超声造影在凝血酶封堵股动脉假性动脉瘤中的应用意义

目的探讨超声造影在凝血酶封堵股动脉假性动脉瘤（PSA）中的应用意义。方法选取2012--2013年3月因股动脉穿刺引起的假性动脉瘤患者30例,假性动脉瘤35个,其中20个彩色多普勒诊断瘤腔大小形态明确,瘤颈部显示清晰,常规封堵一次成功。15个动脉瘤显示不满意,表现瘤腔呈多形性,瘤体较大,或出现瘤中瘤、瘤旁瘤,在常规封堵时不完全或不成功,在造影剂指导下行再封堵术,观察瘤体、瘤颈部形态,再次指导手术进针通路,观察瘤体封堵效果及造影剂的流向。结果15个假性动脉瘤行再封堵术时在术前造影均能良好显示,能观察到瘤颈部,可明确超声引导通道,术中封堵过程中可见瘤腔内造影剂迅速消退,血栓形成,假腔封闭,术后可清晰观察到股动脉边缘及封堵效果。术后随访24h及3～5d均无复发及并发症发生。结论在凝血酶封堵股动脉假性动脉瘤中,超声引导起着关键作用,特别对于瘤颈及瘤腔显示不满意,瘤腔呈多形性,瘤体较大,或出现瘤中瘤、瘤旁瘤的患者,术前行超声造影可提高手术治愈率。     

Treatment of iatrogenic femoral pseudoaneurysms with percutaneous thrombin injection: experience in 54 patients

PURPOSE: To assess the clinical success of ultrasonography (US)-guided thrombin injection for the treatment of iatrogenic femoral pseudoaneurysms and to identify criteria that may predispose to treatment failure. MATERIALS AND METHODS: Fifty-four iatrogenic femoral pseudoaneurysms were treated with US-guided thrombin injection. Forty-five were classified as simple (single lobe) and nine, as complex (at least two lobes and a single neck to the native vessel). Pseudoaneurysm volume, classification, thrombin dose, anticoagulation therapy status, and sheath size were compared between failed and successful cases. Seven- to 10-day follow-up US and a minimum 4-month clinical follow-up were also performed to evaluate success. RESULTS: Fifty of 54 pseudoaneurysms were successfully treated with topical thrombin without complication and included all 45 simple and five of nine complex pseudoaneurysms. US follow-up in all 50 successful cases and clinical follow-up in 37 of these revealed no recurrence. Only a complex pseudoaneurysm classification was significantly associated with failure (P<.01). Among the complex pseudoaneurysms, successful cases involved two injections and a total thrombin dose of at least 1,500 units. In failed cases, pseudoaneurysms were treated with a single injection of 1,000 units, initially thrombosed, and recurred. CONCLUSION: Simple iatrogenic femoral pseudoaneurysms, regardless of size or concomitant anticoagulation therapy, can be treated with a single injection of up to 1,000 units of topical thrombin and require no follow-up. Complex pseudoaneurysms will likely require a second injection (total thrombin dose of at least 1,500 units) and short-term clinical and US follow-up to ensure successful treatment.     

超声对凝血酶注射法治疗医源性股动脉假性动脉瘤的短期和中期疗效监测

目的:超声监测凝血酶注射法治疗医源性股动脉假性动脉瘤的短期和中期疗效.方法:在超声引导下对65例介入术后所致股动脉假性动脉瘤瘤腔内行凝血酶注射法.结果:65例凝血酶注射法治疗,术后24～48h成功率100％.63例患者3个月监测时2例复发,余患者假性动脉瘤均消失或血肿明显缩小.6个月随访时所有患者假性动脉瘤均完全消失.结论:凝血酶注射法治疗股动脉假性动脉瘤操作简单、安全有效,超声对其短期和中期监测显示疗效较好.     

