Choosing a treatment method for post-catheterization pseudoaneurysms guided by the late to early velocity index

Abstract

Ultrasound-guided thrombin injection (UGTI) is often the first-line treatment for iatrogenic post-catheterization pseudoaneurysms (psA). There are also first reports of the use of biologically derived tissue glues (TG) instead of sole thrombin especially when UGTI was unsuccessful or in case of psA recurrence. Previously, we have established that a late to early velocity index (LEVI) < 0.2 could be a predictor of an increased risk of psA recurrence after standard UGTI. In this paper, we report our first experiences when the choice of the first-line treatment method was based on LEVI assessment. From May 2017 till January 2020 we included 36 patients with psA. Of them, 10 had LEVI < 0.2 and they underwent ultrasound-guided tissue glue injection (UGTGI) with biological TG and 26 had LEVI > 0.2 and they underwent UGTI. The injection set containing human thrombin and fibrinogen was used for UGTGI. Bovine thrombin was used for UGTI. The success rate was 100% and no psA recurrence was detected during a 2-week follow-up. It was significantly better when compared to the expected recurrence rates based on our previous 14 years of experience (0% vs. 13%, p = 0.01). All complications (10% in the UGTGI group and 15% in the UGTI group) were mild and transient and included clinical symptoms of paresthesia, numbness, tingling, or pain. Their rates were comparable to the rates we previously reported. No significant differences in other characteristics were observed. The approach to choose the first-line treatment method for iatrogenic psA based on LEVI is encouraging. It may increase the success rate and avoid unnecessary repetition of the procedure, without increasing complication rate while keeping costs of the procedure reasonable.

Figure 1

The examples of late to early velocity index (LEVI) calculations.

Figure 2

The example of the UGTGI procedure. (A) Ultrasound two-dimensional longitudinal image with color Doppler before psA embolization. (B) Pulse-wave Doppler image of inflow and outflow from the sac of psA, LEVI = 0.18. (C) Inserting a needle into the psA sac. The arrow indicates the tip of the needle. (D) Injection of TG into the psA sac. (E) Ultrasound image after the embolization of psA. (F) Follow-up ultrasound examination after 2 weeks. psA—pseudoaneurysm, UGTGI—ultrasound-guided tissue glue injection, LEVI—late to early velocity index, TG—tissue glue.