Ultrasound guided thrombin injection for treating iatrogenic femoral artery pseudoaneurysms: a review focusing upon sonographic diagnosis and treatment

Danai E. Stefanou, Demosthenes D. Cokkinos, Eleni G. Antypa, Ioannis V. Kalogeropoulos


An exponential increase in the number of diagnostic and therapeutic endovascular interventions, as well as in the use of antiplatelet and anticoagulation therapy, has raised the incidence of iatrogenic femoral artery pseudoaneurysms. Historically accepted methods (spontaneous closure in non-anticoagulated patients, ultrasound-guided compression repair, surgical repair) have been introduced in the past as first line treatments, while more novel alternatives have also been suggested to replace them. The purpose of this review is to demonstrate the significance of femoral artery pseudoaneurysm formation, to evaluate the appropriate diagnosis with ultrasound (US) and to present US-guided thrombin injection (UGTI) as the most advocated method of treatment over surgical repair and US-guided compression repair. Complications of UGTI are also discussed, an algorithm for using this procedure is suggested and alternative treatments are reviewed.


femoral artery pseudoaneurysm; thrombin; ultrasound guided treatment

Full Text:



Olsen DM, Rodriguez JA, Vranic M, et al. A prospective study of ultrasound scan-guided thrombin injection of femoral pseudoaneurysm: a trend toward minimal medication. J Vasc Surg 2002; 36(4): 779-782.

La Perna L, Olin JW, Goines D, et al. Ultrasound-guided thrombin injection for the treatment of post catheterization pseudoaneurysms. Circulation 2000; 102: 2391-2395.

Ahmad F, Turner SA, Torrie P, et al. Iatrogenic femoral artery pseudoaneurysms-a review of current methods of diagnosis and treatment. Clin Radiol 2008; 63(12): 1310-1316.

Paulson EK, Sheafor DH, Kliewer MA, et al. Treatment of iatrogenic femoral arterial pseudoaneurysms: comparison of US-guided thrombin injection with compression repair. Radiology 2000; 215(2): 403-408.

Fellmeth BD, Roberts AC, Bookstein JJ, et al. Postangiographic femoral artery injuries: nonsurgical repair with US-guided compression. Radiology 1991; 178 (3): 671-675.

Kang SS, Labropoulos N, Mansour MA, et al. Percutaneous ultrasound guided thrombin injection: a new method for treating postcatheterization femoral pseudoaneurysms. J Vasc Surg 1998; 27(6): 1032-1038.

Mitchell DG, Needleman L, Bezzi M, et al. Femoral artery pseudoaneurysm: diagnosis with conventional duplex and color Doppler US. Radiology 1987; 165(3): 687-690.

Gürel K, Gür S, Özkan U, et al. US-guided percutaneous thrombin injection of postcatheterization pseudoaneurysms. Diagn Interv Radiol 2012; 18: 319-325.

Sheiman, RG, Brophy DP. Treatment of iatrogenic femoral pseudoaneurysms with percutaneous thrombin injection: experience in 54 patients. Radiology 2001; 219(1): 123-127.

Abu-Yousef MM, Wiese JA, Shamma AR. The “to-and-fro” sign: duplex Doppler evidence of femoral artery pseudoaneurysm. AJR Am J Roentgenol 1988; 150(3): 632-634.

Middleton WD, Dasyam A, Teefey SA. Diagnosis and treatment of iatrogenic femoral artery pseudoaneurysms. Ultrasound Q 2005; 21: 3-17.

Mahmoud MZ, Al-Saadi M, Abuderman A, et al. “To-and-fro” waveform in the diagnosis of arterial pseudoaneurysms. World J Radiol 2015; 7(5): 89-99.

Dzijan-Horn M, Langwieser N, Groha P, et al. Safety and efficacy of a potential treatment algorithm by using manual compression repair and ultrasound-guided thrombin injection for the management of iatrogenic femoral artery pseudoaneurysm in a large patient cohort. Circ Cardiovasc Interv 2014; 7(2): 207-215.

Mohler ER 3rd, Mitchell ME, Carpenter JP, et al. Therapeutic thrombin injection of pseudoaneurysms: a multicenter experience. Vasc Med 2001; 6(4): 241-244.

Toursarkissian B, Allen BT, Petrinec D, et al. Spontaneous closure of selected iatrogenic pseudoaneurysms and arteriovenous fistulae. J Vasc Surg 1997; 25(5): 803-808; discussion 808-809.

Kresowik TF, Khoury MD, Miller BV, et al. A prospective study of the incidence and natural history of femoral vascular complications after percutaneous transluminal coronary angioplasty. J Vasc Surg 1991; 13: 328-333; discussion 333-335.

Kotval PS, Khoury A, Shah PM, et al. Doppler sonographic demonstration of the progressive spontaneous thrombosis of pseudoaneurysms. J Ultrasound Med 1990; 9(4): 185-190.

Dean S, Olin JW, Piedmonte MA, et al. Ultrasound-guided compression closure of postcatheterization pseudoaneurysms during concurrent anticoagulation: a review of seventy-seven patients. J Vasc Surg 1996; 23(1): 28-34, discussion 34-35.

Cox GS, Young JR, Gray BH, et al. Ultrasound-guided compression repair of postcatheterization pseudoaneurysms: results of treatment in one hundred cases. J Vasc Surg 1994; 19(4): 683-686.

