IATROGENIC GROIN PSEUDOANEURYSM ECHODOPPLER MANAGEMENT WITH FIBRIN GLUE: OUR EXPERIENCE PSEUDOANEURISMA INGUINALE IATROGENO-TRATTAMENTO PERCUTANEO ECOGUIDATO CON COLLA DI FIBRINA: NOSTRA ESPERIENZA (Angiologia-Chirurgia Vascolare-ULSS 15 Alta Padovana) (Angiology- Vascular Surgery -ULSS 15 Alta Padovana)

1. 1
TREATMENT OF IATROGENIC FEMORAL ARTERY
PSEUDOANEURYSM BY FIBRIN GLUE INJECTION: CLINICAL
EXPERIENCE
F Faresin, F Franz, S Ronsivalle
Department of Cardiovascular Disease – Vascular and Endovascular Surgery
and Angiology, Cittadella, Padua (Italy)
It is a simple, quick, safe and effective procedure in treatment of iatrogenic
pseudoaneurysm. It is a valid and useful alternative to surgical treatment.

2. 2
TREATMENT OF IATROGENIC FEMORAL ARTERY
PSEUDOANEURYSM BY FIBRIN GLUE INJECTION: CLINICAL
EXPERIENCE
ABSTRACT
PURPOSE
Pseudoaneurysms have become more frequently seen as a complication of
iatrogenic cardiovascular interventional techniques.
We report our experience in the treatment of iatrogenic pseudoaneurysms by
injecting fibrin glue into the aneurysm sac under ultrasound guidance.
TECHNIQUE
Between November 2009 to June 2011 35 patients with common femoral
artery and 1 patient with an omeral iatrogenic pseudoaneurysm were treated in
our institution.
All cases completely thrombosed within a few minutes. In two cases a 15 and
30 days echo-color-doppler ultrasound inspection revealed a pseudoaneurysm
sac refilling and were treated surgically.
In 1 case with an omeral pseudoaneurysm there was a complication of left
arm acute ischemia, but it was treated successfully with Fogarty’s
thromboembolectomy.
CONCLUSIONS
In our experience the treatment of iatrogenic pseudoaneurysms by injection of
fibrin glue into the aneurysm sac under echo-color-doppler ultrasound
guidance is a safe and effective procedure after an accurate pre operative echo
color Doppler ultrasound assessment.

3. 3
TREATMENT OF IATROGENIC FEMORAL ARTERY
PSEUDOANEURYSM BY FIBRIN GLUE INJECTION: CLINICAL
EXPERIENCE
INTRODUCTION
A pseudoaneurysm (false aneurysm) occurs when blood escapes from the
lumen of an artery through a defect in one or more layers of the arterial wall
and forms a localised pocket of blood flow either beneath the adventitia (outer
wall of the artery) or in the surrounding tissues, that is connected to the artery
by a “ neck”. The continuing extravasation of blood into the subcutaneous
tissues is contained within a pseudocapsule of fibrous tissues within the
adjacent soft tissue. This leads to a rupture causing catastrophic bleeding and
is a potential complication.
They are most commonly found as a complication of endovascular procedures
(e.g. diagnostic arteriogram, angioplasty, cardiac catheterization), vascular
trauma, or following open vascular surgery. 1,2
Once considered a rare disease in mostly post-traumatic genesis, with the
increased number of percutaneous interventions via artery cannulation, the
incidence rate of iatrogenic pseudoaneurysm has become more frequently
seen, usually in common femoral artery.
It occurs in 0.2 of diagnostic and 8% of interventional procedures but may
increase up to 16% with more complex treatments that necessitate larger
sheaths. 5-7
It is due to the characteristics of the artery wall (as atherosclerotic plaques
and loss of elasticity), lengthy procedures and investigations, using large bore
catheters, anticoagulant or antifibrinolytic therapy, insufficient compression
of the vessel at the end of the procedure.