Iatrogenic femoral pseudoaneurysms that are unresponsive to percutaneous thrombin injection: potential causes

OBJECTIVE: We sought to determine whether any quantitative selection criteria can be established to predict which pseudoaneurysms of the common femoral artery will fail to respond to thrombin. SUBJECTS AND METHODS. Under sonographic guidance, we injected thrombin into 54 consecutive iatrogenic pseudoaneurysms of the common femoral artery. We statistically compared the volume, maximum dimension, and neck diameter of the pseudoaneurysms and thrombin doses injected into the successfully treated (persistent thrombosis on a follow-up duplex sonogram obtained 7-10 days after thrombin injection) and unresponsive (sonographically documented recurrence within 24 hr) pseudoaneuryms to determine whether any of these factors could help to predict a failure to respond to thrombin. For all patients in whom treatment failed, findings at surgical repair were noted and sonograms were reviewed to confirm the dimensions and appearance of the pseudoaneurysm and the absence of an associated arteriovenous fistula. RESULTS: Complete and persistent thrombosis was achieved in 49 (91%) of the 54 common femoral artery pseudoaneurysms. In comparing the 49 successfully treated patients and the five patients in whom treatment failed, we identified no significant differences in the volume, maximum dimension, or neck diameter of the pseudoaneurysm (two-sample t test) or in the thrombin dose (Wilcoxon's rank sum test). In all five patients with failed treatment, an arteriotomy site laceration measuring at least 8.0 mm (n = 4) or infection (n = 1) was identified at surgical repair, none of which were identifiable even in retrospect on duplex and color Doppler sonography. CONCLUSION: Failure of an iatrogenic pseudoaneurysm of the common femoral artery to respond to thrombin may indicate an occult vascular injury. In these patients, surgical repair, rather than reinjection of thrombin, should be considered.     

Ultrasound-guided thrombin injection of femoral artery pseudoaneurysms.

OBJECTIVE: To evaluate whether the positive initial results for ultrasound-guided percutaneous thrombin injection of pseudoaneurysms, reported predominantly in small retrospective series, would be supported in a larger prospective trial. METHODS: In April 1999, our institution adopted ultrasound-guided thrombin injection as the initial treatment for post-catheterization arterial pseudoaneurysm. Colour Doppler imaging delineates the pseudoaneurysm, its neck and the adjacent artery. A 22-gauge spinal needle is attached to a 1-mL syringe preloaded with thrombin at a concentration of 1000 U/mL. Under ultrasound guidance, the needle tip is positioned within the pseudoaneurysm, and real-time colour Doppler imaging is used to monitor the pseudoaneurysm as thrombin is slowly injected. Thrombus formation commences almost immediately, and in most cases, occlusion is complete within 5 seconds. RESULTS: We successfully treated 61 pseudoaneurysms in 61 consecutive patients. The amount of thrombin injected ranged from 20 U to 3000 U (mean 435 U); 55 pseudoaneurysms were successfully treated after a single injection, and 6 patients required a repeat injection for complete occlusion. One patient had 2 pseudoaneurysms treated on consecutive days, and 1 developed a symptomatic vasovagal reaction, which was treated conservatively. No other significant procedural complications were encountered. Fifty-nine patients had a follow-up groin Doppler sonogram between 1 and 5 days after treatment. CONCLUSION: Ultrasound-guided percutaneous thrombin injection is an effective, simple, fast and safe treatment for post-catheterization arterial pseudoaneurysm. It has replaced ultrasound-guided compression repair at our institution and is now our treatment of choice.     

Treatment of femoral artery pseudoaneurysms using ultrasound-guided thrombin injection

Femoral artery pseudoaneurysms, a complication of femoral arterial puncture, is increasing in frequency with the proliferation of endovacular interventions. Pseudoaneurysms have historically been treated by open surgical repair, and more recently by ultrasound-guided compression. Ultrasound-guided compression is painful, and has a relatively low success rate of 51% to 73%. Since 1991, ultrasound-guided thrombin injection has become a treatment option. During injection of thrombin into a pseudoaneurysm, immediate thrombosis can be demonstrated within seconds. The entire procedure can be accomplished within 5 minutes, is simple to learn, and can be performed safely on an outpatient basis.     

