Effective treatment of iatrogenic femoral pseudoaneurysms by combined endovascular balloon inflation and percutaneous thrombin injection


The increasing number of percutaneous endovascular procedures in highly anticoagulated patients has increased the possibility of iatrogenic femoral artery pseudoaneurysm (IFAP). Ultrasound (US)-guided percutaneous thrombin injection is one of the feasible treatments; however, there are concerns about complications such as peripheral embolization. This study was performed to examine the efficacy and safety of treatment of IFAPs using a combination of percutaneous thrombin injection and intravascular balloon inflation. In this retrospective, single-center study, we analyzed 11 patients who developed and were treated for IFAPs from January 2017 through April 2020. The patients were treated with endovascular therapy (EVT) with percutaneous thrombin injection. The technique utilized fluoroscopic guidance to place a balloon at the neck of the IFAP, and the balloon was then inflated to prevent the inflow of blood to the aneurysm. We then performed US-guided thrombin injection. The mean age was 72.36 ± 10.43 years; mean body mass index (BMI) was 25.25 ± 3.18. All patients had hypertension, 72.7% were undergoing hemodialysis, and 54.5% used oral anticoagulant drugs. The mean aneurysm size was 24.34 ± 13.54 mm. The approach was transfemoral in ten patients and transradial in one patient. All procedures were successful, and there were no complications. The mean thrombin dose was 677.3 ± 410.7 IU; the total hemostatic time was 45.4 ± 24.9 min. In conclusion, the combination of percutaneous thrombin injection and endovascular balloon inflation was feasible and safe for the treatment of IFAPs. This technique may contribute to the treatment of IFAPs.

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  1. 1.

    Stone PA, Campbell JE, AbuRahma AF. Femoral pseudoaneurysm after percutaneous access. J Vasc Surg. 2014;60:1359–66.

    Article  Google Scholar 

  2. 2.

    Otsuka M, Shiode N, Nakao Y, Ikegami Y, Kobayashi Y, Takeuchi A, et al. Comparison of radial, brachial, and femoral accesses using hemostatic devices for percutaneous coronary intervention. Cardiovasc Interv Ther. 2018;33:62–9.

    Article  Google Scholar 

  3. 3.

    Schneider C, Malisius R, Kuchler R, Lampe F, Krause K, Bahlmann E, et al. A prospective study on ultrasound-guided percutaneous thrombin injection for treatment of iatrogenic post-catheterisation femoral pseudoaneurysms. Int J Cardiol. 2009;131:356–61.

    Article  Google Scholar 

  4. 4.

    Webber GW, Jang J, Gustavson S, Olin JW. Contemporary management of postcatheterization pseudoaneurysms. Circulation. 2007;115:2666–74.

    Article  Google Scholar 

  5. 5.

    Castillo-Sang M, Tsang AW, Almaroof B, Cireddu J, Sferra J, Zelenock GB, et al. Femoral artery complications after cardiac catheterization: a study of patient profile. Ann Vasc Surg. 2010;24:328–35.

    Article  Google Scholar 

  6. 6.

    Fellmeth BD, Roberts AC, Bookstein JJ, Freischlag JA, Forsythe JR, Buckner NK, et al. Postangiographic femoral artery injuries:nonsurgical repair with US-guided compression. Radiology. 1991;178:671–5.

    CAS  Article  Google Scholar 

  7. 7.

    Stone P, Lohan JA, Copeland SE, Hamrick RE Jr, Tiley EH 3rd, Flaherty SK. Iatrogenic pseudoaneurysms: comparison of treatment modalities, including duplex-guided thrombin injection. W V Med J. 2003;99:230–2.

    PubMed  Google Scholar 

  8. 8.

    Ugurluoglu A, Katzenschlager R, Ahmadi R, Atteneder M, Koppensteiner R, Lang G, et al. Ultrasound guided compression therapy in 134 patients with iatrogenic pseudo-aneurysms: advantage of routine duplex ultrasound control of the puncture site following transfemoral catheterization. Vasa. 1997;26:110–6.

    CAS  PubMed  Google Scholar 

  9. 9.

    Cope CZR. Coagulation of aneurysms by direct percutaneous thrombin injection. AJR Am J Roentgenol. 1986;147:383–7.

    CAS  Article  Google Scholar 

  10. 10.

    Chen DH, Sammel AM, Jain P, Jepson NS. Cardiologist operated ultrasound guided thrombin injection as asafe and efficacious first line treatment for iatrogenic femoral artery pseudoaneurysms. Heart Lung Circ. 2015;24:165–72.

    Article  Google Scholar 

  11. 11.

    Kurzawski J, Sadowski M, Sadowska AJ. Complications of percutaneous thrombin injection inpatients with postcatheterization femoral pseudoaneurysm. J Clin Ultrasound. 2016;44:188–95.

    Article  Google Scholar 

  12. 12.

    Stolt M, Dullaeus RB, Herold J. Do not underestimate the femoral pseudoaneurysm. Vasa. 2018;47:177–85.

    Article  Google Scholar 

  13. 13.

