Traumatic pseudoaneurysm of the anterior tibial artery
treated with ultrasound-guided thrombin injection in a
Jason D. Frasera, Brent E. Cullyb, Douglas C. Rivardb, Charles M. Leysa,
George W. Holcomb IIIa, Shawn D. St. Petera,⁎
aDepartment of Surgery, The Children's Mercy Hospital, Kansas City, MO 64108, USA
bDepartment of Radiology, The Children's Mercy Hospital, Kansas City, MO 64108, USA
Received 9 July 2008; revised 16 August 2008; accepted 18 August 2008
Anterior tibial artery
Abstract Pseudoaneurysms are relatively common in the adult population because of the high volume of
procedures requiring large bore arterial access. This experience has allowed adult caregivers to develop
simple maneuvers to treat pseudoaneurysms such as ultrasound-guided thrombin injection. However,
because of the extremely low volume of pseudoaneurysms seen by pediatric caregivers, this modality
has not been well documented in the pediatric population. Here, we present a case of a 13-year-old
female who had a stab wound to her left leg and subsequently developed a pseudoaneurysm of the
anterior tibial artery that was successfully treated with ultrasound-guided thrombin injection.
© 2009 Elsevier Inc. All rights reserved.
A pseudoaneurysm, or false aneurysm, is a flowing blood
cavity contained by surrounding tissue that communicates
with the arterial system through a defect in the arterial wall.
Pseudoaneurysms are most commonly seen in procedures
where arterial access is obtained such as angiography and
intraarterial procedures. The reported rate of pseudoaneur-
ysm in access sites ranges from 0.88% to 8% [1,2].
Application of techniques requiring intraarterial access
with large bore cannulas are infrequent in children, and as
such, the experience with these lesions in pediatric institu-
tions is limited with scant information in the literature on the
applicability of treatment modalities that have been shown
effective in adults. Therefore, we report our experience with
a traumatic pseudoaneurysm managed with ultrasound-
guided thrombin injection.
1. Case report
A 13-year-old female presented to the emergency
department after being stabbed in the anterolateral left calf
with a long knife. At presentation, she was noted to have a
4-cm stab wound to the described area that was cleansed and
closed with interrupted sutures. At the time of wound
closure, there was brisk bleeding noted, but it was easily
⁎Corresponding author. Department of Surgery, Center for Prospective
Clinical Trials, Children's Mercy Hospital, Kansas City, MO 64108, USA.
Tel.: +1 816 983 3575; fax: +1 816 983 6885.
E-mail address: email@example.com (S.D. St. Peter).
0022-3468/$ – see front matter © 2009 Elsevier Inc. All rights reserved.
Journal of Pediatric Surgery (2009) 44, 444–447
controlled by closing the defect. The patient was given a
tetanus shot and subsequently discharged from the emer-
Seven days later, she returned because of progressive
edema of her left leg to the level of the knee. The area of the
wound was fluctuant without local or systemic signs of
infection. Neurovascular examination result was normal.
Examination of the site revealed tense swelling under the
wound closure, where there appeared to be a pulsatile nature
of the swelling raising the concern for an underlying
An ultrasound demonstrated a 4.0 × 1.6-cm pseudoaneur-
ysm of the left anterior tibial artery (Fig. 1). The patient was
then taken to the interventional radiology suite where she
underwent successful ultrasound-guided thrombin injection
of the pseudoaneurysm using 300 U of thrombin (Figs. 2-3).
Ultrasound scan demonstrating left anterior tibial artery pseudoaneurysm.
Ultrasound scan demonstrating the needle for injection of thrombin being introduced into the pseudoaneurysm.
445 Ultrasound-guided thrombin injection
She clinically responded well with resolution of edema, was
discharged 2 days later, and continues to do well.
Traditionally, pseudoaneurysms have been managed
operatively. These operations pose challenges because
proximal control is imperative before dissection near the
soft tissue containing the pseudoaneurysm that requires a
sizable incision. The vessel edges of the defect are often of
poor quality and require trimming or resection to allow a
sound anastomosis. Therefore, there has been interest to
develop other less invasive treatment modalities.
One such method is ultrasound-guided compression of the
pseudoaneurysm space to allow clotting at or near the orifice
of the vascular defect, preventing further circulatory
communication across the vessel wall, thereby allowing it
to heal. The success rates of this method in published series
range from 78% to 95% [3-5].
A less cumbersome technique involves the direct injection
of thrombin into the pseudoaneurysm inducing coagulation
of the extraluminal blood thereby obliterating the pathologic
space. Initial success rates were reported from 90% to 94%
[6,7]. Ultrasound-guided injection of thrombin has been
prospectively shown to be more effective in generating
thrombosis than ultrasound-guided compression (P = .002)
has been, with no difference in hospital stay and no reported
complications . These results were reaffirmed in a recent
Cochrane database review that examined surgery vs non-
surgical treatment of femoral artery pseudoaneurysms .
