Balloon-Assisted Percutaneous Thrombin Injection for Treatment of Iatrogenic Left Subclavian Artery Pseudoaneurysm in a Critically Ill COVID-19 Patient

Background. Central venous catheter represents an important tool in the management of critically ill patient. In this report, we described a COVID-19-positive case who had COVID-related complications and iatrogenic left subclavian artery pseudoaneurysm after central venous catheter insertion. Case Presentation. A 58-year-old male patient presented with a high-grade fever, myalgia, and shortness of breath due to COVID-19 infection. He required mechanical ventilation support and hemodialysis. He also developed uneventful deep vein thrombosis and myocardial infarction. As a complication of central line insertion, the patient developed pseudoaneurysm that originated from the subclavian artery with significant bleeding and large hematoma. Balloon-assisted percutaneous thrombin injection was done under ultrasound guidance. The patient was extubated 2 days later with no evidence of flow in the pseudoaneurysm. However, he lost movement in the left arm secondary to the compression of the brachial plexus from the pseudoaneurysm/hematoma, and therefore, 1.5 litres of the hematoma was evacuated in the operating room through a lateral left chest wall incision along the anterior axillary line to relieve the compression over the brachial plexus. The patient declined surgical reconstruction of the brachial plexus, and the flaccid paralysis of the arm did not recover during the follow-up. Conclusion. This is a case of unusual complications of COVID infection and iatrogenic left subclavian artery pseudoaneurysm postcentral vein cannulation. Balloon-assisted percutaneous thrombin injection for treatment of left subclavian artery pseudoaneurysm is feasible; however, delayed diagnosis could be associated with long-term or permanent disability.

Balloon assisted, ultrasound guided percutaneous thrombin injection of a large radial artery pseudoaneurysm using a trans-venous approach via an Ipsilateral Arteriovenous Fistula

Background Pseudoaneurysm formation is known to complicate arteriovenous haemodialysis access. Ultrasound guided thrombin injection is a recognised treatment option, but is not possible in pseudoaneurysms with no measurable neck. Balloon assisted techniques have been described in such cases, which transiently obstruct flow out of the pseudoaneurysm and thereby prevent non-target embolization during ultrasound guided percutaneous thrombin injection. We describe a balloon assisted technique for the treatment of a radial artery pseudoaneurysm, via retrograde access from the draining cephalic vein of an arteriovenous fistula. Method A 61-year-old male with a radio-cephalic fistula was found on duplex ultrasound to have a large radial artery pseudoaneurysm with no measurable neck, as well as a juxta-anastomotic cephalic vein stenosis. Endovascular treatment was selected over open surgery. Retrograde cephalic venous access was established, which allowed for concurrent treatment of both the venous stenosis and the arterial pseudoaneurysm. After balloon dilation of the juxta-anastomotic stenosis, a percutaneous transluminal angioplasty balloon catheter was advanced across the arteriovenous anastomosis and inflated across the neck of the radial artery pseudoaneurysm, to transiently obstruct blood flow. This allowed for safe injection of thrombin into the pseudoaneurysm by direct ultrasound guided sac puncture; thereby achieving thrombosis. Conclusions Balloon assisted ultrasound guided thrombin injection is an endovascular treatment option that can obviate the need for open surgery in cases involving pseudoaneurysms with no measurable neck. The technique described allowed both concurrent treatment of a juxta-anastomotic venous stenosis and treatment of an arterial pseudoaneurysm from a single venous puncture. This technique avoided arterial access and its inherent complications.

Traumatic Superficial Temporal Artery Pseudoaneurysm Treated With Thrombin Injection: A Case Report

Pseudoaneurysms of the superficial temporal artery are rare. They commonly occur after blunt trauma to the frontotemporal region of the head. There have been less than 400 cases of superficial temporal artery pseudoaneurysms reported. We present a case of a patient referred for a pulsatile head mass. Physical examination and color Doppler ultrasound confirmed the diagnosis of a superficial temporal artery pseudoaneurysm (STA PSA). This was treated with ultrasound-guided thrombin injection with complete resolution. Anatomical distribution, diagnosis, and treatment of STA PSA are discussed.

