Postoperative Paravertebral Pseudoaneurysm Treated with Percutaneous Ultrasound Guided Thrombin Injection: A Case Report and Literature Review

Postoperative Paravertebral Pseudoaneurysm Treated with Percutaneous Ultrasound Guided Thrombin Injection: A Case Report and Literature Review | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 6 September 2025 V1 Latest version Share on Postoperative Paravertebral Pseudoaneurysm Treated with Percutaneous Ultrasound Guided Thrombin Injection: A Case Report and Literature Review Authors : Qiao Qin 0009-0005-7111-2135 , Huihui Lu , Siqin Xie , and Shaote Wang [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.175714776.64227788/v1 148 views 94 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Paravertebral pseudoaneurysm after posterior spinal instrumentation is a rare complication with limited cases described in the literatures. This case report presents a 52-year-old male who fell from a 5-meter height, resulting in multiple fractures of the lumbar vertebra, ribs, and calcaneus, and was treated with open surgery. However, 24 days after Introduction: Posterior spinal instrumentation was commonly chosen for patients with spine fractures. Postoperative paravertebral pseudoaneurysm (PPA) is a rare complication that is documented in limited reports. 1 The pseudoaneurysm may lead to hemodynamic shock or even death. Percutaneous ultrasound-guided thrombin injection (UGTI), a widely used non-surgical technique for the treatment of pseudoaneurysms at various locations, offers an alternative option for the treatment of postoperative PPA. 2, 3 This report presents a case of postoperative PPA formation which developed following posterior spinal instrumentation. Percutaneous UGTI was applied to treat this postoperative PPA successfully. To the best of our knowledge, this is the first reported case of PPA after posterior spinal instrumentation successfully treated by UGTI. Case description: A 52-year-old male who fell from a 5–meter height presented to the orthopedic department with pain of his chest, lower back, ankle, and paresis of both legs on July 28, 2023. Initial CT scan revealed a compression fracture of lumbar vertebra, ribs, and calcaneus. The patients also reported having traumatic wet lung, bronchitis on both sides and atelectasis, pleural effusion of the left side. After the treatment of the traumatic wet lung and stabilized. The patient received open surgery for those fractures. The patient had symptoms of weakness and hypoesthesia in both lower limbs, so the patient went to the rehabilitation department for further treatment. The patient was found to have a non-tender mass without erythema on the right lower back 24 days after spinal surgery. The mass exhibited a bruit on auscultation. The point-of-care ultrasound(POCUS) scan identified a 5.0 cm×5.2 cm anechoic area within the muscle close to the lumbar vertebra. Color Doppler flow imaging (CDFI) showed a bidirectional, turbulent, swirling blood-flow pattern known as the “yin-yang” sign within the lump which indicated the formation of a pseudoaneurysm. 4 The CTA indicated no signs of dissection or aneurysm (Fig. 1). The patient complained the mass gradually growing larger within 2 days, and no other symptoms were recorded. After a multidisciplinary consultation and the taking patient’s willingness to choose a lower-cost treatment into consideration, the physicians decided to treat the pseudoaneurysm with percutaneous UGTI. UGTI: Before the procedure, the ultrasound scan found a 4.0 cm×2.4 cm×1.5 cm anechoic sac with a neck of 0.8 cm was also found within the mass. CDFI showed a to-and-fro flow in this area (Fig. 2A). Patients were placed in the prone position and lower back skin was prepared with 1% povidone-iodine solution. Under the guidance of ultrasound, an 18-gauge needle was inserted into the anechoic area. When the needle tip was placed at the bottom of the aneurysm sac, 2 ml of thrombin solution (250 IU/ml) was injected slowly (Fig. 2B). The cavity was filled with hyperechoic thrombus progressively within 30 seconds (Fig. 2C). The antithrombotic therapy prescribed before was discontinued, and the patient was prescribed to bed rest and functional exercise of lower extremity. The patient was followed up 4 days later by POCUS. A 2.2×1.8 cm anechoic sac with spiral flow was found beneath the