Three-Year Delayed Presentation of Femoral Pseudoaneurysm after Penetrating Limb Trauma James William Butterworth,1 William A. Butterworth,2 and Roxanne Wu,1 Cairns, Australia; Shrewsbury, United Kingdom
Background: Delayed presentations of lower limb pseudoaneurysms secondary to penetrating trauma are particularly rare. Methods: After presentation of this rare case report, we review relevant published literature. Results: We report a rare case of a 55-year-old man with a progressively enlarging mass measuring 15 cm by 15 cm on his right anteromedial thigh 3 years after penetrating trauma. Computer tomography angiogram revealed this to be a large pseudoaneurysm supplied by a side branch artery from the right superficial femoral artery. Using an open approach, the pseudoanerysm was successfully repaired with the side branch oversewn, and the patient made a good recovery being discharged from hospital 4 days later. Conclusions: Surgeons must retain pseudoaneurysm as a prominent differential for a patient presenting with a progressively enlarging, expansile mass of an extremity after penetrating trauma to ensure urgent investigation and prompt vascular intervention. Both open surgical ablation and endovascular embolization of pseudoaneurysms of the extremities are effective techniques with low rates of complications and morbidity reported in published literature.
Pseudoaneurysms arise from a disruption in the arterial wall and blood dissecting into the tissues around the damaged artery creating a perfused sac that communicates with the arterial lumen. Trauma to the wall of the artery may lead to the development of a pseudoaneurysm.1 Delayed presentation of lower limb pseudoaneurysms secondary to penetrating trauma are particularly rare with only 8 cases reported in the literature.2e5 After presentation of this rare case report we review relevant published literature. 1 Department of Surgery, Cairns Base Hospital, Cairns, Queensland, Australia. 2 Department of Anaesthetics, Royal Shrewsbury Hospital, Shrewsbury, UK.
Correspondence to: James William Butterworth, MBBS, BMedSci, MSc (Hons), DIC, MRCS (Ed), University Hospital Lewisham, High Street, Lewisham, London, SE13 6LH, UK; E-mail: [email protected] Ann Vasc Surg 2015; 29: 362.e11e362.e15 http://dx.doi.org/10.1016/j.avsg.2014.09.019 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: October 31, 2013; manuscript accepted: September 25, 2014; published online: November 13, 2014.
CASE REPORT We report the case of a 55-year-old man with a 3-year history of a progressively enlarging mass over his right anteromedial thigh after a stab wound 3 years previously for which he had been unable to seek surgical attention. The background and details of this traumatic injury to his leg appear unclear from the history. Over the preceding 2 weeks this man had noticed an increased rate of the swelling and worsening pain with associated difficulty in walking. He had not experienced fevers or systemic symptoms of anemia. He had no previous medical conditions or surgical operations and had no regular medications. He is a nonsmoker and denies alcohol use. On examination, he was apyrexial and hemodynamically stable with a large, 15 cm by 15 cm, tense and pulsatile mass over his anteromedial thigh (Fig. 1). Skin overlying the mass was intact, and femoral, popliteal, dorsalis pedis, and posterior tibial pulses were palpable bilaterally. Blood test revealed his hemoglobin was 84 g/dL, reduced from 108 g/dL 1 week previously. Inflammatory markers, coagulation profile, and urea and electrolytes were within normal range. Computer tomography angiogram (Fig. 2) revealed a large round collection in the anterior compartment of the thigh measuring
362.e11
362.e12 Case reports
Annals of Vascular Surgery
Fig. 1. Right leg pseudoaneurysm preoper-atively.
10 cm in both planes, the content being predominantly heterogenous consistent with a hematoma with a soft clot. It was noted that there was a false aneurysm measuring just more than 3 cm in both the directions at the deep aspect in close proximity to the right superficial femoral artery (SFA) in the mid thigh. The neck feeding the aneurysm appeared to be thin and short, approximately 5e7 mm in length. The underlying caliber of the SFA was unaffected. He was then admitted and fasted overnight in preparation for his right femoral pseudoaneurysm repair the following morning. Intraoperatively, proximal and distal control was established after exposure of the right SFA in the proximal thigh and right suprageniculate artery in the medial thigh. The pseudoaneurysm was opened and a large amount of fresh clot evacuated. The SFA was exposed in the area of fresh bleeding and after finding the bleeding to originate from a large side branch it was then oversewn. A drain was inserted and the wound closed. The patient made a good recovery, began mobilizing on day 1 after operation and was discharged from hospital 4 days later.
