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Profunda femoris pseudoaneurysm: An unusual and easily overlooked complication following injuries of the proximal femur
Injury Extra (2008) 39, 92—94
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
journal homepage: www.elsevier.com/locate/inext
CASE REPORT
Profunda femoris pseudoaneurysm: An unusual and easily overlooked complication following injuries of the proximal femur Leong Quor Meng*, Lee Wei Ting, Chia Kok Hoong Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore Accepted 15 August 2007
Introduction Pseudoaneurysm of the profunda femoris artery is a rare complication of trauma and surgery of the upper third of the femur.6 Unlike iatrogenic femoral artery pseudoaneurysms that occur after inadequate haemostasis following arterial catheterisation, diagnosis of pseudoaneurysms of the profunda femoris artery can often be delayed. The key clinical symptoms and signs such as persisting anaemia, hip pain and proximal thigh swelling are subtle but often present. We describe a case of pseudoaneurysm of the profunda femoris artery requiring intraoperative vascular consultation and immediate surgical intervention.
Case report A 36-year-old motorcyclist was involved in a road traffic accident and sustained a close fracture of the right shaft of femur. He developed right thigh and calf compartment syndrome after admission. He underwent emergency surgery on the same day with open reduction and internal fixation of the right femur, using a 10 hole, 4.5 mm broad plate (Fig. 1). Fasciotomy of the thigh and calf was also performed, in view of the compartment syndrome. Intraoperatively, 3081 ml RBC * Corresponding author. Tel.: +65 63577807; fax: +65 63577809. E-mail address: [email protected] (Q.M. Leong).
and 1390 ml FFP was transfused. Post-operative haemoglobin levels were stable at 10.4 g/dl. Over the course 8 days subsequently, patient’s haemoglobin level was noted to be on a downwards trend despite multiple blood transfusion (Fig. 3). The managing team also noted presence of blood clots up to 300 ml in the fasciotomy wounds. There were also multiple wound debridements for infection and swelling on the 3rd, 5th and 8th post-operative day. Adequate pain control was achieved with intramuscular pethidine during this period. During the wound debridement on the 8th post-operative day, a large amount of pulsatile bleeding was encountered over the medial fasciotomy wound. An intraoperative diagnosis of pseudoaneurysm of the profunda femoris artery was made and an on-table vascular consultation was made. Proximal vascular control was achieved via the clamping of the common femoral artery. Further exploration of the medial fasciotomy wound revealed a large pseudoaneurysm of the profunda femoris artery extending from the medial to lateral aspect of the thigh. Screws from the plate were found very close to the pseudoaneurysm (Fig. 2). The proximal and distal stump was identified and tied off. No attempt for surgical repair of the artery was made in view of the high probability of infection. Post-operatively, patient’s haemoglobin level started to rise. The fasciotomy wound required split skin graft for closure. He was noted to have a right sided sciatica nerve palsy. Patient was discharged on partial weight bearing ambulation.
1572-3461/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.08.029
93
Profunda femoris pseudoaneurysm
Figure 3 Table showing haemoglobin trend with blood transfusions over time. Figure 1
Figure 2
Post open reduction and internal fixation radiograph.
Screws found very close to the pseudoaneurysm.
