Percutaneous ultrasonographically guided thrombin injection of iatrogenic pseudoaneurysms in unusual sites

To evaluate the effectiveness and safety of percutaneous ultrasonographically guided thrombin injection as treatment of unusually positioned and unusually large iatrogenic pseudoaneurysms.

Five patients with iatrogenic pseudoaneurysms were evaluated by color duplex ultrasonography. Two patients had additional digital angiography, and 2 had additional computed tomographic angiography. In 3 of the patients, large, painful iatrogenic pseudoaneurysms located proximal (2 patients) and distal (1 patient) to the arteriovenous hemodialysis fistulas had developed, most likely due to erroneous puncture of the arterial side (brachial artery) or venous side (cephalic vein) of the fistulas. An iatrogenic pseudoaneurysm of the anterior tibial artery had developed in the fourth patient after osteotomy of the fibula, and an iatrogenic pseudoaneurysm of the superficial femoral artery had developed in the fifth patient after erroneous puncture during venous transfemoral angiography. With a sterile technique and color duplex ultrasonographic guidance, a diluted solution of bovine thrombin was slowly injected directly into the iatrogenic pseudoaneurysms until cessation of blood flow was seen. Follow-up color duplex ultrasonography was performed 24 to 48 hours after the ultrasonographically guided thrombin injection.

Four iatrogenic pseudoaneurysms were successfully thrombosed during 1 session. Two large iatrogenic pseudoaneurysms necessitated multiple repositions of the injecting needle and several injections of small amounts of thrombin into the residual patent lumen to induce complete thrombosis without an appreciable increase in the total thrombin dosage. Follow-up examinations revealed complete and persistent thrombosis without evidence of distal embolization. One iatrogenic pseudoaneurysm involving the cephalic vein, distal to an arteriovenous hemodialysis fistula, recurred after apparently successful initial thrombosis.

Most iatrogenic pseudoaneurysms are amenable to ultrasonographically guided thrombin injection as long as they are imaged adequately by color duplex ultrasonography.