DISCUSSION Of the 8 delayed presentations of lower limb pseudoaneurysms after penetrating injury in published literature,2e5 interesting examples include a 28year-old man presenting 3 months after a penetrating injury to the buttock with an inferior gluteal artery pseudoaneurysm, successfully treated with an open surgical approach after a failed endovascular embolization attempt.4 Anatomically similar to our case, a patient presented 14 days after penetrating limb injury with a pseudoaneurysm of his left SFA in association with arteriovenous fistula of
Fig. 2. Computer tomography 3-dimensional maximum intensity projection of right femoral artery demonstrating pseudoaneurysm.
his left thigh.3 One retrospective review cites 5 cases of chronic pseudoaneurysm of the gluteal and pudendal vessels secondary to penetrating trauma and warns of the risk of late diagnosis of pseudoaneurysms given 87.5% of the vascular lesions reviewed in this study received inappropriate initial management.5 Iatrogenic lower limb cases include profunda femoris pseudoaneurysms complicating a Birmingham hip resurfacing arthroplasty,6 pseudoaneurysm of the peroneal artery after bone transport with Taylor Spatial Frame,7 and pseudoaneurysm of the superficial palmar arch after endoscopic carpal tunnel release.8 Iatrogenic upper limb pseudoaneurysms have been reported, with 1 delayed presentation after anterior shoulder dislocation successfully treated using open surgical intervention-resectionanastomosis and 1 digital artery pseudoaneurysm after trigger thumb release.9,10 Rarely, lower limb pseudoaneurysms have also been known to develop spontaneously with 1 case involving the right anterior tibial artery and tibioperoneal trunk successfully managed conservatively.11 Promise has been demonstrated for endovascular management of iatrogenic pseudoaneurysms with 1
Vol. 29, No. 2, February 2015
Case reports 362.e13
Table I. Summary of published literature on lower limb pseudoaneurysm management and outcome data Study authors
Gratl A. et al.
15
Number/location
Treatment
Outcome
30 Patients with crural pseudoaneurysms
Open surgery (n ¼ 3; 10%), endovascular procedures (n ¼ 13; 43.3%), and conservative management (n ¼ 14; 46.7%) Incorrectly diagnosed as abscess and directly incised
Median follow-up period of 7 months d8 of 9 endografts were occluded. No minor or a major amputation was necessary
Gilroy D. et al.5
6 Gluteal and internal pudendal
Lopera J.E. et al.16
8 Crural arterial pseudoaneurysms
Coil embolization
Park S.E. et al.17; Xiong J. et al.12; Joglar F. et al.18; Sadat U. et al.19
Case reports: 7 pseudoaneurysms of medial plantar, peroneal, and tibial arteries 1 Spontaneous right anterior tibial artery and tibioperoneal trunk 11 Pseudoaneurysms of iatrogenic and traumatic etiology
Transcatheter embolization
Case reports/series of common femoral, popliteal, doralis pedis, and inferior gluteal artery (n ¼ 4) 1
Open surgical approach to lower limb pseudoaneurysms
12 Patients with pseudoaneurysm 50 Infected femoral pseudoaneurysms
Open, mainly autologous vein graft Open surgery including vein angioplasty, femoral artery ligation, and delayed revascularization
