Figure 1
Pre-embolization femoral angiogram
Play Video
Left femoral angiogram showing leak from a small branch of profunda femoris into the pseudoaneurysm
Coil embolization of a pseudoaneurysm of profunda femoris artery
SectionInterventional radiology
Case TypeClinical Cases
AuthorsFawcett R, Leahy F.
Connected authors
39 years, male
Clinical History
A 39 year old male patient presented with a two day history of worsening pain and swelling in the left groin and upper thigh. Examination revealed a tender, pulsatile mass in the left groin.
Imaging Findings
A 39 year old male patient presented with acute onset of worsening pain and increasing swelling of the left groin of two days duration with no history of trauma. Past medical history included infective endocarditis and subsequent mitral valve replacement 18 months previously requiring lifelong warfarin therapy.
Examination revealed a tense, tender, pulsatile mass in the left groin. Blood sampling showed the patients INR to be at a level of 3.9, slightly above the recommended range of 2.5-3.5 for patients post metallic valve insertion.
Doppler ultrasound scan revealed a complex collection in the upper left thigh of 9cm diameter, consistent with a large haematoma containing thrombus. There was active bleeding with a large vessel, most likely profunda femoris, leading to the collection. A diagnosis of pseudoaneurysm of the left profunda femoris artery was made.
Warfarin therapy was temporarily discontinued and intravenous heparin was commenced in preparation for coil embolisation of the pseudoaneurysm.
Initial angiography demonstrated rapid bleeding from a branch of the profunda femoris into a large collection, with another vessel leading away from the pseudoaneurysm to the periphery (Fig 1). The vessel was entered selectively and several coils were deployed proximal and distal to the neck of the aneurysm occluding this segment completely. A completion angiogram demonstrated successful thrombosis of the pseudoaneurysm (Fig 2), and a post-procedure doppler ultrasound scan confirmed this.
A six month follow-up appointment revealed no complications.
Examination revealed a tense, tender, pulsatile mass in the left groin. Blood sampling showed the patients INR to be at a level of 3.9, slightly above the recommended range of 2.5-3.5 for patients post metallic valve insertion.
Doppler ultrasound scan revealed a complex collection in the upper left thigh of 9cm diameter, consistent with a large haematoma containing thrombus. There was active bleeding with a large vessel, most likely profunda femoris, leading to the collection. A diagnosis of pseudoaneurysm of the left profunda femoris artery was made.
Warfarin therapy was temporarily discontinued and intravenous heparin was commenced in preparation for coil embolisation of the pseudoaneurysm.
Initial angiography demonstrated rapid bleeding from a branch of the profunda femoris into a large collection, with another vessel leading away from the pseudoaneurysm to the periphery (Fig 1). The vessel was entered selectively and several coils were deployed proximal and distal to the neck of the aneurysm occluding this segment completely. A completion angiogram demonstrated successful thrombosis of the pseudoaneurysm (Fig 2), and a post-procedure doppler ultrasound scan confirmed this.
A six month follow-up appointment revealed no complications.
Discussion
Pseudoaneurysm of the profunda femoris artery is rare. However, all patients taking warfarin are at an increased risk of bleeding, especially with an INR above therapeutic levels.
For suspected femoral pseudoaneurysm the imaging modality of choice is a femoral arterial duplex study.
Small femoral pseudoaneurysms clot spontaneously and usually require no treatment. Larger femoral pseudoaneurysms may lead to complications including rupture and compression of the adjacent femoral vein (with resulting venous thrombosis) or of the femoral nerve. Symptomatic pseudoaneurysms, those with a diameter greater than 3 cm, and those found in patients who are anticoagulated should usually be treated. Surgery has traditionally been considered the 'gold standard' treatment, although it is not without risk. Surgical pseudoaneurysm repair should be undertaken in the setting of infection, rapid expansion, or if less invasive methods are not technically feasible. Less invasive treatment options include duplex ultrasound-guided compression and percutaneous thrombin injection. This case demonstrates that endovascular coil embolization is an excellent treatment for femoral pseudoaneurysms.
Awareness of pseudoaneurysm formation and the treatment options allows prompt diagnosis and successful treatment.
For suspected femoral pseudoaneurysm the imaging modality of choice is a femoral arterial duplex study.
Small femoral pseudoaneurysms clot spontaneously and usually require no treatment. Larger femoral pseudoaneurysms may lead to complications including rupture and compression of the adjacent femoral vein (with resulting venous thrombosis) or of the femoral nerve. Symptomatic pseudoaneurysms, those with a diameter greater than 3 cm, and those found in patients who are anticoagulated should usually be treated. Surgery has traditionally been considered the 'gold standard' treatment, although it is not without risk. Surgical pseudoaneurysm repair should be undertaken in the setting of infection, rapid expansion, or if less invasive methods are not technically feasible. Less invasive treatment options include duplex ultrasound-guided compression and percutaneous thrombin injection. This case demonstrates that endovascular coil embolization is an excellent treatment for femoral pseudoaneurysms.
Awareness of pseudoaneurysm formation and the treatment options allows prompt diagnosis and successful treatment.
Differential Diagnosis List
Pseudoaneurysm of left profunda femoris artery.
Final Diagnosis
Pseudoaneurysm of left profunda femoris artery.
References
[1] Tisi PV, Callam MJ (2009) Treatment for femoral pseudoaneurysms. Cochrane Database Syst Rev Apr 15;(2):CD004981. (PMID: 19370614)
[2] Kronzon I (1997) Diagnosis and treatment of iatrogenic femoral artery pseudoaneurysm: a review. J Am Soc Echocardiogr 10(5):30A-31. (PMID: 9109690)
[3] Corriere MA, Guzman RJ (2005) True and false aneurysms of the femoral artery. Semin Vasc Surg 18(4):216-23. (PMID: 16360579)
Case information
| URL: | https://www.eurorad.org/case/7873 |
| DOI: | 10.1594/EURORAD/CASE.7873 |
| ISSN: | 1563-4086 |
Figure 2
Post-embolization femoral angiogram
Play Video
Completion angiogram demonstrates occlusion of the branch of profunda femoris and of the pseudoaneurysm