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CASE REPORT
Year : 2022 | Volume
: 9
| Issue : 4 | Page : 313-315
Delayed traumatic superficial femoral artery pseudoaneurysm and arteriovenous fistula over the left lower limb
Jayesh Patel, Pratiksha Shah, Roshni Patel, Ravi Patel, Fenil Gandhi
Vascular Surgery Department, Pramukhswami Medical College, Karamsad, Gujarat, India
Correspondence Address:
Pratiksha Shah
Vascular Surgery Department, Pramukhswami Medical College, Karamsad, Gujarat
India
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/ijves.ijves_3_22
A pseudoaneurysm is a pulsating, encapsulated hematoma in communication with a ruptured vessel (1); there is an accumulation of blood between the tunica media and tunica adventitia layers of the vessel. We report a case of a young male with complaints of swelling, skin discoloration, and a tingling sensation of the left lower limb. A peripheral angiography was performed, which revealed an arteriovenous fistula at the middle of the left superficial femoral artery. The patient underwent a left superficial femoral artery pseudoaneurysm excision and repair. In this case report, we discuss the presenting clinical features, methods of evaluation, and the management of the superficial femoral artery pseudoaneurysm accompanied with arteriovenous fistula.
Keywords: Arteriovenous fistula, femoral artery, pseudoaneurysm
A pseudoaneurysm is a pulsating, encapsulated hematoma in communication with a ruptured vessel;[1] there is an accumulation of blood between the tunica media and tunica adventitia layers of the vessel. On the other hand, a true aneurysm involves dilatation of all three layers of vessel wall. Although they can arise in almost any artery of the body, pseudoaneurysms of the superficial femoral artery are commonly seen due to the large numbers of percutaneous procedures performed by cardiologists.
Femoral artery pseudoaneurysms can be caused by iatrogenic or noniatrogenic trauma, which can be penetrating or blunt in nature.[2],[3] Iatrogenic pseudoaneurysms may arise as a complication of arterial catheterization performed for both diagnostic and interventional purposes. The incidence of diagnostic postcatheterization pseudoaneurysms ranges from 0.05% to 2%, whereas interventional postcatheterization pseudoaneurysms ranges from 2% to 6%.[4]
In comparison, the incidences of femoral pseudoaneurysms induced by nonsurgical trauma are relatively less common and comprise a small fraction of such cases. Pseudoaneurysms may be asymptomatic or symptomatic, manifesting with signs and symptoms of paresthesia, pulsatile hematoma, skin discoloration, and/or pain and tenderness. They may lead to spontaneous thrombosis or advance further and develop into complications such as rupture, embolization, and neuropathy.[3]
Case ReportA 31-year-old male presented with a complaints of swelling, skin discoloration, and a tingling sensation of the left lower limb [Figure 1]. Eight years before presentation, the patient was involved in a road traffic accident where he sustained an injury to his left thigh after the vehicle overturned. At the time, he was treated conservatively. The patient had no significant medical history. Two years before presentation, he noted a swelling in the left thigh, which progressively enlarged. In addition, the patient experienced a tingling sensation of the left lower extremity. Approximately a year thereafter, he noticed discoloration of the skin over his left limb.
Physical examination revealed a bruit in the left thigh with a palpable, pulsatile swelling. There was decreased sensation, discoloration, and engorgement of the superficial veins of the left lower extremity. All other physical examination findings were within normal limits.
A peripheral angiography was performed under local anesthesia. The entry point was through a retrograde puncture of the right common femoral artery under ultrasonography guidance. The angiography revealed an arteriovenous fistula (AVF) at the middle of the left superficial femoral artery with a pseudoaneurysm measuring 5.5 cm × 3.5 cm at the site of the fistula [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d. In addition, adequate distal run off was noted.
Figure 2: (a-d) An arteriovenous fistula present at the middle of the left superficial femoral artery with a pseudoaneurysm measuring 5.5 cm × 3.5 cm at the site of the fistulaThe patient underwent a left superficial femoral artery pseudoaneurysm excision and repair under spinal anesthesia. A vertical incision was made along the length of the pseudoaneurysm, which extended proximally and distally to the common femoral artery, superficial femoral artery, and the profunda femoris artery. After accessing the pseudoaneurysm sac, a large hematoma was removed, and nylon tapes were wrapped around the common femoral artery, superficial femoral artery, and profunda femoris artery for vascular control. After excision, there was a defect in the wall of the artery. Accordingly, a greater saphenous vein interposition graft was used to maintain the vascular continuity [Figure 3]. To repair the arteriovenous fistula, the superficial vein was then ligated and hemostasis was achieved. Upon discharge, the patient was mobilized and the patient reported of no complaints.