4. 4
The diagnosis is confirmed by an echo-color-doppler ultrasound which shows
the size of the sac, the characteristics and rate of flow through communication
with the artery.
Small pseudoaneurysms usually resolve with compressive treatment.
The larger ones because of the risk of rupture, require treatment by surgery in
case of failure of the compression technique.
Open surgical repair was the gold standard for iatrogenic pseudoaneurysm
until 1991.
Fellmeth et al reported on using ultrasound scan-guided compression (UGCR)
as a nonsurgical intervention for femoral pseudoaneurysm. 7
UGCR proved to be a beneficial nonoperative technique for femoral
pseudoaneurysm; however it’s painful for the patient and time consuming.
UGCR has less success with larger pseudoaneurysms, those lasting more than
2 weeks, and those in patients who were undergoing anticoagulation therapy.
7-9
Ultrasound scan-thrombin guided injection (UGTI) was first introduced in
1986 by Cope and Zeits.
There is a reluctance in using this technique possibly because the potential
intra-arterial injection could promote a subsequent thrombosis.
We report our experience in the treatment of iatrogenic pseudoaneurysms by
injection of fibrin glue into the pseudoaneurysm sac under echo-color-doppler
ultrasound guidance.

5. 5
TECHNIQUE
Patients and methods
From November 2009 to June 2011 over 2450 patients had coronary or
peripheral angiography and angioplasty in Interventional Cardiology.
All complications related to arterial puncture sites such as bruit, hematoma,
pulsatile hematoma, or marked pain or tenderness were studied.
A color Doppler ultrasound analysis evaluated the presence of a
pseudoaneurysm or other complications, such as arteriovenous fistula.
EchocolorDoppler ultrasound confirmed the diagnosis in all cases.
Out of the 2450 procedures there were 65 pseudoaneurysms (2.6%); all were
treated with compression or ultrasound scan-guided compression. 27 patients
(41.5%) had good results but 3 patients (4.6%) with neck’s pseudoaneurysms
less than 10 mm long and/or more than 0,8 mm large, after compression or
ultrasound scan-guided compression failure, underwent surgical repair.
35patients (53.8%) with a common femoral artery iatrogenic pseudoaneurysm
and one patient (1.5%) with an omeral iatrogenic pseudoaneurysm after
compression or ultrasound scan-guided compression failure, were treated in
our Institution with fibrin glue injection inside the pseudoaneurysm sac.
Diagnostic Duplex scan was done with Siemens Acuson S2000 with 5 MHz
to 7 MHz linear array transducer.
Informer consent was obtained.
Pedal and radial pulses were assessed before and after the procedures.
The groin and the antecubital fossa were prepared and draped in the usual
sterile fashion.
With direct ultrasound scan guidance the tip of the needle 18 or 19 G was
placed within the pseudoaneurysm and the two components of fibrin glue
(fibrinogen solution and thrombin solution) were simultaneously injected into
the sac through a needle connected on a DUPLOJECT two way syringe clip.

6. 6
Back pressure was maintained at the syringe plunger to prevent clotting of the
needle.
The injection of fibrin glue was performed with ultrasound scan guidance to
confirm thrombosis of the sac.
A second injection with the same amount was required in 7 patients (19.4%).
Successful resolution was visualized within moments. During the injection a
probe echo guided pressure is made in order to close the pseudoaneurysm
neck and avoid the suction of fibrin glue inside the vessels.
At the end of a procedure, the patency of the common, superficial, profunda
femoral along with distal arteries and veins was assessed with
echocolordoppler scan evaluation.
Repeated echo-color-doppler ultrasound evaluations were performed at 24
hours and at 30 days.
Fibrin sealant
Fibrin glue (Tisseel/Tissucol; Baxter-Hyland Immuno AG, Vienna, Austria) is
a fully absorbable biological adhesive matrix without cytotoxic effects, made
of two main components: 1) a fibrinogen solution containing plasma proteins
and factor XIII; 2) a thrombin solution containing calcium chloride and
aprotinin. These components are commercially prepared from human plasma,
except for aprotinin, which is extracted from bovine lung. When mixed
together they recreate the final phase of the natural coagulation cascade
forming a structured fibrin clot similar to the physiological clot, susceptible of
fibrinolytic degradation caused by proteolytic enzymes such as plasmin.
Over the last 3 decades, fibrin glue has been used extensively by surgeons.
The required dose of sealant to cover 40 cm2
or 3.5 cm3
is about 5 ml,
however, its use in pseudoaneurysm sac embolization is an off-label
indication.

