The British Journal of Radiology, 81 (2008), 154–163

PICTORIAL REVIEW

Ultrasound-guided thrombin injection of iatrogenic groin

pseudoaneurysm: Doppler features and technical tips
1 2
J M HANSON, FFRRCSI, FRCR, M ATRI, MD, FRCP(C) and 3N POWER, FRCR, MRCPI

1
Department of Rodiology, Our Lady of Lourdes Hospital, Drogheda, Co. Louth, Ireland, 2Abdominal Imaging, Princess
Margaret Hospital, 610 University Avenue, Toronto, ON M5G 2MG, Canada and 3Department of Medical Imaging, St
Bartholomew’s Hospital, West Smithfield, London ECIA 7BE, UK

ABSTRACT. The practice of angiographic procedures is increasing and, concomitantly,

there has been an increase in the incidence of iatrogenic femoral pseudoaneurysms Received 13 January 2006
(PA). Ultrasound-guided thrombin injection is becoming the accepted gold standard in Revised 16 May 2006
the treatment of PA. It is a cost-effective, safe and efficacious treatment that requires a Accepted 6 June 2006
short learning curve. The aim of this pictorial review is to demonstrate the Doppler and
DOI: 10.1259/bjr/52029321
ultrasound features used to diagnose PA and those that help differentiate it from
alternative diagnoses, and to describe the procedure of thrombin injection, ’ 2008 The British Institute of
highlighting technical tips and ways to avoid potential complications. Radiology

Pseudoaneurysms (PAs) occur after incomplete hae-
mostasis of a punctured artery. The resulting continued
extravasation of blood into the subcutaneous tissues is
contained within a pseudocapsule of fibrous tissue
within the adjacent soft tissue. PAs are becoming
increasingly prevalent with the widespread use of
endovascular procedures. Incidence rates vary and are
quoted between 0.05% and 4%, and as high as 16% [1].
Patients present with a range of signs and symptoms
including pain, pulsatile mass and rapidly enlarging
mass. Some PAs are subclinical and resolve sponta-
neously [2], but there is always a risk of growth and
rupture, overlying skin necrosis, distal embolus and
neurological symptoms owing to compression. Although
it is difficult to predict spontaneous closure, low flow in
the aneurysm suggests potential for spontaneous closure
[3]. Despite the surgical approach being simple, it often
requires general anaesthesia. The surgical approach has
been replaced in the last two decades by compression
under US guidance. This treatment is often a lengthy
procedure and may fail because of patient discomfort,
patient obesity and anticoagulation. Success rates for
compression of PA range from 30% to 62% for patients
on anticoagulation and from 74% to 95% when not on
anticoagulation [4, 5]. The larger the PA, the less likely
compression will be efficacious.
Operators have shown success with thrombin injection
of PA. The reported success rates range from 90% to 100%
[1, 6]. Complications are rare. In one literature review,
3/319 complications have been documented [7]. These
were all thrombotic complications, which required surgi-
cal repair in one case. Bovine thrombin is highly
immunogenic. There are case reports describing the
Address correspondence to: Dr John M Hanson, Consultant
Radiologist, Medical Imaging, Our Lady of Lourdes Hospital,
Drogheda, Co. Louth, Louth, Ireland. E-mail: maryjohnny@
eircom.net
immunogenic complications in the literature [8]. Another
consequence of bovine thrombin exposure is the potential
development of antibodies to human clotting proteins and
thrombin, in particular factor V, resulting in a coagulo-
pathy and excessive bleeding [9]. Such complications are
not seen with newer human-derived thrombin. This is
taken from pooled blood products and, therefore, there is
theoretical possibility of infection from such human blood
products. All of the immunogenic and infective risks can
be avoided by the autologous use of thrombin. A sufficient
sample of thrombin can be isolated from a 50 ml sample of
a patient’s own blood in a straightforward procedure of
less than 1 h [10]. Thrombin injection has largely been used
in the treatment of lower limb PA. Cases describing
aneurysms of the upper limb and mesenteric arterial tree
as well as the thoracic aorta have been noted in the
literature [11–14].
In this pictorial essay, we present a brief description of
the US-guided compression procedure, emphasizing the
role of Doppler ultrasound in the diagnosis and
treatment of iatrogenic PA of the groin.
Diagnosis of pseudoaneurysm using
ultrasound
The diagnosis of a PA is based on a triad of ultrasound
findings:
(1) a hypoechoic sac in the vicinity of the parent vessel;
(2) swirling high resistance flow on Doppler ultra-
sound within this mass;
(3) ‘‘to and fro’’ type waveform in the neck or in the
sac close to the neck (Figure 1).
This waveform may be dampened in the periphery of
larger PA sacs, where it may be confused with that of a
venous waveform [15]. The ‘‘to and fro’’ flow pattern is
synchronous with the cardiac cycle.

