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Vascular and Interventional Radiology |
1 From the Department of Radiology (K.K., M.Z., D.S., J.B., K.L.) and Institute for Medical Statistics, Informatics and Epidemiology (H.S.), University of Cologne, Joseph-Stelzmann-Str, 50924 Cologne, Germany. Received April 26, 2004; revision requested June 15; final revision received October 8; accepted October 19. Address correspondence to K.K. (e-mail: Karsten.Krueger{at}uni-koeln.de).
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS: The university institutional review board approved the study. Informed consent was obtained from all patients. Two hundred forty patients with postcatheterization femoral artery (n = 132) or brachial artery (n = 8) pseudoaneurysms were treated with US-guided bovine thrombin (1.000 IU/mL) injection. At diagnosis, 107 (44.6%) patients received anticoagulation therapy; 159 (66.2%), antiplatelet therapy; and 76 (31.7%), both therapies. Pseudoaneurysm size, length and width of pseudoaneurysm neck, thrombin dose, therapy outcome, and complications were documented. The peak blood flow in peripheral arteries was determined before and after thrombin injection. Follow-up duplex US was performed 12–24 hours, 5–7 days, and 21–25 days after treatment. A nonpaired t test was used to compare differences in age between the male and female patients. Two-way analysis of covariance was performed to analyze the influences of factors that may have been related to the amount of thrombin used.
RESULTS: Mean pseudoaneurysm volume was 4.69 cm3 ± 5.49 (standard deviation). Simple and complex pseudoaneurysms were treated in 165 and 75 patients, respectively. A total of 260 thrombin injections were performed: 1.04 injections per patient with a simple pseudoaneurysm and 1.17 injections per patient with a complex pseudoaneurysm. The mean injected thrombin dose was 425.31 IU ± 341.75 for all pseudoaneurysms, 382.12 IU ± 281.00 for simple pseudoaneurysms only, and 520.33 IU ± 434.64 for complex pseudoaneurysms only. There was only a computational correlation between pseudoaneurysm size and thrombin dose (r2 = 0.07). The primary success rate was 93.8% overall, 95.8% for simple pseudoaneurysms, and 89% for complex pseudoaneurysms. The secondary success rate was 99.6% overall, 100% for simple pseudoaneurysms, and 99% for complex pseudoaneurysms. Early (at 
24 hours) reperfusion occurred in one simple and five complex pseudoaneurysms. Four late reperfusions—two in simple and two in complex pseudoaneurysms—were detected at 1-week follow-up; no late reperfusions were detected at 3 weeks. Thromboembolic complications occurred in two patients and resolved spontaneously. One mild allergic reaction and no infections occurred.
CONCLUSION: US-guided percutaneous thrombin injection enables successful, safe management of postcatheterization pseudoaneurysms.
© RSNA, 2005
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Various approaches for the management of pseudoaneurysms have been introduced, with ultrasonographically (US) guided compression repair and surgical revision being the most established methods. However, when anticoagulation therapy is given, the success rate of US-guided compression repair decreases from more than 90% (3) to 62%–73% (4,5). Additionally, not all patients can tolerate the usually time-consuming and sometimes very painful compression procedure (6,7). One of the noted disadvantages of the surgical repair of pseudoaneurysms is the remarkably high complication rate. Nineteen percent to 32% of patients develop wound-healing disorders and permanent femoral neuralgias (1,8). Reported frequencies of lymphatic leaks are as high as 40% (9).
In recent years, US-guided percutaneous thrombin injection has become an alternative treatment for pseudoaneurysms (7,10–18). Even in patients who receive anticoagulation or antiplatelet therapy, the success rate with US-guided thrombin injection has been higher than that with compression alone (7,16,19,20), and complications appear to occur at a low frequency. Notwithstanding these positive results, isolated cases of thromboembolic complications secondary to thrombin injection into the pseudoaneurysm have been described in the literature (9,13,15,19,21,22).