102 Iatrogenic were groin aneurysms.
70 Cases treated nonoperatively by ultrasound-guided compression obliteration. 2 casesdpercutaneous thrombin injection (2%) and 23 by observation only (22.5%)
Shah S. et al.11
Maleux G. et al.13
Holland A.J. and Ibach E.G.4; Dalsing et al.20; Bozio G. et al.21
Kouvelos G.N. et al.22
Siddique M.K. et al.23 Salimi J. et al.24
Szendro G. et al.25
Because of late diagnosis, 87.5% received inappropriate initial management. 6 Treated successfully with minimal complications. One developed groin hematoma one recurred Treated successfully using transcatheter embolization
Managed conservatively
Successful
Endovascular embolotherapy
Success in 84% of patients with no long-term embolization-related complications Successful with no complications
Hybrid open surgical and endovascular techniques
Used successfully, minimizing risk to the patient Not stated Forty-four (77.2%) patients achieved a normal lifestyle. Early critical ischemia and late claudication were reported in 2 (3.5%) and 8 (14%) patients, respectively Nonoperative management: 95.7% success rate (67 cases)
362.e14 Case reports
retrospective review revealing successful elimination of 4 cases of pseudoaneurysm.12 Furthermore, in a 12-year retrospective review of 8 pseudoaneurysms, of both iatrogenic and traumatic etiology, primary clinical success was obtained in 84% of patients with no long-term embolization-related complications.13 However, further pseudoaneurysm, arteriovenous fistula, and retroperitoneal hematoma are among the recognized serious complications of endovascular procedures.14 Case reports, series and retrospective studies reporting the management of lower limb pseudoaneurysms and outcome data are summarized in Table I.4,15e25 Few comparative studies exist assessing endovascular versus open approaches to lower limb pseudoaneurysm; however, 1 long-term (38e 83 months) prospective study of 15 patients with true and false subclavian artery aneurysms revealed good long-term technical results, patency rates, and low procedure-associated morbidity in both those receiving open and endovascular surgery.26 Combined classic open surgical and endovascular techniques were used successfully in a diabetic patient with a pseudoaneurysm and venous outflow stenosis of his thigh arteriovenous graft (AVG), allowing graft salvage and revascularization of this leg.22 Controversially, 1 old prospective study of 20 arterial injuries, including 1 pseudoaneurysm, managed without surgery suggested nonoperative observation may be a safe and feasible method of managing clinically occult arterial injuries.27 On review of the literature summarized above, we would recommend an endovascular approach is particularly useful for pseudoaneurysms in difficult access vessels such as the subclavian arteries. Primary open surgical approach is useful for easier to access vessels such SFA pseudoaneurysms; however, open surgery is also important in management of failed endovascular ablations. Hybrid open and endovascular approaches are useful for complex cases such as the previously described successfully managed pseudoaneurysm with venous outflow stenosis of a thigh AVG.22 Delay in diagnosis and definitive surgical management can result in disastrous sequelae of complications as demonstrated by 1 case series of 6 children with lower limb vascular injuries in which diagnostic delay resulted in 2 major amputations and 1 insensate foot.20 A report of 3 initially clinically unrecognized lower limb vascular injuries, which were later discovered to be arteriovenous fistulas and false aneurysms, emphasizes the importance of surgeons being aware of subtle clinical signs and arranging early preoperative angiography to ensure prompt diagnosis.28
Annals of Vascular Surgery
In conclusion, surgeons must be aware that delayed presentation of lower limb pseudoaneurysm is a rare and serious consequence of penetrating trauma. Such patients require thorough clinical assessment, urgent investigation with arteriography, and prompt definitive open or endovascular surgical management to avoid limb loss and optimize patient outcome.
We would like to thank the medical secretaries at Cairns Base Hospital who helped to procure the records for the above case report.