Figure 3: Effective excision of pseudoaneurysm sac and maintenance of vascular continuity Discussion Superficial femoral artery pseudoaneurysms can arise as a complication of iatrogenic procedures or trauma. Commonly, femoral artery pseudoaneurysms may by induced by catheterization procedures; however, traumatic pseudoaneurysms have become more commonplace. They can develop in almost every artery of the body and can occur due to severe blunt or penetrating injury. Although infrequent, pseudoaneurysms with an associated AVF have been reported. AVF is abnormal connections between an artery and vein, which bypasses the capillary bed. Similar to pseudoaneurysms, AVFs can form due to blunt or penetrating trauma when a vein and an artery are in proximity.[5] Pseudoaneurysms can manifest as a swelling with a palpable thrill or bruit. Necrosis and color change of surrounding tissue may occur due to ischemia, and edema may be seen if adjacent veins are compressed. Paresthesia and other neurological manifestations may arise due to ischemia or nerve compression. Rupture of a Pseudoaneurysm (PSA) is a potentially lethal complication that can lead to hemorrhage and shock.[6],[7] Smaller AVFs may be asymptomatic, whereas larger ones may present with a pulsatile mass, machinery murmur, or distended superficial veins. If not treated promptly, heart failure, limb loss, infection, or rupture could arise.[8],[9]
Since 1991, ultrasound-guided compression repair (UGCR), a noninvasive method, has become the first step in management of femoral pseudoaneurysms.[10] With this modality, the neck of the aneurysm is compressed, eventually leading to thrombosis of the blood within the sac. Termination of blood flow into the pseudoaneurysm from the native artery can be verified by direct ultrasound visualization. Limiting factors of UGCR include the time it takes to achieve thrombosis, which can range from 10 to 300 min, and the possible need of multiple sessions to induce sustained thrombosis.[11] UGCR has a success rate of 75%–98%.[12] However, if it is ineffective, thrombin can be used to achieve embolization of the neck of the aneurysm.
Thrombin injections have been used since 1996 and are considered the treatment of choice for pseudoaneurysm.[1],[13] In this procedure, thrombin is directly injected into the chamber of the pseudoaneurysm under USG guidance. By doing so, thrombin converts fibrinogen to fibrin leading to the immediate formation of a clot, which will arrest blood flow to the pseudoaneurysm.[13] Initial thrombin injection success rate ranges from 94% to 100%.[14] Despite its efficacy in the management of pseudoaneurysms, thrombin injections can lead to intra-arterial thrombosis, pruritus, and anaphylactic shock. The presence of AVFs is a contradiction to thrombin injections due to potential risk of venous thrombosis and was thus avoided in the management of this patient.[1]
Surgical closure is considered the ideal treatment for femoral artery pseudoaneurysms. Surgical indications include infection of the pseudoaneurysm, rapid expansion, contraindications or failure of other treatments, skin necrosis, and compressive syndromes such as neuropathy, claudication, or critical limb ischemia. For this case, treatment undertaken was surgical excision and repair of the left femoral pseudoaneurysm. Initially, a peripheral angiography was conducted through a right common femoral artery retrograde puncture under Duplex ultrasonography guidance. An AVF was noted at the left middle superficial femoral artery, and a pseudoaneurysm 5.5 cm × 3.5 cm was identified at the fistula site. A vertical incision was made along the length of the pseudoaneurysm, which extended proximally and distally to the common femoral artery, superficial femoral artery, and profunda femoris artery. After accessing the pseudoaneurysm sac, a large hematoma was removed, and nylon tapes were wrapped around the common femoral artery, superficial femoral artery, and profunda femoris artery for vascular control. A greater saphenous vein interposition graft was used to repair the arterial wall. To repair the AVF, the superficial femoral vein was then ligated and hemostasis was achieved. Complications of surgical repair include bleeding, infection, neuralgia, perioperative myocardial infarction, and rarely death.
ConclusionFemoral artery pseudoaneurysm is a relatively uncommon condition, but a well-known entity. Treatment by UGCR is raising in popularity and the use of thrombin injections is a straightforward and effectual procedure. Surgical excision and repair is considered the gold standard method in the management of a femoral artery pseudoaneurysm with an AVF.
This case was unique due to the 7-year time lapse from the time of trauma to the onset of the patient's presentation. In addition, the superficial femoral artery was accompanied by an AVF, which had to be managed accordingly. Despite the presence of an unusual prolonged onset and the coinciding AVF, surgical excision and repair proved to be effective with limited postoperative complications in this patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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