Discussion A pseudoaneurysm, also known as a false aneurysm, is a dilation of an artery with actual disruption of one or more layers of its walls, rather than an expansion of all wall layers. The profunda femoris artery runs deep in the thigh but lies in close proximity to the shaft of the femur. It is well protected from external trauma by the vastus medialis muscle yet vulnerable to injury following proximal femoral fractures and orthopaedic procedures. The injury to the vessel is rare and can occur due to bone fragments, displaced implants, excessive drilling and screws during reduction and fixation of these fractures.4 Many authors have described various presentations of profunda femoris pseudoaneurysms. Unlike pseudoaneurysms of the femoral artery, where the aneurysms are easily palpable and an early diagnosis can often be made, the diagnosis of pseudoaneurysms of the profunda femoris artery are often delayed. This is due to the non-palpable nature of the aneurysm situated deep in the thigh and the minimal symptoms associated with such a lesion. In the early stages, subtle signs and symptoms such as pain, swelling and haematoma formation caused by the expanding lesion are often dismissed as part of the initial recovery process from a recent
orthopaedic operation. As the aneurysm continues to enlarge, a pulsatile haematoma with an audible bruit may result. With continual inflow into the cavity, the expanding lesion may even cause compartment syndrome of the thigh.5 Distal perfusion is not compromised unless the superficial femoral artery has pre-existing arteriosclerotic disease. The initial bleeding episodes are delayed as illustrated by this case. This delay occurs because the initial injury only weakens the vessel wall and with time, this weakness develops into a pseudoaneurysm. Various radiological investigations have been used to diagnose profunda femoris pseudoaneurysms. These include colour-flow duplex ultrasonography (CDU), magnetic resonance imaging (MRI), computer tomography (CT) and digital subtraction angiography (DSA). CDU is a non-invasive test that can define the size and extent of the lesion. It is cheap, simple, and quick and can be performed at the bedside without the need for patient transport. It is both sensitive and specific. Its main disadvantage is that it is operator dependent.2 MRI is not the primary diagnostic modality to investigate pseudo aneurysms. Its main use is in patients in whom CT scan or angiography is contraindicated, either due to contrast allergy or due to the effects of contrast nephrotoxity. DSA is considered the gold standard in diagnosing pseudoaneurysms in any location. It can accurately diagnose the size and site of the lesion, the presence of feeding vessels and the patency of distal flow. It has the advantage of being both diagnostic as well as potentially therapeutic if coil embolization is being used. Various treatment modalities have been described in the literature with good results. These include ultrasound guided compression therapy, ultrasound guided thrombin injection, selective angioembolisation of distal feeding vessels and surgical repair.1 In this case, the diagnosis was only made during the operation, requiring immediate vascular consultation and intervention. The decision to ligate the aneurysm was made after ascertaining that there was adequate flow to the rest of the leg. No surgical repair was attempted due to the presence of infection. This patient developed sciatic nerve injury, a complication similar to femoral neuropathy previously described in the literature.3
Conclusion This case serves to highlight the need for an increased awareness and a high index of suspicion for the possibility
94 of pseudoaneurysm of the profunda femoris artery in association with proximal femur fractures and orthopaedic procedures. The triad of (1) persisting anaemia, (2) pain and (3) proximal thigh swelling is subtle but its presence should alert the clinician to the possibility this rare and forgotten entity. Failure to do so can result in a delayed diagnosis with complications.
References 1. Canbaz S, Acipayam M, Gurbuz H, Duran E. False aneurysm of perforating branch of the profunda femoris artery after external fixation for a complicated femur fracture. J Cardiovasc Surg 2000;43:519—21.
Q.M. Leong et al. 2. Coughlin BD, Paushter D. Peripheral pseudoaneurysms: evaluation with duplex ultrasound. Radiology 1988;108:339. 3. Dillon J, O’Brien G, Laing A, Adelowokan T, Dolan M. Pseudoaneurysm of the profunda femoris artery following an inter-trochanteric fracture of the femur. Injury Extra 2004;35:30—2. 4. Hanna GB, Holdsworth RJ, McCallum PT. Profunda femoris artery pseudoaneurysm following orthopaedic procedures. Injury 1994;25:477—9. 5. Karkos CD, Hughes R, Prasad V, D’Souza S. Thigh compartment syndrome as a result of a false aneurysm of the profunda femoris artery complicating fixation of an intertrochanteric fracture. Injury 1999;47:393—5. 6. Nachbur B, Meyer RP, Verkkala K, Zurcher R. The mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop 1979;141:122.
