Asian Cardiovascular and Thoracic Annals

Asian Cardiovascular
and Thoracic Annals
http://aan.sagepub.com/
Pseudoaneurysms of the Profunda Femoris Artery
Senol Yavuz, Özer Selimoglu, Mehmet Tugrul Göncü and Ibrahim Ayhan Özdemir
Asian Cardiovascular and Thoracic Annals 2001 9: 73
DOI: 10.1177/021849230100900122
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C
ASE STUDY
Yavuz
PSEUDOANEURYSMS OF THE PROFUNDA FEMORIS ARTERY
PSEUDOANEURYSMS OF THE
PROFUNDA FEMORIS ARTERY
Şenol Yavuz, MD, Özer Selimoğlu, MD,
Mehmet Tugrul Göncü, MD,
İbrahim Ayhan Özdemir, MD
Department of Cardiovascular Surgery
Bursa Yüksek İhtisas Hospital
Bursa, Turkey
ABSTRACT
Three cases of pseudoaneurysm of the profunda femoris artery as a late complication
of various traumas, were confirmed by femoral arteriography. Successful surgical
repair was performed. Angiography is recommended for accurate diagnosis.
(Asian Cardiovasc Thorac Ann 2001;9:73–5)
I NTRODUCTION
Injury to the profunda femoris artery (PFA) accounts for
approximately 2% of peripheral arterial wounds.1,2
Complications of undiagnosed and inaccessible arterial
injuries include pseudoaneurysm, arteriovenous fistula,
and vessel occlusion. Pseudoaneurysms may result from
blunt, penetrating, or high velocity trauma.3 Traumatic
occlusion of the PFA does not normally result in distal
ischemia if the common and superficial femoral arteries
are intact.
CASE REPORTS
PATIENT 1
A 20-year-old man sustained a stab wound in the middle
of the posterior left thigh, which was treated by primary
suturing. He was discharged with patent distal pulses.
Two months later, he was admitted to our clinic with
increasing pain and swelling in the inner left thigh. A
4 × 5 cm pulsatile mass was observed in this area. Distal
pulses were detected manually. On auscultation, a loud
systolic bruit was heard over the mass. Peripheral
arteriography showed a pseudoaneurysm of the PFA
(Figure 1). The patient underwent repair through a left
vertical incision under epidural anesthesia. Control of the
common, superficial, and deep femoral arteries was
obtained. Axial dissection of the PFA was carried out,
exposing it alongside the deep femoral vein. A 4 × 5 cm
pseudoaneurysm containing a hematoma was extirpated.
The circumflex and first perforator branches of the PFA
were preserved and the distal segment was ligated. The
postoperative course was uncomplicated and the patient
was discharged on the fifth postoperative day. At
follow-up, all peripheral pulses were present. One year
after the operation, he was readmitted for angiography;
the arteriogram showed no evidence of pseudoaneurysm
(Figure 2). The distal segment of the main trunk of the
PFA was not visualized but the proximal part was patent.
PATIENT 2
A 42-year-old woman sustained a stab wound in the inner
posterior right thigh. She had no signs of vascular injury
immediately after the trauma and she was discharged
after wound dressing and antibiotic prophylaxis. She was
admitted to our clinic 45 days later with constant pain and
swelling in the region of the wound. Physical examination
revealed a 3 × 6 cm well-defined firm pulsating mass at
For reprint information contact:
Şenol Yavuz, MD Tel: 90 224 360 5055
Fax: 90 224 360 2928 email: [email protected]
Department of Cardiovascular Surgery, Bursa Yüksek İhtisas Hospital, Duaçinari, Bursa 16330, Turkey.
2001, VOL. 9, NO. 1
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Yavuz
PSEUDOANEURYSMS OF THE PROFUNDA FEMORIS ARTERY
the inner posterior aspect of her right thigh. The
circumference of the right thigh measured at the one-third
proximal level was 8.6 cm greater than that of the left side
at the same level. A loud systolic bruit was heard over the
right femoral region, which was more pronounced at the
inner thigh. All distal pulses were present and equal
bilaterally. Chest radiography and laboratory findings
were normal except for mild bilirubin elevation. Diagnosis
was confirmed by selective peripheral arterial angiography.
The patient was operated upon through a vertical femoral
incision. Control of the common, superficial, and profunda
femoris arteries was obtained. On evacuating a hematoma,
the PFA was found to have a laceration of 4-mm in
length. The injury was repaired primarily with 5/0
polypropylene suture to restore arterial continuity. The
postoperative course was uneventful and the patient was
discharged on the eighth postoperative day. She was
symptom-free at follow-up 16 months later.
PATIENT 3
A 35-year-old man sustained a gunshot wound to the
posterior left thigh 90 days before admission to our clinic
with a 7-day history of increasing pain and swelling in
the left thigh. He reported no history of cardiac
catheterization. A painful pulsatile mass was found in the
left thigh, extending to the groin. Left lower limb pulses
were present. A plain radiograph excluded hip fracture.
Peripheral angiography revealed pseudoaneurysm of the
PFA. The patient was explored under epidural anesthesia
via a vertical incision. A large hematoma was found in the
region of the femoral artery. On evacuating the hematoma,
the common femoral artery appeared to be of normal
caliber. After obtaining control of the proximal PFA, the
pseudoaneurysm was extirpated by proximal and distal
ligation. The patient did well postoperatively and was
discharged on the 10th day. He was asymptomatic during
34 months of follow-up.
Figure 1. Preoperative angiogram of patient no. 1, demonstrating
pseudoaneurysm (arrows) of the left profunda femoris artery.
