Endovascular Pseudoaneurysm Repair Using Transarterial Thrombin Injection and Covered Stent

Abstract

Pseudoaneurysms are a well-known complication of percutaneous femoral arterial puncture. While surgical repair was previously the gold standard, ultrasound-guided thrombin injection has lately become the treatment of choice. We present herein a case of a large femoral artery pseudoaneurysm that was treated via transarterial thrombin injection and a covered stent.

Case

A 62-year-old male with a known history of abdominal aortic aneurysm (AAA), coronary artery disease with ischemic cardiomyopathy, hypertension, and dyslipidemia presented to the endovascular clinic for a 6-month follow up of his AAA. Physical examination was remarkable for a palpable abdominal mass and a soft bruit. Computed tomography (CT) angiography of the abdomen and pelvis measured the AAA at 5.5 cm in oblique anteroposterior (AP) diameter compared to 5.2 cm at preceding study 6 months prior. In the setting of a progressively enlarging AAA, the decision was made to perform an endovascular aneurysm repair of the AAA.

The patient was brought to the catheterization laboratory, prepped, and draped in sterile fashion for percutaneous access. Micropuncture access was obtained in bilateral femoral arteries with placement of 6 French sheaths bilaterally. Selective angiograms confirmed common femoral artery access and Prostar XL percutaneous vascular surgical devices (Abbott Vascular) were pre-deployed to deliver sutures at each puncture site for hemostasis at completion of procedure. A descending aortogram confirmed a distal AAA with a long infra-renal neck. Percutaneous endovascular aneurysm repair was performed successfully without complications and final aortogram confirmed an excellent angiographic result, with apposition of the graft in the aortic and iliac segments, and no evidence of endovascular leak.  

Hemostasis was achieved in bilateral femoral arteries upon completion of the procedure by completing the suture deployment from the pre-delivered Prostar XL vascular closure devices. The patient was discharged home the following day without complications. However, the patient returned to the hospital the second day after discharge with significant ecchymosis and pain in the left femoral artery access site. Ultrasound confirmed a large wide-neck pseudoaneurysm (PA) and the patient was brought back urgently to the catheterization laboratory.  

Selective angiogram of the left external iliac artery via left brachial artery access confirmed a large PA arising from the left common femoral artery (Figure 1). A 7 French Pinnacle Destination sheath (Terumo) was advanced over an Amplatz stiff wire (Cook Medical) into the left iliac limb of the stent graft. A Grand Slam guide wire (Abbott) was advanced across the PA into the distal left superficial femoral artery. A Prowater wire (Abbott) was then advanced into the PA and coiled within the aneurysm. Selective angiogram of the PA confirmed the size and neck of the aneurysm from the common femoral artery (Figure 2). A Sprinter 1.25 x 6 mm over-the-wire balloon (Medtronic) was advanced over the Prowater wire into the PA and position confirmed within this space. A Submarine 8.0 x 40 mm balloon (Invatec) was inflated over the Grand Slam wire in the common femoral artery across the origin of the PA to occlude flow into and out of the aneurysm. With this balloon inflated, a total of 10,000 IU of thrombin was slowly injected directly into the PA via the Sprinter balloon (Figure 3) over a period of 20 minutes. Subsequent angiogram revealed slow flow within the PA. A Viabahn 8.0 x 50 mm covered stent graft (Gore) was deployed across the origin of the PA in the common femoral artery, and post-dilated with an excellent angiographic result and no residual filling of the PA (Figure 4). Hemostasis was achieved in the left brachial artery with manual compression.  The patient was discharged home the following day without complications.

Discussion

The number of percutaneous endovascular interventions has been growing rapidly with the evolution of technology and availability of smaller profile devices. The common femoral artery is the most common access site for endovascular procedures and requires the knowledge to recognize and manage the complications associated with this access.¹ The most frequent complications include hematoma, PA, arteriovenous fistula, and in-situ arterial dissection with or without associated thrombosis.² Risk factors that influence the likelihood of complications include larger sheath size³ and inappropriate location of arterial puncture⁴. Recent increase in the use of vascular closure devices has improved patient comfort and shortened the time for hemostasis, ambulation, and discharge⁵, but their effect on the rate of access-related complications remain unclear. The use of the “pre-closure” technique with 2 ProGlide devices (Abbott Vascular) or a single ProStar device for larger sheath sizes has been shown to be technically successful with low rates of adverse events.⁶  

The reported incidence of femoral PAs ranges from 0.2% to 0.5% after diagnostic angiography and from 2% to 8% after coronary interventions.⁷ Signs and symptoms of PA include pain, swelling, and ecchymosis at the access site, and sometimes even a palpable thrill or pulsatile mass.⁸ Complications may include progressive pain and swelling, thromboembolization, skin necrosis, infection, or nerve compression, but the most serious is rupture.⁸  

