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• W2053282495 abstract "To the Editors: A recent article by Kang et al (J Vasc Surg 1998;27:1032-8) reported a new and effective method of treating the problem of false aneurysms after femoral arterial catheterization. Their method, modified and reported by others,13 has several advantages over the standard first-line treatment of ultrasound scan–guided compression repair in that the procedure is quick, involves minimal pain, and has a high success rate, even in patients with large false aneurysms and in patients who are currently undergoing anticoagulation therapy. In the series of patients reported, there were no significant procedure-related complications, in particular, systemic reactions to the thrombin. However, a recent case in our institution has brought this issue to light as more than a theoretical consideration. A 10-month-old boy was assessed after the development of a pulsatile lump in the antecubital fossa after intravenous cannulation during anesthesia for endoscopy. A duplex scan confirmed a 3 cm–diameter pseudoaneurysm originating from the posterior aspect of the brachial artery with a 3-mm neck and 1.8-cm cavity in continuity with the artery, the remainder of the aneurysm being filled with thrombus. In full, ultrasound scan–guided compression was carried out with general anesthetic for 20 minutes but was unsuccessful. This was followed by a percutaneous injection of thrombin with ultrasound scan guidance. Thrombin (1000 U/mL) was injected slowly with a 25G needle into the center of the cavity to a total of 200 units (0.2 mL). There was immediate thrombosis with highly echogenic clot followed 30 seconds later by an acute and dramatic ischemia of the forearm and hand associated with a loss of the radial pulse and absence of flow in the brachial artery on duplex scan. The mottling improved and the hand became viable in 15 minutes, but the brachial occlusion persisted and it was decided to explore the artery. The thrombus and organized hematoma were successfully removed as shown in Fig. 1, and the defect in the artery was repaired with direct suturing.After this, there was restoration of the radial pulse and no subsequent complications. We believe that this case raises some issues regarding the assessment of patients who may be suitable for this new and appealing option of treatment. The effect may be related to total dosage of thrombin used, the rate of administration, or the size of the neck of the sac, all of which may allow systemic “spillage” of a highly thrombogenic substance. There are no pharmaceutical guidelines on dosages, so small incremental volumes seem reasonable. However, even a small dose entering the arterial circulation may not be neutralized by natural fibrinolysis. It is unknown whether the dose required relates either to the size of the patient or to the size of the pseudoaneurysm being treated. In the event of systemic thrombosis, thrombolysis with tissue plasminogen activator could be administered. This has been successfully used in infants at doses of 0.25 to 0.5 mg/kg/hr after iatrogenic femoral thromboses.4Zenz W Muntean W Beitzke A Zobel G Riccabona M Gamillscheg A. Tissue plasminogen activator (alteplase) treatment for femoral artery thrombosis after cardiac catheterisation in infants and children.Br Heart J. 1993; 70: 382-385Crossref PubMed Scopus (58) Google Scholar However, in an acute severely ischemic limb this may not be justified. The authors describe monitoring for this complication but not their policy of treatment should it occur. It is also difficult to accurately assess with duplex scan whether the neck will allow the passage of thrombin into the native artery, and an alternate technique of inflating an angioplasty balloon at the site of the neck via the contralateral groin to prevent leakage has been described2Payne SPK Loose H. Non-operative treatment of false aneurysms using percutaneous injection of fibrin adhesive. Abstract presented to 8th European Congress of Surgery, Budapest.Br J Surg. 1998; 85: 4Google Scholar to potentially decrease the risk of this complication. A different method compresses the neck of the sac during the thrombin injection to prevent leakage.3Hawkins GC Frawley JE. Non-operative treatment of iatrogenic femoral artery pseudoaneurysms. Abstract presented to RACS Annual Scientific Congress, Sydney.Aust N Z J Surg. 1998; 68: 151-152PubMed Google Scholar Both these techniques interrupt the flow into the distal artery and into the cavity during injection and may slow the process of thrombosis. All the methods have excellent success rates on small numbers of patients, and therefore, at this stage, no individual technique can be considered superior in terms of efficacy or safety." @default.
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• W2053282495 date "1998-12-01" @default.
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• W2053282495 title "Regarding “Percutaneous ultrasound guided thrombin injection: A new method for treating postcatheterization femoral pseudoaneurysms”" @default.
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• W2053282495 doi "https://doi.org/10.1016/s0741-5214(98)70041-2" @default.
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