Pseudoaneurysm of the profunda femoris artery following an inter-trochanteric fracture of the femur

Silent iatrogenic pseudoaneurysm after intertrochanteric fracture fixation with proximal femoral nailing and cerclage wiring: case report and review of literature

Pseudoaneurysm is a rare complication after intertrochanteric fracture fixation. Herein, we present a rare case of late development of a pseudoaneurysm with silent clinical symptoms. The case was a 91-year-old woman treated with proximal femoral nailing and cerclage wiring. Postoperatively, the patient was able to ambulate with a walker without abnormal symptoms. During the follow-ups, the radiographic images showed progressive cortical scalloping on the medial femoral shaft. Ultrasonography revealed a yin-yang sign, and a CT scan confirmed a pseudoaneurysm at the profunda femoris artery (PFA). In this case, many possible causes of pseudoaneurysm were hypothesized. We showed that the excessive displaced, long spiral pattern of an intertrochanteric fracture, which was irreducible by a closed technique, is the risk of a PFA injury. An atherosclerotic vessel was seen in preoperative radiography, indicating poor vessel elasticity which may be a risk of vessel tear during fracture reduction using multiple reduction instruments in excessive displaced fracture. Moreover, over-penetration when drilling should not be overlooked. We also discuss the predisposing factors, surgical techniques which may lead to this type of PFA injury and summarize the literature of pseudoaneurysms related to intertrochanteric fracture fixation.

Vascular surgical management of profunda femoris artery aneurysms: A single center experience

OBJECTIVE

Profunda femoris artery aneurysms (PFAAs), which comprise true profunda femoris artery aneurysms (TPFAAs) and profunda femoris artery pseudoaneuryms (PFA PSAs), are rare but clinically significant diseases of the peripheral arterial vasculature. Our aim is to describe our institution's 15-year experience with PFAAs (TPFAAs and PFA PSAs) to provide insight into patient characteristics, diagnostic imaging modalities, and surgical interventions that contribute to clinically important outcomes in patients with PFAAs.

METHODS

We conducted a retrospective study at our institution using our radiology database.

RESULTS

We identified six patients with PFA PSAs and four patients with TPFAAs. The clinical presentation of PFA PSAs included a triad of thigh pain, bleeding, and unexplained anemia. There was variety in the aetiologies of PFA PSAs, arising from catheterizations, upper thigh fractures, anastomotic complications, or unknown causes. Most patients with PFA PSAs had hypertension and coronary artery disease, and half of our cohort had peripheral vascular disease. All patients were imaged with duplex ultrasonography (DUS) or computed tomography (CT), the latter being more accurate. All patients with PFA PSAs underwent endovascular treatment, including glue, thrombin, or coil embolization as well as stent-graft insertions. All TPFAAs presented to our center were small and incidentally discovered, explaining the conservative management of our TPFAAs. Two of the four TPFAAs were idiopathic in nature, while one was attributed to post-stenotic dilatation, and another was found in a patient with Ehlers Danlos Syndrome. There was an association between TPFAAs and multiple synchronous or asynchronous aneurysms.

CONCLUSION

Pseudoaneurysms of the PFA are mostly iatrogenic in nature and can present with the triad of thigh swelling, bleeding, and unexplained anemia. If the clinical picture is suggestive of a PFA PSA but DUS does not detect a pseudoaneurysm, CT may be added as a more accurate imaging modality. Endovascular embolization is used in smaller pseudoaneurysms and in poor surgical candidates. Multiple glue, coil, or thrombin injections may be required to fully thrombose the pseudoaneurysm sac. True aneurysms of the PFA are associated with synchronous/asynchronous aneurysms and small TPFAAs should be carefully monitored, as there is a risk of enlargement and rupture.

Pseudoaneurysm of the Profunda Femoris Artery following Blunt Trauma Treated by Endovascular Coil Embolization: Review of Two Cases and Relevant Literature

Profunda femoris artery (PFA) pseudoaneurysm after blunt trauma without associated femur fracture is a rare occurrence. Most of the reported cases of PFA pseudoaneurysm in the English literature developed after penetrating trauma, surgical procedures, and femur fractures. We present two such cases following blunt trauma and without any associated long bone injury. After initial imaging failed to show any long bone fracture, CT angiography confirmed pseudoaneurysm of the branch of the PFA. Both patients were then treated with emergent coil embolization of the bleeding vessel. Pseudoaneurysms typically present late and signs of persistent hip pain, thigh swelling, presence of a pulsatile mass, and even unexplained anemia all may suggest the diagnosis. Recognition of PFA pseudoaneurysm requires high index of suspicion and is often difficult to diagnose clinically because of its location.

Proximal femoral fractures and vascular injuries in adults: Incidence, aetiology and outcomes

INTRODUCTION

Vascular injuries (VI) presenting during internal fixation (IF) of proximal femoral fractures (PFF) are potentially limb- and life-threatening. The purpose of this systematic review of the literature is to report on their incidence, associated complications and to give special emphasis in their prevention.

