Common femoral artery erosion as a source of thromboembolic acute limb ischemia.

We have reported a case of delayed hip prosthetic erosion into the common femoral artery (CFA) 3 years after implantation. The patient had initially presented with left lower extremity acute limb ischemia secondary to a popliteal artery embolism. However, the metal artifact around the hip joint prevented CFA evaluation using conventional imaging. Diagnostic angiography with intraoperative intravascular ultrasound revealed CFA dilatation with adherent intraluminal thrombus. Open surgical repair showed hip prosthesis erosion through the posterior wall of the CFA. Our findings emphasize the necessity for a thorough, multimodal embolic workup and the usefulness of intravascular ultrasound as an adjunctive tool for intravascular anatomy evaluation.

Vascular injuries after orthopedic hip procedures are rare, comprising 0.25% of cases.1, 2, 3 Moreover, vessel injuries will present in 0.05% of primary hip arthroplasty cases and 0.14% of revision cases. These will commonly involve the common femoral and external iliac vessels and can occur intraoperatively during the use of retractors or screw implantation.5, 6, 7, 8, 9 We have described a case of prosthetic common femoral artery (CFA) erosion detected by intravascular ultrasound (IVUS) 3 years after implantation. The patient provided written informed consent for the report of their case details and imaging studies.

Case report

A 44-year-old woman with a history of Marfan syndrome and congenital hip dysplasia after left total hip replacement 3 years previously had presented with acute left lower extremity pain and sensory loss. The patient had developed left ileofemoral deep vein thrombosis 9 months after her original hip replacement surgery and rivaroxaban therapy was started. The patient was followed up by hematologic and orthopedic specialists. The radiographic appearance of the prosthesis remained stable, with no concerns regarding prosthesis size mismatch or dislocation. On presentation, the vascular physical examination demonstrated equally palpable bilateral femoral pulses and absent ipsilateral popliteal and pedal pulses, with normal contralateral pulse examination findings. The patient had preserved motor function and diminished sensory function in the left foot. The arterial Doppler ultrasound examination revealed ipsilateral monophasic signals in the pedal arteries. The preoperative arterial duplex ultrasound examination demonstrated tibial arterial occlusions but failed to show thrombus, stenosis, or aneurysmal dilatation in the CFA. Computed tomography angiography (CTA) revealed embolic popliteal artery occlusion. However, the CFA evaluation was limited by the extreme artifact from the metallic hip prosthesis (Fig 1). A heparin drip was started, and open thrombectomy of the left popliteal and tibial arteries was performed through an infrapopliteal incision. Intraoperative angiograms through the popliteal artery demonstrated good outflow and inflow. Four-compartment fasciotomies were performed. Postoperatively, the patient had a palpable femoral pulse and improved Doppler signals at the pedal arteries. A hematologic consultation confirmed the negative findings from a hypercoagulable workup. A definitive source of the embolization was not detected by arterial duplex ultrasound, CTA of the chest, abdomen, and pelvis, or transthoracic echocardiography. The patient was discharged after an 18-day hospitalization to a rehabilitation center with warfarin therapy and remained compliant.

Fig 1

Computed tomography (CT) showing imaging artifacts from a hip implant at the level of the left common femoral artery (CFA; blue arrow).

At a follow-up visit on postdischarge day 23, the patient had stable pulses on examination but experienced persistent foot numbness and severe disabling claudication. Arterial duplex ultrasound of the pedal arteries demonstrated monophasic flow. Because of the persistent symptoms and monophasic arterial flow, an angiogram was performed to delineate the anatomy and determine the cause of her symptoms.

The findings from a left lower extremity angiogram, performed in retrograde fashion via the contralateral CFA, suggested a filling defect with a high-grade stenosis in the left CFA. However, the angiogram was obscured by the hip prosthesis (Fig 2). The CFA also demonstrated a P2 popliteal segment occlusion with reconstitution of the anterior tibial and posterior tibial arteries. Intraprocedural IVUS was used to better delineate the CFA intraluminal anatomy. A 0.014-in. Eagle Eye platinum catheter (Philips Volcano, San Diego, Calif) over a 0.014-in. wire revealed aneurysmal dilation of the distal external iliac and CFA with associated, adherent intraluminal thrombus. A metallic structure, presumed to be the hip prosthesis, was observed adjacent to the thrombus (Fig 3). No evidence of atherosclerotic disease was found above or below the aneurysmal dilatation level. Given the unusual thrombotic burden, history of connective tissue disorder, and the patient's younger age, open CFA repair was pursued.

