Ultrasound-guided thrombin injection for treatment of femoral artery pseudoaneurysm with concomitant AV-fistula – a retrospective single centre experience
Abstract
Abstract.Background: Increasing volume of complex percutaneous endovascular procedures in highly anticoagulated patients generate a not negligible percentage of femoral pseudoaneurysms (PSA) with concomitant arteriovenous fistulas (AVF). While ultrasound-guided thrombin injection (UGTI) is the therapy of choice for PSA, concomitant AVF is regarded as a contraindication for UGTI, as venous thromboembolism is feared. In this retrospective, register-based cohort study, we report on and evaluate the use of UGTI for the treatment of PSA with AFV. Patients and methods: All patients (n = 523), who underwent UGTI for femoral PSA at the German Heart Centre Munich from January 2011 until January 2018, were retrospectively reviewed for the presence of a concomitant AVF and outcomes were recorded. Results: Forty femoral PSA/AVFs treated by UGTI were identified. The mean enddiastolic arterial-flow-velocity above the AVF, an estimate of the AVF size, was 14.61 ± 1.7 cm/sec. The Majority of patients exhibited flow-velocities < 25 cm/sec (n = 31; 77.5 %) and were on either uninterrupted oral anticoagulation (n = 32; 80 %) or dual antiplatelet therapy (n = 8). Twenty-eight (70 %) PSA/AVFs could be successfully closed by UGTI. In eight multicompartmental PSAs, partial obliteration necessitated combined treatment with manual compression, while one partial occlusion was treated by observation. There were three failures, of which two underwent covered-stent-graft-implantation and one surgical repair. One DVT (2.5 %) occurred two days after UGTI in the by far largest AVF (60 cm/sec) included in the study. Besides two late PSA recurrences treated by surgery, no other complications were observed. AVF persisted in 65 %, all of them asymptomatic. The mean follow-up was 6 ± 15.5 months. Conclusions: UGTI appears to be a treatment option in femoral PSA/AVF, at least under oral anticoagulation in small fistulas with enddiastolic arterial-flow-velocities ≤ 25 cm/sec. However, caution is necessary in larger AVFs, which should remain a contraindication for UGTI.
Literature
Femoral pseudoaneurysms after percutaneous access. J Vasc Surg. 2014;60(5): 1359–66.
.Ultrasonographic evaluation of complications related to transfemoral arterial procedures. Ultrasonography. 2018 Apr;37(2):164–73.
.Treatment for femoral pseudoaneurysms. Cochrane Database Syst Rev. 2013;(11):CD004981.
.Ultrasound Guided Compression Versus Ultrasound Guided Thrombin Injection for the Treatment of Post-Catheterization Femoral Pseudoaneurysms: Systematic Review and Meta-Analysis of Comparative Studies. Eur J Vasc Endovasc Surg. 2016;51(6): 815–23.
.Contemporary management of postcatheterization pseudoaneurysms. Circulation. 2007;115(20):2666–74.
.Treatment of iatrogenic femoral artery pseudoaneurysm with percutaneous thrombin injection. J Vasc Surg. 1997(1):18–23.
.Safety and efficacy of a potential treatment algorithm by using manual compression repair and ultrasound-guided thrombin injection for the management of iatrogenic femoral artery pseudoaneurysm in a large patient cohort. Circ Cardiovasc Interv. 2014(2):207–15.
Ultrasound-Guided Thrombin Injection Is a Safe and Effective Treatment for Femoral Artery Pseudoaneurysm in the Morbidly Obese. Vasc Endovascular Surg. 2017;51(6):368–72.
.Comparison of Ultrasound-Guided Thrombin Injection of Iatrogenic Pseudoaneurysms Based on Neck Dimension. Ann Vasc Surg. 2018 Feb;47:121–7.
, et al.Vascular complications after percutaneous mitral valve repair and venous access closure using suture or closure device. J Interv Cardiol. 2018;31(2):223–9.
, et al.Ultrasound-guided compression closure of postcatheterization pseudoaneurysms during concurrent anticoagulation: a review of seventy-seven patients. J Vasc Surg. 1996;23(1):28–34, discussion 34–5.
.A prospective evaluation of surgically treated groin complications following percutaneous cardiac procedures.Am Surg. 1994 Feb;60(2):132–7.
, et al.Ultrasound Guided Percutaneous Injection of Thrombin: Effective Technique for Treatment of Iatrogenic Femoral Pseudoaneurysms. J Clin Diagn Res. 2017; 11(4):TC04–TC06.
.Ultrasound-guided thrombin injection for the treatment of postcatheterization pseudoaneurysms. Circulation. 2000;102(19):2391–5.
.Treatment of iatrogenic femoral pseudoaneurysm by ultrasound-guided compression therapy and thrombin injection. Angiology. 2007;58(4):435–9.
, et al.Impact of obesity on venous hemodynamics of the lower limbs. J Vasc Surg. 2010;52(3):664–8.