Figure 2. Postoperative angiogram of patient no. 1, showing a patent
proximal segment and no visualized distal segment of the profunda
femoris artery; the pseudoaneurysm can no longer be seen.
DISCUSSION
Pseudoaneurysms of the PFA are uncommon and occur
as a late complication of various traumas. Causes include
iatrogenic (percutaneous or open arterial catheterizations,
leakage occurring at anastomoses between grafts and
vessels, or orthopedic manipulations), traumatic (blunt,
penetrating, and gunshot injuries), and other factors such
as infection, hip torsion during sporting activity, intravenous drug usage, and true aneurysms.3–5 In our cases,
the etiology was traumatic. Laceration of an artery can be
sealed by a hematoma that may lyse, resulting in formation
of a pseudoaneurysm. This is generally characterized by
a pulsatile mass connected to the arterial lumen, originating
from the surrounding structures as a densely fibrous
capsule. Its development may take weeks to months. If
untreated, it may rupture at any time or ultimately develop
into a chronic aneurysm.6
Arterial occlusion and thrombosis are the usual findings
after blunt trauma. Hematoma is the most consistent sign
A SIAN C ARDIOVASCULAR & T HORACIC ANNALS
of vascular injury in patients with penetrating arterial
injuries. Ischemia is often not apparent, and pulses distal
to a penetrating injury are present in approximately onethird of such patients.1,6,7 Spontaneous pseudoaneurysms
are extremely uncommon. Calligaro and colleagues4
reported a PFA pseudoaneurysm caused by acute trunk
and hip torsion during a golf swing. Vascular complications
such as hematoma, pseudoaneurysm, and arteriovenous
fistula occurring after intracoronary or intracardiac
procedures are responsible for significant morbidity and
even mortality.5 PFA injuries may be overlooked due to
delayed presentation and also because distal pulses are
usually present. Accurate diagnosis is difficult as this
artery is located deep in the thigh. The most common
clinical presentation of pseudoaneurysm is a pulsating,
sometimes painful, mass that expands during systole,
usually associated with a strong systolic murmur.1,6 Pain
and paresthesia, venous occlusion, thrombosis, and edema
may develop due to pressure on adjacent nerves and
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2001, VOL. 9, NO. 1
Yavuz
PSEUDOANEURYSMS OF THE PROFUNDA FEMORIS ARTERY
veins. Careful examination and auscultation should be
performed over an injured area.
Injuries to the common and superficial femoral arteries
usually result in ischemia of the lower extremities, which
is easily diagnosed. PFA injuries may not cause ischemia
if the common and superficial femoral arteries are intact.
PFA injury is usually only diagnosed arteriographically
because overt clinical signs and symptoms are absent. A
B-mode ultrasound scan and angiography together with
computed tomography or magnetic resonance imaging
have been helpful in establishing the correct diagnosis.1,3,6,7
In our cases, selective arterial angiography was effective
in diagnosing the PFA pseudoaneurysms.
be performed in cases with a high index of suspicion. A
simple surgical approach is effective in preventing such
complications.
REFERENCES
1.
Synder WH III, Thal ER, Perry MO. Vascular injuries of
the extremity. In: Rutherford RB, editor. Vascular surgery.
3rd ed. Philadelphia: Saunders, 1989:613–37.
2.
Loubeau JM, Bahnson HT. Traumatic false aneurysm and
arteriovenous fistula of the profunda femoris artery: surgical
management and review of the literature. Surgery 1977;
81:222–7.
3.
Yilmaz AT, Arslan M, Demirkilic U, Ozal E, Kuralay E,
Tatar H, et al. Missed arterial injuries in military patients.
Am J Surg 1997;173:110–4.
Experience in treatment of PFA pseudoaneurysms is
limited. If the superficial femoral artery is patent, as was
observed in our patients, the pseudoaneurysm can be
treated by simple ligation. Ligation was commonly used
in the treatment of vascular injuries during World War
II.1,2,6 Ligation of the femoral artery above the profunda
resulted in an 81.1% amputation rate compared with
54.8% when the artery was ligated below the PFA.
However, amputation was not determined by ligation of
the PFA alone. There was no limb loss in our patients who
had ligation of the PFA. Other therapeutic options include
ultrasound-guided compression and transcatheter
embolization.5,8
4.
Calligaro KD, Savarese RP, Goldberg D, Doerr KJ,
Dougherty MJ, DeLaurentis DA. Deep femoral artery
pseudoaneurysm caused by acute trunk and hip torsion.
Cardiovasc Surg 1993;1:392–4.
5.
Currie P, Turnball CM, Shaw TR. Pseudoaneurysm of the
femoral artery after catheterization: diagnosis and treatment
by manual compression guided by Doppler color-flow
imaging. Br Heart J 1994;72:80–4.
6.
Hewitt RL. Vascular injuries. In: Haimovici H, editor.
Vascular surgery. 2nd ed. Norwalk, CT: AppletonCentury-Crofts, 1984:389–411.
7.
Lindfors O, Pauklu P, Totterman S. A false aneurysm of
the deep femoral artery. Acta Chir Scand 1982;148:
201–2.
As these cases illustrate, clinical findings are insufficient
to diagnose occult traumatic profunda femoris arterial
injuries. When they are overlooked, pseudoaneurysms
can develop as late complications. Angiography should
8.
Barnes DI, Broude HB. False aneurysm of the profunda
femoris artery complicating fracture of the femoral shaft
and treated by transcatheter embolization. S Afr Med J
1985;67:824–6.
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