REFERENCES ganjer M, Z ganjer V, Cigit I, et al. Pseudoaneurysm of the 1. Z brachial artery in a four-month-old boy: diagnosis and treatment. Arch Iran Med 2012;15:650e1. 2. Georgiadis GS, Deftereos SP, Eleftheriadou E, et al. Delayed presentation of a posterior tibial false aneurysm. Surgery 2006;139:446e7. 3. Ariyoshi H, Miyaso S, Aono Y, et al. Delayed presentation of superficial femoral artery injury: report of a case. Surg Today 2001;31:471e3. 4. Holland AJ, Ibach EG. False aneurysm of the inferior gluteal artery following penetrating buttock trauma: case report and review of the literature. Cardiovasc Surg 1996;4:841e3. 5. Gilroy D, Saadia R, Hide G, et al. Penetrating injury to the gluteal region. J Trauma 1992;32:294e7. 6. Thomas MS, O’Hara JN, Davies AM, et al. Profunda femoris pseudoaneurysm following Birmingham hip resurfacing: an important differential diagnosis for a periarticular cystic mass. Skeletal Radiol 2012;41:853e6. 7. Sala F, Salerno CF, Albisetti W. Pseudoaneurysm of the peroneal artery: an unusual complication of open docking site procedure in bone transport with Taylor Spatial Frame. Musculoskelet Surg 2013;97:183e6. 8. Didailler P, Ragois P, Morales P. Pseudoaneurysm of the superficial palmar arch, following endoscopic carpal tunnel release. A case report. Chir Main 2011;30:73e5. 9. Palcau L, Gouicem D, Dufranc J, et al. Delayed axillary artery pseudoaneurysm as an isolated consequence to anterior dislocation of the shoulder. Ann Vasc Surg 2012;26:279. 10. Taylor SA, Osei DA, Jain S, et al. Digital artery pseudoaneurysm following percutaneous trigger thumb release: a case report. J Bone Joint Surg Am 2012;18:94. 11. Shah S, Fischman A, Marin M, et al. Spontaneous tibioperoneal trunk and anterior tibial artery pseudoaneurysms. Vasc Med 2012;17:164e7. 12. Xiong J, Liu M, Guo W, et al. A retrospective study on endovascular management of iatrogenic vascular injuries. Vascular 2012;20:65e71. 13. Maleux G, Herten PJ, Vaninbroukx J, et al. Value of percutaneous embolotherapy for the management of traumatic vascular limb injury. Acta Radiol 2012;53:147e52. 14. Tonnessen BH. Iatrogenic injury from vascular access and endovascular procedures. Perspect Vasc Surg Endovasc Ther 2011;23:128e35. 15. Gratl A, Klocker J, Glodny B, et al. Treatment options of crural pseudoaneurysms. Vasa 2014;43:209e15.
Vol. 29, No. 2, February 2015
16. Lopera JE, Suri R, Cura M, et al. Crural artery traumatic injuries: treatment with embolization. Cardiovasc Intervent Radiol 2008;31:550e7. 17. Park SE, Kim JC, Ji JH, et al. Post-traumatic pseudoaneurysm of the medial plantar artery combined with tarsal tunnel syndrome: two case reports. Arch Orthop Trauma Surg 2013;133:357e60. 18. Joglar F, Kabutey NK, Maree A, et al. The role of stent grafts in the management of traumatic tibial artery pseudoaneurysms: case report and review of the literature. Vasc Endovascular Surg 2010;44:407e9. 19. Sadat U, See T, Cousins C, et al. Peroneal artery pseudoaneurysmea case report and literature review. BMC Surg 2007;29:4e7. 20. Dalsing MC, Cikrit DF, Sawchuk AP. Open surgical repair of children less than 13 years old with lower extremity vascular injury. J Vasc Surg 2005;41:983e7. 21. Bozio G, Tronc F, Douek P, et al. Dorsalis pedis artery pseudoaneurysm: an uncommon cause of soft tissue mass of the dorsal foot in children. Eur J Pediatr Surg 2009;19:113e6. 22. Kouvelos GN, Xanthopoulos DK, V Harissis H, et al. Hybrid management of a false aneurysm complicating an
Case reports 362.e15
23.
24.
25.
26.
27.
