Stone Patrick A, Aburahma Ali F, Flaherty Sarah K
Division of Vascular and Endovascular Surgery, Department of Surgery, West Virginia University (Charleston Division), USA.
J Vasc Surg. 2006 Jun;43(6):1211-5. doi: 10.1016/j.jvs.2006.02.044.
Ultrasound-guided thrombin injection has become the initial treatment of choice for femoral access-related pseudoaneurysms. Patients typically undergo serial duplex examinations to assess for spontaneous resolution of small iatrogenic pseudoaneurysms (IPSAs) (<2.5 cm), or may require repeated diagnostic, therapeutic, and follow-up studies for larger IPSAs (>2.5 cm). We evaluated the impact of a revised treatment algorithm that includes primary treatment of both small (<2.5 cm) and larger pseudoaneurysms (>2.5 cm), rather than observation of smaller ones, and attempts to establish a single duplex examination via a point-of-care treatment strategy.
We reviewed 105 consecutive patients treated with ultrasound-guided thrombin injection from July 2001 through September 2004. Patient, IPSAs, characteristics, and treatment methods were examined. The number of duplex examinations per patient was evaluated over the treatment interval. Also, published cost data were used to compare primary treatment of small ISPAs vs observation with serial duplex examinations.
Successful thrombosis occurred in 103 (98.1%) of 105 treated pseudoaneurysms. No minor or major complications occurred after thrombin injection in either small or large ISPAs, and both failures requiring operation were in the large aneurysm group. The recurrence rate for the series was 1.9% (2/105), and both recurrences were successfully treated with an additional thrombin injection. A single injection was successful in treating 43 (97.7%) of 44 small (<2.5 cm) IPSAs, and one required a second injection. Patients had an average of 3.3 duplex examinations in our first year of treatment experience, which declined to 1.5 by our third year with the institution of a point-of-care service model for all pseudoaneurysms. Based on this decreased use of duplex examination and an average treatment cohort of 35 IPSA patients per year our institution, we determined this results in a reduction of 35 hours of laboratory time and nearly 70 ultrasounds per year. Similarly for small pseudoaneurysms, a point-of-service primary treatment program rather than observation results in an estimated cost savings of $12,000, based on treating 15 small IPSAs per year.
Ultrasound-guided thrombin injection is safe and effective for the treatment of nearly all iatrogenic pseudoaneurysms. We recommend primary treatment of small pseudoaneurysms by ultrasound-guided thrombin injection rather than observation with serial duplex scans. A point-of-care treatment algorithm can result in cost savings by reducing the number of necessary duplex examinations.
超声引导下注射凝血酶已成为股动脉穿刺相关假性动脉瘤的首选初始治疗方法。对于小型医源性假性动脉瘤（<2.5 cm），患者通常需接受系列双功超声检查以评估其是否能自行消退；而对于较大的医源性假性动脉瘤（>2.5 cm），则可能需要反复进行诊断、治疗及随访研究。我们评估了一种修订后的治疗方案的影响，该方案包括对小型（<2.5 cm）和大型假性动脉瘤（>2.5 cm）均进行初始治疗，而非仅观察小型动脉瘤，并尝试通过即时治疗策略建立单次双功超声检查。
我们回顾了2001年7月至2004年9月期间连续接受超声引导下注射凝血酶治疗的105例患者。检查了患者、医源性假性动脉瘤及其特征和治疗方法。评估了每位患者在治疗期间的双功超声检查次数。此外，还使用已发表的成本数据比较小型医源性假性动脉瘤的初始治疗与系列双功超声检查观察的情况。
105个接受治疗的假性动脉瘤中有103个（98.1%）成功形成血栓。小型和大型医源性假性动脉瘤注射凝血酶后均未发生轻微或严重并发症，且需要手术治疗的2例失败病例均在大型动脉瘤组。该系列的复发率为1.9%（2/105），2例复发均通过再次注射凝血酶成功治疗。44个小型（<2.5 cm）医源性假性动脉瘤中有43个（97.7%）单次注射成功，1个需要第二次注射。在我们治疗的第一年，患者平均接受3.3次双功超声检查，随着对所有假性动脉瘤采用即时服务模式，到第三年这一数字降至1.5次。基于双功超声检查使用的减少以及我们机构每年平均有35例医源性假性动脉瘤患者的治疗队列，我们确定这每年可减少35小时的实验室时间和近70次超声检查。同样对于小型假性动脉瘤，基于每年治疗15个小型医源性假性动脉瘤，即时服务初始治疗方案而非观察可节省约12,000美元的成本。
超声引导下注射凝血酶对几乎所有医源性假性动脉瘤的治疗都是安全有效的。我们建议对小型假性动脉瘤采用超声引导下注射凝血酶进行初始治疗，而非通过系列双功超声扫描观察。即时治疗方案可通过减少必要的双功超声检查次数来节省成本。
