Symptomatic Deep Femoral Artery Pseudoaneurysm Endovascular Exclusion. Case Report and Literature Review

Accepted Manuscript Symptomatic deep femoral artery pseudoaneurysm endovascular exclusion. Case report and literature review Felice Pecoraro, Ettore Dinoto, Umberto M. Bracale, Giovanni Badalamenti, Arduino Farina, Guido Bajardi PII:

S0890-5096(16)30754-3

DOI:

10.1016/j.avsg.2016.11.026

Reference:

AVSG 3240

To appear in:

Annals of Vascular Surgery

Received Date: 27 August 2016 Revised Date:

27 October 2016

Accepted Date: 28 November 2016

Please cite this article as: Pecoraro F, Dinoto E, Bracale UM, Badalamenti G, Farina A, Bajardi G, Symptomatic deep femoral artery pseudoaneurysm endovascular exclusion. Case report and literature review, Annals of Vascular Surgery (2017), doi: 10.1016/j.avsg.2016.11.026. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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TITLE PAGE

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Title: Symptomatic deep femoral artery pseudoaneurysm endovascular exclusion. Case report and

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literature review.

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4 Authors: Felice Pecoraro,1 Ettore Dinoto,1 Umberto M Bracale,2 Giovanni Badalamenti,1 Arduino

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Farina,1 Guido Bajardi.1

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Affiliation:

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University of Palermo, Vascular Surgery Unit, AOUP ‘‘P. Giaccone’’, Palermo, Italy

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Department of vascular and endovascular surgery, University Federico II of Naples, Naples, Italy

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10 Corresponding author:

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Felice Pecoraro, MD

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University of Palermo, Vascular Surgery Unit, AOUP ‘‘P. Giaccone’’, Palermo, Italy

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Via L. Giuffrè 5, 90127- Palermo, Italy

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Telephone: +39 0916552750, fax: +39 0916552750

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e-mail address: [email protected]

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Conflict of Interest: The authors declare that they have no conflict of interest.

ACCEPTED MANUSCRIPT ABSTRACT

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Deep femoral artery pseusoaneurysms (DFAPs) are rare and generally occur after penetrating

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trauma or surgical procedures. A 36-year old obese man presented with pain in correspondence of

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the anterior-lateral thigh after 6 months from gunshot wound. Duplex and computed tomography

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(CT) showed a bilobed right DFAP (maximal diameter 12.9 cm). The patient was managed urgently,

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under local anaesthesia, by placement in the distal DFA of a Viabahn 8 x 100mm stent-graft (W L

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Gore & Associates, Inc). The post-operative course was uneventful and the 24-months CT showed

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regular stent-graft patency and 20 mm DFPA shrinkage. The literature review reported 8 cases of

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DFAPs; of these 6 were managed by endovascular mean (3 stent-graft implantations and 3 coil

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embolization). The remaining 2 cases were managed surgically (one of these after failed coil

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embolization). In conclusion the use of covered stent-graft was effective to treat a DFAP localized

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in the medium DFA. This tool allowed maintaining the native DFA patency and the preservation of

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its main branches.

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Key words: Deep femoral artery pseudoaneurysm; endovascular; stent-graft; exclusion; gunshot

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ACCEPTED MANUSCRIPT MAIN TEXT

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Introduction

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Deep femoral artery pseudoaneurysms (DFAPs) are rare with a 2% reported incidence of

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peripheral arterial wounds [1]. Deep femoral artery (DFA) iatrogenic injury during

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vascular/orthopaedic procedures and thigh penetrating trauma are the most common cause of

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DFAPs [2]. Generally DFAPs are associated to thigh pain, swelling and claudication; haemorrhagic

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and eventually shock signs have also been reported. Less frequently DFAPs can be asymptomatic

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during the first period after the initial injury; in such cases they can be undetected [3]. DFAPs

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optimal treatment is still matter of debate [4]. Recently, the endovascular approach has been

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reported in pseudoaneurysm treatment with its related advantages [5]. Herein we report a case of

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DFAP treated by endovascular means and a review of the relevant literature.

