|Year : 2016 | Volume
| Issue : 4 | Page : 142-144
A Traumatic Profunda Femoris Artery Pseudoaneurysm and Literature Review
Navneel Shahi1, Jim Zhong1, Stephen Bradley1, Peter Vowden2
1 Department of Vascular Surgery and Interventional Radiology, University of Leeds/ Leeds Teaching Hospitals, Great George Street, Leeds, UK
2 Department of Vascular Surgery, Bradford Royal Infirmary, Bradford, UK
|Date of Web Publication||30-Sep-2016|
Department of Vascular Surgery and Interventional Radiology, University of Leeds/ Leeds Teaching Hospitals, Great George Street, Leeds
Source of Support: None, Conflict of Interest: None
Profunda femoris artery pseudoaneurysms (PFAPs) have been described as an iatrogenic phenomenon, principally following orthopedic procedures and open or closed trauma to the upper thigh, although remain rare. The diagnosis of PFAPs is challenging and often delayed due to the nonspecific manner of the presentation with clinical features including pain, swelling, and unexplained anemia as demonstrated in this case report of a PFAP following a stab injury to the thigh. The use of computed tomography angiography (CTA) or transcatheter angiography allows for early accurate diagnosis and treatment of vascular complications secondary to trauma, especially when there is concern of vascular injury and possible pseudoaneurysm formation in the clinical context.
Keywords: Computed tomographic angiography, profunda femoris artery, pseudo aneurysm
|How to cite this article:|
Shahi N, Zhong J, Bradley S, Vowden P. A Traumatic Profunda Femoris Artery Pseudoaneurysm and Literature Review. Indian J Vasc Endovasc Surg 2016;3:142-4
| Introduction|| |
Profunda femoris artery pseudoaneurysms (PFAPs) have been described as an iatrogenic phenomenon, principally following orthopedic procedures  and open or closed trauma to the upper thigh,  although PFAPs remain rare. The diagnosis of PFAPs is often delayed due to the nonspecific manner of the presentation with clinical features including pain, swelling, and unexplained anemia. Diagnosis can be a challenge and requires a high index of suspicion. Imaging modalities can aid in diagnosis, including ultrasound, conventional arteriography, or computed tomography angiography (CTA).  While treatment options depend largely on the site and size of the pseudoaneurysm, some authorities believe that the complication rates of even asymptomatic lesions warrant intervention. 
We present a case of PFAP following a stab wound to the thigh.
| Case Report|| |
A 17-year-old man was brought into the accident and emergency department, having sustained a stab wound to the anterior aspect of the thigh. There was no reported loss of consciousness, and the patient was resuscitated as per advanced trauma life support protocol.
On examination, the only positive finding was a 0.5 cm stab wound on the anterior aspect of the upper third of the thigh just lateral to the mid-inguinal point, with a surrounding hematoma, but no active bleeding. To rule out any injury to the superficial femoral artery, the patient underwent arterial duplex ultrasonography. This confirmed a small hematoma on the anterior aspect of the thigh with no obvious injury to the superficial femoral artery or any other major artery. No pseudoaneurysm was visualized. The patient was scheduled on the emergency list for an exploration of the wound under general anesthetic in the morning following the presentation. Intraoperatively, a small hematoma was evacuated. No active bleeding was noted at the time; the wound was, therefore, washed and packed.
In the following 24 h, the patient continued to bleed necessitating three further dressing changes and clot evacuation. The patient was noted to be clinically anemic and his full blood count demonstrated a significant drop in the hemoglobin level, necessitating transfusion of 3 units. Computed tomography angiography (CTA) was therefore performed to determine the site of blood loss, with a view to embolization or further surgical exploration. The CTA revealed a 1.4 cm × 1.1 cm pseudoaneurysm arising from one of the branches of the profunda femoris artery [Figure 1] with a 3.5 cm × 2.3 cm hematoma lying anteriorly. This pseudo aneurysm was deemed suitable for endovascular treatment. Access was obtained from the contra-lateral femoral artery and followed by super selective cannulation of the bleeding profunda branch and successful distal coil embolization with a single, soft 3 mm × 3 mm coil that was deployed into the feeding vessel and a satisfactory position was achieved [Figure 2]. Postprocedure angiograms confirmed complete exclusion of the pseudoaneurysm and no further hemorrhage [Figure 3].
|Figure 1: Reconstructed computed tomography arteriograms of the lower limbs, revealed a 1.4 cm × 1.1 cm pseudoaneurysm arising from one of the branches of the profunda femoris artery|
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|Figure 2: Transfemoral catheter angiogram via contralateral femoral artery approach (preembolization)|
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|Figure 3: Postembolization angiogram confirms successful exclusion of the pseudoaneurysm|
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| Discussion|| |
Profunda femoris artery pseudoaneurysms (PFAPs) have been described as an iatrogenic phenomenon, principally following orthopedic procedures  and open or closed trauma to the upper thigh,  although PFAPs remain rare. 