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Pictorial review: Ultrasound-guided thrombin injection of iatrogenic groin pseudoaneurysm

(a) (b) (c)

Figure 1. Typical example of a pseudoaneurysm. In (a), transverse view, there is a short-necked pseudoaneurysm (PA) with spiral
flow within the aneurysm sac (arrowheads). The high-resistance flow pattern is demonstrated in (b). In (c), a post-thrombin
injection image, the PA is thrombosed and the cavity is now echogenic (arrows).

Table 1. Procedure summary and technical tips

1. Evaluate the shape of the PA: single lobe vs multilobed. Lack of recognition of multilocularity may result in failure of the
procedure (Figure 9).
2. Acknowledge the contraindications to treatment; superficial infection; co-existent AVF.
3. Identify the neck of the aneurysm by looking for the ‘‘to and fro’’ waveform in the connection between the aneurysm and
the native artery. If the neck is not clearly visible, the location of the maximal ‘‘to and fro’’ waveform in the aneurysm would
help identify the neck. This reduces the risk of embolization of thrombin by injecting close to the neck.
4. When there is difficulty demonstrating the connecting tract in deeper lesions, use of a lower MHz probe helps identify the
tract or exclude a PA (Figure 7).
5. The presence of forward diastolic flow in the aneurysm suggests an associated AVF (Figure 4). Lack of communication
between the PA and vein should be established before injecting the aneurysm, as existence of an AVF is a contraindication to
thrombin injection (Figures 3 and 4).
6. When there is more than one lobe, it is best to inject the lobe closest to the neck first as the thrombus formed can propagate
to involve the entire PA, precluding the need for individual lobar injections. Injection should be performed under real-time
grey-scale and with intermittent colour Doppler US guidance.
7. Complete thrombosis should be confirmed immediately after injection to determine the need for continuous or re-injection.
Early clot may be hypo- or anechoic so its presence is established by colour Doppler (Figure 11). In some cases, injection in the
non-thrombosed portion of the aneurysm is required since clot surrounding the first injection site prevents extension of
thrombin to the non-thrombosed portion.
8. The native artery and vein should be examined at the completion of the procedure to document their patency. Ankle pulses
should be checked at the end of a procedure.
AVF, arteriovenous fistula; PA, pseudoaneurysm.

The British Journal of Radiology, February 2008 155

 J M Hanson, M Atri and N Power

Figure 2. Tissue vibration around the neck of a pseudoaneur-

ysm. Tissue vibration is an indication of underlying high-velocity
flow. On this transverse image, there is vibration artefact
surrounding the neck of the pseudoaneurysm (PA) (arrow).

(a) (b) (c)

Figure 3. Arteriovenous fistula. In (a), there is tissue vibration artefact (arrows) surrounding the femoral vein. This should be an
alarming finding for the existence of a high-velocity flow. The low-resistance arterial flow with high diastolic component is seen
at the fistulous site in (b) and in (c), pulsatile flow is shown in the femoral vein downstream from the fistula.

156 The British Journal of Radiology, February 2008

Pictorial review: Ultrasound-guided thrombin injection of iatrogenic groin pseudoaneurysm

(a) (b)

Figure 4. Pseudoaneurysm (PA) and arteriovenous fistula (AVF). This is an absolute contraindication to thrombin injection. Note
the low-resistance arterial flow pattern in the aneurysm in (a) and in (b) there is low resistance and high velocity across the
arterial connection of this aneurysm on spectral Doppler instead of the expected ‘‘to and fro’’ pattern.

