Abstract
Femoral artery pseudoaneurysms are usually the result of femoral artery cannulation for percutaneous cardiac or endovascular procedures. It causes compression of surrounding structures, may cause distal embolization, arteriovenous fistula formation, or might rupture. Most close spontaneously by thrombosis, and the remainder need intervention, either percutaneous or surgical repair. We describe a unique case of femoral pseudoaneurysm that was repaired percutaneously by excluding it via stenting and simultaneous closure of residual aneurysm by direct access and coil embolization.
Highlights
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Femoral artery pseudoaneurysms are usually the result of femoral artery cannulation for percutaneous cardiac or endovascular procedures.
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Percutaneous endovascular repair with covered stent serves as an alternative in candidates with prohibitive surgical risk.
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Direct stenting with residual coiling through the actual pseudoaneurysms is a viable alternative in experienced hands
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Direct access of the pseudoaneurysms with further refinement of technology may make this a more frequented access route in the future
1
Introduction
Pseudoaneurysm (PSA) is a tear through all the layers of the artery with persistent flow outside the vessel into the perivascular space, usually as a result of an incompletely healed arterial puncture site. Femoral artery PSAs are usually the result of femoral artery cannulation with reported incidence of 2–6% [ ]. Factors predisposing PSA formation are advanced age, smoking, obesity, female sex, calcified vessel, increased sheath size, use of anticoagulant and improper closure techniques [ ]. PSAs may spontaneously thrombose or may be treated with ultrasound guided thrombin injection. However, once the size reaches >1.8 cm, the likelihood of spontaneous thrombosis decreases [ ]. Over time, it can become very painful and may cause distal embolization, compression of surrounding structures, arteriovenous fistula formation, or extravasation. Risk of rupture increases with size >3 cm [ , , ] and would need surgical repair. We describe a unique case of large femoral PSA that was repaired percutaneously by excluding it via stenting and simultaneous closure of residual aneurysm by direct access and coil embolization.
2
Case
A 94 year old male with history of coronary artery disease, atrial fibrillation, hypertension, hyperlipidemia, ischemic cardiomyopathy, and peripheral artery disease presented with a 3 year history of enlarging pulsatile right groin mass. There was no prior inciting event that he could recollect. Although fully functional, his ambulation and functional capacity were now compromised. Right lower extremity exam revealed a 6 × 6 cm pulsatile mass in the right groin area extending across the groin crease. Vascular exam revealed non-palpable pulses with audible Doppler signals in the distal right lower extremity. The rest of his physical examination was unremarkable.
The baseline serum creatinine was 1.4 mg/dl and GFR was 60 ml/min/1.73 m 2 . A 2D transthoracic echocardiogram revealed an ejection fraction of 35% with distal anterior wall hypokinesis. There was no evidence of left ventricular thrombus or valvular abnormality. Doppler Ultrasound of lower extremity revealed a large right groin PSA arising anteriorly from the common femoral artery with partial thrombosis measuring 5 × 3 × 4.2 cm ( Fig. 1 ). The neck was fairly wide measuring about 6 mm and about 8 mm long. Color flow demonstrated a “yin-yang” sign typical of a PSA ( Fig. 2 ). Although the size of his aneurysm warranted consideration for surgical intervention, he was deemed high risk for peri-operative cardiac events by vascular surgery, prompting percutaneous intervention.
After informed consent, and under local anesthesia, access was obtained in the left common femoral artery (CFA). Distal abdominal aortography with runoff revealed a totally occluded right superficial femoral artery (SFA) with a large PSA measuring at least 3 cm in size at the level of origin of the profunda femoral artery. There were two lobes to this PSA with a patent profunda femoral artery. There were extensive collateralizations from the profunda femoral artery into the tibio-peroneal trunk.
After discussion with vascular surgery, it was decided to exclude the PSA neck with a covered stent and possible thrombosis or embolization of the aneurysmal sac. Wire access into the aneurysm was obtained via contralateral access, which was coiled up into the larger sac of the aneurysm followed by access into the profunda femoral artery using another buddy wire. Direct access of the PSA was then obtained using ultrasound guidance with a micropuncture needle and a 5F sheath (Terumo). ( Fig. 3 ).
