Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 253-255

Ultrasound-Guided thrombin injection of a pseudoaneurysm with concomitant deep vein thrombosis


Department of Vascular and Endovascular Surgery, Vascular Institute of New York, New York, USA

Date of Submission25-Nov-2021
Date of Acceptance29-Dec-2021
Date of Web Publication21-Aug-2022

Correspondence Address:
Mark Awad
Department of Vascular and Endovascular Surgery, Vascular Institute of New York, New York
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_124_21

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  Abstract 


The formation of a pseudoaneurysm (PSA) is one of the most common complications following arterial catheterization. These pseudoaneurysms have the potential to cause life-threatening complications. One such extremely uncommon complication is the development of deep vein thrombosis (DVTs). Successful treatment of a PSA can be hindered in patients receiving anticoagulants and special considerations are necessary in such cases. We present a 70-year-old female who developed a postarterial catheterization PSA which was treated with Ultrasound-Guided Thrombin Injection (UGTI) while the patient was receiving apixaban for treatment of a PSA-induced DVT. Peri-procedural imaging helped correctly identify this complex pathology, guide thrombin injection, and observe in real-time instantaneous thrombosis of the PSA while confirming adjacent femoral artery patency. Given the risk of associated complications, patients with a PSA who are receiving anticoagulation should undergo an UGTI for PSA closure. Anticoagulation may cause difficulty in achieving complete thrombosis of PSAs, but recent research has suggested that UGTI remains the preferred method with high overall success rates. Patients receiving anticoagulation undergoing this procedure may benefit from serial postprocedure duplex scans to assess for incomplete PSA closure, thrombosis, or recurrence.

Keywords: Apixaban, pseudoaneurysm, thrombin-injection


How to cite this article:
Awad M, Ascher E, Marks N, Hingorani A. Ultrasound-Guided thrombin injection of a pseudoaneurysm with concomitant deep vein thrombosis. Indian J Vasc Endovasc Surg 2022;9:253-5

How to cite this URL:
Awad M, Ascher E, Marks N, Hingorani A. Ultrasound-Guided thrombin injection of a pseudoaneurysm with concomitant deep vein thrombosis. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Oct 1];9:253-5. Available from: https://www.indjvascsurg.org/text.asp?2022/9/3/253/354066




  Introduction Top


Pseudoaneurysm (PSA) formation is one of the most common complications associated with arterial catheterization. PSAs are created as a result of an incomplete seal at the puncture site that allows for blood to escape into surrounding layers of tissue creating various size spheric, egg-shaped, or multi-chamber hollow masses with pulsatile blood flow of various velocity. Their incidence after arterial catheterization is reported in 0.6%–6% of patients.[1] Common complications of PSAs include local pain, rupture, distal embolization, neuropathy, and skin ischemia. On rare occasion, compression of an adjacent vein by a PSA can lead to deep vein thrombosis (DVT), a life-threatening complication that can be avoided by ensuring early intervention and complete PSA closure.[2] This unusual complication of a PSA-induced DVT has very few cases reported in the literature and no studies ever conducted on treatment efficacy.

Treatment of a PSA typically comes in the form of one of three options: surgical management, ultrasound-guided compression closure (UGCC), or ultrasound-guided thrombin injection (UGTI). When comparing UGCC and UGTI treatments for patients receiving anticoagulation who have developed a PSA, UGTI has proven to consistently have higher success rates of complete closure and lower rates of recurrence. Both treatment modalities have the added benefit of avoiding the risks and complications of surgical PSA repair.[3],[4] However, the majority of current research on effectiveness of UGTI in anticoagulated patients examines its use in patients receiving unfractionated heparin, warfarin, or enoxaparin.[3],[4],[5],[6] With the recent introduction of new oral anticoagulants, there is a need for data regarding procedural efficacy in patients receiving these potent medications. This case presentation depicts successful PSA closure through UGTI in a patient anticoagulated with apixaban.


