Successful Thrombin Injection of BA-PSA after Two Weeks of Failed Manual Compression in Patient on Triple Therapy

Case Report

Austin Surg Case Rep. 2018; 3(1): 1023.

Successful Thrombin Injection of BA-PSA after Two Weeks of Failed Manual Compression in Patient on Triple Therapy

Yeritsyan NB1, Stolt M1, Halloul Z2, Udelnow A2, Braun-Dullaeus RC1 and Herold J1*

1Division of Cardiology and Angiology, University Hospital Magdeburg, Leipziger, Germany

2Division of Vascular Surgery, University Hospital Magdeburg, Leipziger, Germany

*Corresponding author: Herold J, Division of Cardiology and Angiology, University Hospital Magdeburg, Germany

Received: January 12, 2018; Accepted: January 31, 2018; Published: February 08, 2018


An 83-year-old male with a brachial artery pseudoaneurysm (BA-PSA) following transbrachial digital subtraction angiography was admitted to our hospital. After failing both manual and ultrasound-guided compression of the BA-PSA, the percutaneous ultrasound-guided thrombin injection (UGTI) was successfully used as second-line therapy. It was shown that the UGTI is a feasible strategy to treat the brachial artery PSA in older patients on dual antiplatelet and anticoagulant therapy.

Keywords: Brachial Artery; Pseudo Aneurysm; Compression Sonography; Ultrasound-Guided Thrombin Injection


Therapeutic angiographies lead to higher incidences of iatrogenic PSA, because these procedures are associated with larger sheath sizes, more aggressive peri- and post-procedural anticoagulation and platelet aggregation inhibitors. The use of catheters with a large diameter (>7 F) [1-3], and platelet inhibitors [2], have been shown to be independent predictive factors of PSA formation in several studies. Parallel to the rapid progression of endovascular technology, upper extremity access has become a preferred interventional strategy during the past decade [4,5]. This resulted in an increase in iatrogenic radial and brachial pseudoaneurysms [5,6]. Until the 1990s, open surgical repair was the preferred method for the treatment of iatrogenic pseudoaneurysms, but this method was replaced by non-invasive methods. However, open surgical repair remains indicated in complicated cases, such as a septic or large PSA causing compression neuropathy. Additional indications include distal ischemia and skin and tissue necrosis [2,7,8]. Surgical repair, which can be performed under either local or general anesthesia, is an effective treatment. However, surgical repair is associated with a high incidence of postoperative complications, ranging from 16% to 71% [9-11]. Conventional approaches to manage PSAs are ultrasound-guided compression (UGC) and the surgical revision of the pseudoaneurysm. Nevertheless, in patients with dual antiplatelet or/and anticoagulation therapy, compressing strategy often fails and may become less efficient, while being painful and time-consuming [12]. The use of pressure bandages (for 12-24h) may cause a reduction of peripheral arterial circulation. Furthermore, it can lead to an increased risk of venous thrombosis due to the compression of the elastic venous walls, sometimes compressed by the pseudoaneurysm itself. Dimensions of the pseudoanerysm and the width and length of the PSA-neck can, in their turn, become factors compromising a successful outcome in UGC.

In the past three decades, there has been increasing popularity in the treatment of iatrogenic PSAs using a minimally-invasive percutaneous US-guided thrombin injection (UGTI) [5,13]. The efficacy of this approach is shown to be higher than that of compression repair alone [14]. Low complication rates, relative ease of performance, and shorter procedure times favor the use of US-guided thrombin injection in treating femoral pseudoaneurysm. However, limited studies have tested the UGTI in the management of BA-PSA, and the existing data are inconclusive on the safety and efficacy of this procedure [6,13,15,16]. The complex anatomical features of the brachial PSA, such as close proximity to the median nerve in the medial brachial fascial compartment and its smaller diameter predisposing to thrombosis, make the choice of treatment strategy highly challenging [16].  

In this case report we describe a successful treatment of BA-PSA with UGTI after two weeks of failed manual compression and UGC in an aged patient on anticoagulation and dual antiplatelet therapy. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008.

Case Presentation

An 83-year-old man was initially admitted with a non-healing ulcer on the second toe of the left foot for an emergency digital subtraction angiography. The patient was a smoker with a history of ischemic heart disease, who underwent coronary stent placements using the right-side transfemoral access a month prior. In addition, his medical history included hypertension, pulmonary disease, chronic kidney disease, and subclavian artery occlusive disease with stenting of the right subclavian artery. He was positively tested for Methicillin-resistant Staphylococcus aureus (MRSA). Two years earlier the patient underwent an amputation on the right leg due to progressive peripheral arterial occlusive disease.

The digital subtraction angiography (DSA) was performed using the right-side trans-brachial access. High-grade stenosis along the right and left superficial femoral artery, the left popliteal and the fibular artery were revealed. The antegrade percutaneous transluminal angioplasty of the superficial femoral artery and fibular artery was planned and performed.

Citation: Yeritsyan NB, Stolt M, Halloul Z, Udelnow A, Braun-Dullaeus RC and Herold J. Successful Thrombin Injection of BA-PSA after Two Weeks of Failed Manual Compression in Patient on Triple Therapy. Austin Surg Case Rep. 2018; 3(1): 1023.