Low-dose thrombin injection to treat iatrogenic femoral artery pseudoaneurysms

OBJECTIVE: Treatment of iatrogenic femoral artery pseudoaneurysms with thrombin injection has been reported as an efficacious and safe procedure. The major risk of this procedure is distal limb ischemia from thrombosis, resulting from thrombin escape. The cumulative average dose of thrombin reported in the literature is approximately 1100 U per patient. Minimizing the thrombin dose may reduce the risks of the procedure. This study reports our experience with low-dose thrombin injection for the treatment of pseudoaneurysms. MATERIALS AND METHODS: Twenty-three patients with 26 postcatheterization femoral pseudoaneurysms were administered thrombin injection with color-flow Doppler sonographic guidance. Pseudoaneurysm volume ranged from 1 to 41 cm(3) with an average of 6.7 cm(3) and a median of 4 cm(3). Two patients received therapeutic doses of IV heparin for anticoagulation. When possible, the neck of the pseudoaneurysm was occluded during the injection to promote stagnation and prevent thrombin leakage. Sonographic follow-up was routinely performed after 24 hr. RESULTS: An average dose of 192 U of thrombin was used (range, 50-450 U), and time to coagulation ranged from 10 to 60 sec. All 26 pseudoaneurysms were successfully thrombosed, although one required repeated treatment because of recanalization noted at 1-day follow-up. There were no complications. CONCLUSION: Doses of thrombin at an average of fivefold lower than previously reported were effective in the treatment of 26 iatrogenic femoral pseudoaneurysms, even in the presence of anticoagulation. This experience shows that a much smaller dose of a potentially dangerous medication can achieve the same efficacy as previously used higher doses.     

Iatrogenic femoral pseudoaneurysms: thrombin injection after failed US-guided compression

Fifteen iatrogenic femoral pseudoaneurysms failed ultrasonography (US)-guided compression treatments. Despite concomitant antiplatelet or anticoagulation treatment, the 15 pseudoaneurysms were successfully and definitively treated without complication with US-guided thrombin injection. Results in this preliminary study suggest US-guided thrombin injection is a safe, expeditious, low-cost, and comfortable definitive treatment for femoral pseudoaneurysms that has advantages over both US-guided compression and open surgical repair.     

Percutaneous injection of human thrombin to treat iatrogenic femoral pseudoaneurysms: short- and midterm ultrasound follow-up

Our objective was to determine the efficacy of ultrasound-guided direct injection of human thrombin to close postcatheterization pseudoaneurysms and to evaluate the midterm results of this new percutaneous technique by ultrasound follow-up. One hundred one postcatheterization pseudoaneurysms in 100 patients were treated by direct injection of human thrombin (mean dose 200 IU, range 50–750 IU) under ultrasound guidance. Patient demographics, clinical data and ultrasonographic morphology of the pseudoaneurysms were analyzed. Midterm (mean 99 days, range 25–210 days) ultrasonographic follow-up was performed in 57 of 82 called patients (69.5%). Ninety-six of 101 pseudoaneurysms thrombosed completely after the first procedure. Of the remaining 5 pseudoaneurysms, 3 were treated successfully after the second attempt, and 2 patients underwent surgical repair; thus, the primary success rate was 95% (96 of 101), and the overall success rate was 98% (99 of 101). No changes in distal pulses or other adverse events were noted immediately or 1 day after the procedure. Ultrasound follow-up revealed complete disappearance of the pseudoaneurysm in 70% (40 of 57), presence of small, residual groin hematoma in 26% (15 of 57), and partial reperfusion of the pseudoaneurysm in 3.5% (2 of 57). Human thrombin injection under ultrasound guidance is a very effective and safe method of therapy. Failure (immediate and late) of the technique as well as procedure-related complications are very rare. In our institution, sonographically guided human thrombin injection has become the treatment of choice for postcatheterization pseudoaneurysms. Electronic Publication     

Treatment of iatrogenic femoral artery pseudoaneurysms using ultrasound-guided injection of thrombin

AIM: To evaluate the use of ultrasound-guided percutaneous injection of thrombin for treatment of femoral artery pseudoaneurysms. METHOD: Nine patients with a confirmed femoral false aneurysm were included in the study. 0.5-1 ml of a 2000 U/ml solution of activated bovine thrombin was injected under ultrasound visualization into the neck of the aneurysm to induce thrombosis. The parent artery and adjacent major vessels were checked during and after the procedure to exclude propagation of thrombus. A check ultrasound examination was undertaken on the following day. RESULTS: Eight patients were successfully treated by a single injection. One patient required a second injection due to recurrence of their pseudoaneurysm 4 days after the initial treatment. The procedure was well tolerated in all cases and no complications were encountered. CONCLUSION: This small series provides further evidence that ultrasound-guided thrombin injection is a promising new method for the treatment of femoral false aneurysms.Hughes, M. J. et al. (2000). Clinical Radiology55, 749-751.     