a v a i l a b l e a t w w w. s c i e n c e d i r e c t . c o m
journal homepage: www.elsevier.com/locate/inext
CASE REPORT
Profunda femoris pseudoaneurysm: An unusual and easily overlooked complication following injuries of the proximal femur Leong Quor Meng*, Lee Wei Ting, Chia Kok Hoong Department of General Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore 308433, Singapore Accepted 15 August 2007
Introduction Pseudoaneurysm of the profunda femoris artery is a rare complication of trauma and surgery of the upper third of the femur.6 Unlike iatrogenic femoral artery pseudoaneurysms that occur after inadequate haemostasis following arterial catheterisation, diagnosis of pseudoaneurysms of the profunda femoris artery can often be delayed. The key clinical symptoms and signs such as persisting anaemia, hip pain and proximal thigh swelling are subtle but often present. We describe a case of pseudoaneurysm of the profunda femoris artery requiring intraoperative vascular consultation and immediate surgical intervention.
Case report A 36-year-old motorcyclist was involved in a road traffic accident and sustained a close fracture of the right shaft of femur. He developed right thigh and calf compartment syndrome after admission. He underwent emergency surgery on the same day with open reduction and internal fixation of the right femur, using a 10 hole, 4.5 mm broad plate (Fig. 1). Fasciotomy of the thigh and calf was also performed, in view of the compartment syndrome. Intraoperatively, 3081 ml RBC * Corresponding author. Tel.: +65 63577807; fax: +65 63577809. E-mail address: [email protected] (Q.M. Leong).
and 1390 ml FFP was transfused. Post-operative haemoglobin levels were stable at 10.4 g/dl. Over the course 8 days subsequently, patient’s haemoglobin level was noted to be on a downwards trend despite multiple blood transfusion (Fig. 3). The managing team also noted presence of blood clots up to 300 ml in the fasciotomy wounds. There were also multiple wound debridements for infection and swelling on the 3rd, 5th and 8th post-operative day. Adequate pain control was achieved with intramuscular pethidine during this period. During the wound debridement on the 8th post-operative day, a large amount of pulsatile bleeding was encountered over the medial fasciotomy wound. An intraoperative diagnosis of pseudoaneurysm of the profunda femoris artery was made and an on-table vascular consultation was made. Proximal vascular control was achieved via the clamping of the common femoral artery. Further exploration of the medial fasciotomy wound revealed a large pseudoaneurysm of the profunda femoris artery extending from the medial to lateral aspect of the thigh. Screws from the plate were found very close to the pseudoaneurysm (Fig. 2). The proximal and distal stump was identified and tied off. No attempt for surgical repair of the artery was made in view of the high probability of infection. Post-operatively, patient’s haemoglobin level started to rise. The fasciotomy wound required split skin graft for closure. He was noted to have a right sided sciatica nerve palsy. Patient was discharged on partial weight bearing ambulation.
1572-3461/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.08.029
93
Profunda femoris pseudoaneurysm
Figure 3 Table showing haemoglobin trend with blood transfusions over time. Figure 1
Figure 2
Post open reduction and internal fixation radiograph.
Screws found very close to the pseudoaneurysm.
