The patient had undergone a subtotal gastrectomy with Billroth reconstruction, after presenting with haematemesis and melaena caused by active gastric bleeding. A surgical drain was placed in the left iliac fossa. 36 hours after removal of the drain, the patient suffered acute pain in the left iliac fossa. On physical examination a non-pulsatile soft mass was found in the same area where the surgical drain had been located. A contrast-enhanced abdominal CT examination was performed. The study revealed a pseudoaneurysm of 5cm x 7cm, localised in the left rectus muscle (Fig. 1). Colour Doppler sonography confirmed the presence of a pseudoaneurysm, apparently originating from the left epigastric artery, with simultaneous bidirectional flow within its lumen (Fig. 2a). After the diagnosis of pseudoaneurysm of the lower left epigastric artery was confirmed, it was compressed under echographic guidance, on two occassions of 10 minutes each, in an attempt to induce thrombosis, without obtaining a positive result.
The patient was referred for futher assessment and treatment. After the diagnosis was confirmed, thrombosis of the pseudoaneurysm by means of ultrasound-guided percutaneous human thrombin injection was proposed. Once the patient's written consent had been obtained, the skin of the left iliac fossa was prepared with pavidone iodine (Betadine, ASTA MEDICA, Madrid, Spain) and covered with sterile drapes. A 3.5 inch, 22-gauge spinal needle (B/Braun, Melsungen, Germany), was inserted into the lumen of the pseudoaneurysm using a Powervision 6000 sonography unit (Powervision 6000, Toshiba, Japan) equipped with an 6-12MHz multifrequency probe wrapped in a sterile sheath, while the tip of the needle was situated within the periphery as far possible from the neck (Fig. 2b). The needle was inserted under continuous sonogram control, in greyscale. A 2ml syringe containing human thrombin (Tyssucol Duo, Baxter, Glendale, USA) at a concentration of 500U/ml was fitted to the needle. The injection began with a slow bolus of 0.1-0.2ml/sec under constant colour Doppler control. After approximately 2 seconds, once 0.3ml (150U) had been injected, complete thrombosis of the pseudoaneurysm was verified; colour Doppler flow was maintained in the left epigastric artery (Fig. 2c). In a colour Doppler study performed on the following day, no recurrence of the pseudoaneurysm was detected.