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Technical note

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A 36-year-old Caucasian man was referred to our centre for a right anterior-lateral thigh

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hematoma. At personal history the patient had a gunshot wound in correspondence of the

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posterior thigh six months earlier. At that time, the patient was managed in another hospital by

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bullet removal. This operation was uneventful and the patient was discharged at home. After

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three months from bullet removal the patient referred an initial thigh swelling, but the patient did

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any medical consultation. At six months from the initial operation the patient presented at our

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centre with pain and swelling of the thigh. The patient referred also a reduction of walking

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capacity since one month. At clinical examination a large non-expandable pulsatile mass in the

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anterior-lateral right thigh was palpable; pedal pulses were palpable. This young obese (BMI: 35)

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patient was emodynamically stable but a reduced haemoglobin was evident (8.0 g/dl)

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ACCEPTED MANUSCRIPT The duplex sonography (DUS) showed a large pseudoaneurysm (approximately 8 x 6 cm) in

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correspondence of the right thigh with connections to the DFA. The computed tomographic

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angiography (CTA) showed a bilobed DFAP beginning at 10 cm from DFA origin. The larger DFAP

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lobe was localized in correspondence of the anterior fascial compartment and measured 7.8 cm x

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7.8 cm x 12.9 cm; the smaller lobe was between the medial and posterior fascial compartment and

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measured 5.6 cm x 4.3 cm x 6.6 cm. The CTA revealed a femur bone fragment (8 x 3 x 25 mm)

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adjacent to the DFAP at 10 cm from its origin. (Figure. 1) The native DFA diameter was 7.1mm

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proximally and 6.9 distally. No evident collaterals in correspondence of the DFAP for 7 cm above

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and 7 cm below from the supposed DFAP origin were registered. Distally to the DFAP, two major

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division vessels were reported. The patient was transferred urgently in the operating room and,

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under local anaesthesia, the omolateral femoral bifurcation was surgically exposed. The common

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femoral artery was punctured and a 6F sheath (Avanti+, Cordis Corporation, Miami, FL, US) was

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introduced into the DFA. The arteriogram confirmed the bilobed DFAP and the regular patency of

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the distal DFA. (Figure 2A) With a standard angled hydrophilic 0.035″ Terumo wire (Terumo Corp.,

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Somerset, NJ, US) and a Berestein catheter (Cordis Corporation, Miami, FL, US) the DFAP was

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crossed maintaining the DFA true lumen. (Figure 2B) Then a stiff 0.035″ wire (Amplatz, Boston

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Scientific, Natick, MA, US) was placed in the distal DFA and a stent-graft (Viabahn 8 x 100, W L

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Gore & Associates, Inc) was delivered across the DFAP neck. (Figure 2C) The stent-graft was

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deployed and dilated with a 8x60 mm Powerflex Pro balloon (Cordis Corporation, Miami, FL, US).

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(Figure 2D) The completion angiography showed the DFAP exclusion with no endoleaks. (Figure

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3A)

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Immediately after the intervention the patient reported pain reduction and he was mobilized on

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the first postoperative day (POD). Medical therapy consisted of dual antiplatelet therapy

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(Acetylsalicylic Acid 100mg/die and Clopidogrel 75mg/die) for one month and antibiotic for 15

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ACCEPTED MANUSCRIPT days (Amoxicillin - Clavulanic acid 2g/die). The patient remained in the surgical ward for 7 days

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where no perioperative complications were noted but a decreasing pain and upswing of walking

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distance. Dismissal was on the 8th POD. The haemoglobin values reached the physiological values

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at 6 months follow-up. The Angio-CT scan showed regular patency of stent-graft (Figure 3B) at 12

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and 24 months with a 4 and 20 mm DFPA shrinkage respectively.

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Discussion

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A pseudoaneurysm occurs when the blood escapes from the arterial lumen through a defect in

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one or more layers of the arterial wall [6]. It generates a localized pocket of flow either beneath

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the adventitia (outer wall of the artery) or in the surrounding tissues [7]. Injury to the DFA

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accounts for approximately 2% of peripheral arterial wounds [1]. The DFAP anatomy, lying in the

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thigh behind the vastus medialis, represents a protection against external trauma up to the sub-

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trochanteric area [3]. To our knowledge a limited number of cases of post-traumatic DFAP have

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been reported in the literature [1, 8-10]. The available data regarding DPAP clinical characteristics

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and the related treatment are summarized in Table 1.

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DFA injuries may be overlooked due to the delayed clinical manifestation and the presence of

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distal pulses. Generally an accurate diagnosis is difficult as this artery is located deep in the thigh

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[4]. Pseudoaneurysms typically present late signs such as persistent hip pain, thigh swelling, and

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compression to adjacent structures; the presence of a pulsatile mass and unexplained anaemia

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may suggest the diagnosis [3, 11]. DUS is an easy, non-invasive, useful diagnostic tool to identify

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the DFAP and its main information such as the DFAP size, the cavity length and eventually the neck

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diameter [8]. When DUS is not conclusive and it doesn’t permit a precise lesion characterization,

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an Angio CT scan or angiography should be used to define properly DFA anatomy and eventually

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the operative strategy. The DFAP surgical exploration is the treatment of choice in such lesions

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ACCEPTED MANUSCRIPT and the standard procedure consists of pseudoaneurysm resection and blood flow restoration.