7. 7
Fibrin glue does not alter in any way MRI scanning, CT and CDU imaging.
In Italy 2 ml of Tissucol costs 180 euros, about 256 dollars. 11-14
Results
Thirty-five patients with a common femoral pseudoaneurysm and one with
omeral pseudoaneurysm developed after percutaneuous cardiac catheterism
have been treated with fibrin glue injection inside the pseudoaneurysm sac.
Sac mean diameter was 30.3 ± 11.2 mm. True lumen mean diameter was 2.3 ±
0.9 mm. Neck mean length was 15.2 ± 1.6 mm. Neck mean diameter was 0.4
± 0.2 mm.
In 12 cases (33.3%) more than one cavity were seen.
In all 35 common femoral artery pseudoaneurysm cases there was a complete
thrombosis of pseudoaneurysm sac within minutes, confirmed by echo-color-
doppler ultrasound inspection which was performed at 24 hours (Fig 1-2-3 A
and 1-2-3 B).
In 2 patients who were undergoing anticoagulation therapy, an echo-color-
doppler ultrasound inspection at 15 and 30 days respectively, revealed a
pseudoaneurysm sac refilling and were treated surgically.
One case of an omeral pseudoaneurysm had complications of acute
thrombosis of omeral, radial and ulnar ateries with left arm acute ischemia.
The patient was treated successfully with Fogarty’s thromboembolectomy.

8. 8
DISCUSSION
Fibrin glue is formed by two components that when mixed together they
recreate the final phase of the natural coagulation cascade forming a
structured fibrin clot similar to the physiological clot.
Over the last 3 decades it has been used extensively by surgeons and since
2003 we have used it successfully in prevention of EL type II with
thrombization of aneurysm sac with biomaterials during EVAR. 11-14
We have transferred our experience in aneurysm sac thrombization during
EVAR into an iatrogenic pseudoaneurysm treatment.
We believe that, compared to thrombin alone, fibrin glue is more effective in
promoting sac thrombosis and neck closure, most of all in patients who are
undergoing anticoagulation or heavy antiaggregant therapy.
Nevertheless, we point out that it is not safe to treat pseudoaneurysms with
short and wide necks that have a high risk of peripheral embolization.
In fact the case with the omeral pseudoaneurysm had a short and wide neck
(Fig 1-C and 2-C) with high blood pressure and stormy flow inside the sac
which probably caused fibrin glue suction inside the vessels and subsequently
peripheral embolization.
There were no cases of allergic or anaphylactic reactions.
We had primary success with immediate pseudoaneurysm sac thrombosis in
35 patients (97.2%), a peripheral embolization in 1 patient (2.8%) and two
cases of pseudoaneurysm refilling (5.5%). One after 15 days and the other at
30 days who both had to have surgical treatment.
As of today, our results are encouraging but more experience is necessary to
confirm validity of this method.

9. 9
CONCLUSIONS
In our experience the treatment of iatrogenic pseudoaneurysms by injection of
fibrin glue into the pseudoaneurysm sac under echo-color-doppler ultrasound
guidance is a safe, rapid, low cost, well tolerated and effective procedure.
An accurate pre-procedural echo color Doppler ultrasound assessment is
necessary in order not to treat pseudoaneurysms with anatomical features that
are at a high risk of peripheral embolization. Further studies are necessary to
assess the long term results of this procedure.