28.
arteriovenous graft in a patient with critical limb ischemia. J Vasc Access 2009;10:216e8. Siddique MK, Majeed S, Irfan M, et al. Missed vascular injuries: presentation and outcome. J Coll Physicians Surg Pak 2014;24:428e31. Salimi J, Shojaeefar A, Khashayar P. Management of infected femoral pseudoaneurysms in intravenous drug abusers: a review of 57 cases. Arch Med Res 2008;39:120e4. Szendro G, Golcman L, Klimov A, et al. Arterial false aneurysms and their modern management. Isr Med Assoc J 2001;3:5e8. Zehm S, Chemelli A, Jaschke W, et al. Long-term outcome after surgical and endovascular management of true and false subclavian artery aneurysms. Vascular 2014;22: 161e6. Frykberg ER, Vines FS, Alexander RH. The natural history of clinically occult arterial injuries: a prospective evaluation. J Trauma 1989;29:577e83. Graham AN, Barros D’Sa AA. Missed arteriovenous fistulae and false aneurysms in penetrating lower limb trauma: relearning old lessons. Injury 1991;22: 179e82.
Background: Delayed presentations of lower limb pseudoaneurysms secondary to penetrating trauma are particularly rare. Methods: After presentation of this rare case report, we review relevant published literature. Results: We report a rare case of a 55-year-old man with a progressively enlarging mass measuring 15 cm by 15 cm on his right anteromedial thigh 3 years after penetrating trauma. Computer tomography angiogram revealed this to be a large pseudoaneurysm supplied by a side branch artery from the right superficial femoral artery. Using an open approach, the pseudoanerysm was successfully repaired with the side branch oversewn, and the patient made a good recovery being discharged from hospital 4 days later. Conclusions: Surgeons must retain pseudoaneurysm as a prominent differential for a patient presenting with a progressively enlarging, expansile mass of an extremity after penetrating trauma to ensure urgent investigation and prompt vascular intervention. Both open surgical ablation and endovascular embolization of pseudoaneurysms of the extremities are effective techniques with low rates of complications and morbidity reported in published literature.
Pseudoaneurysms arise from a disruption in the arterial wall and blood dissecting into the tissues around the damaged artery creating a perfused sac that communicates with the arterial lumen. Trauma to the wall of the artery may lead to the development of a pseudoaneurysm.1 Delayed presentation of lower limb pseudoaneurysms secondary to penetrating trauma are particularly rare with only 8 cases reported in the literature.2e5 After presentation of this rare case report we review relevant published literature. 1 Department of Surgery, Cairns Base Hospital, Cairns, Queensland, Australia. 2 Department of Anaesthetics, Royal Shrewsbury Hospital, Shrewsbury, UK.
Correspondence to: James William Butterworth, MBBS, BMedSci, MSc (Hons), DIC, MRCS (Ed), University Hospital Lewisham, High Street, Lewisham, London, SE13 6LH, UK; E-mail: [email protected] Ann Vasc Surg 2015; 29: 362.e11e362.e15 http://dx.doi.org/10.1016/j.avsg.2014.09.019 Ó 2015 Elsevier Inc. All rights reserved. Manuscript received: October 31, 2013; manuscript accepted: September 25, 2014; published online: November 13, 2014.
CASE REPORT We report the case of a 55-year-old man with a 3-year history of a progressively enlarging mass over his right anteromedial thigh after a stab wound 3 years previously for which he had been unable to seek surgical attention. The background and details of this traumatic injury to his leg appear unclear from the history. Over the preceding 2 weeks this man had noticed an increased rate of the swelling and worsening pain with associated difficulty in walking. He had not experienced fevers or systemic symptoms of anemia. He had no previous medical conditions or surgical operations and had no regular medications. He is a nonsmoker and denies alcohol use. On examination, he was apyrexial and hemodynamically stable with a large, 15 cm by 15 cm, tense and pulsatile mass over his anteromedial thigh (Fig. 1). Skin overlying the mass was intact, and femoral, popliteal, dorsalis pedis, and posterior tibial pulses were palpable bilaterally. Blood test revealed his hemoglobin was 84 g/dL, reduced from 108 g/dL 1 week previously. Inflammatory markers, coagulation profile, and urea and electrolytes were within normal range. Computer tomography angiogram (Fig. 2) revealed a large round collection in the anterior compartment of the thigh measuring
362.e11
362.e12 Case reports
Annals of Vascular Surgery
Fig. 1. Right leg pseudoaneurysm preoper-atively.