Treatment of femoral pseudoaneurysms. Percutaneous US-guided thrombin injection versus US-guided compression

Purpose:
Thrombin injection in femoral pseudoaneurysms has been suggested to be superior to traditional US-guided compression. Our aim was to evaluate results with compression therapy with special reference to use of thrombin in case of failure. We also studied 7 patients who underwent primary thrombin injection. Material and Methods:
We retrospectively reviewed all (n=44) femoral artery pseudoaneurysms diagnosed at our department during October 1998-May 1999. US-guided compression with the Femostop device or US-guided thrombin injection (100-1000 IU) was the first choice according to the physicians' preference, followed by the other regime if the first choice was non-successful. Results:
Thirty-nine (89%) of the patients received anticoagulation treatment and/or concomitant antiplatelet drugs. Out of the 44 patients, 37 were treated with compression as the first choice. This regime was successful in 22 (59%). This group included 2 lesions that resolved spontaneously after initially failed compression and 1 deep venous thrombosis after treatment. The persistent 15 pseudoaneurysms after failed compression received thrombin injection, and it was also the primary therapy in 7 patients. Complete thrombosis within the pseudoaneurysm was immediately induced after treatment. One early recurrence required a second injection. No complication of thrombin was noted and no surgery was required. Conclusion:
US-guided thrombin injection is an effective treatment for embolisation of pseudoaneurysms. The technique is superior to compression therapy.     

Percutaneous ultrasound-guided thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms

Purpose

To audit our experience with ultrasound-guided thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms.

Methods

A retrospective study of 85 consecutive patients undergoing percutaneous ultrasound-guided thrombin injection of post-catheterization femoral pseudoaneurysms during the period January 2002 to May 2007.

Results

Pseudoaneurysms had a mean maximum diameter of 3.3 cm (range 1.0-7.6 cm) and a mean neck width of 3.4 mm (range 1.0-7.0 mm). No statistically significant correlation existed between maximum diameter and neck width (Kendall's rank correlation tau b = −0.09, p = 0.5). The median dose of thrombin injected was 425 U (range 100-1500 U). The procedure resulted in complete sac thrombosis in 81 (95%) patients. Seventy-nine pseudoaneurysms thrombosed immediately after one injection, whereas two required a second thrombin injection. There were no procedural complications. The maximum diameter of the pseudoaneurysm was predictive of procedural success (Wilcoxon's rank sum test, p = 0.001) and of the 5 patients with a pseudoaneurysm measuring ≥6 cm, ultrasound-guided thrombin injection was unsuccessful in 4 (4/5 versus 0/80, p < 0.0001, Fisher's exact test). Three of these necessitated implantation of a stent-graft, whereas one required repeated thrombin injection and coil placement. In contrast, the pseudoaneurysm neck width did not seem to relate to the success of the procedure.

Conclusion

Percutaneous ultrasound-guided thrombin injection of is a quick, effective and safe treatment for iatrogenic femoral pseudoaneurysms. For larger pseudoaneurysms, although it is worth attempting more than one thrombin injection, endovascular repair may eventually be required.     

Treatment of iatrogenic femoral arterial pseudoaneurysms: comparison of US-guided thrombin injection with compression repair

PURPOSE: To evaluate and compare the treatment of iatrogenic femoral arterial pseudoaneurysms by using ultrasonographically (US) guided direct thrombin injection with US-guided compression repair. MATERIALS AND METHODS: Twenty-six patients with iatrogenic femoral arterial pseudoaneurysms were treated with direct thrombin injection. With US guidance, a 22-gauge needle was placed into the pseudoaneurysm flow lumen and thrombin (mean volume, 0.35 mL; range, 0.10-0.60 mL) was injected with continuous color Doppler US guidance. Demographics, clinical variables, pseudoaneurysm characteristics, and results in these patients were compared with those in 281 consecutive patients who underwent US-guided compression repair. RESULTS: The success rate of thrombin injection was 96% (25 of 26 patients), which was significantly higher than that of compression, 74% (209 of 281 patients) (P =.013). Twenty of 26 (77%) patients required a single injection, and six (23%) required two injections. Mean thrombosis time for thrombin injection was 6 seconds, compared with 41.5 minutes for compression. For thrombin injection, there were no complications, foot pulses did not change and no patients required conscious sedation. Follow-up US at 24 hours showed no recurrent pseudoaneurysms. CONCLUSION: For the treatment of iatrogenic femoral arterial pseudoaneurysms, thrombin injection with US guidance appears to be superior to compression repair.     