treated area (Fig. 3A). CDFI also found a 2 mm feeding artery with PSV of 2.0 m/s. After rest in bed for 4 days, the sac still existed. Thus, a second percutaneous UGTI was performed. After injection of 1 ml thrombin solution (500 IU/ml), the anechoic cavity was thrombosed within 30 seconds (Fig. 3B-C). Then the patient was continued to rest in bed and take functional exercise of lower limbs. Outcome and follow-up: During follow-up, the mass was gradually getting smaller and no other complaints were reported. In the follow-up of 4 days, 11 days, 1 month, and 2 months after the second UGTI, ultrasound scans indicated that the hypoechoic area was getting smaller and no blood flow was observed on CDFI (Fig. 4). Discussion: There is less literature on the successful treatment of PPA using UGTI. We reviewed the literature from 1989 to the present, and 17 related articles were found, also, only 3 cases of paravertebral aneurysms were successfully treated with UGTI (Table 1). 5-20 Our case is the first reported about PPA after posterior spinal instrumentation successfully treated by UGTI. PPA is a rare event after posterior spinal instrumentation. Pseudoaneurysms from iliac artery, aorta, arterial intercostal, or lumbar artery can present as a paravertebral cavity. 7, 8 Patients can present with different symptoms based on the location of the PPA. Apart from posterior spinal instrumentation, several reports indicated that PPA could occur after spinal intervention, biopsy, and tuberculosis. 7, 8, 13 As far as we know, only a few papers reported PPA after spinal surgery. Eissa et al 1 and Suh et al 15 reported postoperative paravertebral pseudoaneurysm treated by embolism and surgery. However, this case reported a postoperative PPA successfully treated by UGTI, which has not been reported before. Percutaneous UGTI has been proposed as an alternative treatment of pseudoaneurysms at various locations, especially in femoral pseudoaneurysms after catheter-related intervention. 2, 3, 21 Compared with open surgery and intravascular interventional therapy, UGTI is a less invasive procedure and more friendly to patients with financial burdens. 22 In this case, UGTI was performed twice. After the first treatment, a hypervascular area was still observed beneath the thrombosed sac, which was later believed to be a small pseudoaneurysm. External compression is not applicable after injection. Thus, the pseudoaneurysm beneath the thrombosed sac was emerged during follow-up. A second UGTI was performed, and the sac is completed thrombosed. Thus, UGTI therapy may be performed twice in some cases to achieve a better outcome. 23 However, UGTI still needs clarification in treating PPA. It was complicated by thrombosis of the extremity artery in some cases. This method is not suitable for PPA with large cavity and wide neck due to its higher risk of ectopic embolism. 24 Taif et al 12 reported that UGTI failed to treat PPA (8.5 cm×7 cm×6 cm) from the iliac artery and embolism was found in femoral artery after injection. Despite the emerging role of UGTI, surgery and endovascular intervention are still needed in many cases. In summary, PPA is a rare complication of spinal surgery. This case reports a patient with PPA after spinal instrumentation successfully treated by percutaneous UGTI. In clinical practice, UGTI has a unique value in the emergency treatment of postoperative PPA. 25,26 Understanding UGTI is an alternative treatment for postoperative PPA could be helpful for optimizing clinical decision. Figures: Figure 1: Scout image (A), axial (B, C) views of the lumbar spine and CT angiography (CTA). Posterior instrumentation is intact. No signs of dissection, aneurysm, or paravertebral pseudoaneurysm was observed. Figure 2: the first ultrasound-guided thrombin injection. Color Doppler flow image showed a to-and-fro flow(A). Percutaneous ultrasound-guided thrombin injection of the paravertebral pseudoaneurysm (B). The cavity filled with hyperechoic thrombus (blue arrow), a hypervascular area beneath the thrombosed sax (yellow arrow), twinkling artifact because of spinal instrumentation were observed (C). Figure 3: the second ultrasound-guided thrombin injection. Color Doppler flow image showed a to-and-fro flow (whit arrow) and a feeding artery (yellow arrow) (A). A second percutaneous ultrasound-guided thrombin injection of the