  Case Report Top


A 70-year-old female with a past medical history of hypertension, peripheral arterial disease, spinal stenosis, and varicose veins with edema of the left lower extremity presented to an outpatient clinic with symptoms of left calf claudication. Conservative therapy was attempted without significant symptomatic improvement. The patient returned to the outpatient clinic where arterial duplex of bilateral lower extremities confirmed left popliteal artery occlusion above the knee.

The patient was scheduled for a left lower extremity angiogram and angioplasty. Left lower extremity angiogram with popliteal artery subintimal angioplasty and stenting was successfully performed 8 days later in the outpatient clinic under local anesthesia and conscious sedation. Immediate postprocedure imaging showed patent popliteal artery stent with no significant stenoses and intact right common femoral artery (CFA) puncture site with no PSA or any other arterial injury. The patient was started on clopidogrel 75 mg daily regimen at that time. She came to the clinic 3 days later with a new complaint of right calf and ankle edema, venous duplex demonstrated acute occlusive thrombosis of the common femoral vein (CFV) and proximal femoral vein which prompted recommendations for anticoagulation therapy with apixaban 10 mg twice a day for 7 days with subsequent transition to 5 mg twice daily dose from day 8. Arterial duplex of the right groin performed at the same time showed formation of a 3 cm × 3.5 cm × 3 cm right-sided PSA originating from the CFA depicted in Video 1[Additional file 1]. After discussing possible treatment options for the PSA, the patient agreed to undergo UGTI with the understanding that if it were unsuccessful, surgical intervention may be necessary. She was instructed not to take her next dose of apixaban and scheduled for the procedure the following morning. Imaging obtained during this time showed compression of the CFV by the PSA causing obstruction of flow and a right-sided acute DVT [Video 2][Additional file 2]. The patient underwent successful UGTI of her right CFA PSA [Video 3][Additional file 3].

Immediately following the procedure, the patient was restarted on apixaban having missed one dose. An arterial duplex of the right lower extremity 3 days later showed complete thrombosis of the former CFA PSA. The patient returned 6 days later for a follow-up visit when arterial duplex confirmed complete thrombosis of the former PSA and venous duplex of the right lower extremity demonstrated complete resolution of the CFV compression and DVT with normal flow pattern resumed in all visualized veins. Subsequent follow-up 16 days later showed resolved claudication pain in the left calf with patient reporting walking 3,000–4,000 steps daily.


  Discussion Top


UGTI is known to be an effective treatment of PSAs in patients receiving anticoagulation. A review of 70 patients who underwent UGTI for the treatment of a PSA showed that of the 21 patients receiving anticoagulation with either heparin, warfarin, or both at the time of the procedure, all but one had successful thrombosis of the PSA with a success rate of 95%.[3] In a similar publication that examined the results of a multicenter study, the data from 91 patients across 4 sites were compiled to examine the efficacy of UGTI in a patient population that contained a majority of patients receiving one or more antiplatelet agents and/or anticoagulants. The results indicated favorable responses to UGTI whether or not the patient was anticoagulated with a success rate of 98%.[4] Notably, there was a second injection of thrombin necessary in three patients, and one patient required three injections to achieve complete PSA thrombosis. In addition, there were two patients with PSAs that did not thrombose with multiple injections of thrombin, one of whom was successfully treated with ultrasound-guided compression the next day.

There is a lack of data on the efficacy of UGTI in patients receiving novel oral anticoagulants including direct thrombin inhibitors (dabigatran) and factor Xa inhibitors (rivaroxaban, apixaban). This has resulted in clinicians inferring similar results to other anticoagulants without extensive data to support it. The limited research that has been conducted on the use of the novel oral anticoagulants during UGTI has been promising although limited by sample size with one such study citing successful thrombosis in all patients taking each of the three anticoagulants mentioned.[7]

The results of studies investigating UGTI for PSA closure in anticoagulated patients have differed among researchers and more recent research has suggested that there is a decreased success rate in patients on anticoagulation. In one such large-scale retrospective study, 326 subjects who underwent UGTI for a femoral PSA were analyzed. Of those patients, the researchers were able to review the medications for 143 patients, 61 of whom were on anticoagulation with Warfarin, Heparin, or Enoxaparin. Analysis showed that there was a statistically significant higher rate of incomplete thrombosis in patients taking one of these three medications than those who were not. Twenty three of the 26 patients who had incomplete thrombosis were receiving anticoagulant therapy.[5] However, there is evidence which suggests that with repeat thrombin injections, closure is attainable in most patients whether anticoagulated or not. The patients in this study had a 97% overall success rate when patients who underwent repeat thrombin injections within 24 h were included.

