2013session3 1
- 1. Pseudoaneurysm treatment by ultrasound-guided thrombin injection J.M. Patapas, V. Daniel, C. Abraham, D. Obrand, K. Mackenzie, O. Steinmetz, M.M. Corriveau
- 2. Overview • Pathophysiology • Objectives • Results • Discussion – Time to treatment – Bi-lobe – CKD – Anticoagulation • Future directions
- 3. Background • A pseudoaneurysm, or false aneurysm, is a pulsating hematoma surrounded by a thin fibrous capsule in communication with the lumen of a ruptured vessel • Unlike a true aneurysm, pseudoaneurysm does not consist of the true layers of the arterial wall Georgetownhospitalsystem.org
- 4. Indications to repair • Pain • DVT formation • Skin blistering • Size (≥ 2.5 cm)
- 5. Treatment options • Open surgical repair – PA is opened, direct suture repair – Invasive • Ultrasound-guided compression – Identify PA and compress with probe – Failure rate up to 25% (Mansour 2007) • Ultrasound-guided thrombin injection – safe, effective – Risk of arterial embolization or thrombosis (<1%) (Mansour 2007)
- 6. Objectives • To examine the efficacy of UGTI as a treatment for pseudoaneurysms • To identify successful treatment – Patient characteristics – Procedural characteristics – antiplatelet/anticoagulation therapy
- 7. Methods • A retrospective chart review – all patients who underwent UGTI for pseudoaneurysms – Royal Victoria and Jewish General Hospitals – December 1, 2006 until December 31, 2012
- 8. Results • Thirty-nine patients identified • Post endovascular procedures via CFA access • Successful (n=28) – Definitive thrombosis of PA – No arterial ischemia • Unsuccessful (n=11) – Requiring open repair (3) – Requiring additional thrombin injection (3) – Increased size or unchanged after 30 days (5)
- 9. Results
- 11. Results P=0.04
- 12. Results
- 13. Results - summary • Successfully thrombosis by UGTI – Chronic kidney disease – Shorter time-to-treatment • Unsuccessfully thrombosis by UGTI – Bi-lobed P.A.s
- 14. Discussion • Time to treatment – UGTI most successful within two-weeks post- catheterization (Gurel 2012) • Bilobed – Multilobed P.A.s successfully treated when proximal lobe is injected first (Hanson 2008) • CKD – Early stage = prothrombotic, late stage = uremic platelet dysfunction (Jalal 2010)
- 15. Role of anticoagualation and antiplatelet therapy • Anticoagulation (Stone 2006) and low platelet count (Mlekusch 2006) are risk factors for development of P.A.s • Successful UGTI regardless of anticoagulation (Lennox 2000)
- 16. Summary • PA most common complication of arterial catheritization • UGTI safe and efficacious first line therapy • We show successful UGTI associated with – Chronic kidney disease – Shorter time-to-treatment • UGTI failure associated with – Bi-lobed P.A.s – Longer time-to-treatment
- 17. Future directions • Prospective study • Multi centre
Editor's Notes
- #5: Pain = nerve compression or stretch of overlying skin our patients underwent repair with sizes smaller than 2.5 cm, because many of them were undergoing CABG or other interventions
- #7: -given the increased use of endovascular procedures, pseudoaneurysms development is also increasing. UGTI is becoming a more popular treatment choice. While safe and effective, it is nevertheless benign.
- #9: Average time to follow-up = 32 days
- #10: Risk factors for iatrogenic PA development: female sex, increased BMI
- #11: NO difference in anticoagulation, however antiplatelet showed a trend in unsucessful group. P = 0.06 (approaching significance). Not significant, BUT interesting to mention since CKD is a significant finding
- #12: Comorbidities reflect our pt population (vasculopaths) having HTN, CAD, and DMKeep in mind there was a small sample size in eachINTERSTINGLY, CKD was significant in the success group. P = 0.04
- #13: Longer time to treat may allow the PA more time to grow in size and become more difficult to thrombose Failure of bilobed may be due to difficult getting the needle in both lobes (more on this in discussion)
- #15: - Gurel: aftrer 2-weeks there were more failures, might be due to “matured intimal coating within the PA lobe”- Hanson 2008: multilobed-PAs are more successfully treated when the lobe closest to the parent vessel is injected, thereby cutting off flow to the more superficial lobes. Injecting the more distal lobes, however, lowers the risk of injecting the parent artery. - Multi-lobed P.A.s not a risk for failure (Lennox 2000) - Platelet dysfunction renders antiplatelet agents less effective (Alexopoulos 2011, van Bladel 2012)Endothelial changes, uremic toxins, anemia, and plasma factors also contribute (Alexopolous 2011)Changes in platelet transcriptome (Plé 2012)Early stages prothrombitic, later stages bleeding
- #16: While our data only came close to significance, this is interesting to discuss nevertheless, especially given our finding on CKD being significant for successful UGTI (CKD has platelet dysfunction, see next slide). - Role of anticoagulation and anti-platelet seem to be associated with development of PA but do not affect success of UGTI
- #18: Prospective study to gather more standardized data: dose of thrombin injection, etc.