The purpose of our study was to prospectively evaluate US-guided percutaneous thrombin injection for treatment of femoral artery and brachial artery pseudoaneurysms.
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MATERIALS AND METHODS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Percutaneous injection of thrombin into a pseudoaneurysm was considered to be the primary therapy. Pseudoaneurysm was diagnosed in 232 patients within 3 days after removal of the arterial sheath, in seven patients 3–7 days after sheath removal, and in one patient 21 days after sheath removal. Thrombin was usually injected immediately after the indication was established (K.K., M.Z., and D.S., with 9, 9, and 2 years of experience in interventional radiology, respectively). The longest delay until treatment was 12 hours after the indication to treat was established.
Imaging and Interventional Procedures
A 5.0- or 7.5-MHz transducer (part of Elegra US unit; Siemens, Erlangen, Germany) was used to perform diagnostic US and US-guided thrombin injection. In patients who had extensive inguinal hematomas, a 3.5-MHz transducer was used additionally to better visualize the pseudoaneurysm's geometric features and to ascertain the pseudoaneurysm's position in relation to the artery.
The pseudoaneurysm's geometry and position in relation to the artery, along with the following parameters, were documented prospectively before the injection:
1. Number of pseudoaneurysm lobes: Simple pseudoaneurysms have one lobe, and complex pseudoaneurysms have two or more lobes separated from each other. The lobe closest to the artery was defined as the proximal lobe, and the lobe most distant from the artery was defined as the distal lobe.
2. Lobe volume, calculated as length times height times width times 0.523.
3. Position of the pseudoaneurysm lobes in relation to each other (in complex pseudoaneurysms).
4. Length and width of the pseudoaneurysm neck.
Lyophilized, sterilized, and virus-inactivated bovine thrombin (1000 or 5000 IU, Jones Medical Industries, St Louis, Mo; or Vascular Solutions, Bochum, Germany) was dissolved in 1 mL of isotonic saline (5000 IU in 5 mL of isotonic saline) and drawn into a 1-mL syringe. Thus, 0.1 mL of solution was equivalent to 100 IU of thrombin.
The peak blood flow in the ipsilateral anterior and posterior tibial arteries in femoral pseudoaneurysms and in the radial and ulnar arteries in brachial pseudoaneurysms was determined (by K.K., M.Z., and D.S.) by using duplex US before the thrombin injection. The local anesthetic (5 mL of 1% mepivacaine hydrochloride [Scandicain; AstraZeneca, Wedel, Germany]) and thrombin were injected under sterile conditions. The thrombin injections were administered by using a 20-gauge, 89-mm-long spinal needle (Dahlhausen, Cologne, Germany) or a 22-gauge, 90- or 150-mm-long echo-coat Chiba needle (Cook, Mönchengladbach, Germany) that was advanced toward the pseudoaneurysm in an orientation longitudinal to the transducer. To keep the puncture needle parallel to the transducer surface, the puncture was made as caudad from the pseudoaneurysm as possible.
The tip of the needle was placed in the lobe of the pseudoaneurysm. Blood flow patterns within the pseudoaneurysm lobe did not affect the positioning of the needle tip. Puncture of the pseudoaneurysm neck was avoided. Only in selected patients who had repeated reperfusion and high flow in the neck was thrombin injected directly into the neck by an experienced investigator (K.K.) in this study.
After the position of the needle tip in the pseudoaneurysm lobe was documented by using non–color- and color-coded US, thrombin was injected in incremental doses of 100 IU (0.1 mL) with color-coded US guidance at a low-pulse repetition frequency. Injections were administered one after the other until the color signal disappeared completely. The thrombin dose was recorded. The pseudoaneurysm neck was not compressed during the thrombin injection.