10. 10
REFERENCES
1. Hanson JM, Atri M, Power N. Ultrasound guided thrombin injection of
iatrogenic groin pseudoaneurysm: Doppler features and technical tips. The
British Journal of Radiology, 81 (2008), 154–163
2. Surgery versus non surgical treatment for femoral pseudoaneurysms.
Cochrane Database Syst Rev. 2006 Jan 25;(1):CD004981.
3. Treatment for femoral pseudoaneurysms. Cochrane Database Syst Rev.
2009 Apr 15;(2):CD004981.
4. Ricci MA, Trevisani GT, Pilcher DV. Vascular complications of cardiac
catheterization. Am J Surg 1994;167:375-8.
5. Lumsden AB, Miller JM, Kosinski AS, Allen RC, Dodson TF, Salam
AA, et al. A prospective evaluation of surgically treated groin complications
following percutaneous cardiac procedures. Am Surg 1994;60:
132-7.
6. Ahmad f, A. Turnery SA, Torrie P, Gibson M . Iatrogenic femoral artery
pseudoaneurysms A review of current methods of diagnosis and treatment.
Clinical Radiology (2008) 63, 1310e1316
7. Olsen DM, Rodriguez J, Vranic M, Ramaiah V, Ravi R, Diethrich EB., A
prospective study of ultrasound scan–guided thrombin injection of femoral
pseudoaneurysm: A trend toward minimal medication. J Vasc Surg
2002;36:779-82.
8.Danzi GB, Sesana M, Capuano C, Baglini R, Bellosta R, Luzzani L, Carugati C,
Sarcina A. Compression repair versus low-dose thrombin injection for the treatment of
iatrogenic femoral pseudoaneurysm: a retrospective case-control study. Ital Heart J.
2005 May;6(5):384-9.

11. 11
9. Hussein A. Heisa, Kamal E. Bani-Hania,*, Mwaffaq A. Elheisb, Rami J.
Yaghana, Bayan K. Bani-Hani Postcatheterization femoral artery
pseudoaneurysms: Therapeutic options. A case-controlled study .
International Journal of Surgery (2008) 214-219
10. Bloom AI, Sasson T et al. Ultrasound-Guided Thrombin Injection for the
Treatment of Iatrogenic Pseudoaneurysm of the Femoral Artery IMAJ
2001;3:649±652
11. Zanchetta M, Faresin F, Pedon L, Ronsivalle S. Fibrin glue aneurysm sac
embolization at the time of endografting. J Endovasc. Ther. 2005; 12: 579-
582.
12. Zanchetta M; Faresin F; Pedon L; Riggi M; Colonna S; Lipari R;
Pettenuzzo F; Ronsivalle S. Funnel technique for first line treatment of an
abdominal aortic aneurysm with an ectatic proximal neck. J Endovasc. Ther.
2006; 13: 775-778.
13. Zanchetta M, Faresin F, Pedon L, Ronsivalle S. Intraoperative intrasac
thrombin injection to prevent type II endoleak after endovascular aortic
aneurysm repair.J Endovasc. Ther. 2007; 14: 176-183.
14. Ronsivalle S, Faresin F, Franz F, Rettore C, Zanchetta M, Olivieri A.
Aneurysm sac “Thrombization “ and stabilization in EVAR : A technique to
reduce the risk of type II endoleak. J Endovasc. Ther. 2010; 17: 517-524.

12. 12
FIGURE LEGEND
Figure 1: Typical example of a pseudoaneurysm. 1A a necked
pseudoaneurysm (PA) with flow within the aneurysm sac. 1B a post-fibrin
glue injection image, the PA is thrombosed and the cavity is now echogenic
1C the flow pattern in common femoral artery
Figure 2: Typical example of a pseudoaneurysm. 2 A a necked
pseudoaneurysm (PA) with flow within the aneurysm sac. 2B and 2 C a post-
fibrin glue injection image, the PA is thrombosed and the cavity is now
echogenic
Figure 1 and 2 C: Pseudoaneurysm with short and wide neck with high
pressure and stormy flow inside the aneurysm sac.