Percutaneous thrombin injection with intra-arterial balloon protection for iatrogenic puncture site pseudoaneurysm: a case series

Objective: To evaluate the technical feasibility and preliminary outcomes of percutaneous thrombin injection with intra-arterial balloon protection to treat iatrogenic puncture site pseudoaneurysm (IPA) following neurovascular intervention. Methods: The data of eight patients treated for IPAs following neurointerventions at a single institution between 2021 and 2024 were retrospectively reviewed. Three, two, and three patients were treated with ultrasound-guided thrombin injection (UGTI), covered stents, and thrombin injection with intra-arterial balloon protection, respectively. The patients treated with thrombin injection with intra-arterial balloon protection were included in the analysis. Two of these IPA cases involved the femoral artery, and one involved the brachial artery. Results: Technical success, defined as complete thrombosis of the pseudoaneurysm sac with preservation of the parent artery, was achieved in all cases. No procedure-related complications, such as distal embolism or parent artery occlusion, were observed. Antiplatelet therapy was continued without interruption, and the technique remained effective in one patient with mild thrombocytopenia. Follow-up ultrasonography at one day and one week confirmed the absence of recurrence and maintained patency of the parent artery. Furthermore, no symptoms of limb ischemia were observed immediately, one-day, three days, one-week and one-month clinical follow-up period. Conclusion: Percutaneous thrombin injection combined with intra-arterial balloon protection is a technically feasible and potentially safe method for managing IPAs, particularly in patients requiring uninterrupted antiplatelet therapy. Use of the distal radial approach for balloon access may further reduce puncture-site complications. Larger, prospective studies are warranted to validate these findings and to compare this technique with established treatment modalities.