Successful Transcatheter Arterial Embolization Using N-Butyl-2-Cyanoacrylate as a Treatment for Refractory Inferior Epigastric Artery Pseudoaneurysm Accompanied by an Enterocutaneous Fistula: A Case Report

: Inferior epigastric artery (IEA) pseudoaneurysms are well-known postoperative abdominal complications, which often require proper treatment. Treatment options include surgical ligation, transcatheter embolization, and thrombin injection. Here, we report a rare case of an IEA pseudoaneurysm, accompanied by a postsurgical enterocutaneous fistula. The pseudoaneurysm relapsed after transcatheter coil embolization and percutaneous thrombin injection; it was completely occluded by transcatheter arterial embolization using n-butyl-2-cyanoacrylate. The present case shows that a coexisting enterocutaneous fistula can affect the unresponsiveness of patients with IEA pseudoaneurysm to widely accepted treatments, such as coil embolization and thrombin injection, by creating an inflammatory environment. In such cases, repeated therapeutic trials may be required. Transcatheter arterial embolization using n-butyl-2-cyanoacrylate can be a feasible therapeutic option for patients with refractory IEA pseudoaneurysm, accompanied by an enterocutaneous fistula.

Balloon Assisted, Ultrasound Guided Percutaneous Thrombin Injection of a Large Radial Artery Pseudoaneurysm Using a Trans-Venous Approach via an Ipsilateral Arteriovenous Fistula.

Background: Pseudoaneurysm formation is known to complicate arteriovenous haemodialysis access. Ultrasound guided thrombin injection is a recognised treatment option, but is not possible in pseudoaneurysms with no measurable neck. Balloon assisted techniques have been described in such cases, which transiently obstruct flow out of the pseudoaneurysm and thereby prevent non-target embolization during ultrasound guided percutaneous thrombin injection. We describe a novel balloon assisted technique for the treatment of a radial artery pseudoaneurysm, via retrograde access from the draining cephalic vein of an arteriovenous fistula. Method: A 61 year old male with a radio-cephalic fistula was found on duplex ultrasound to have a large radial artery pseudoaneurysm with no measurable neck, as well as a juxta-anastomotic cephalic vein stenosis. Endovascular treatment was selected over open surgery. Retrograde cephalic venous access was established, which allowed for concurrent treatment of both the venous stenosis and the arterial pseudoaneurysm. After balloon dilation of the juxta-anastomotic stenosis, a percutaneous transluminal angioplasty balloon catheter was advanced across the arteriovenous anastomosis and inflated across the neck of the radial artery pseudoaneurysm, to transiently obstruct blood flow. This allowed for safe injection of thrombin into the pseudoaneurysm by direct ultrasound guided sac puncture; thereby achieving thrombosis. Conclusions: Balloon assisted ultrasound guided thrombin injection is an endovascular treatment option that can obviate the need for open surgery in cases involving pseudoaneurysms with no measurable neck. The novel technique described allowed both concurrent treatment of a juxta-anastomotic venous stenosis and treatment of an arterial pseudoaneurysm from a single venous puncture. This technique avoided arterial access and its inherent complications.

Management of Visceral Artery Pseudoaneurysms by Combined Technique of Percutaneous Thrombin Injection and Endovascular Coiling

Purpose To describe our initial experience with percutaneous thrombin injection combined with endovascular coiling of high-flow visceral artery pseudoaneurysms. Materials and Methods Institutional review board approval was obtained. Between January 2019 and February 2020, 21 patients with nonvariceal upper gastrointestinal (GI) bleed underwent multidetector CT angiography. Four patients with acute pancreatitis and large pseudoaneurysms were selected for the combined technique. Human thrombin reconstituted with calcium chloride was injected percutaneously. Partially thrombosed aneurysms were treated up to three times. Simultaneously or within 15 days, coil embolization of the neck or patent part of pseudoaneurysm was performed. Patients were followed up to 1 month postprocedure. Results The size of the pseudoaneurysms ranged from 3 cm to 6 cm. All were accessed percutaneously by 22G Chiba needle under ultrasound guidance and 500 to 1500 units of thrombin was injected in one to three attempts. Subsequently, endovascular coiling of the neck of the pseudoaneurysm or of the feeding artery was performed. Technical success with cessation of flow was achieved in all four patients. One patient developed obstructive jaundice postprocedure and another continued to have GI bleeding despite thrombin injection. Conclusion Percutaneous thrombin injection is an easy to use and effective tool for treating visceral artery pseudoaneurysms and can be combined with endovascular coiling for successful occlusion of large pseudoaneurysms.