The British Journal of Radiology, February 2008 157

 J M Hanson, M Atri and N Power

(a)
Figure 5. Pulsatile flow in a groin vein after angiography. As
a consequence of transmission of flow from the adjacent
artery, pulsatile flow is seen in a groin vein after angio-
graphy. The two are compressed by surrounding oedema
and haematoma. This should not be confused with the
appearance of the draining vein of an AVF.

Figure 6. An example of a lymph node. In (a), the feeding

artery of a lymph node (curved arrow) could be confused for
the neck of an aneurysm. However, it has a normal low-
resistance arterial flow pattern on spectral Doppler, and in
(b) the hypoechoic node does not demonstrate the high-
resistance flow expected in a PA.
(b)

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Pictorial review: Ultrasound-guided thrombin injection of iatrogenic groin pseudoaneurysm

(a) (b)

Figure 7. The role of a low-frequency probe. In (a), a low-frequency probe shows a small PA lying between the artery and the
vein (arrows). This was difficult to see using a high-frequency probe. The neck of the PA is seen with a ‘‘to and fro’’ Doppler
waveform in image (b).

(a) (b)

Figure 8. Pseudoneck: sagittal views. (a) A typical example of a PA (arrowheads) prior to treatment. In (b), the post-thrombin
injection, there is a branch artery adjacent to the haematoma (arrow), demonstrating a low-resistance arterial flow pattern that
is often seen after angiography because of hyperaemia. This flow pattern helps differentiating this from a true neck.

The British Journal of Radiology, February 2008 159

 J M Hanson, M Atri and N Power

(a) (b) (c)

Figure 9. An example of a tri-lobed PA: transverse views. In (a), on grey-scale US, the larger more anterior distal lobe was
spontaneously thrombosed (white arrows). The smaller proximal lobes were patent (white arrowheads). In (b), a neck is
demonstrated between proximal and middle PAs with ‘‘to and fro’’ waveform (black arrow). These aneurysms were thrombosed
following thrombin injection of the proximal lobe of the aneurysm in (c).

(a) (b)

Figure 10. PA treated with a single injection of thrombin followed by a brief period of compression (sagittal views). In (a), there
is minimal filling of a PA (arrows) after injection, and in (b) a small clot (curved arrow) is demonstrated adherent to the site of
the neck of the PA within the parent vessel. This was non-consequential.