10 cm in both planes, the content being predominantly heterogenous consistent with a hematoma with a soft clot. It was noted that there was a false aneurysm measuring just more than 3 cm in both the directions at the deep aspect in close proximity to the right superficial femoral artery (SFA) in the mid thigh. The neck feeding the aneurysm appeared to be thin and short, approximately 5e7 mm in length. The underlying caliber of the SFA was unaffected. He was then admitted and fasted overnight in preparation for his right femoral pseudoaneurysm repair the following morning. Intraoperatively, proximal and distal control was established after exposure of the right SFA in the proximal thigh and right suprageniculate artery in the medial thigh. The pseudoaneurysm was opened and a large amount of fresh clot evacuated. The SFA was exposed in the area of fresh bleeding and after finding the bleeding to originate from a large side branch it was then oversewn. A drain was inserted and the wound closed. The patient made a good recovery, began mobilizing on day 1 after operation and was discharged from hospital 4 days later.
DISCUSSION Of the 8 delayed presentations of lower limb pseudoaneurysms after penetrating injury in published literature,2e5 interesting examples include a 28year-old man presenting 3 months after a penetrating injury to the buttock with an inferior gluteal artery pseudoaneurysm, successfully treated with an open surgical approach after a failed endovascular embolization attempt.4 Anatomically similar to our case, a patient presented 14 days after penetrating limb injury with a pseudoaneurysm of his left SFA in association with arteriovenous fistula of
Fig. 2. Computer tomography 3-dimensional maximum intensity projection of right femoral artery demonstrating pseudoaneurysm.
his left thigh.3 One retrospective review cites 5 cases of chronic pseudoaneurysm of the gluteal and pudendal vessels secondary to penetrating trauma and warns of the risk of late diagnosis of pseudoaneurysms given 87.5% of the vascular lesions reviewed in this study received inappropriate initial management.5 Iatrogenic lower limb cases include profunda femoris pseudoaneurysms complicating a Birmingham hip resurfacing arthroplasty,6 pseudoaneurysm of the peroneal artery after bone transport with Taylor Spatial Frame,7 and pseudoaneurysm of the superficial palmar arch after endoscopic carpal tunnel release.8 Iatrogenic upper limb pseudoaneurysms have been reported, with 1 delayed presentation after anterior shoulder dislocation successfully treated using open surgical intervention-resectionanastomosis and 1 digital artery pseudoaneurysm after trigger thumb release.9,10 Rarely, lower limb pseudoaneurysms have also been known to develop spontaneously with 1 case involving the right anterior tibial artery and tibioperoneal trunk successfully managed conservatively.11 Promise has been demonstrated for endovascular management of iatrogenic pseudoaneurysms with 1
Vol. 29, No. 2, February 2015
Case reports 362.e13
Table I. Summary of published literature on lower limb pseudoaneurysm management and outcome data Study authors
Gratl A. et al.
15
Number/location
Treatment
Outcome
30 Patients with crural pseudoaneurysms
Open surgery (n ¼ 3; 10%), endovascular procedures (n ¼ 13; 43.3%), and conservative management (n ¼ 14; 46.7%) Incorrectly diagnosed as abscess and directly incised
Median follow-up period of 7 months d8 of 9 endografts were occluded. No minor or a major amputation was necessary
Gilroy D. et al.5
6 Gluteal and internal pudendal
Lopera J.E. et al.16
8 Crural arterial pseudoaneurysms
Coil embolization
Park S.E. et al.17; Xiong J. et al.12; Joglar F. et al.18; Sadat U. et al.19
Case reports: 7 pseudoaneurysms of medial plantar, peroneal, and tibial arteries 1 Spontaneous right anterior tibial artery and tibioperoneal trunk 11 Pseudoaneurysms of iatrogenic and traumatic etiology
Transcatheter embolization
Case reports/series of common femoral, popliteal, doralis pedis, and inferior gluteal artery (n ¼ 4) 1
Open surgical approach to lower limb pseudoaneurysms
12 Patients with pseudoaneurysm 50 Infected femoral pseudoaneurysms
Open, mainly autologous vein graft Open surgery including vein angioplasty, femoral artery ligation, and delayed revascularization