For complex pseudoaneurysms, our aim was to puncture the proximal pseudoaneurysm lobe. In patients who had concomitant inguinal hematomas with a proximal pseudoaneurysm lobe deep under the skin, we punctured the next closest distal lobe when it proved to be technically impossible to puncture the proximal lobe. Otherwise, the technique for injecting thrombin was identical to that described in the preceding paragraph.
Ten minutes after the thrombin injection, the following parameters were examined by using color-coded duplex US and documented: (a) extent of thrombosis in the pseudoaneurysm lobe(s), (b) extent of residual blood flow in the pseudoaneurysm lobe(s), (c) extent of blood flow in the pseudoaneurysm neck, and (d) extent of perfusion in the artery feeding the pseudoaneurysm.
Additionally, the duplex US determinations of the spectrum and peak of blood flow in the ipsilateral anterior and posterior tibial arteries at the level of the upper subtalar joint were repeated. A dressing was wrapped around the thigh, and all patients were instructed to maintain bed rest following the procedure until the first US follow-up examination 6–24 hours after the thrombin injections.
Assessment of Complications
The following complications of US-guided thrombin injection were assessed (by M.Z., D.S., K.K., and J.B.): thromboembolic complications, defined as direct visualization of a thrombus within the lumen of the feeding femoral or brachial artery, reduced peak blood flow in the anterior or posterior tibial artery in femoral pseudoaneurysms or of the radial or ulnar artery in brachial pseudoaneurysms, or recurrence or exacerbation of arterial occlusive disease; reperfusion of one or more pseudoaneurysm lobes; infection; allergic reaction; need for surgical or interventional procedures due to complications of the treatment itself; and complications that occurred during the follow-up period.
Early Follow-up
Color-coded duplex US was performed (by K.K., J.B., and D.S.) 6–24 hours after the first thrombin injection, and the extent of thrombosis in the pseudoaneurysm lobe(s) was examined again. If there still was evidence of blood flow in one of the pseudoaneurysm lobes, we injected another dose of thrombin, as described above. If the pseudoaneurysm neck was still open, a new dressing was applied and the patient was required to maintain bed rest. Whenever repeated thrombin injections were given or the pseudoaneurysm neck was open, color-coded duplex US was repeated within 6–24 hours.
Primary and Secondary Successes
Primary success of pseudoaneurysm repair was defined as complete obliteration of the pseudoaneurysm seen at the follow-up examination performed 6–24 hours after the initial thrombin injection. Secondary success was defined as complete obliteration of the pseudoaneurysm after one or more thrombin injections.
Later Follow-up
Color-coded duplex US was performed (by K.K., J.B., D.S.) 5–7 days and 21–25 days after successful repair of the pseudoaneurysm. We documented the extent of thrombosis in the pseudoaneurysm lobe(s); the extent of residual blood flow in the pseudoaneurysm lobe(s); the extent of blood flow in the neck of the pseudoaneurysm and perfusion in the feeding artery; the volume of the thrombosed pseudoaneurysm lobes; and any symptoms reported by the patients, including signs of inflammation, new occurrence or exacerbation of claudication symptoms, and groin pain. The patients classified the pain as none, slight, moderate, or severe.
Statistical Analyses
The summary statistical values cited in the text are given as means ± standard deviations. A nonpaired t test was used to compare differences in age between the male and female patients. To analyze the influences of factors that may have been related to the amount of thrombin used, two-way analysis of covariance was performed with sex and lumen type (simple vs complex) as fixed factors and age as a covariate and with estimated effects adjusted in a design accounting for all main factors (sex and lumen type), as well as for interactions of the main factors (sex with lumen type) and interactions of sex and age. To avoid the assumption of homogeneity of variances for residuals, the target variable—thrombin dose—was transformed by using a log transformation. Pseudoaneurysm volume was correlated with total injected thrombin dose. Owing to the design of the analyses, the P values cited should be interpreted exploratively. Computations for explorative test statistics were performed (by H.S.) with SPSS, version 12, for Windows (SPSS, Chicago, Ill).
