Neurointervention.  2020 Mar;15(1):25-30. 10.5469/neuroint.2019.00206.

Safety and Effectiveness of Percutaneous Low-Dose Thrombin Injection for Femoral Puncture Site Pseudoaneurysms in Neurointervention: Single-Center Experience

• Shin JH
• Song Y
• Sheen JJ
• Lee D
• Chung J
• Lee GY
• Jeong H
• Han S
• Choi JH
• Hwang SM
• Lee DH

• KMID: 2502079
• DOI: http://doi.org/10.5469/neuroint.2019.00206

Abstract

Purpose
We present ultrasound-guided percutaneous low-dose thrombin (200–250 IU) injection for the treatment of iatrogenic femoral pseudoaneurysms. Second, we compared patient and procedure factors between subcutaneous hematoma and pseudoaneurysm groups.
Materials and Methods
From April 2012 to May 2018, 8425 patients underwent neurointervention. Among these patients, 18 had small subcutaneous hematomas and 6 had pseudoaneurysms. Pseudoaneurysms in the neck and entire sac were visualized, and low-dose thrombins were injected while visualizing a “whirlpool” hyperechoic core in the pseudoaneurysm sac. Subcutaneous hematomas were treated with simple compression. We compared the following parameters between the subcutaneous hematoma group and pseudoaneurysm group: sex, age, body mass index (BMI), type of procedure, heparin usage, sheath size, procedure time, and number of previous neurointervention procedures with the Mann-Whitney U test.
Results
Most of the pseudoaneurysms were successfully occluded with 200 IU of thrombin (n=5). Only 1 pseudoaneurysm required a slightly higher thrombin concentration (250 IU, n=1). During the short-term follow-up, no residual sac was observed and no surgical repair was necessary. Pain in the groin region was alleviated. During the 1-month follow-up, no evidence of pseudoaneurysm recurrence nor subcutaneous hematoma was noted. Patient factors (sex, age, and BMI) and procedure factors (heparin usage, sheath size, procedure time, number of previous procedures) were not statistically different between the subcutaneous hematoma and pseudoaneurysm groups.
Conclusion
Ultrasound-guided percutaneous low-dose thrombin injection (200–250 IU) is safe, effective, and less invasive for treating iatrogenic femoral pseudoaneurysm in neurointervention.

Keyword

Thrombin; Arteries; Punctures

Figure

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  Fig. 1. Ultrasound-guided thrombin injection. (A, B) The most important procedure in thrombin injection is to visualize the entire sac and the location of the pseudoaneurysm neck. Carefully, the low-dose thrombin is injected as far away from the neck as possible. It is vital to keep track of the tip of the needle. (C, D) After a few seconds, swirling patterns of echogenic thrombosis (arrow) are noted. If echogenic cores are not visualized despite the injection, additional injection of 50 IU to 100 IU thrombin can be considered. After completing the procedure, manual compression and absolute bed rest are recommended.

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  Fig. 2. Thrombogenesis and occlusion within pseudoaneurysms after thrombin injection. (A, B) A 40-year-old male underwent coil embolization and complained of right inguinal pain after 10 days. The ultrasound demonstrated a small pseudoaneurysm in which low-dose thrombin injection successfully occluded the sac without inadvertently leaking the thrombin into the neck (arrow). (C, D) Similarly, a 62-yearold female underwent elective coil embolization, and a pseudoaneurysm was detected after 4 days. The entire sac and neck (arrow) were visualized and thrombin injection was performed, thereby enabling thrombogenesis and occlusion of the pseudoaneurysm. Both the patient’s pain and discomfort were alleviated, and follow-up ultrasound before discharge demonstrated no recurrence of the pseudoaneurysm.

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