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DFAP localization over the DFA is relevant to chose the appropriate treatment. Proximal DFAP are

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generally addressed with standard surgical approach to spare proximal collaterals. Proximal

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ligation can be required in some circumstances. At the opposite, when DFAP is located more

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distally in the profunda, a proximal ligation is advocated to reduce surgical exposure and blood

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loss [8] but the risk of late limb ischemia represents an issue in patients with peripheral arterial

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disease.

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Reported less invasive alternative to DFAP ligation are the endovascular coil embolization or

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percutaneous thrombin injection. Coil embolization has the advantage to be less invasive when

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compared to conventional surgery. If in correspondence of the mid-distal part of the DFA,

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embolization allows to spare collaterals. Reconstructive surgery is generally limited to the origin of

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the DFA. Mid or distal DFAP are generally addressed by proximal ligation. Percutaneous thrombin

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injection is carried with DUS and requires long DFAP neck to avoid thrombin mobilization into the

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true arterial lumen. DFA anatomic course and DFAP localization (mid or distal) can represent a

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limitation to an adequate DUS visualization that is mandatory in such procedure [1, 9, 10]. Another

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valid alternative to exclude the DFAP maintaining arterial blood flow is the use of covered stent

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[8].

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Anatomic characteristics represent the determinant of the treatment choice. The neck length,

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DFAP sizes, DFAP location (distal or proximal DFA), relevant collaterals originating from the DFAP,

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and previous groin interventions should be considered in the treatment planning. Also the

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vascular access (ipsilateral or contralateral) should be considered in such treatment. An ipsilateral

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surgical approach was chosen over a percutaneous access due to the patients’ obesity with the

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perception of a complex percutaneous procedure and the technical difficulty to engage the DFA

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with a percutaneous approach. A contralateral approach was excluded because of a narrow aortic

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ACCEPTED MANUSCRIPT angle. In addition the surgical approach had the advantage to proceed to the DFA ligation in case

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of inability to cross the DFAP.

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In our case, the combination of distal DFAP localization and the presence of adequate proximal

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and distal landing zones were indications to exclusion with a 8 x 100 mm Viabhan (Viabahn, W L

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Gore & Associates, Inc) stent-graft. Collaterals in correspondence of the DFA should be spared

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whenever possible with shorter stent-graft. Moreover long stents are at higher risk of kinking,

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fracture or occlusion. Large DFAP dimension (8 x 6 cm) could represent a limitation to an

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endovascular treatment but a percutaneous blood aspiration was not precluded [12].

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Long term results of endovascular approach with stent-graft represent an issue and still remain

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mandatory to validate the technique [13]. The costs related to the stent-graft represent another

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limitation to the endovascular repair. These are generally tempered by a shorter intensive care

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and in-hospital length of stay.

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Conclusions

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In conclusion the use of covered stent-graft was effective to treat a DFAP localized in the medium

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DFA. This tool allowed maintaining the native DFA patency and the preservation of its main

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branches.

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ACCEPTED MANUSCRIPT REFERENCES

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[1] Naouli H, Jiber H, Bouarhroum A. False aneurysm of perforating branch of the deep femoral

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artery-Report of two cases. Int J Surg Case Rep 2015; 14:36-9.

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[2] Gabriel M, Pawlaczyk K, Waliszewski K, Krasinski Z, Majewski W. Location of femoral artery

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puncture site and the risk of postcatheterization pseudoaneurysm formation. Int J Cardiol 2007;

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120:167-71.

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[3] Hanna GB, Holdsworth RJ, McCollum PT. Profunda femoris artery pseudoaneurysm following

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orthopaedic procedures. Injury 1994; 25:477-9.

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[4] Saad NE, Saad WE, Davies MG, Waldman DL, Fultz PJ, Rubens DJ. Pseudoaneurysms and the

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role of minimally invasive techniques in their management. Radiographics 2005; 25 Suppl 1:S173-

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89.

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[5] Bracale UM, Corte G, Del Guercio L, Pecoraro F, Dinoto E, La Rosa G, et al. Endovascular

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treatment of abdominal aortic anastomotic pseudoaneurysm. The experience of two centers. Ann

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Ital Chir 2012; 83:509-13.

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[6] Dinoto E, Bracale UM, Vitale G, Cacciatore M, Pecoraro F, Cassaro L, et al. Late, giant brachial

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artery aneurysm following hemodialysis fistula ligation in a renal transplant patient: case report

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and literature review. Gen Thorac Cardiovasc Surg 2012; 60:768-70.

