Two cases of an acute arterial embolic occlusion following ultrasound guided thrombin injection of iatrogenic femoral artery pseudoaneurysm

Purpose: Here, were present 2 cases of iatrogenic femoral pseudoaneurysm following transfemoral aortic valve implantation (TAVI). Shortly after therapeutic thrombin injection postinterventional embolic occlusion of the femoral artery developed.

Material and methods: A 86-year-old- and a 83-year-old male patient were admitted to our hospital because of severe aortic stenosis. TAVI (Edwards Sapien XT bioprosthesis, 26 mm) was carried out using a large femoral bore-catheter (18 french) Postinterventional B-mode-imaging and color duplex revealed a 3 × 2 cm p.a. near the outlet of the right V. femoralis, and one 2 × 1 cm on the left side in the second case. The neck was < 1 cm in both cases. Ultrasound-guided thrombin injection (Beriplast®P Combi-Set 1 ml) was executed.

Results: Immediately after successful thrombin obliteration, a sufficient perfusion of the femoral artery was observed on duplex sonography. However, few hours later both patients developed a sudden onset of lower leg pain with sensor motor deficits. Acute embolic occlusionof the femoral artery confirmed by computertomographic angiography and duplex sonography. Emergency thrombectomy of the affected arteries was performed in both cases with successful reperfusion. Histopathology showed fresh thrombus material.

Conclusion: Acute arterial embolic occlusion is a rare but serious complication of ultrasound guided thrombin injection of p.a. TAVI is increasingly used in interventional cardiology and requires the use of large bore catheters (18 french). Our two reported cases are aimed to raise awareness of the increased risk of 1) development of p.a. in these patients, and 2) an increased risk for postinterventional embolic occlusions following therapeutic thrombin injections. Moreover, a short p.a. neck (< 1 cm) can be considered as additional risk for embolic complications.