102 Iatrogenic were groin aneurysms.
70 Cases treated nonoperatively by ultrasound-guided compression obliteration. 2 casesdpercutaneous thrombin injection (2%) and 23 by observation only (22.5%)
Shah S. et al.11
Maleux G. et al.13
Holland A.J. and Ibach E.G.4; Dalsing et al.20; Bozio G. et al.21
Kouvelos G.N. et al.22
Siddique M.K. et al.23 Salimi J. et al.24
Szendro G. et al.25
Because of late diagnosis, 87.5% received inappropriate initial management. 6 Treated successfully with minimal complications. One developed groin hematoma one recurred Treated successfully using transcatheter embolization
Managed conservatively
Successful
Endovascular embolotherapy
Success in 84% of patients with no long-term embolization-related complications Successful with no complications
Hybrid open surgical and endovascular techniques
Used successfully, minimizing risk to the patient Not stated Forty-four (77.2%) patients achieved a normal lifestyle. Early critical ischemia and late claudication were reported in 2 (3.5%) and 8 (14%) patients, respectively Nonoperative management: 95.7% success rate (67 cases)
362.e14 Case reports
retrospective review revealing successful elimination of 4 cases of pseudoaneurysm.12 Furthermore, in a 12-year retrospective review of 8 pseudoaneurysms, of both iatrogenic and traumatic etiology, primary clinical success was obtained in 84% of patients with no long-term embolization-related complications.13 However, further pseudoaneurysm, arteriovenous fistula, and retroperitoneal hematoma are among the recognized serious complications of endovascular procedures.14 Case reports, series and retrospective studies reporting the management of lower limb pseudoaneurysms and outcome data are summarized in Table I.4,15e25 Few comparative studies exist assessing endovascular versus open approaches to lower limb pseudoaneurysm; however, 1 long-term (38e 83 months) prospective study of 15 patients with true and false subclavian artery aneurysms revealed good long-term technical results, patency rates, and low procedure-associated morbidity in both those receiving open and endovascular surgery.26 Combined classic open surgical and endovascular techniques were used successfully in a diabetic patient with a pseudoaneurysm and venous outflow stenosis of his thigh arteriovenous graft (AVG), allowing graft salvage and revascularization of this leg.22 Controversially, 1 old prospective study of 20 arterial injuries, including 1 pseudoaneurysm, managed without surgery suggested nonoperative observation may be a safe and feasible method of managing clinically occult arterial injuries.27 On review of the literature summarized above, we would recommend an endovascular approach is particularly useful for pseudoaneurysms in difficult access vessels such as the subclavian arteries. Primary open surgical approach is useful for easier to access vessels such SFA pseudoaneurysms; however, open surgery is also important in management of failed endovascular ablations. Hybrid open and endovascular approaches are useful for complex cases such as the previously described successfully managed pseudoaneurysm with venous outflow stenosis of a thigh AVG.22 Delay in diagnosis and definitive surgical management can result in disastrous sequelae of complications as demonstrated by 1 case series of 6 children with lower limb vascular injuries in which diagnostic delay resulted in 2 major amputations and 1 insensate foot.20 A report of 3 initially clinically unrecognized lower limb vascular injuries, which were later discovered to be arteriovenous fistulas and false aneurysms, emphasizes the importance of surgeons being aware of subtle clinical signs and arranging early preoperative angiography to ensure prompt diagnosis.28
Annals of Vascular Surgery
In conclusion, surgeons must be aware that delayed presentation of lower limb pseudoaneurysm is a rare and serious consequence of penetrating trauma. Such patients require thorough clinical assessment, urgent investigation with arteriography, and prompt definitive open or endovascular surgical management to avoid limb loss and optimize patient outcome.
We would like to thank the medical secretaries at Cairns Base Hospital who helped to procure the records for the above case report.
