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Vascular » Peripheral Vascular
Right common femoral artery pseudoaneurysm
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Presentation Patient presenting with a mass in the groin two weeks post femoral artery catheterization. A bruit was heard over the puncture site. Serial ultrasound scans were performed.
Caption: Transverse view of the right groin.
Description: A large rounded heterogeneous area with a predominant hypoechoic component is seen in the right groin, in the region of the puncture site.
Caption: Color Doppler view of the mass.
Description: The mass noted in the right groin shows two separate areas of flow peripherally.
Caption: Color Doppler scan in the region of the mass.
Description: The mass is seen to be in close proximity to a vessel [the common femoral artery] and appears to arise from the artery. This suggests the possibility of a pseudoaneurysm with an associated hematoma.
Caption: Spectral study of the mass.
Description: Spectral analysis of one of the areas showing prominent flow shows an arterial waveform with a component of reversed flow, in the region of the the neck of the pseudoaneurysm.
Caption: Color Doppler study of the mass after two weeks.
Description: The pseudoaneurysm appears to have spontaneously thrombosed. The two areas of flow which were seen in the earlier scan are not detected in the current study.
Differential Diagnosis Pseudoaneurysm arising from the right common femoral artery.
Final Diagnosis Iatrogenic pseudoaneurysm with a hematoma arising from the common femoral artery with spontaneous thrombosis.
Discussion The incidence of vascular complications is on the rise due to the higher number of radiological procedures now performed via the femoral artery. The incidence of femoral artery pseudoaneurysm is around 1% following angiographies and interventional procedures. The other arterial complications that occur are arterial thrombosis, hematoma formation and arterivenous fistula. The longer duration of complex interventional procedures, usage of wide bore catheters and sheaths, and extensive anticoagulant therapy during the procedure are some of the risk factors responsible for the rising incidence of these pseudoaneurysms.

By definition, a pseudoaneurysm is a pulsatile hematoma which communicates with an artery through a disruption in the arterial wall. Clinically a pseudoaneurysm presents as a pulsatile mass often with a bruit or palpable thrill and to-and-fro murmur. Ultrasound with Doppler plays a crucial role in the diagnosis of these iatrogenic vascular abnormalities. It demonstrates the cavity of the pseudoaneurysm, its size and communication with the femoral artery. A swirling pattern of blood flow may be seen in the pseudoaneurysm and the velocities can be measured in the pseudoaneurysm, its neck and the femoral artery. Documentation of the to-an-fro flow with spectral Doppler is essential to making the diagnosis. The size of the aneurysm may guide the physician as to whether a conservative approach or treatment is indicated. Kronzon, et al in his study reported that smaller aneurysms [< 2 cm] may usually be followed up; however depending on the size of the pseudoaneurysm a number of treatment options can be offered.

A study by Toursarkissian, et al concluded that over 80% of stable pseudoaneurysms [pseudoaneurysms less than 3 cm in diameter were considered stable] and AV fistulae underwent spontaneous closure. Patients who had severe symptoms with an enlarging hematoma, groin infection, ischemia or nerve compression at the time of presentation were treated aggressively.

When treatment is indicated, radiological measures are now replacing the conventional surgical vascular repairs. Most of these minimally-invasive treatment options are ultrasound guided, the most common being direct compression of the pseudoaneurysm and percutaneous thrombin injection into the lumen of the pseudoaneurysm, both under ultrasound guidance. Compression therapy may not be very successful if there is an associated arterivenous fistula. The introduction of these procedures has reduced the morbidity and hospital stay of the patient. Embolization and stent placements may also be performed in indicated cases.

Case References 1. Kronzon I. Diagnosis and treatment of iatrogenic femoral artery pseudoaneurysm: a review. J Am Soc Echocardiogr. 1997 Apr; 10(3):236-45.
2. Paulson E, et al. CDS of groin complications following femoral artery catheterization. AJR. 1995 Aug;165(2):439.
3. Norwood M, et al. The changing face of femoral artery false aneurysms. Eur J Vasc Endovasc Surg. 2004 Apr; 27(4):385-8.
4. Rath J, et al. Formation, therapy and prevention of false aneurysm of the femoral artery following heart catheterization. Dtsch Med Wochen. 1997 Jun 13; 122(24):771-7.
5. Pinto F, et al. CDS in the diagnosis and treatment of iatrogenic pseudoaneurysms. Radiol Med (Torino). 1997 Sep; 94(3):198.
6. Toursarkissian B, et al. Spontaneous closure of selected iatrogenic pseudoaneurysms and AV fistulae. J Vasc Surg. 1997 May; 25(5):803-8; discussion 808-9.
7. Morgan R, et al. Current treatment methods for postcatheterization pseudoaneurysms. J Vasc Interv Radiol. 2003 Jun; 14(6).
Follow Up This patient had altered mentation [was a known case of Parkinson`s disease], coronary artery disease and congestive heart failure. He was followed up by serial ultrasounds until the pseudoaneurysm thrombosed and the hematoma resolved.
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