Lumsden AB, Miller JM, Kosinski AS, et al. A prospective evaluation of surgically treated groin complications following percutaneous cardiac procedures. Am Surg 1994; 60(2): 132-137.

Cope C, Zeit R. Coagulation of aneurysms by direct percutaneous thrombin injection. AJR Am J Roentgenol 1986; 147(2): 383-387.

Wixon CL, Philpott JM, Bogey WM Jr, et al. Duplex-directed thrombin injection as a method to treat femoral artery pseudoaneurysms. J Am Coll Surg 1998; 187(4): 464-466.

Liau CS, Ho FM, Chen MF, et al. Treatment of post-catheterization femoral artery pseudoaneurysm with percutaneous thrombin injection. J Vasc Surg 1997; 26(1): 18-23.

Kuma S, Morisaki K, Kodama A, et al. Ultrasound-guided percutaneous thrombin injection for post-catheterization pseudoaneurysm. Circ J 2015; 79(6): 1277-1281.

Krüger K, Zähringer M, Söhngen FD, et al. Femoral pseudoaneurysms: management with percutaneous thrombin injections-success rates and effects on systemic coagulation. Radiology 2003; 226(2): 452-458.

Kleczynski P, Rakowski T, Dziewierz A, et al. Ultrasound-guided thrombin injection in the treatment of iatrogenic arterial pseudoaneurysms: single-center experience. J Clin Ultrasound 2014; 42(1): 24-26.

Sadler JE. Thrombomodulin structure and function. Thromb Haemost 1997; 78(1): 392-395.

Gruber A, Mori E, del Zoppo GI, et al. Alteration of fibrin network by activated protein. Blood 1994; 83(9): 2541-2548.

Loose HW, Haslam PJ. The management of peripheral arterial aneurysms using percutaneous injection of fibrin adhesive. Br J Radiol 1998; 71(852): 1255-1259.

Elford J, Burrell C, Freeman S. Human thrombin injection for the percutaneous treatment of iatrogenic pseudoaneurysms. Cardiovasc Intervent Radiol 2002; 25(2): 115-118.

Esterson YB, Pellerito JS. Recurrence of thrombin-injected pseudoaneurysms under ultrasound guidance: a 10-year retrospective analysis. J Ultrasound Med 2017: 36(8): 1617-1624.

Yoo T, Starr JE, Go MR, et al. Ultrasound-guided thrombin injection is a safe and effective treatment for femoral artery pseudoaneurysm in the morbidly obese. Vasc Endovascular Surg 2017; 51(6): 368-372.

Krueger K, Zaehringer M, Strohe D, et al. Postcatheterization pseudoaneurysm: results of US-guided percutaneous thrombin injection in 240 patients. Radiology 2005; 236(3): 1104-1110.

Paulson EK, Nelson RC, Mayes CE, et al. Sonographically guided thrombin injection of iatrogenic femoral pseudoaneurysms: further experience of a single institution. AJR Am J Roentgenol 2001; 177(2): 309-316.

Kurzawski J, Sadowski M, Janion-Sadowska A. Complications of percutaneous thrombin injection in patients with postcatheterization femoral pseudoaneurysm. J Clin Ultrasound 2016; 44(3): 188-195.

Hamraoui K, Ernst SM, van Dessel PF, et al. Efficacy and safety of percutaneous treatment of iatrogenic femoral artery pseudoaneurysm by biodegradable collagen injection. J Am Coll Cardiol 2002; 39(8): 1297-1304.

Pope M. Johnston KW. Anaphylaxis after thrombin injection of a femoral pseudoaneurysm: recommendations for prevention. J Vasc Surg 2000; 32(1): 190-191.

Jalaeian H, Misselt A. Anaphylactic reaction to bovine thrombin in ultrasound-guided treatment of femoral pseudoaneurysm. J Vasc Interv Radiol 2015; 26(6): 915-916.

Tawes RL, Sydorak GR, DuVall TB. Autologous fibrin glue: the last step in operative hemostasis. Am J Surg 1994; 168(2): 120-122.

AHFS drug information. Hemostatics 1997; 20: 12-16.

Owen RJ, Haslam PJ, Elliott ST, et al. Percutaneous ablation of peripheral pseudoaneurysms using thrombin: a simple and effective solution. Cardiovasc Intervent Radiol 2000; 23(6): 441-446.

Vergaro G, Emdin M, Del Corso A. Correction of procedural arterial pseudoaneurysms: established and novel procedures. Expert Rev Cardiovasc Ther 2014; 12(7): 843-850.

Finkelstein A, Bazan S, Halkin A, et al. Treatment of post-catheterization femoral artery pseudo-aneurysm with para-aneurysmal saline injection. Am J Cardiol 2008; 101(10): 1418-1422.

Gehling G, Ludwig J, Schmidt A. Percutaneous occlusion of femoral artery pseudoaneurysm by para-aneurysmal saline injection. Catheter Cardiovasc Interv 2003; 58(4): 500-504.

ElMahdy MF, Kassem HH, Ewis EB, et al. Comparison between ultrasound-guided compression and para-aneurysmal saline injection in the treatment of postcatheterization femoral artery pseudoaneurysms. Am J Cardiol 2014; 113(5): 871-876.

Kurzawski J, Janion-Sadowska A, Sadowski M. A novel minimally invasive method of successful tissue glue injection in patients with iatrogenic pseudoaneurysm. Br J Radiol 2018; 91(1087): 20170538.


  • There are currently no refbacks.