Another modality to treat pseudoaneurysms is endovas-
cular stent placement at the site of injury, which has been
reported in adults with a traumatic anterior tibial artery
pseudoaneurysms, including a patient with the same
mechanism as ours [8,9]. However, this is an invasive
procedure, and permanent synthetic material is a suboptimal
solution in children. Vessel size, vessel integrity, possible
growth, and changes in vessel size over time are among some
of the principles of vascular surgery in children that present
additional considerations compared to adults . With these
principles in mind, ultrasound-guided thrombin injection is
not only less invasive than the emerging therapy for
endovascular repair but does not alter the native vascular
anatomy to introduce future concerns.
The use of ultrasound-guided thrombin injection in the
pediatric patient has been shown to be effective, however, in
small numbers. A child who developed a pseudoaneurysm of
the superficial temporal artery after sustaining facial trauma
was successfully treated with ultrasound-guided thrombin
injection . Furthermore, this method was shown to be
effective in a series of 3 pediatric patients, two of which
sustained femoral artery pseudoaneurysms after cardiac
catheterizations and one of which developed a pseudoaneur-
ysm of the inferior epigastric artery after laparoscopy .
Although further study would be ideal before evidence-
based recommendations could be made for the treatment of
pseudoaneurysms in the pediatric population, the expected
volume of these lesions will unlikely allow this to be
possible forcing us to depend on reports of individual
experiences. This injury occurred at an unusual site, the
anterior tibial artery, but it resulted from a common
mechanism—stabbing. It is likely that similar lesions will
Ultrasound scan demonstrating successful thrombin induced coagulation of left anterior tibial artery pseudoaneurysm.
446 J.D. Fraser et al.
be encountered in the future by those involved in the care of
the traumatized patient, especially in more accessible areas
such as the femoral and brachial arteries. This treatment will
likely be applicable in those situations as well. In our
experience, it appears ultrasound-guided thrombin injection
is a safe and effective means of treating a pseudoaneurysm
in the pediatric patient.
 Olsen DM, Rodriguez JA, Vranic M, et al. A prospective study of
ultrasound scan-guided thrombin injection of femoral pseudoaneur-
ysm: a trend toward minimal medication. J Vasc Surg 2002;36:779-82.
 Tisi PV, Callam MJ. Surgery versus non-surgical treatment for
femoral pseudoaneurysms. Cochrane Database Syst Rev 2006;25(1):
 Hajarizadeh H, LaRosa CR, Cardullo P, et al. Ultrasound-guided
compression of iatrogenic femoral pseudoaneurysm failure, recur-
rence, and long-term results. J Vasc Surg 1995;22:425-30.
 Ugurluoglu A, Katzenschlager R, Ahmadi R, et al. Ultrasound guided
compression therapy in 134 patients with iatrogenic pseudo-aneur-
ysms: advantage of routine duplex ultrasound control of the puncture
site following transfemoral catheterization. Vasa 1997;26:110-6.
 Heis HA, Bani-Hani KE, Elheis MA, et al. Postcatheterization femoral
artery pseudoaneurysms: therapeutic options. A case-controlled study.
Int J Surg 2008;6:214-9.
 Sackett WR, Taylor SM, Coffey CB, et al. Ultrasound-guided
thrombin injection of iatrogenic femoral pseudoaneurysms: a pro-
spective analysis. Am Surg 2000;66:937-40.
 Calton Jr WC, Franklin DP, Elmore JR, et al. Ultrasound-guided
thrombin injection is a safe and durable treatment for femoral
pseudoaneurysms. Vasc Surg 2001;35:379-83.
 van Hensbroek PB, Ponsen KJ, Reekers JA, et al. Endovascular
treatment of anterior tibial artery pseudoaneurysm following locking
compression plating of the tibia. J Orthop Trauma 2007;21:279-82.
 Golledge J, Velu R, Quigley F. Use of a covered stent to treat two
large false aneurysms of the anterior tibial artery. J Vasc Surg 2008;
 St. Peter SD, Ostlie DJ. A review of vascular surgery in the pediatric
population. Pediatr Surg Int 2007;23:1-10.
 Mann GS, Heran MK. Percutaneous thrombin embolization of a post-
traumatic superficial temporal artery pseudoaneurysm. Pediatr Radiol
 Pelchovitz DJ, Cahill AM, Baskin KM, et al. Pseudoaneurysm in
children: diagnosis and interventional management. Pediatr Radiol
447 Ultrasound-guided thrombin injection