Asian Cardiovasc Thorac Ann 2001;9:73-75
© 2001 Asia Publishing EXchange Pte Ltd
Pseudoaneurysms of the Profunda Femoris Artery
enol Yavuz, MD,
Özer Selimo
lu, MD,
Mehmet Tugrul Göncü, MD,
brahim Ayhan Özdemir, MD
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Department of Cardiovascular Surgery Bursa Yüksek htisas Hospital Bursa, Turkey
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For reprint information contact: enol Yavuz, MD Tel: 90 224 360 5055 Fax: 90 224 360 2928 email: syavuz64{at}yahoo.com Department of Cardiovascular Surgery, Bursa YÜksek htisas Hospital, Duaçinari, Bursa 16330, Turkey.
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Abstract
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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.
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Introduction
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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.
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Case Reports
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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 x 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 x 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.
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Figure 1. Preoperative angiogram of patient no. 1, demonstrating pseudoaneurysm (arrows) of the left profunda femoris artery.
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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.
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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 x 6 cm well-defined firm pulsating mass at 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.
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Discussion
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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, intra-venous 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 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 one-third 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 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.
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
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 be performed in cases with a high index of suspicion. A simple surgical approach is effective in preventing such complications.
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References
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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.[Medline]
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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.[Medline]
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Abstract
Introduction