paravertebral pseudoaneurysm (B). The cavity was filled with hyperechoic thrombus (C). Figure 4: Ultrasound follow up of the 4 days (A), 11 days (B),1 month (C) after the second treatment. Ultrasound scans showed that no blood flow was observed on color Doppler flow image backend=biber, style=numeric, sorting=none ]biblatex Table: Table1：Literature review on about pseudoaneurysms 1 [5] Male 78 Pseudoaneurysm of the internal iliac artery Surgical debridement for T11–12 diskitis-osteomyelitis Yes NA Interventional radiation 2 [6] Male 46 Intercostal Pseudoaneurysms Could be due to hypertension and an old cerebrovascular accident No 3-4cm Interventional radiation 3 [7] Male 62 Paravertebral pseudoaneurysms Radiofrequency ablation and kyphoplasty No 2.6cm *Failure of Interventional radiation, eight days later, Ultrasound-guided thrombin injection 4 [7] female 88 Paravertebral pseudoaneurysms Needle puncture from vertebral augmentation No 2.3 cm Surgical operation 5 [8] Female 35 Thoracic aortic pseudoaneurysm Spinal tuberculosis Yes 5.7 × 3.7 × 5.8cm Surgical operation 6 [9] Male 31 Vertebral artery fusiform aneurysm and a pseudoaneurysm Neurofibromatosis type 1 No NA Interventional radiation 7 [10] Male 50 A 10-year history of pedicle screw internal fixation in the thoracic spine and heroin abuse Thoracic aortic perforation, a paravertebral pseudoaneurysm, and an intrapulmonary hematoma. Yes NA Interventional radiation 8 [11] Male 30 Thoracic aortic pseudoaneurysm Tubercular aortitis Yes 1.6×1.4×1.4cm Interventional radiation 9 [12] Male 37 Iliac artery pseudoaneurysm Not clear No 8.5×7×6 cm Failure of Ultrasound-guided thrombin injection, and then perform urgent open surgery 10 [13] Male 79 Apseudoaneurysm within the lumbar musculature Vertebral biopsy Yes 3.1×2.7×2.0cm *Ultrasound-guided thrombin injection 11 [14] Male 72 Tuberculous mycotic aortoiliac pseudoaneurysm Tuberculosis Yes 6.5×3.7×7.0cm Interventional radiation 12 [15] Female 21 Delayed onset common iliac artery perforation and infected pseudoaneurysm Malpositioned pedicle screw Yes 6.5×11×9cm Surgical operation 13 [16] Female 67 Pseudoaneurysm of the abdominal aorta Infectious spondylitis due to Klebsiella pneumoniae Yes NA Drainage of the abscess and administration 14 [17] Male 39 Pseudoaneurysm of a segmental lumbar artery Transforaminal full-endoscopic surgery No NA Interventional radiation 15 [18] Male 18 Pseudoaneurysm of the abdominal aorta Gunshot wound NA 3.5cm Interventional radiation 16 [19] Male 62 Lumbar pseudoaneurysm Two anesthetic infiltrations for lumbar pain and one biopsy of a suspected hematopoietic site NA 4.5cm *Ultrasound-guided thrombin injection 17 [20] Female 39 Iliac artery false aneurysm Lumbar disc surgery NA 7.0×5.2×4.8cm Surgical operation backend=biber, style=numeric, sorting=none ]biblatex References 1 Eissa AT, Shahbaz A, Alhelal F, et al. Postoperative Paralumbar Pseudoaneurysm: A Case Report. J Neurol Surg Rep. 2020. 81(2): e33-e37. 2 Peters S, Braun-Dullaeus R, Herold J. Pseudoaneurysm. Hamostaseologie. 2018. 38(3): 166-172. 3 Mishra A, Rao A, Pimpalwar Y. Ultrasound Guided Percutaneous Injection of Thrombin: Effective Technique for Treatment of Iatrogenic Femoral Pseudoaneurysms. J Clin Diagn Res. 2017. 11(4): TC04-TC06. 4 Stravodimos G, Komporozos V, Papazoglou A. Case report of a successful non-operative management of postoperative bleeding from pseudoaneurysm of the gastroduodenal artery, following gastric surgery. Int J Surg Case Rep. 2021. 78: 54-57. 5 Kvint S, Malhotra NR, Cox M, Mondschein JI, Pukenas BA, Bagley LJ. Giant Iliac Artery Pseudoaneurysm Mimicking Postoperative Fluid Collection and Diskitis. World Neurosurg. 2020. 136: 253-257. 6 AlSalman M, Aleissa S, Alhandi A, et al. Spinal Pseudoaneurysms Mimicking an Osteogenic Tumor: A Case Report. J Am Acad Orthop Surg Glob Res Rev. 2020. 4(5): e1900156. 7 Nam D, Johnson MH, Mojibian H, Hebert RM, Cornman-Homonoff J. Development of paravertebral pseudoaneurysms following vertebral augmentation: a report of two cases. Clin Imaging. 2022. 90: 39-43. 8 Chen Y, Sheng B, Li J, Lv F. Tuberculous Thoracic Aortic Pseudoaneurysm Associated With Spinal Tuberculosis: A Case Report and Literature Review. Front Med (Lausanne). 2022. 9: 882697. 9 Saleh U, Ismail MI, Sapiai NA, Loh KB, Abd Wahab N, Abdullah JM. Reverse Cervical Lordosis Caused by Giant Vertebral Artery Aneurysm in von Recklinghausen Disease. Cureus. 