Catheter-directed endovascular application of thrombin: Report of 3 cases and review of the literature

Abstract

Purpose: To report 3 new cases of catheter-directed endovascular application of thrombin and explore trends by analysis of published case series.

Materials and methods: Institutional Review Board approved this retrospective study. All cases of non-tumoral arterial embolization performed from January 2003 to January 2015 at our institution were retrospectively reviewed. Thrombin was used in 7 of 589 cases. In 3 cases intra arterial thrombin was injected via catheter to treat active hemorrhage. Four cases were excluded due to percutaneous injection into visceral pseudoaneurysms (n=3) and making ex vivo autologous clot to be injected via catheter (n=1). Fisher's exact and the Wilcoxon rank sum tests were used to assess for association with acute nontarget thrombosis.

Results: Catheter-directed thrombin was used in 3/589 (0.5%) cases at our institution. All three cases were technically successful with no further bleeding (100%). Nontarget thrombosis of proximal branches occurred in 2 patients (67%) with no significant clinical consequences. Including our 3 cases, a total of 28 cases were reviewed. Of the variables examined-location (p=0.99), size (p=0.66) and etiology of vascular lesion (p=0.92), pseudoaneurysm neck anatomy (p=0.14), thrombin units (p=0.47), volume (p=0.76) or technique of use of small doses (p=0.99), use of other embolic material (p=0.67) and use of adjunct techniques (p=0.99)-none were found to be significantly associated with acute nontarget thrombosis. Technical success was 96% with no reports of reperfusion after treatment.

Conclusions: Catheter-directed endovascular thrombin can be an additional tool to treat pseudoaneurysms not amenable to conventional embolization. Further studies are required to optimize technique and outcomes.

Keywords: Catheter-directed; Endovascular; Pseudoaneurysm; Thrombin; Thrombosis.

Figure 1

a) Angiography 2 weeks after prior embolization shows filling of a 3.4 cm left renal artery pseudoaneurysm (asterisk) with jet phenomenon through a previously embolized branch (dotted arrow). Two other previously coil embolized branches are depicted with solid arrows. b) Selective injection of the culprit vessel just proximal to the indwelling coils. The jet phenomenon is depicted with solid arrow. c) Injection of the left renal artery after embolization with 1500 units of thrombin shows cessation of flow in the pseudoaneurysm and the culprit branch as well as thrombosis of the proximal renal artery branch (solid arrow). The other main renal artery branch remained patent.

Figure 2

a) Large right pelvic pseudoaneurysm (PSA, asterisk) arising a few centimeters distal to the origin of the internal iliac artery. Some of the coils (arrow) from prior embolizations are visible. b) Angiography via an occlusion balloon (solid arrow) into the bilobed PSA (asterisks) which communicated with the perineal wound (not shown). Coils deployed initially at this intervention (dotted arrow) were forcefully expelled into the PSA with no effect on flow. c) Final angiogram after thrombin injection and additional coils show no flow into the PSA.

Figure 3

CT scan of pelvis performed five days post embolization (a)showed a large right pelvic side wall pseudoaneurysm containing coils, high density material representing trapped contrast within the clot (asterisk) and gas bubbles from communication with the perineal wound. Trapped contrast made definitive assessment of flow within the pseudoaneurysm difficult. CT angiography performed two weeks after embolization (b) showed resolution of trapped contrast with no flow in the pseudoaneurysm (asterisk). Coils and gas bubbles are again seen.