Life-threatening ruptured femoral artery pseudoaneurysm: A delayed complication of endovascular aortic repair of abdominal aortic aneurysm.

The Editor,

A 60-year-old, male patient was admitted with gradually progressive swelling over the right groin. He was known the case of coronary artery disease and abdominal aortic aneurysm. Coronary artery bypass surgery (CABG) was done 3 months back. Fifteen days following elective CABG, he underwent infrarenal abdominal aortic stent graft for abdominal aortic aneurysm. Two and half months later, he was readmitted with 10 cm × 10 cm pulsatile swelling over the right groin. The distal pulses were not felt, and all other physical examination findings were within normal limits. Ultrasound examination confirmed pseudoaneurysm of the right femoral artery. A noncontract computed tomography (CT) angiography of the pelvis revealed infrarenal abdominal aortic stent graft in situ, but a large leaking pseudoaneurysm seen in relation to right groin originating from right femoral artery [Figure 1]. The periphery of pseudoaneurysm was showing an evidence of hematoma formation measured 7.12 mm × 7.05 mm × 6.8 mm, which was repaired with 8 mm woven Dacron tube graft under general anesthesia.

Figure 1

Computed tomography angiography image of the right groin demonstrates a large pseudoaneurysm of right common femoral artery and patent endovascular aortic repair stent graft

The common femoral artery is the most common site for iatrogenic pseudoaneurysm formation. Pseudoaneurysm at this site usually has long, narrow necks (<10 mm). The incidence of pseudoaneurysm formation is approximately 1% with diagnostic studies but increases to 3.2% when an interventional procedure is performed. After catheter removal, the reported average time of pseudoaneurysm onset varies from 5 to 6 days, with a late onset of 12 days.[1]

Kassem et al.,[2] in their prospective study reported some independent procedure-related risk factors for femoral arterial pseudoaneurysm such as diagnostic angiography, low puncture, multiple punctures, and the use of dual ant platelet and/or anticoagulant therapy. Our patient also had similar risk factors.

Arterial thrombosis, dissection, or pseudoaneurysm formation has been documented in up to 3% of endovascular aortic repair of the abdominal aortic aneurysm. Maleux et al.,[3] reported a large pseudoaneurysm in the right groin 1 week after endovascular aneurysm stent grafting on CT scan. With the growing use of large diameter sheaths and more potent anticoagulant regimens, the rate of incidence of this complication has been increasing as high as 6–8%.[4]

Our intention to write this case is due to two unusual reasons firstly there was 2½ month time lapse from the interventional procedure through the femoral artery and secondly patient presenting with life-threatening ruptured femoral artery pseudoaneurysm requiring emergent surgery. However, thorough knowledge of the potential complications, early (radiological) diagnosis, and appropriate treatment are mandatory to reduce morbidity or even mortality due to these complications.

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