2022. 14(9): e29795. 10 Li L, Lao YH. Massive Hemoptysis Caused by an Aortobronchial Fistula Related to Pedicle Screw Impingement. Vasc Endovascular Surg. 2021. 55(7): 761-765. 11 Mehra R, Dhillan R, Manral S. Endovascular salvage of tubercular aortitis presenting as descending thoracic aortic pseudoaneurysm in association with vertebral tuberculosis. BMJ Case Rep. 2022. 15(11). 12 Taif S, Alrawi A, Al-Kalbani J. Iliac artery pseudoaneurysm presenting as a paravertebral collection: a potentially fatal mimic. BMJ Case Rep. 2014. 2014. 13 Kulkarni K, Matravers P, Mehta A, Mitchell A. Pseudoaneurysm following vertebral biopsy and treatment with percutaneous thrombin injection. Skeletal Radiol. 2007. 36(12): 1195-8. 14 Villegas MO, Mereles AP, Tamashiro GA, et al. Endovascular treatment of an aortoiliac tuberculous pseudoaneurysm. Cardiovasc Intervent Radiol. 2013. 36(2): 540-4. 15 Suh SW, Kim GU, Lee HN, Yang JH, Chang DG. Delayed presentation of infected common iliac artery pseudoaneurysm caused by malpositioned pedicle screw after minimally invasive scoliosis surgery. Eur Spine J. 2019. 28(Suppl 2): 68-72. 16 Sugawa M, Tanaka R, Nakamura M, et al. A case of infectious pseudoaneurysm of the abdominal aorta associated with infectious spondylitis due to Klebsiella pneumoniae. Jpn J Med. 1989. 28(3): 402-5. 17 Panagiotopoulos K, Gazzeri R, Bruni A, Agrillo U. Pseudoaneurysm of a segmental lumbar artery following a full-endoscopic transforaminal lumbar discectomy: a rare approach-related complication. Acta Neurochir (Wien). 2019. 161(5): 907-910. 18 Quigley MJ, Bret PM. Occult pseudoaneurysm of the abdominal aorta following gunshot wound: the importance of plain film findings. J Trauma. 1995. 38(2): 269-72. 19 Luján S, Puras E, Cancer S, Perera M. Paravertebral pseudoaneurysm thrombosed after percutaneous thrombin injection. Ann Vasc Surg. 2005. 19(3): 421-4. 20 Hanel RA, Madalozzo LE, Araújo JC, Rodrigues MA, Truite LV. [Common iliac artery false aneurysm as complication of lumbar disc hernia surgery. Case report]. Arq Neuropsiquiatr. 1999. 57(3B): 890-4. 21 Vlachovsky R, Staffa R, Novotny T. Pseudoaneurysm of the Dorsalis Pedis Artery: Case Report and Literature Review. J Foot Ankle Surg. 2017. 56(2): 398-400. 22 Rashaideh MA, Janho KE, Shawaqfeh JS, Ajarmeh E, As’ad M. Ultrasound-guided thrombin injection versus ultrasound-guided compression therapy of iatrogenic femoral false aneurysms: Single center experience. Med J Armed Forces India. 2020. 76(3): 293-297. 23 Lillis AP, Shaikh R, Alomari AI, Chaudry G. Percutaneous coil embolization of massive pelvic pseudoaneurysm in an infant. Pediatr Radiol. 2015. 45(6): 931-5. 24 Jiaxin L, Yan L, Sheng Z, Zhiyi D, Jichang W, Shaoying L. Case report: Successful and effective percutaneous closure of a deep femoral artery pseudoaneurysm using proglide device. Front Surg. 2023. 10: 1109243. 25 Chandralekha B, Tripathy T, Phukan P, Lynser D. A Modified Manual Compression Technique for the Treatment of Traumatic Pseudoaneurysm of Superficial Temporal Artery. Neurol India. 2022. 70(1): 345-347. 26 Li L, Deng H, Yuan Y, Ye X. Thrombin injection under B-flow and ultrasound guidance: A safe and effective treatment of pseudoaneurysms. Vascular. 2024. 32(1): 147-153. Information & Authors Information Version history V1 Version 1 06 September 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Keyword neurosurgery Authors Affiliations Qiao Qin 0009-0005-7111-2135 Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital) Tongji Medical College Huazhong University of Science &Technology View all articles by this author Huihui Lu Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital) Tongji Medical College Huazhong University of Science &Technology View all articles by this author Siqin Xie Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital) Tongji Medical College Huazhong University of Science &Technology View all articles by this author Shaote Wang [email protected] Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital) Tongji Medical College Huazhong University of Science &Technology View all articles by this author Metrics & Citations Metrics Article Usage 148 views 94 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Qiao Qin, Huihui Lu, Siqin Xie, et al. 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