It also occurs in the context of femoral fractures , or subsequent internal fixation.  Since 1964 there have been 61 published cases of pseudoaneurysm following proximal femoral shaft repairs. 
Published accounts of PFAPs occurring following penetrating trauma are few. One retrospective study focusing on fragment trauma sustained by military personnel showed the profunda femoris was among the least frequently affected vessel while the superficial femoral was most commonly injured.  Profounda femoris injuries may result more commonly from stab wounds. In a review of gluteal stab wounds, 17 of the 21 arterial injuries documented were PFAPs. 
As in this case, the diagnosis of profunda femoris pseudo aneurysm is usually delayed. Features such as leg swelling, pain, and unexplained anemia may be the only early clues to the diagnosis. Trauma surgeons should, therefore, be aware of this complication and have a high index of suspicion, especially in cases that involve penetrating injuries. Undetected vascular trauma can be present in a nonspecific manner, such as arteriovenous fistulae manifesting as high output cardiac failure. 
As demonstrated by this case, early arterial duplex ultrasonography may fail to demonstrate the arterial injury and pseudoaneurysm formation. The diagnosis therefore usually relies on more detailed and selective arterial imaging.
Management of pseudoaneurysms is dependent largely on their location and size. Active intervention is required in larger (>3 cm) and symptomatic lesions. Current therapeutic options include open surgical repair, ultrasound-guided compression, ultrasound-guided thrombin injection, or a transfemoral catheter-based endovascular approach using coil embolization or stent-graft insertion. In this case, the segmental branch feeding the pseudoaneurysm was selectively cannulated and embolized with platinum coils. A postprocedure angiogram confirmed occlusion of the feeding vessel with obliteration of the pseudoaneurysm and no extravasation of contrast.
| Conclusion|| |
This case demonstrates both the nonspecific presentation of arterial pseudoaneurysms and the high index of suspicion that is required for vascular injury in cases of penetrating injury. In the case of such injuries, it is not possible to accurately predict both the trajectory of the penetrating object and the precise delineation of the underlying vascular anatomy. Responsible teams, therefore, require a low threshold for investigating these patients, to rule out underlying vascular trauma.
Our experience suggests that duplex arteriography is not adequate to reliably demonstrate pseudo aneurysms of the profunda femoris, which may be more satisfactorily elicited on CTA. Performing transfemoral catheter angiography from the outset allows for diagnosis and treatment, with therapeutic options such as stent graft placement, coiling, or use of other embolic agents to occlude the pseudoaneurysm.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Hanna GB, Holdsworth RJ, McCollum PT. Profunda femoris artery pseudoaneurysm following orthopaedic procedures. Injury 1994;25:477-9.
Unay K, Poyanli O, Akan K, Poyanli A. Profunda femoris artery pseudoaneurysm after surgery and trauma. Strategies Trauma Limb Reconstr 2008;3:127-9.
Johnson CA, Goff JM, Rehrig ST, Hadro NC. Asymptomatic profunda femoris artery aneurysm: Diagnosis and rationale for management. Eur J Vasc Endovasc Surg 2002;24:91-2.
Leong QM, Lee WT, Chia KH. Profunda femoris pseudoaneurysm: An unusual and easily overlooked complication following injuries of the proximal femur. Inj Extra 2008;39:92-4.
Chong KC, Yap EC, Lam KS, Low BY. Profunda femoris artery pseudoaneurysm presenting with triad of thigh swelling, bleeding and anaemia. Ann Acad Med Singapore 2004;33:267-9.
Dillon JP, O'Brien GC, Laing AJ, Adelowokan T, Dolan ML. Pseudoaneurysm of the profunda femoris artery following an inter-trochanteric fracture of the femur. Inj Extra 2004;35:30-2.
Patelis N, Koutsoumpelis A, Papoutsis K, Kouvelos G, Vergadis C, Mourikis A, et al.
Iatrogenic injury of profunda femoris artery branches after intertrochanteric hip screw fixation for intertrochanteric femoral fracture: A case report and literature review. Case Rep Vasc Med 2014;2014:694235.
Yilmaz AT, Arslan M, Demirkiliç U, Ozal E, Kuralay E, Tatar H, et al.
Missed arterial injuries in military patients. Am J Surg 1997;173:110-4.
Guven K, Rozanes I, Ucar A, Poyanli A, Yanar H, Acunas B. Pushable springcoil embolization of pseudoaneurysms caused by gluteal stab injuries. Eur J Radiol 2010;73:391-5.
Rymer JA, Anderson LL, Posenau JT, Jones WS. Remote stab wound resulting in AV fistula and high-output heart failure. Case Rep Cardiol 2013;2013:902719.
[Figure 1], [Figure 2], [Figure 3]