A 72-year-old male with a history ofhypertension complained of a pain-ful pulsatile mass and extensive

bruit in the left groin one week after corona-ry angioplasty and stent placement. ColourDoppler Imaging (Acuson, Sequoia 512Mountain View) showed a lobulated pseu-doaneurysm with two cavities, the larger ofwhich was 38 mm in diameter, arising justabove the femoral bifurcation. The pseudo-aneurysm was compressed under ultrasoundguidance for 30 minutes, resulting in throm-bosis of the greater cavity. However, swirl-ing colour flow remained in the 26.8 mmsmaller locule (Figure 1), together with atypical to-and-fro flow signal in a track lead-ing from the femoral artery to the locule(pseudoaneurysm neck) (Figure 2).

While anticoagulation was continued,ultrasound-guided injection of thrombinwas decided upon and informed consentwas obtained from the patient. The throm-bin was obtained from a commercial kit forthe local management of bleeding from vas-cular access sites (D-stat, Vascular Solu-tions, Minneapolis, USA) and was dilutedin physiological serum with calcium chlo-ride (1 ml = 1000 U). The affected groinwas cleaned with povidone-iodine and cov-ered with a sterile drape. Using a freehandtechnique, a sterilized linear 7.5 MHz array

112 ñ HJC (Hellenic Journal of Cardiology)

Ultrasound Guided Percutaneous ThrombinInjection for the Treatment of Post-CatheterisationFemoral PseudoaneurysmDIMITRIOS TSETIS1, GEORGE KOCHIADAKIS2, MICHAEL HAMILOS2, ASTERIOS KATSAMOURIS3,NIKOLAOS GOURTSOYIANNIS1

1Radiology Department, 2Cardiology Department, 3Department of Vascular Surgery, Heraklion University Hospital,Crete, Greece

Manuscript received:January 4, 2006;Accepted:February 7, 2006.

Address:

Dimitrios Tsetis

Radiology DepartmentHeraklion UniversityHospitalP.O. Box 1352Stavrakia71110 Heraklion, CreteGreecee-mail: tsetis@med.uoc.gr

Key words:Pseudoaneurysm,thrombin.

Hellenic J Cardiol 47: 112-113, 2006

Cardiac ImagingCardiac Imaging

transducer was used to guide a 20-gauge,echogenic needle with side delivery portpercutaneously to the middle of the pseu-doaneurysm, away from the neck. Slow in-jection (0.1 ml/s) of 0.5 ml of the thrombinwas performed under continuous sonogra-phic guidance (Figure 3). After the first in-jection, colour Doppler confirmed partialthrombosis of the pseudoaneurysm (Figure4) and an additional injection of 0.5 ml with-out needle repositioning was needed in or-der to achieve complete thrombosis of thecavity (Figure 5). Once the pseudoaneu-rysm was thrombosed the needle was with-drawn and the presence of normal flow inthe superficial and deep femoral arterywas confirmed by colour Doppler ultra-sound. The patient was restricted to bedrest for 4 hours and a repeat ultrasoundexamination 24 hours later showed no evi-dence of recurrent flow inside the pseu-doaneurysm.

Ultrasound-guided percutaneous throm-bin injection is a safe and efficacious first-line method of treating post-catheterisationpseudoaneurysms with a distinct neck, de-monstrating an overall thrombosis rate of93-100%.1 In the majority of patients athrombin dose of 500-1000 U is adequate.The procedure can be performed in any rel-atively clean room with standard ultrasound

equipment and needles. Anticoagulation does notseem to affect the efficacy of the procedure. Most in-terventionalists favour the use of human thrombinsince bovine thrombin has the potential to induce al-lergic reactions.

After this encouraging initial experience we intendto use this method in our institute as initial treatment,instead of the traditional ultrasound-guided compres-

sion, because of its advantages in saving time for the op-erator and avoiding discomfort for the patient.

References

1. Morgan R, Belli AM: Current treatment methods for post-catheterization pseudoaneurysms. J Vasc Interv Radiol 2003;14: 697-710.

Percutaneous Thrombin for Femoral Pseudoaneurysm

(Hellenic Journal of Cardiology) HJC ñ 113

Figure 1.: Persisting swirling colour flow inthe smaller locule of the pseudoaneurysmafter thrombosis of the greater cavity usingultrasound-guided compression.

Figure 5. Complete thrombosis of the pseu-doaneurysm after a total injection of 1000 Uof thrombin.

Figure 3. Schematic illustration of the ultra-sound-guided percutaneous thrombin injec-tion technique.

Figure 4. Partial thrombosis of the pseudoa-neurysm after injection of 0.5ml (500 U) ofthrombin. The arrow shows the echogenictip of the 20G needle in the middle of thepseudoaneurysmal cavity.

Figure 2. Typical to-and-fro flow pattern at the pseudoaneurysm neck.