameter, and time to thrombosis were compared using unpaired Student's t tests. Introducer sheath size used during catheterization was compared between each group using Wilcoxon's rank sum test. Fisher's exact test was used to compare initial and overall success between the two groups. For all analyses, a p value of less than 0.05 was considered statistically significant.
|
TopIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
From January 1994 to July 1998, 19 postcatheterization femoral artery pseudoaneurysms were diagnosed using sonography. Of these, five were treated conservatively, and two underwent surgical repair. The remaining 12 patients were referred for sonographically guided compression. Twenty-four-hour Doppler sonography was performed on 11 patients.
The two groups were similar in terms of patient age and mean pseudoaneurysm diameter. There was a significant difference between the median introducer sheath size, 5 French in the sonographically guided thrombin injection group and 7 French in the sonographically guided compression group (p = 0.003). there was also a significant difference between the mean procedure times of the two groups, less than 1 min for sonographically guided thrombin injection and 22 min for sonographically guided compression (p = 0.0008). Initial procedural success occurred in all patients in the sonographically guided thrombin injection group (n = 16) and in nine of 12 patients in the sonographically guided compression group. The overall procedural success rose to 11 of 12 patients in the sonographically guided compression group. Of the patients who initially failed sonographically guided compression (n = 3), thrombosis was achieved in two after a second attempt at sonographically guided compression that was performed after anticoagulation therapy was stopped. The third patient was treated surgically because the second attempt at sonographically guided compression was too painful despite conscious sedation. All five patients undergoing anticoagulation in the sonographically guided thrombin injection group were successfully treated. Only half the patients undergoing anticoagulation in the sonographically guided compression group (n = 4) were treated successfully.
There were no complications associated with either procedural group. No patients in the sonographically guided thrombin injection group required analgesia; one patient in the sonographically guided compression group required conscious sedation.
|
TopIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
Our study suggests sonographically guided thrombin injection is more efficient than sonographically guided compression. Complete thrombosis was achieved in a mean procedure time of less than 1 min in the sonographically guided thrombin injection group compared with a mean time of 22 min to achieve thrombosis in the sonographically guided compression group (p < 0.0008). These results are also comparable with those of published series [1, 4,5,6]. In the sonographically guided thrombin injection group, all patients required only one injection of thrombin; three patients in the sonographically guided compression group required repeated compression.
Anticoagulation, specifically heparin, is a significant risk factor for the failure of sonographically guided compression [1, 7]. In our sonographically guided compression group, two of four patients undergoing anticoagulation failed compression initially, but their pseudoaneurysms were successfully thrombosed after reversal of anticoagulation. Within the sonographically guided thrombin injection group, all anticoagulated pseudoaneurysms (n = 5) were successfully thrombosed without a need for reversal of anticoagulation. The ability to treat femoral artery pseudoaneurysms while maintaining anticoagulation is highly advantageous in cardiac patients.
Although we observed no complications associated with sonographically guided thrombin injection or sonographically guided compression in our study, there are legitimate safety concerns with the intravascular administration of bovine thrombin, including thromboembolic events and allergic reactions. Total intravascular thrombin doses of up to 10,000 U have been used clinically to treat esophageal and gastric varices without significant side effects. Our modified technique involving simultaneous compression of the pseudoaneurysm neck during sonographically guided thrombin injection is intended to minimize the possibility of thrombin extravasation into the arterial circulation. Exposure to bovine thrombin preparations promotes the development of antibodies against thrombin and other coagulation factors [8] with the potential for allergic reactions or disseminated intravascular coagulation. For this reason, at our institution we do not treat a patient who has had a previous exposure to thrombin.
We did observe a difference in introducer sheath size between the two groups; the patients in the sonographically guided compression group had larger sheaths placed during catheterization than those in the sonographically guided thrombin injection group (p = 0.003). This could have accounted for the failures in the sonographically guided compression group.
In summary, this single-institution series indicates that a technique of simultaneous compression of the pseudoaneurysm neck and sonographically guided thrombin injection is a simple, well tolerated, and superior treatment for postcatheterization femoral artery pseudoaneurysms compared with conventional sonographically guided compression, especially in the patients undergoing anticoagulation. Further evaluation of this technique is warranted.
|
TopIntroductionMaterials and MethodsResultsDiscussionReferences |
|---|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
This article has been cited by other articles:
|
|
 |
|
  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]
|
|
|
|
 |
|
 E. R Mohler III, M. E Mitchell, J. P Carpenter, D E. Strandness Jr, M. R Jaff, J. A Beckman, and M. Gerhard-Herman Therapeutic thrombin injection of pseudoaneurysms: a multicenter experience Vascular Medicine, November 1, 2001; 6(4): 241 - 244. [Abstract] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