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RESULTS |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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The primary success rate was 89% (67 of 75 patients) for the complex pseudoaneurysms. Ten minutes after the injection, there was residual blood flow (corresponding to only partial thrombosis of the lobe) in the proximal lobe of six complex pseudoaneurysms. At 12 hours, spontaneous occlusion had occurred in three patients; the remaining three patients required repeat treatment. In five patients, reperfusion of a previously thrombosed lobe was observed 6–24 hours after therapy; this reperfusion was limited to the proximal lobe.
Secondary therapeutic success was observed in 239 (99.6%) of the 240 pseudoaneurysms: in all 165 (100%) simple pseudoaneurysms and in 74 (99%) complex pseudoaneurysms. One complex pseudoaneurysm in which only partial thrombosis was achieved required surgery. When we assessed brachial pseudoaneurysms separately, both the primary and the secondary success rates were 100%. Reperfusion did not occur.
Thrombin Dose
The total thrombin dose required for primary and secondary repair of the pseudoaneurysms ranged from 50 to 2300 IU (mean dose, 425.31 IU ± 341.75). The mean thrombin dose required to repair the simple pseudoaneurysms (382.12 IU ± 281.00; range, 50–1500 IU) was significantly lower (P = .013) than that required to repair the complex pseudoaneurysms (520.33 IU ± 434.64; range, 100–2300 IU). The statistical models revealed that only the lumen type (simple vs complex) had a significant effect on the required thrombin dose (P = .006). Neither other factors nor the interactions of factors had a significant influence on the thrombin dose used. There was a computational but not clinically relevant correlation between the size of the pseudoaneurysm lobe and the thrombin dose (r2 = 0.07, P < .001).
Pseudoaneurysm Neck
In 11 (4.6%) pseudoaneurysms—four of which were simple and seven of which were complex—only the neck was still perfused immediately after successful thrombosis of the pseudoaneurysm lobe. In two patients, thrombin was directly injected into the neck of the pseudoaneurysm for the following reasons: One patient, who received anticoagulation therapy because of a deep venous thrombosis, had recurrent perfusion—it occurred three times—and in another patient, residual perfusion of the pseudoaneurysm neck was determined at the first US examination performed 12 hours after treatment. In all other patients, the residual perfusion in the neck occluded spontaneously.
Peripheral Arteries
We observed no major differences between the mean peak blood flow rates in the anterior and posterior tibial arteries in femoral pseudoaneurysms or in the radial and ulnar arteries in brachial pseudoaneurysms measured before and those measured after the injection of thrombin. The mean peak flow rate was 60.79 cm/sec ± 26.8 before and 60.46 cm/sec ± 27.06 after the injection in the anterior tibial arteries, 55.55 cm/sec ± 23.13 before and 57.63 cm/sec ± 25.00 after the injection in the posterior tibial arteries, 80.7 cm/sec ± 28.0 before and 76.3 cm/sec ± 17.5 after the injection in the radial arteries, and 72.7 cm/sec ± 43.5 before and 75.0 cm/sec ± 43.1 after the injection in the ulnar arteries. No occlusion of arteries that were perfused before treatment was observed. In one patient, the peak flow velocity after thrombin injection was reduced from 66 cm/sec to 37 cm/sec in the anterior tibial artery and from 92 cm/sec to 52 cm/sec in the posterior tibial artery, as evidenced at poststenotic spectral analysis. At the first follow-up US examination 12 hours later, the peak flow rate had returned to the pretreatment rate.
Feeding Artery
The feeding artery was partially thrombosed after thrombin injection in one patient who had a femoral pseudoaneurysm; this thrombus dissolved spontaneously within 24 hours. In all other patients, the feeding artery remained completely perfused. No complications occurred in patients with brachial pseudoaneurysms.
