Several therapeutic strategies have been developed to treat this complication. They include ultrasound-guided compression repair (UGCR), surgical repair, and minimally invasive percutaneous treatments (thrombin injection, coil embolization and insertion of covered stents)
Reeder et al. introduced this new method of low-dose thrombin injection for the treatment of pseudoaneurysms. An average dose of 192 U of thrombin was used (5-fold lower than previously reported). Time to coagulation ranged from 10 to 60 seconds. There were no complications. The investigators were able to successfully thrombose all pseudoaneurysms, even in the presence of anticoagulation. Their study demonstrated that a much smaller dose of a potentially dangerous medication can achieve the same efficacy as previously used higher doses.
Compared with surgical repair, treatment of pseudoaneurysms with thrombin injection offers many advantages. The success rate of thrombin injection reported in the literature has been consistently high, at an average of 97%, even with patients treated with therapeutic levels of anticoagulants. Treatment can usually be completed within several minutes. The results from studies conducted suggest that for most iatrogenic femoral arterial pseudoaneurysms, thrombin injection should replace compression repair as the first line of therapy.
Theoretically, a lower dose of a potentially dangerous medication should decrease the risks associated with its use. As more reports are published, it is possible more complications will come to light. In addition to distal limb ischemia caused by in situ thrombosis from thrombin leakage, there is a hypothetical risk of type I IgE-mediated allergic reaction to bovine thrombin. Topical bovine thrombin has been used extensively for hemostasis for more than 20 years. Recent descriptions of antibody responses show high titers against endogenous coagulation factors, with resulting bleeding complications. Prior exposure to bovine thrombin is considered a contraindication to treatment of pseudoaneurysms with thrombin by some investigators.
In conclusion, as vascular interventional radiological procedures are on a rise, there are more possibilities for occurrence of Iatrogenic Pseudoaneurysms. Initially Ultrasound Guided Compression Repair was the preferred treatment as it was non invasive. But due to its failure in 25% of patients on studies conducted, increased pain experienced by the patient, long procedure time and recent development of other minimally invasive treatments which are more effective, UGCR is less preferred nowadays. Percutaneous injection of thrombin can be completed in several minutes, has the advantage of avoiding surgical intervention or the pain associated with ultrasound-guided compression, and can be performed effectively in patients who have received anticoagulation. Due to the procedural simplicity, cost effectiveness ultrasound-guided injection of thrombin remains a very appealing treatment to most physicians.