Duplex ultrasound (US) is the modality of choice to screen for a PA and to determine its characteristics, such as size, shape, and presence of thrombus.⁹ Conservative management with spontaneous closure is expected when the PA size is < 1.8 cm in diameter.¹⁰ Invasive treatment is recommended when the PA is > 3 cm in diameter.¹¹  

The success of surgical open repair maintained it as the gold standard of therapy until 1991, but US-guided minimally invasive therapy has become the first-line approach for treatment of PA.¹² US-guided compression repair is a simple procedure, but often requires intravenous analgesia or sedation, and is plagued by a significant failure rate. US-guided percutaneous thrombin injection is now the treatment of choice for femoral artery PAs with a discrete neck, due to much higher success rates.¹³ Percutaneous thrombin injection with simultaneous balloon occlusion of the entry site of the PA has been described in cases where the neck is short, wide, or absent due to the risk of thrombin leakage into the femoral artery.¹⁴ Stent grafts have been used as a reliable option for PAs that cannot be repaired with US-guided thrombin injection or that are associated with arteriovenous fistula.¹⁵ Transarterial thrombin injection into the PA through the neck has been reported in few cases when the PA is not percutaneously accessible.¹⁶  

We present herein a case of endovascular pseudoaneurysm repair using transarterial thrombin injection and covered stent deployment. 

Disclosure: Dr. George reports no conflicts of interest regarding the content herein.

Dr. Jon George can be contacted at: jcgeorgemd@gmail.com.

References

1. Tsetis, D.  Endovascular treatment of complications of femoral arterial access.  Cardiovasc Intervent Radiol. 2010; 33: 457-468.
2. Samal AK, White CJ.  Percutaneous management of access site complications.  Catheter Cardiovasc Interv. 2002; 57: 12-23.
3. Muller DWM, Shamir KJ, Ellis SG, et al. Peripheral vascular complications after conventional and complex percutaneous coronary intervention procedures. Am J Cardiol. 1992; 69: 63-68.
4. Altin RS, Flicker S, Naidech HJ. Pseudoaneurysm and arteriovenous fistula after femoral artery catheterization:  association with low femoral punctures.  AJR Am J Roentgenol. 1989; 152: 629-631.
5. Schwartz BG, Burstein S, Economides C, et al. Review of vascular closure devices. J Invasive Cardiol. 2010; 22(12): 599-607.
6. Kim WH, Shin S, Ko YG, et al. Efficacy and safety of the preclose technique following percutaneous aortic stent-graft implantation. J Endovasc Ther. 2013; 20(3): 350-355.
7. Lumsden AB, Miller JM, Kosinski AS, et al. A prospective evaluation of surgically treated groin complications following percutaneous cardiac procedures. Am Surg. 1994; 60: 132-137.
8. Morgan R, Belli AM. Current treatment methods for postcatheterization pseudoaneurysms.  J Vasc Interv Radiol. 2003; 14: 697-710.
9. Middleton WD, Dasyam A, Teefey SA. Diagnosis and treatment of iatrogenic femoral artery pseudoaneurysms. Ultrasound Q. 2005; 21: 3-17.
10. Kent KC, McArdle CR, Kennedy B, et al. A prospective study of the clinical outcome of femoral pseudoaneurysms and arteriovenous fistulas induced by arterial puncture. J Vasc Surg. 1993; 17: 125-131.
11. Toursarkissian B, Allen BT, Petrinec D, et al. Spontaneous closure of selected iatrogenic pseudoaneurysms and arteriovenous fistulae. J Vasc Surg. 1997; 25: 803-809.
12. Fellmeth BD, Roberts AC, Bookstein JJ, et al. Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression. Radiology. 1991; 178: 671-675.
13. Tisi PV, Callam MJ. Treatment for femoral pseudoaneurysms. Cochrane Database Syst Rev. 2009; 15(2): CD004981.
14. Loose HW, Haslam PJ. The management of peripheral arterial aneurysms using percutaneous injection of fibrin adhesive. Br J Radiol. 1998; 71: 1255-1259.
15. Baltacioglu F, Cim NC, Cil B, et al. Endovascular stent-graft applications in iatrogenic vascular injuries. CardioVasc Interv Radiol. 2003; 26: 434-439.
16. Walker TG, Geller SC, Brewster SC. Transcatheter occlusion of a profunda femoral artery pseudoaneurysm using thrombin.  AJR Am J Roentgenol. 1987; 149: 185-186.