PSA treatment is essential to avoid possible sequela such as rupture, distal embolization, local pain, neuropathy, and skin ischemia. Although extremely unusual, a few cases of PSA compression-induced DVT have been reported.[8],[9],[10],[11] In such cases, patients may be anticoagulated before PSA treatment as was the patient in our report. While there is evidence that patients receiving anticoagulation have a lower initial success rate with one thrombin injection, there is sufficient data to support that with identification of incomplete thrombus formation, injecting additional thrombin and/or attempting a subsequent UGCC will more often than not lead to eventual success. The majority of this data has been based on anticoagulants with different mechanisms of action when compared to the novel oral anticoagulants, and increased research on applicability to such drugs must be conducted to achieve consensus on the optimal treatment modality for patients receiving them.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Morgan R, Belli AM. Current treatment methods for postcatheterization pseudoaneurysms. J Vasc Interv Radiol 2003;14:697-710.  Back to cited text no. 1
    
2.
Eisenberg L, Paulson EK, Kliewer MA, Hudson MP, DeLong DM, Carroll BA. Sonographically guided compression repair of pseudoaneurysms: Further experience from a single institution. AJR Am J Roentgenol 1999;173:1567-73.  Back to cited text no. 2
    
3.
La Perna L, Olin JW, Goines D, Childs MB, Ouriel K. Ultrasound-guided thrombin injection for the treatment of postcatheterization pseudoaneurysms. Circulation 2000;102:2391-5.  Back to cited text no. 3
    
4.
Mohler ER 3rd, Mitchell ME, Carpenter JP, Strandness DE Jr., Jaff MR, Beckman JA, et al. Therapeutic thrombin injection of pseudoaneurysms: A multicenter experience. Vasc Med 2001;6:241-4.  Back to cited text no. 4
    
5.
Ehieli WL, Bozdogan E, Janas G, Jaffe TA, Miller CM, Bashir MR, et al. Imaging-guided percutaneous thrombin injection for the treatment of iatrogenic femoral artery pseudoaneurysms. Abdom Radiol (NY) 2019;44:1120-6.  Back to cited text no. 5
    
6.
Dean SM, Olin JW, Piedmonte M, Grubb M, Young JR. Ultrasound-guided compression closure of postcatheterization pseudoaneurysms during concurrent anticoagulation: A review of seventy-seven patients. J Vasc Surg 1996;23:28-34.  Back to cited text no. 6
    
7.
Yang EY, Tabbara MM, Sanchez PG, Abi-Chaker AM, Patel J, Bornak A, et al. Comparison of ultrasound-guided thrombin injection of iatrogenic pseudoaneurysms based on neck dimension. Ann Vasc Surg 2018;47:121-7.  Back to cited text no. 7
    
8.
Rishavy TJ, Rivela LJ, Tyndall SH. Superficial femoral artery pseudoaneurysm causing extensive deep venous thrombosis. Vasc Surg 1997;31:489-93.  Back to cited text no. 8
    
9.
Hung B, Gallet B, Hodges TC. Ipsilateral femoral vein compression: A contraindication to thrombin injection of femoral pseudoaneurysms. J Vasc Surg 2002;35:1280-3.  Back to cited text no. 9
    
10.
Papadakis M, Zirngibl H, Floros N. Iatrogenic femoral pseudoaneurysm and secondary ipsilateral deep vein thrombosis: An indication for early surgical exploration. Ann Vasc Surg 2016;34:269.e13-5.  Back to cited text no. 10
    
11.
Khalid M, Murtaza G, Kanaa M, Ramu V. Iatrogenic pseudoaneurysm: An uncommon cause of deep vein thrombosis. Cureus 2018;10:e2375.  Back to cited text no. 11
    




 

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