Follow-up
Follow-up US and clinical examinations were performed in 217 of the 240 (90.4%) patients 5–7 days (first examination) and in 193 (80.4%) patients 21–25 days (second examination) after the thrombin injection treatment. At the first follow-up examination, the pseudoaneurysm, including the neck, was completely obliterated in 236 patients: 163 (98.8%) patients with simple pseudoaneurysms and 73 (97%) patients with complex pseudoaneurysms. Partial reperfusion of the pseudoaneurysm occurred in two simple (Fig 2) and two complex (proximal-lobe) pseudoaneurysms. At the 12-hour examination, these pseudoaneurysms had become thrombosed. Subsequently, two patients underwent aortic valve surgery with standard anticoagulation. After a new thrombin injection, the pseudoaneurysms in these patients became permanently occluded. At the second follow-up examination, all documented pseudoaneurysms were completely obliterated. The mean volume of the thrombosed pseudoaneurysm lobes had decreased to 5.21 cm3± 6.58 by the first follow-up examination and to 2.88 cm3± 4.78 by the second examination.
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Other Complications
There were no clinical or US signs of infection and no recurrences or exacerbation of arterial occlusive disease. One patient had a transient fever 12 hours after the thrombin treatment. This temperature elevation was most likely an allergic reaction. No patient underwent surgical or interventional procedures owing to complications of thrombin injection.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Our study results showed that the US-guided injection of thrombin into the pseudoaneurysm lobe is a practical method of managing femoral and brachial pseudoaneurysms. In our study, 239 of 240 patients were successfully treated with thrombin injection into the pseudoaneurysms. The overall success rate was 99.6%. Just one patient underwent surgical repair owing to incomplete occlusion of a complex pseudoaneurysm after a single thrombin injection and refusal to undergo a second injection.
In recent years, a number of studies, usually involving fewer than 50 patients, demonstrating the high success rate of US-guided thrombin injection have been published. In most studies, successful treatment was accomplished in more than 90% of patients. In only one study (23) was the success rate lower than 90%. When studies involving more than 50 patients are considered, the success rate ranges between 92% and 100% (9,15–17,24–28) and is comparable to that achieved in our study.
US-guided compression therapy previously had been regarded as the therapy of choice for the treatment of postcatheterization pseudoaneurysms. However, compression proved to have disadvantages in that it is time consuming and involves more pain and discomfort for the patient than does US-guided thrombin injection. The failure rate with compression therapy increased from 38% to 48% when a group of patients in whom the treatment was stopped because of technical reasons or severe pain were included in the statistical analysis (7). Moreover, the success rates with US-guided compression were markedly lower in patients who received anticoagulation or antiplatelet therapy.
Compared with the success rate with compression therapy, the success rate with percutaneous thrombin injection into pseudoaneurysm lobes is higher. In a study conducted by Paulson et al (10), obliteration of the pseudoaneurysm was successful in 74% of cases with US-guided compression and in 96% of cases with thrombin injection. Likewise, in comparative studies conducted by Pezzullo et al (6), Taylor et al (29), and Weinmann et al (30), thrombin therapy led to successful obliteration of pseudoaneurysms in the majority of cases.
Summing up the results of all relative studies cited in the reviewed literature, with the exclusion of case reports, a total of 1488 patients in 34 studies received US-guided thrombin injections. Treatment failed in 42 patients; thus, the overall success rate was 97.2%. In terms of success rates, there is little doubt that US-guided thrombin injection should replace US-guided compression for the management of postcatheterization pseudoaneurysms.
The complication rate with US-guided thrombin injection is low. In our study, we observed two types of complications: The first was reperfusion of previously completely thrombosed pseudoaneurysms. Repeated thrombin injections (up to four injections) led to the successful occlusion of all pseudoaneurysms. The reperfusion rates reported in the reviewed literature are consistent with our results: Parts of previously thrombosed pseudoaneurysms became reperfused in 31 of the 1488 patients in the other studies—that is, the overall reperfusion rate was 2.1%. Twenty-seven of these 31 patients were successfully treated by means of repeat thrombin injections, and four were successfully treated with surgery, as repeat thrombin injection was not attempted.