Discussion A pseudoaneurysm, also known as a false aneurysm, is a dilation of an artery with actual disruption of one or more layers of its walls, rather than an expansion of all wall layers. The profunda femoris artery runs deep in the thigh but lies in close proximity to the shaft of the femur. It is well protected from external trauma by the vastus medialis muscle yet vulnerable to injury following proximal femoral fractures and orthopaedic procedures. The injury to the vessel is rare and can occur due to bone fragments, displaced implants, excessive drilling and screws during reduction and fixation of these fractures.4 Many authors have described various presentations of profunda femoris pseudoaneurysms. Unlike pseudoaneurysms of the femoral artery, where the aneurysms are easily palpable and an early diagnosis can often be made, the diagnosis of pseudoaneurysms of the profunda femoris artery are often delayed. This is due to the non-palpable nature of the aneurysm situated deep in the thigh and the minimal symptoms associated with such a lesion. In the early stages, subtle signs and symptoms such as pain, swelling and haematoma formation caused by the expanding lesion are often dismissed as part of the initial recovery process from a recent
orthopaedic operation. As the aneurysm continues to enlarge, a pulsatile haematoma with an audible bruit may result. With continual inflow into the cavity, the expanding lesion may even cause compartment syndrome of the thigh.5 Distal perfusion is not compromised unless the superficial femoral artery has pre-existing arteriosclerotic disease. The initial bleeding episodes are delayed as illustrated by this case. This delay occurs because the initial injury only weakens the vessel wall and with time, this weakness develops into a pseudoaneurysm. Various radiological investigations have been used to diagnose profunda femoris pseudoaneurysms. These include colour-flow duplex ultrasonography (CDU), magnetic resonance imaging (MRI), computer tomography (CT) and digital subtraction angiography (DSA). CDU is a non-invasive test that can define the size and extent of the lesion. It is cheap, simple, and quick and can be performed at the bedside without the need for patient transport. It is both sensitive and specific. Its main disadvantage is that it is operator dependent.2 MRI is not the primary diagnostic modality to investigate pseudo aneurysms. Its main use is in patients in whom CT scan or angiography is contraindicated, either due to contrast allergy or due to the effects of contrast nephrotoxity. DSA is considered the gold standard in diagnosing pseudoaneurysms in any location. It can accurately diagnose the size and site of the lesion, the presence of feeding vessels and the patency of distal flow. It has the advantage of being both diagnostic as well as potentially therapeutic if coil embolization is being used. Various treatment modalities have been described in the literature with good results. These include ultrasound guided compression therapy, ultrasound guided thrombin injection, selective angioembolisation of distal feeding vessels and surgical repair.1 In this case, the diagnosis was only made during the operation, requiring immediate vascular consultation and intervention. The decision to ligate the aneurysm was made after ascertaining that there was adequate flow to the rest of the leg. No surgical repair was attempted due to the presence of infection. This patient developed sciatic nerve injury, a complication similar to femoral neuropathy previously described in the literature.3
Conclusion This case serves to highlight the need for an increased awareness and a high index of suspicion for the possibility
94 of pseudoaneurysm of the profunda femoris artery in association with proximal femur fractures and orthopaedic procedures. The triad of (1) persisting anaemia, (2) pain and (3) proximal thigh swelling is subtle but its presence should alert the clinician to the possibility this rare and forgotten entity. Failure to do so can result in a delayed diagnosis with complications.
References 1. Canbaz S, Acipayam M, Gurbuz H, Duran E. False aneurysm of perforating branch of the profunda femoris artery after external fixation for a complicated femur fracture. J Cardiovasc Surg 2000;43:519—21.
Q.M. Leong et al. 2. Coughlin BD, Paushter D. Peripheral pseudoaneurysms: evaluation with duplex ultrasound. Radiology 1988;108:339. 3. Dillon J, O’Brien G, Laing A, Adelowokan T, Dolan M. Pseudoaneurysm of the profunda femoris artery following an inter-trochanteric fracture of the femur. Injury Extra 2004;35:30—2. 4. Hanna GB, Holdsworth RJ, McCallum PT. Profunda femoris artery pseudoaneurysm following orthopaedic procedures. Injury 1994;25:477—9. 5. Karkos CD, Hughes R, Prasad V, D’Souza S. Thigh compartment syndrome as a result of a false aneurysm of the profunda femoris artery complicating fixation of an intertrochanteric fracture. Injury 1999;47:393—5. 6. Nachbur B, Meyer RP, Verkkala K, Zurcher R. The mechanisms of severe arterial injury in surgery of the hip joint. Clin Orthop 1979;141:122.