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[7] Pecoraro F, Dinoto E, Pakeliani D, La Rosa G, Corte G, Bajardi G. Spontaneous symptomatic

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common carotid artery pseudoaneurysm: case report and literature review. Ann Vasc Surg 2015;

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29:837 e9-12.

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[8] Kouvelos GN, Papas NK, Arnaoutoglou EM, Papadopoulos GS, Matsagkas MI. Endovascular

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repair of profunda femoral artery false aneurysms using covered stents. Vascular 2011; 19:51-4.

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[9] Chong KC, Yap EC, Lam KS, Low BY. Profunda femoris artery pseudoaneurysm presenting with

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triad of thigh swelling, bleeding and anaemia. Ann Acad Med Singapore 2004; 33:267-9.

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ACCEPTED MANUSCRIPT [10] Patelis N, Koutsoumpelis A, Papoutsis K, Kouvelos G, Vergadis C, Mourikis A, et al. Iatrogenic

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injury of profunda femoris artery branches after intertrochanteric hip screw fixation for

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intertrochanteric femoral fracture: a case report and literature review. Case Rep Vasc Med 2014;

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2014:694235.

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[11] Bajardi G, Pecoraro F, Vitale G, La Rosa G, Bellisi M, Bracale UM. A popliteal artery aneurysm

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presenting with ab extrinseco popliteal vein occlusion and compartment syndrome: a case report.

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Ann Ital Chir 2012; 83:441-4.

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[12] Rancic Z, Pecoraro F, Nigro G, Simon R, Frauenfelder T, Mayer D, et al. Branch ligatures and

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blood aspiration for post-traumatic superficial temporal artery pseudoaneurysm: surgical

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technique. Gen Thorac Cardiovasc Surg 2014; 62:68-70.

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[13] Pecoraro F, Sabatino ER, Dinoto E, La Rosa G, Corte G, Bajardi G. Late Complication after

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Superficial Femoral Artery (SFA) Aneurysm: Stent-graft Expulsion Outside the Skin. Cardiovasc

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Intervent Radiol 2015; 38:1299-302.

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ACCEPTED MANUSCRIPT TABLE Table 1 Deep Femoral Artery Pseudoaneurysm Literature review

Chong KC et al.,

Age/sex Clinical Presentation

24y/m Swelling and Anemia

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DFAP Cause

Treatment

Fractures of femur

Endovascular

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Author, year

Chong KC et al.,

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25y/m Swelling and Anemia

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persistent pain

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Kouvelos GN et al., 42y/m 20118

Swelling and

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Kouvelos GN et al., 70y/m

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Wound bleeding

Fractures of femur

embolization) Endovascular procedure (Coil embolization)

Complication after

Endovascular

surgical procedure

procedure (Viabahn in DFA)

Gunshot wound

Endovascular procedure (Viabahn in DFA)

Kouvelos GN et al., 75y/m Swelling and anemia

Complication after

Endovascular

201110

surgical procedure

procedure (Viabahn in DFA)

ACCEPTED MANUSCRIPT Patelis N et al.,

92y/m Enlarging hematoma

201310

Complication after

Endovascular

surgical procedure

procedure (Coil embolization)

23y/m

Increasing pain and

20151 Naouli H et al.,

Stab wound

swelling 28y/m

Wound bleeding

Stab wound

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DFA: deep femoral artery aneurysm; DFA: deep femoral artery. 201 202

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Surgery

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Surgery after failed embolization

ACCEPTED MANUSCRIPT FIGURE LEGEND

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Figure 1. Preoperative computed tomography. Maximum intense projection showing (A) the

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bilobed deep femoral artery pseudoaneurysm (DFAP) and (B,C) the bone fragment. 3D volume

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rendering showing (D,E) the bilobed DFAP.

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Figure 2. Intraoperative angiography showing (A) the bilobed deep femoral artery

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pseudoaneurysm (DFAP) at contrast injection with regular patency of the distal deep femoral

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artery (DFA); (B) the DFAP crossing maintaining the DFA true lumen; (C) the 8x100mm Viabahn

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stent-gaft (W L Gore & Associates, Inc) delivery; (D) the stent-graft balloon dilation.

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Figure 3. (A) Completion intraoperative angiography showing the stent-graft regular patency,

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deep femoral artery pseudoaneurysm (DFAP) exclusion and no endoleaks. (B) Postoperative 12-

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months 3D volume rendering showing stent-graft regular patency and complete DFAP exclusion.

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