REFERENCES ganjer M, Z ganjer V, Cigit I, et al. Pseudoaneurysm of the 1. Z brachial artery in a four-month-old boy: diagnosis and treatment. Arch Iran Med 2012;15:650e1. 2. Georgiadis GS, Deftereos SP, Eleftheriadou E, et al. Delayed presentation of a posterior tibial false aneurysm. Surgery 2006;139:446e7. 3. Ariyoshi H, Miyaso S, Aono Y, et al. Delayed presentation of superficial femoral artery injury: report of a case. Surg Today 2001;31:471e3. 4. Holland AJ, Ibach EG. False aneurysm of the inferior gluteal artery following penetrating buttock trauma: case report and review of the literature. Cardiovasc Surg 1996;4:841e3. 5. Gilroy D, Saadia R, Hide G, et al. Penetrating injury to the gluteal region. J Trauma 1992;32:294e7. 6. Thomas MS, O’Hara JN, Davies AM, et al. Profunda femoris pseudoaneurysm following Birmingham hip resurfacing: an important differential diagnosis for a periarticular cystic mass. Skeletal Radiol 2012;41:853e6. 7. Sala F, Salerno CF, Albisetti W. Pseudoaneurysm of the peroneal artery: an unusual complication of open docking site procedure in bone transport with Taylor Spatial Frame. Musculoskelet Surg 2013;97:183e6. 8. Didailler P, Ragois P, Morales P. Pseudoaneurysm of the superficial palmar arch, following endoscopic carpal tunnel release. A case report. Chir Main 2011;30:73e5. 9. Palcau L, Gouicem D, Dufranc J, et al. Delayed axillary artery pseudoaneurysm as an isolated consequence to anterior dislocation of the shoulder. Ann Vasc Surg 2012;26:279. 10. Taylor SA, Osei DA, Jain S, et al. Digital artery pseudoaneurysm following percutaneous trigger thumb release: a case report. J Bone Joint Surg Am 2012;18:94. 11. Shah S, Fischman A, Marin M, et al. Spontaneous tibioperoneal trunk and anterior tibial artery pseudoaneurysms. Vasc Med 2012;17:164e7. 12. Xiong J, Liu M, Guo W, et al. A retrospective study on endovascular management of iatrogenic vascular injuries. Vascular 2012;20:65e71. 13. Maleux G, Herten PJ, Vaninbroukx J, et al. Value of percutaneous embolotherapy for the management of traumatic vascular limb injury. Acta Radiol 2012;53:147e52. 14. Tonnessen BH. Iatrogenic injury from vascular access and endovascular procedures. Perspect Vasc Surg Endovasc Ther 2011;23:128e35. 15. Gratl A, Klocker J, Glodny B, et al. Treatment options of crural pseudoaneurysms. Vasa 2014;43:209e15.
Vol. 29, No. 2, February 2015
16. Lopera JE, Suri R, Cura M, et al. Crural artery traumatic injuries: treatment with embolization. Cardiovasc Intervent Radiol 2008;31:550e7. 17. Park SE, Kim JC, Ji JH, et al. Post-traumatic pseudoaneurysm of the medial plantar artery combined with tarsal tunnel syndrome: two case reports. Arch Orthop Trauma Surg 2013;133:357e60. 18. Joglar F, Kabutey NK, Maree A, et al. The role of stent grafts in the management of traumatic tibial artery pseudoaneurysms: case report and review of the literature. Vasc Endovascular Surg 2010;44:407e9. 19. Sadat U, See T, Cousins C, et al. Peroneal artery pseudoaneurysmea case report and literature review. BMC Surg 2007;29:4e7. 20. Dalsing MC, Cikrit DF, Sawchuk AP. Open surgical repair of children less than 13 years old with lower extremity vascular injury. J Vasc Surg 2005;41:983e7. 21. Bozio G, Tronc F, Douek P, et al. Dorsalis pedis artery pseudoaneurysm: an uncommon cause of soft tissue mass of the dorsal foot in children. Eur J Pediatr Surg 2009;19:113e6. 22. Kouvelos GN, Xanthopoulos DK, V Harissis H, et al. Hybrid management of a false aneurysm complicating an
Case reports 362.e15
23.
24.
25.
26.
27.
28.
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