Fig 2

Diagnostic angiogram showing left common femoral artery (CFA) filling defect (red arrow and red bracket) within close proximity to the hip prosthesis (black dashed line).

Fig 3

Intravascular ultrasound (IVUS) demonstrating intraluminal thrombus (thick arrow), aneurysmal dilatation, and metallic artifact (thin arrow).

The CFA, exposed through a vertical groin incision, appeared aneurysmal with a periarterial adhesive process, and circumferential control was not feasible. The inguinal ligament was partially divided, and control was achieved on the distal external iliac artery. The aneurysm rapidly tapered at the femoral bifurcation. After obtaining proximal and distal control, the artery was opened through a longitudinal arteriotomy, revealing an organized thrombus adherent to the posterior arterial wall. Thrombus removal exposed posterior arterial wall erosion at the junction of the external iliac artery and CFA with protrusion of the metal prosthesis into the arterial lumen (Fig 4). The artery appeared aneurysmal only in the common femoral segment where intraluminal thrombus formation was noted. The arterial diameter in the external iliac artery and at the CFA bifurcation appeared nonaneurysmal. We suspect that the arterial dilatation had resulted from luminal expansion due to thrombus-induced luminal stenosis. The metal portion of the prosthesis was covered with a bovine pericardium patch and surrounding tissue. An interposition bypass from the external iliac artery to the distal CFA was then performed with a Dacron graft. An arterial wall tissue specimen was not submitted for pathologic evaluation. Additionally, popliteal artery thrombectomy was performed using an over-the-wire embolectomy catheter. The patient tolerated the procedure well and had a palpable dorsal pedal pulse. She was discharged several days later to a rehabilitation center. At the 2-month follow-up visit, the bypass graft remained patent with no lower extremity symptoms or evidence of infection. CTA of the abdomen and pelvis with lower extremity runoff demonstrated preserved patency of the bypass graft and popliteal artery. The pulse examination findings remained unchanged. The patient continued anticoagulation therapy with warfarin and aspirin in accordance with the hematology recommendations. Given the imaging complexity with the hip prosthesis in place, the long-term follow-up regimen will include a physical examination and an ankle brachial index measurement every 3 months for 1 year and annually thereafter. Additionally, patients with Marfan syndrome have a risk of developing aneurysmal degeneration at the arterial anastomosis site, and we will evaluate for those late complications with CTA every 5 years.

Fig 4

Intraoperative photograph of the left common femoral artery (CFA) with erosion through the arterial wall and adherent thrombus (arrow).

Discussion

We have described a late vascular complication of hip replacement surgery. Despite the proximity of blood vessels and hip structures, vascular complications have been relatively rare., Delayed complications have been even more uncommon and have been identified intraoperatively rather than with the CTA.

Acute vascular complications after orthopedic procedures have been well-documented but have mostly occurred intraoperatively., Several studies have described acute CFA pseudoaneurysm formation, commonly caused by vessel wall erosion from cement or retractor placement., Delayed vascular complications, especially in patients with Marfan syndrome, after total hip replacement have not been reported. In a similar case, at 1 year after hip implantation, the patient had experienced an embolic event from a pseudoaneurysm secondary to arterial wall erosion by a piece of bone cement, although the patient did not have Marfan syndrome. Marfan syndrome is an autosomal-dominant connective tissue disorder caused by the fibrillin gene mutation and can predispose patients to increased complications owing to fragile blood vessels. Considering the complications of Marfan syndrome, our patient had had neither thoracic aortic aneurysm or dissection nor lens dislocation or myopia. She had a moderate pectus excavatum and stable aortic root dilatation to 32 mm.

Despite the low incidence and delayed presentation, arterial erosion can cause limb-threatening ischemia and extremity loss. Significant imaging artifacts from a metallic hip necessitates the preference for alternative imaging modalities instead of CTA. For the present patient, the use of IVUS during angiography was instrumental in the diagnosis and detected the abnormal CFA appearance with adherent wall thrombus and potential arterial wall erosion by the hip implant. IVUS is a powerful imaging modality for evaluating the vessel luminal diameter and characterizing the plaque volume, morphology, and calcification extent. Vascular specialists should use IVUS when traditional imaging is obscured by artifacts such as a metallic hip prosthesis.

Conclusions

Delayed CFA erosion by a metallic hip implant is a rare, potentially limb-threatening complication. Traditional imaging modalities such as CTA can be compromised by metallic artifacts. A high index of suspicion and alternative imaging modalities such as IVUS can aid in detecting this uncommon complication.