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Pictorial review: Ultrasound-guided thrombin injection of iatrogenic groin pseudoaneurysm
Figure 11. PA requiring multiple injections; transverse view.
Follow-up US at 24 h shows a large component of aneurysm
thrombosed (arrows) with persistent PA filling centrally
(arrowheads). This responded to a repeat injection of 500
units of thrombin.
High-velocity flow across the neck can cause vibration
of the adjacent soft tissues. This vibration artefact is
seen as a speckling artefact on colour Doppler (Figure 2)
and is helpful in locating the neck. The velocity of
high-resistance flow within the aneurysm is diminished
in aneurysms that are imminently closing.
Differential diagnosis of pseudoaneurysm
The diagnosis of PA can be confused with lymph
node, arteriovenous fistula, haematoma, abscess, lym-
phocoele, deep venous thrombosis (DVT) and a femoral
hernia [15, 16]. However, most of these conditions are
easily differentiated from PA using colour and pulsed
Doppler (Figures 3–6).
Thrombin injection
PAs can have a benign course and have been treated
expectantly [2]. They may remain static in size, regress or
even thrombose spontaneously. Therefore, if the aneurysm
is small or is mostly thrombosed and shows little flow, it
can potentially be observed, and a repeat Doppler
ultrasound needs to be performed if there has been a delay
between the diagnostic scan and possible intervention [17–
19]. In a small study sample, Kent et al [19] saw that PAs
with a mean size of less than 1.8 cm would thrombose
spontaneously. The mean time for this was 22 days (3–
34 days). The skin overlying the proposed injection site
should be intact and free of infection as this is a
contraindication to percutaneous injection. Because of the
risk of thrombin leakage into the venous circulation, the
presence of a coexistent arteriovenous fistula (AVF) is an
absolute contraindication to thrombin injection (Figure 3).
The British Journal of Radiology, February 2008
Thrombin works in the final common pathway of the
clotting cascade and therefore bypasses the factors
influenced by heparin and Coumadin. The procedure is
relatively straightforward and requires a short learning
curve. Patients usually require no preparation, sedation or
long post-procedure hospital stay [6]. Prior to and after the
procedure, distal pedal pulses are examined. Initially, the
morphology of the PA is studied. If there is more than one
lobe, each lobe may have to be considered for injection
separately if injection in one lobe does not thrombose the
entire aneurysm. A low-frequency probe is helpful when
characterizing deeper aneurysms and their necks
(Figure 7). The injection should be done as far from the
PA neck as possible. Position of the maximum ‘‘to and fro’’
waveform in the PA helps in localizing the adjacent neck of
the aneurysm. The operator should be cautious that the
surrounding vessels are not mistaken for the neck of the
PA (Figure 8). Needle sizes for the injection of thrombin
range from 19 to 25 gauge. We use a 1 ml tuberculin
syringe and a 25-gauge needle. Doses as high as 1000 IU
were initially used in the treatment of PA, although
concentrations have been reduced with more experience.
Taylor et al [20] have successfully treated PAs with
concentrations as low as 100 IU. We have successfully
treated PAs with doses as low as 20 IU of thrombin.
Thrombin injection is performed under real-time grey-
scale US guidance to quantify the necessary amount of
thrombin needed as most aneurysms thrombose imme-
diately. Grey-scale and colour Doppler are intermittently
used to confirm thrombosis, since, occasionally, acute
thrombus can be hypoechoic and not clearly visible on
grey-scale imaging. Documenting the complexity of a
multilobar aneurysm is important, as the knowledge of
the number and location of the various lobes will
increase the success rate of thrombosis. With multilobar
aneurysms, injection of the lobe closest to the parent
artery may result in subsequent thrombosis of more
distal lobes by stopping the flow to those distal
components (Figure 9) [15, 18, 21]. Sheiman and
Mastromatteo [22] and Brophy et al [17] suggest the less
efficacious method of injecting the distal lobe first to
reduce the risk of injecting thrombin into the parent
vessel. All of their failed procedures were multicompart-
mental PAs [21]. Compression following incomplete
closure of the aneurysm may be effective (Figure 10).
This should not be encouraged owing to the risk of
forcing thrombin from the PA into the native vessel. We
prefer to reinject because of the danger of expelling a
thrombus into the native artery with compression
(Figure 11). Multiple injections are uncommonly needed
and procedure failure is rare (Figure 12). Those unre-
sponsive to percutaneous thrombin injection would
require surgical intervention, as a parent vessel lacera-
tion is a likely cause of PA reperfusion. PAs from vessel
lacerations will not respond to thrombin injection and
usually require surgical repair [22] (Figure 12).
After thrombin injection, distal pedal pulses should be
palpated to assess parent vessel patency. Initial reports
of this procedure had insisted on bed rest for a fixed
period of time but, as confidence has increased, it is
increasingly performed as an outpatient procedure
without the need for conscious sedation or bed rest [6].
Grewe et al [23] injected ultrasound contrast media
into PAs prior to treatment and noted leakage into the
161
 J M Hanson, M Atri and N Power

(a) (b)

(c) (d)

Figure 12. Procedure failure in a deep aneurysm; (a) and (b) sagittal US views; (c) and (d) axial enhanced CT examination
images. In (a) a large short-necked PA (arrows) arising from the distal external iliac artery is seen. The ‘‘to and fro’’ flow pattern
across the neck is documented in (b). (c) Despite three injections, there was persistent filling of the aneurysm (arrows) as shown
on a CT scan after thrombin injection. (d) There is an associated large retroperitoneal haematoma (arrows).

parent artery in 58% of initial needle placements. A small
leak of thrombin into the parent vessel usually presents
no sequelae as thrombin loses efficacy in rapid-flowing
vessels and it is deactivated by circulating anti-thrombin
III as was noted in one of our patients (Figure 10) [20].
Table 1 shows the steps to take to maximize the
success of this procedure and prevent complication.
Conclusions
US-guided thrombin injection is now an established
treatment of iatrogenic groin PAs. However, the knowledge
of Doppler features of PAs is important for proper
diagnosis, treatment and differentiation from its mimickers.
The procedure is relatively simple with a short learning
curve.
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