On the basis of the results of our study and of the results reported in the literature, we are convinced that repeat thrombin injection should be the treatment of choice for reperfused pseudoaneurysms. There might be exceptions, however. Sheiman and Mastromatteo (31) analyzed the potential causes of failed thrombin embolization. In five cases of treatment failure, an arteriotomy site laceration measuring at least 8.0 mm or an infection was identified during the surgical repair. The authors concluded that the failure of an iatrogenic pseudoaneurysm of the common femoral artery to respond to thrombin injection is indicative of an occult vascular injury. In such cases, surgical repair should be preferred over repeat thrombin injection.
However, it should be noted that reperfusion may occur a few days after successful thrombin injection treatment. In four patients in our study, partial reperfusion was diagnosed 6 days after the 12-hour follow-up examination had revealed complete obliteration. Two of these patients subsequently underwent aortic valve replacement with anticoagulation. However, two patients did not receive anticoagulation therapy. There is also a report in the literature of a patient who had late reperfusion 4 days after successful thrombin-induced occlusion (32). Therefore, our standard procedure includes regular follow-up examinations. We performed clinical and US follow-up examinations 12–24 hours and 1 and 3 weeks after the interventions. Because of the low rate of late reperfusion noted in both our study and the literature (32), follow-up US examinations can be limited to symptomatic patients and patients who receive anticoagulation therapy. However, we recommend performing follow-up examinations early after thrombin embolization.
Thromboembolic complication, the second type of complication that we observed, is a serious side effect. The two patients in our study who had thromboembolic complications were asymptomatic, and their thromboses resolved spontaneously. The 0.8% rate of thromboembolic complications in our study is in good agreement with the complication rates reported in the literature (9,15,21,22). Thromboembolic complications occur for several reasons. One type of thromboembolic complication occurs when thrombin is injected into the artery (15,25). Injection into the artery should be strictly avoided. Thrombin injection should never be performed if exact positioning of the tip of the injection needle is not possible. This positioning problem may occur in the treatment of complex pseudoaneurysms with diffuse hematomas or when the pseudoaneurysm lobe is deep beneath the skin. In the latter case, we use a long injection needle to ensure that the needle stays parallel to the transducer.
Thromboembolic complications can also occur when thrombin is injected into the pseudoaneurysm neck (15). Interestingly, Hughes et al (32) proposed injecting thrombin directly into the neck of the pseudoaneurysm as a standard therapy. However, it is usually not necessary to puncture the neck of the pseudoaneurysm. If residual perfusion exists, complete occlusion of the neck may occur after bed rest. In our study, most of the patients with residual blood flow in the neck experienced spontaneous thrombosis. In two patients, we very cautiously injected thrombin into pseudoaneurysm necks located very near the artery wall. However, such a procedure should be performed only when the tip of the needle is easy to visualize and the interventionist has appropriate experience.
An additional cause of thromboembolic complications may be the typical blood flow patterns within the neck of the pseudoaneurysm, where inflow and outflow conditions prevail. Grewe et al (33) observed the flow of US contrast material from the pseudoaneurysm lobe into the feeding artery. The binding of thrombin to antithrombin III results in a thrombin–antithrombin III complex that neutralizes the prothrombotic effect of thrombin. However, the level of thrombin–antithrombin III complex is known to increase substantially within minutes after the thrombin injection (34). So there is evidence that thrombin flows into the feeding artery.