MATERIALS AND METHODS

A comprehensive review of the literature was undertaken using the PRISMA guidelines with no language restriction. Case reports of VIPFF-IF and series of PFF-IF with cases of VI published between inception of journals to March 2015 were eligible for inclusion. Relevant information was divided in two parts. Part I included the analysis of cases of VIPFF-IF, with the objective of establishing the frequency of injury of each vessel, the types and mechanisms of injury, the diagnostic and therapeutic modalities, and the outcomes. Part II analysed series of PFF-IF, which included case(s) of VI for assessing the incidence of VIPFF-IF.

RESULTS

Overall 160 articles with 182 cases of VIPFF-IF met the inclusion criteria. The injuries to extrapelvic vessels prevailed over those of intrapelvic vessels. There was a higher frequency of injury to the deep femoral artery and its branches in extrapelvic vessels and of external iliac artery and vein in intrapelvic vessels. The types of injury were: compression, intimal flap tear, disruption of the intimal layer with thrombosis, laceration with haemorrhage, and puncture or progressive erosion leading to a pseudoaneurysm (PSA) or arteriovenous fistula (AVF), with high prevalence for PSA, followed by lacerations. PSAs were more frequent in extrapelvic lesions and lacerations in the intrapelvic vessels. There were 7 non-iatrogenic injuries, produced by a displaced lesser trochanter fragment or other bone fragments, and 175 iatrogenic injuries (96.15%). The intrapelvic intraoperative protrusion of instruments or implants, or the post-operative migration of implants produced the injuries of intrapelvic vessels. For iatrogenic injuries of extrapelvic vessels the prevalent mechanism was a displaced lesser trochanter fragment, either intra- or postoperatively, followed by injuries by an overshot drill bit or a protruding screw; several other mechanisms completed the list. The clinical and radiological investigations were similar to those of VI elsewhere. VI occurred either at the time of fracture, during surgery or after it, early or late, weeks, months or even years after IF. The diagnostic and therapeutic modalities were most diverse, and the incidence of morbidity and mortality was 18.06%. The overall incidence of VIPFF-IF was 0.49%.

CONCLUSION

The incidence of VIPFF-IF is low, though it will probably rise because of the increasing frequency of PFF. With few exceptions, these injuries, which are potentially limb and life-threatening, are iatrogenic, resulting of errors in IF, with different types of lesions to intra- and extrapelvic vessels running in close proximity to the bone. Although the surgeon should bear in mind this possibility and achieve early diagnosis and prompt accurate treatment, there is no consensus as to what is the best diagnostic or therapeutic modality. A precise diagnosis of the preoperative vascular status of the limb, monitoring of the displacement of the lesser trochanter fragment, careful and gentle reduction of the fracture, and precise handling of instruments and implant selection and placement during IF, are factors to consider in order to prevent this complication, which should never be underestimated.

[Femoral artery pseudoaneurysms encountered in orthopedics and traumatology]

BACKGROUND AND PURPOSE

Most published articles regarding orthopedic- and trauma-related femoral artery pseudoaneurysms (FAPs) are case reports in English. Reported cases are often associated with a literature review but actually provide little robust data. We wanted to summarize the current knowledge on diagnostic and therapeutic features of these FAPs.

METHODS

A new case of superficial FAP is described followed by a review of the literature. A bibliographic search was performed online (PubMed, ScinceDirect) from 1964 to 2015 using the descriptors "traumatic femoral pseudoaneurysm, orthopedic surgery, osteochondroma".

RESULTS

A total of 64 cases of FAPs was analyzed. There were 50 men with an average age of 40.72±26.45 years old. The most common clinical presentation was painful swelling (34%). Arteriography was the commonest radiological investigation used (63%). The main etiologies were orthopedic injuries (47%), surgery of the upper thigh (30%) and femoral osteochondromas (23%). Arterial injuries included superficial femoral (47%) and profunda femoris artery (50%). The treatment was open surgery (56%) or endovascular repair (36%). Deep femoral artery and its branches were embolized (47%) or ligated (38%). Endovascular stenting was performed in 30% of posttraumatic FAPs. All FAPs relating to osteochondromas were repaired surgically. Postoperative courses were uneventful in 95% of patients.

CONCLUSION

Endovascular embolization is preferred in management of postsurgical FAPs which have usually involved the deep femoral artery. Endovascular stenting graft may be proposed for posttraumatic FAPs, for which the superficial femoral trunk is the most often involved vessel. Surgical repair should be performed when endovascular stenting graft is not feasible. Surgical repair is mandatory for all FAPs secondary to traumatic exostoses.

Endovascular repair of profunda femoral artery false aneurysms using covered stents

Pseudoaneurysms of the profunda femoral artery (PFA) have been reported following different types of trauma, mostly iatrogenic. We present three cases of PFA false aneurysm formation, two after vascular procedures and one as a result of a gunshot injury, which were successfully treated with the endovascular deployment of covered stents. Treating these patients by endoluminal means is an efficient and feasible minimally invasive approach. If the patient is relatively stable and there are no major compression issues, stenting could be considered as adequate therapy for these situations. Certainly, a larger series are needed in order to testify to the long-term results and ascertain the durability of such a repair.