    Toursarkissian B, Allen BT, Petrinec D, Thompson RW, Rubin BG, Reilly JM, et al. Spontaneous closure of selected iatrogenic pseudoaneourysms and arteriovenous fistulae. J Vasc Surg. 1997;25:803–8.

    CAS  Article  Google Scholar 

  14. 14.

    Eisenberg L, Paulson EK, Kliewer MA, Hudson MP, DeLong DM, Carroll BA. Sonographically guided compression repair of pseudoaneurysms: future experience from a single institution. AJR Am J Roentgenol. 1999;173:1567–73.

    CAS  Article  Google Scholar 

  15. 15.

    Kang SS, Labropoulos N, Mansour MA, Michelini M, Filliung D, Baubly MP, et al. Expanded indications for ultrasound-guided thrombin injection of pseudoaneurysms. J Vasc Surg. 2000;31:289–98.

    CAS  Article  Google Scholar 

  16. 16.

    Hofmann I, Wunderlich N, Robertson G, Kieback A, Haller C, Pfeil W, et al. Percutaneous injection of thrombin for the treatment of pseudoaneurysm: the German multicentre registry. Eurointervention. 2007;3:321.

    Article  Google Scholar 

  17. 17.

    Kodama A, Yamamoto M, Shimura T, Kagase A, Koyama Y, Tada N, et al. Comparative data of single versus double ProGlide vascular preclose technique after percutaneous transfemoral transcatheter aortic valve implantation from the Optimized CathEter vAlvular iNtervention (OCEAN-TAVI) Japanese Multicenter Registry. Catheter Cardiovasc Interv. 2017;90:55–62.

    Article  Google Scholar 

  18. 18.

    Mogi S, Endo A, Kawamura A. Left main trunk perforation sealed by 90 second perfusion balloon inflation. J Invasive Cardio. 2012;24:115–8.

    Google Scholar 

  19. 19.

    Nakabayashi K, Kaneko N, Sunaga D, Matsui A, Tanaka K, Ando H, et al. Utility of a 0.035′′ compatible rapid-exchange balloon (Metacross RX) as a perfusion balloon in endovascular therapy compared with conventional percutaneous coronary intervention: a mini-review. Cardiovasc Revasc Med. 2017;18:619–22.

    Article  Google Scholar 

  20. 20.

    Shinozaki N, Ikari Y. Superficial femoral artery stenting via radial access using R2P® Misago® stents: first-in-human report of the new R2P® system. SAGE Open Med Case Rep. 2019;7:1–4.

    Google Scholar 

  21. 21.

    Parodi JC, Schonholz C, Ferreira LM, Bergan J. Endovascular stent-graft treatment of traumatic arterial lesions. Ann Vasc Surg. 1999;13:121–9.

    CAS  Article  Google Scholar 

  22. 22.

    Moulakakis KG, Sfyroeras GS, Alexiou VG, Kakisis J, Lazaris A, Vasdekis SN, et al. Endovascular management of infected illiofemoral pseudoaneurysms: a case series. Vasc Endovascular Surg. 2016;50:421–6.

    Article  Google Scholar 

  23. 23.

    Hadziomerovic A, Jetty P, Gupta A. Angioseal-assisted closure of iatrogenic refractory femoral arterial pseudoaneurysm: a novel technique. JACC Cardiovasc Interv. 2016;9:e55–7.

    Article  Google Scholar 

  24. 24.

    Ibrahim K, Christoph M, Wunderlich C, Jellinghaus S, Loehn T, Youssef A, et al. A novel interventional method for trating femoral pseudoaneurysms:results from a monocentric experience. Eurointervention. 2017;13:366–70.

    Article  Google Scholar 

  25. 25.

    Ergun O, Çeltikçi P, Güneş Tatar İ, Yılmaz M, Hekimoğlu B. Percutaneous thrombin injection treatment of a femoral artery pseudoaneurysm with simultaneous arterial balloon occlusion: Case report and review of the literature. Turk Kardiyol Dern Ars. 2016;44:684–9.

    PubMed  Google Scholar 

  26. 26.

    Vowels TJ, Zubair MM, Bismuth J, Le L. Balloon-assisted ultrasound-guided percutaneous thrombin injection of iatrogenic femoral artery pseudoaneurysms: a case report and description of the technique. Vasc Endovascular Surg. 2020;54:532–5.

    Article  Google Scholar 

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We thank Andrea Baird, MD, from Edanz Group (https://en-author-services.edanzgroup.com/ac) for editing a draft of this manuscript.


This research received no specific grants from any funding agency in the public, commercial, or not-for-profit sectors.

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Correspondence to Naoki Hayakawa.

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The authors declare no potential conflicts of interest regarding the research, authorship, and/or publication of this article.

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All procedures were performed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The study was approved by the Institutional Review Board of Asahi General Hospital.

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Hayakawa, N., Kodera, S., Miyauchi, A. et al. Effective treatment of iatrogenic femoral pseudoaneurysms by combined endovascular balloon inflation and percutaneous thrombin injection. Cardiovasc Interv and Ther (2021). https://doi.org/10.1007/s12928-021-00764-9

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  • Endovascular procedures
  • Thrombin
  • Pseudoaneurysm
  • Iatrogenic
  • Complication