It is not easy to prevent thrombin from flowing into the feeding artery. McNeil and Clark (35) proposed performing US-guided thrombin injection and simultaneous manual pseudoaneurysm neck compression. In our experience, however, this procedure is difficult to perform in obese patients, on large pseudoaneurysms, and on pseudoaneurysms with a short neck. Another proposed method of occluding the neck is that of placing a balloon in the feeding artery (36,37). This method makes the procedure substantially more invasive, costly, and time consuming, however, and, so far, it has been performed only in isolated cases, as reported in the literature.
There have been more complications involving percutaneous thrombin embolization of pseudoaneurysms. In the current study, one patient developed a transient fever 12 hours after the thrombin treatment. This complication was most likely an allergic reaction. Allergic reactions to thrombin injected for the treatment of pseudoaneurysms are rare (38,39). Quarmby et al (40) have thus proposed injecting autologous thrombin for the treatment of pseudoaneurysms.
Other complications have been described in the literature: Hung et al (41) observed two cases of femoral venous compression that were associated with thrombin injections for the treatment of pseudoaneurysms and resulted in deep venous thrombosis. We encountered no such complications in our study. On the basis of our study results and of the results reported in the literature, the general conclusion of these authors that thrombin injection should be avoided in favor of early surgical intervention is not valid.
Groin pain can occur after thrombin injection. In our study, 41% of all patients who underwent follow-up examinations reported having slight to severe groin pain 1 week after the thrombin treatment. This rate decreased to about 10% after 3 weeks.
We induced local anesthesia in all 240 patients before puncturing the pseudoaneurysm for thrombin injection. The need for local anesthesia is still being discussed. If the position of the needle has to be changed, however, local anesthesia might be helpful.
In the literature, alternative approaches to pseudoaneurysm management have been described. One interesting technique was assessed by Gehling et al (42): Saline was injected beneath the communication tract of the pseudoaneurysm to accomplish rapid occlusion in six patients. There is no risk of thromboembolic complications or anaphylactic reactions with this method. So far, however, the number of patients who have been treated with this method has been very limited, and the injection may be difficult to perform in patients with a short or no pseudoaneurysm neck. Larger studies need to be performed to confirm these results.
The relatively small number of patients with brachial pseudoaneurysms was a limitation of our study. The conclusions of our study are based mainly on the results of femoral pseudoaneurysm treatments. All of the brachial pseudoaneurysms were treated successfully without complications; however, more data are necessary.
When one considers all of the alternative treatments described in the literature, the numerous advantages reported—namely, high success rates, low complication rates, ease of performance, short procedure times, and no radiation exposure—favor the use of US-guided thrombin injection as the treatment of choice for treating pseudoaneurysms. In conclusion, US-guided percutaneous injection of thrombin can be regarded as the therapy of choice for the management of postcatheterization pseudoaneurysms.
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FOOTNOTES |
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Author contributions: Guarantors of integrity of entire study, K.K., K.L.; study concepts and design, K.K.; literature research, K.K.; clinical studies, K.K., M.Z., D.S., J.B.; data acquisition, K.K., M.Z., D.S., J.B.; data analysis/interpretation, K.K., K.L.; statistical analysis, H.S., K.K.; manuscript preparation, definition of intellectual content, editing, revision/review, and final version approval, K.K.
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TOPABSTRACTINTRODUCTIONMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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This article has been cited by other articles:
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  G. W. Webber, J. Jang, S. Gustavson, and J. W. Olin Contemporary Management of Postcatheterization Pseudoaneurysms Circulation, May 22, 2007; 115(20): 2666 - 2674. [Full Text] [PDF]
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 A. P. Hingorani, E. Ascher, and N. Marks Duplex Arteriography for Lower Extremity Revascularization Perspectives in Vascular Surgery and Endovascular Therapy, March 1, 2007; 19(1): 6 - 20. [Abstract] [PDF]
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M. Ashraf Mansour and J. M. Gorsuch Diagnosis and Management of Pseudoaneurysms Perspectives in Vascular Surgery and Endovascular Therapy, March 1, 2007; 19(1): 58 - 64. [Abstract] [PDF]
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