1. Medstar Washington Hospital Center, Washington DC
Safety and Efficacy of Ultrasound-Guided Thrombin Injections at the ‘Neck’ of Pseudoaneurysms
Salem Badr, Vinay Gupta, Hironori Kitabata, Israel M. Barbash, Saar minha, , Lakshmana K Pendyala, Jousha P Loh, Rebecca Torguson, Fang Chen,
William O. Suddath, Lowell F. Satler, Augusto D. Pichard, Ron Waksman, Nelson L Bernardo.
Medstar Washington Hospital Center, Washington DC

2. I/we have no real or apparent conflicts of interest to report.
Salem Badr, MD
I/we have no real or apparent conflicts of interest to report.

3. Background Vascular Access Sites: Femoral artery
Most commonly used in the US
Radial artery
Distal pedal artery – DP, PT, Peroneal
Brachial artery
Popliteal artery
Axillary artery
Ulnar artery

4. Vascular Access for Catheterization
Vascular access complications will happen
Diagnostic caths: %
Therapeutic/PCI: %
Factors: Patient, Anti-coagulation Tx, anti-platelet Tx, bigger sheath size, delayed sheath removal, etc.
Complications lead to:
Morbidity/Mortality
Increased length of stay
Adds to health care cost

5. Complications: Femoral Artery Access
Femoral artery complications: 2-10%
Complications:
Groin Hematoma
(1-10%)
Pseudoaneurysm
(1-6%)
AV fistula
(<1%)
Retroperitoneal bleed
( %)
Acute closure
Dissection (intimal)
Vessel Laceration
Neural injury
Infection
Venous thrombosis (+/- right heart cath)
Sheath/catheter clot

6. Pseudoaneurysm (PSA):
False lumen that occurs at an arterial puncture site and contains active flowing arterial blood – ‘pulsatile hematoma’
False Aneurysm resulting from:
Penetrating or Blunt Trauma
Iatrogenic
Orthopaedic surgery, Arterial reconstruction
Arterial puncture site – ‘Low stick’, ??Hemostatic technique

7. Pseudoaneurysm (PSA):
Signs & Symptoms
Pain
Tenderness +/- Ecchymosis
Pulsatile mass
+ Systolic bruit
Diagnostic tool
Ultrasound ‘duplex’ scan
r/o concomittant A-V fistula

8. R Common Femoral Artery PSA
PSA: Duplex scan – CFA PSA
R Common Femoral Artery PSA

9. Pseudoaneurysm (PSA): Tx Options
Conservative Therapy
‘Watch and Wait’
~ < 2-3 cm in size
89% spontaneous closure in 2 months
< 3 cm size and Asymptomatic
Toursarkissian, B. et. al. J Vasc Surg 1997;25(5):
External Mechanical Compression
Application of Femo-stop
Painful and time-consuming
??success rate

10. Pseudoaneurysm (PSA): Tx Options
Ultrasound-guided Compression
Introduced in Fellmeth, B. et. al. Radiology 1991;178:671.
Painful and time-consuming (1-2 hours)
Variable results ~ 74% effective
Percutaneous Thrombin Injection
Treatment of choice
2-3% failure/repeat rate
Case selection to avoid catastrophy
Risk: Distal embolization

11. Pseudoaneurysm When do we treat PSA? Symptomatic patients
PSA size > cm diameter
Low threshold ~ on anti-coagulation
~ ??dual anti-platelet
~ ??follow-up compliance
~ complex PSA > 1 lobe

12. PSA: Percutaneous Thrombin Injection
Equipments/Materials:
Thrombin – reconstitute 1:1000 units/ml and use tuberculin syringe
Lidocaine – local anesthesia
Spinal needle 21 gauge
Trocar prevents insinuation of tissue into needle lumen
1-2 cm of needle tip is “scored” by scalpel to make needle sonolucent
Ultrasound machine + probe

13. Thrombin Injection of PSA: Step-by-step
Check ABI (Ankle-Brachial index)
Baseline and post-injection
Prep Groin
Betadine
Local anesthesia
From Reeder, S.B. et. al. AJR 2001;177:

14. Thrombin Injection of PSA: Step-by-step
Correctly identify vessels/structures
??concomittant A-V fistula
Check doppler flow signal of each structure

15. Thrombin Injection of PSA: Step-by-step
Ideal PSA Morphology
‘Long’ and ‘Narrow’ neck
How ‘short is short’ or ‘wide is wide’ ?
Very subjective, operator-dependent

16. Percutaneous Thrombin Injection of PSA
Make the neck ‘narrow’
Inject normal saline to the neck region
Watch the neck narrows
‘Enter’ PSA cavity and inject Thrombin
From Finkelstein, A. et. al. Am J Cardiolo 2008;

17. Thrombin Injection of PSA: Step-by-step
Under direct ultrasound guidance, insert spinal needle
Direct needle to the “neck” area

18. Thrombin Injection of PSA: Step-by-step
Needle  just above the ‘neck’ of the PSA

19. Successful PSA Thrombin Injection
Check post-procedure ABI
Repeat arterial duplex scan following morning

20. PSA: WHC Experience NTI STI
Between March 2008 and June 2012, 146 consecutive patients underwent thrombin injection for post PCI.
Ninety-one patients had superficial thrombin injection (STI) and 55 patients had neck thrombin injection (NTI).
STI
NTI

21. PSA: WHC Experience
Baseline characteristics for anti-platelet use, anticoagulation therapy given, number of lobes, length and width of neck of the PSAs were similar in both groups.

22. Variables
NTI
(n = 56)
STI
(n = 91)
p value
Amount of thrombin[IU]
Mean (SD)
(920)
(1384.7)
0.02
Neck length [mm]: min;max
0; 2.43
0.76 (0.56)
0.13; 3.3
1.06 (0.66) NS
Neck width [mm]:
min; max
0.1; 2.0
0.67 (0.47)
0.1; 2.3
0.78 (0.47)
Number of sacs: 1 2 3
37 (66.1%)
15 (26.8%)
4 (7.1%)
57 (62.6%)
28 (30.8%)
6 (6.6%)
Success
56 (100%)
87 (96.7%)
Recurrence
2 (3.8%)
11 (12.6%)
The NTI technique utilized lesser amount of Thrombin with a trend to a higher success rate and lesser recurrence.

23. In Summary:
Successful vascular access with uncomplicated hemostasis of the access site is key to the success of any invasive procedure and avoid any access site complications.
Thrombin injection at the “neck” of PSA is safe and efficacious in the treatment of femoral artery pseudoaneurysms.
Proper training and case selection are critical to optimize outcomes and avoid complications.

24. Thank you