Sonographically guided thrombin injection of iatrogenic femoral pseudoaneurysms: further experience of a single institution.

OBJECTIVE: In September 1998, we began to treat iatrogenic femoral pseudoaneurysms with direct thrombin injection under sonographic guidance. Our purpose was to determine the success and complication rate of this technique. SUBJECTS AND METHODS: We treated 114 consecutive patients who had iatrogenic femoral pseudoaneurysms using direct thrombin injection. A 22-gauge spinal needle was placed into the pseudoaneurysm lumen with sonographic guidance, and bovine or human thrombin (mean dose, 306 U; range, 50--1600 U) was injected under continuous color Doppler sonographic visualization. Distal pulses were monitored. Patient demographics, clinical variables, and pseudoaneurysm characteristics were collected. RESULTS: One hundred three (90%) of 114 patients had pseudoaneurysm thrombosis after the first procedure. Of the remaining 11 patients who required a second procedure 1 day later, thrombosis occurred in seven (64%) of 11. Thus, the overall success rate was 96% (110/114). Of the patients who required one injection, the mean thrombosis time was 12 sec (range, 3--90 sec). Three (3%) of 114 patients required conscious sedation. Of the patients with successful thrombosis, 24-hr follow-up sonograms showed no recurrent pseudoaneurysm. Four patients (4%) had potential complications: a "blue toe" 15 hr after the thrombin injection that resolved spontaneously, a groin abscess, leg ischemia that resolved spontaneously after 4 hr, and crampy buttock pain that resolved spontaneously. CONCLUSION: For the treatment of iatrogenic femoral pseudoaneurysms, thrombin injection under sonographic guidance is a quick and effective method of therapy. Failures and complications are infrequent. At our institution, sonographically guided thrombin injection has replaced compression repair.     

Percutaneous ultrasound-guided thrombin injection for coagulation of post-traumatic pseudoaneurysms

Most peripheral pseudoaneurysms are iatrogenic or, less commonly, post-traumatic. Pseudoaneurysms are associated with characteristic findings of a pulsatile palpable mass and an audible to and fro murmur. The diagnosis can be easily confirmed using colour duplex ultrasound. A successful treatment for the coagulation of pseudoaneurysms as an alternative to ultrasound-guided manual compression is described. The method involves ultrasound-guided direct percutaneous injection of a small quantity of thrombin through a fine needle. This technique is simple and effective, resulting in rapid occlusion of the pseudoaneurysm. Two cases are reported.     

超声引导下注射凝血酶治疗医源性股动脉假性动脉瘤

目的:探讨超声引导下瘤腔内注射凝血酶治疗医源性股动脉假性动脉瘤的方法及其可行性和安全性.方法:6例患者因行股动脉穿刺于术后2～5 d发生6处股动脉假性动脉瘤,均在彩色多普勒超声定位下通过瘤腔内注射凝血酶进行治疗,治疗后即刻超声复查,并定期随访.结果:4例患者4处假性动脉瘤一次性注射凝血酶300～500 U后瘤腔即刻闭合,随访10～90 d,假性动脉瘤无复发.2例患者2处假性动脉瘤瘤体较大,第1次注射后于第3 d复发,行第2次注射后,假性动脉瘤无复发.其中1例患者出现一过性肢体栓塞临床表现,经观察后肢体栓塞临床表现消失,未特殊处理.6例患者均未出现过敏反应等并发症.结论:瘤腔内注射凝血酶治疗医源性股动脉假性动脉瘤是一种创伤小、有效、安全的方法,但操作时需注意瘤体的大小及凝血酶的用量.