Delayed bleeding of femoral artery pseudoaneurysm

A rare complication of endovascular technique

Abstract

Femoral artery pseudoaneurysm is the most common complication of femoral artery access. Since the 1990s, the most common access site for intracranial endovascular interventions has been the femoral artery. The incidence of pseudoaneurysm has been documented around 0.2%–0.5% following diagnostic procedures and up to 8% following therapeutic interventions. This study aimed to assess the rationale of observation of pseudoaneurysm and the risk therein. A 52-year-old female presented with a subarachnoid haemorrhage and basilar artery aneurysm. Endovascular coiling was done using the standard technique on the right femoral artery percutaneous access. On post-operative day, she had swelling in the right groin region with bluish discolouration of the skin. Later on, a necrotic skin patch developed. On palpation, tenderness and pulsatile mass were present. Colour Doppler and computed tomography angiography were suggestive of pseudoaneurysm. On post-operative day 24th, the patient developed sudden onset of bleeding and haematoma expansion. The patient was taken for emergency surgery with primary repair of pseudoaneurysm with bilobed skin graft for closer of skin defect. Pseudoaneurysms at the puncture site can increase during observation, can bleed and may require curative repair.

INTRODUCTION

Puncture-site bleeding, retroperitoneal haemorrhage, arterial occlusion and arteriovenous fistula have been reported as complications involving puncture-site vessels after catheter intervention,[¹] including pseudoaneurysms developing at the puncture-site vessel due to insufficient haemostasis.[²] Here, we report a patient with a giant femoral artery pseudoaneurysm at the puncture site that developed after endovascular coiling of the basilar artery aneurysm.

The reported incidence of femoral artery pseudoaneurysms varies widely in the literature, with some guidelines expecting an acceptable rate of <0.2%.[²] More recent studies demonstrated similar results when routine ultrasound imaging was performed routinely after the intervention, with an incidence of 2.9%.[³]

A pseudoaneurysm also sometimes called a false aneurysm is a contained rupture, in which blood leaks from an artery into the surrounding tissue [Figure 1]. The pseudoaneurysm is contained by the surrounding tissue, which may include the surrounding adventitia, femoral sheath in case of femoral artery, fat or scar tissue.[⁴] Pseudoaneurysm has many causes, including infection and trauma. This article focuses on femoral artery pseudoaneurysm following arterial access for therapeutic procedures.

Figure 1: Illusration of nomal layer of an artery (left), pseudoaneurysm occurs when tear through tunica intima and media layers (right)

Multiple patient-related and procedure-related factors have been identified as risk factors for femoral artery pseudoaneurysms. These include advance age, female gender, increased body mass index (BMI) and low platelet count. Other factors include existing collagen tissue disorder, smoking and use of oral antiplatelet and oral anticoagulant. Emergency procedures have higher risk factors as compared to elective procedures.[⁵]

CASE REPORT

A 52-year-old obese female patient presented with a history of hypertension since 5 years, and thunderclap headache 4 days prior. It was associated with 4–5 episodes of vomiting in the last 4 days. On examination, the patient was drowsy but obeying commands with modified Hunt and H Grade III. Platelets count 2.31 lakh with INR 0.9.

Non-contrast computed tomography (NCCT) (HEAD) revealed a subarachnoid haemorrhage in the bilateral Sylvian fissure. Computed tomography (CT) angiography (CTA) brain was suggestive of a large saccular 18 mm × 18 mm aneurysm arising from basilar tip neck aneurysm with the bilateral posterior cerebral artery (PCA) arising just proximal to the neck of the aneurysm [Figure 2].

Figure 2: Computed tomography angiography brain s/o Wide neck basilar artery aneurysm

Neuroendovascular intervention was performed under general anaesthesia (GA). The total procedure time was 30 min. A 7 Fr femoral sheath was inserted into the right femoral artery. The puncture site of the femoral artery from the inguinal crease was about 3 cm below. DSA showed a large 18 mm × 18 mm basilar top narrow neck aneurysm with bilateral posterior cerebral artery just proximal neck of the aneurysm. Endovascular coiling was done with the standard technique, post-coiling Raymond-Roy occlusion Grade II was achieved, with the patent flow in both PCA and SCA.

In post-operative period, the patient was conscious and oriented with no neurological deficit. Non-Contrast Computed Tomography (NCCT) of the head was normal, with artifact of basilar top coiling [Figure 3]. Check flow removed on post-operative day 1. Post-operative day 2, the patient had complaint of right groin swelling which gradually increased in size with bluish discolouration of overlying skin; she was managed conservatively; ultrasonography revealed a small local haematoma; symptomatic treatment was given; peripheral pulsations in lower limb were normal. Later, a necrotic skin patch developed [Figure 4] over that area which was 5 cm × 4 cm with surrounding bluish discolouration of the skin; on palpation, tenderness was present with pulsation over the swelling; distal pulsations were present.

Figure 3: Post-endovascular coiling with Raymond-Roy occlusion Grade II

Figure 4: Pre-operative image with necrotic patch

A repeat colour Doppler was suggested a heteroechoic, well-defined area with narrowing intimal echoes seen in the right inguinal region, 40 mm × 38 mm × 45 mm, with shows yin–yang (35–40 cc) sign likely pseudoaneurysm. CTA of iliac and femoral vessels, there is evidence of contrast-filled outpouching measuring 7 cm × 4.4 cm in dimensions arising from a defect in the right common femoral artery suggestive of pseudoaneurysm [Figure 5]. The neck of the aneurysm measures 2 mm. Adjacent crescentic-shaped soft tissue is seen as suggestive of thrombosis.

Figure 5: Computed tomography angiography of iliac and femoral vessels shows pseudoaneurysm arising from the right common femoral artery

In view of these findings, surgery was planned and she was posted for aneurysmorraphy, however, she had a sudden bleed at night before (day 24^th) and landed into haemorrhagic shock. Surgery was performed after stabilising the vitals by fluid replacement and blood transfusion.

Emergency surgery for the femoral arterial puncture site pseudoaneurysm (resection of the pseudoaneurysm, removal of haematoma and repair) was performed under general anaesthesia. A necrotic patch was removed, the common femoral artery right below the inguinal ligament was secured, the pseudoaneurysm was incised under a temporary clamp of the common femoral artery, and the haematoma was removed. A 3mm rent was present in the right common femoral artery, for which primary closure was carried out with proline 6-0 [Figure 6]. Moreover, a temporary clamp was removed. Skin closed with a bilobed flap and Romo Vac drain kept. She was kept on clexane 0.4 μg sc bd and clopidogrel 75 mg OD.

Figure 6: Intraoperative image after right femoral artery rent repair, and after completion of procedure

After surgery, the patient was extubated on POD 1^st, conscious and oriented with obeying commands and the negative suction drain was removed on day 5. After surgery, neither recurrence of puncture site pseudoaneurysm nor circulatory disorder of the lower extremity developed. The patient was discharged on POD 14^th.

DISCUSSION

Femoral artery puncture site complications are the common complications of neuroendovascular intervention. These complications are mainly noted in cardiovascular intervention, but recently also have been noted in neuroendovascular procedures. Oneissi et al. suggested (16 randomised control trials [RCTs] and 17 non-RCTs) that the overall incidence of puncture-site complications was 5.13% in RCT and 2.78% in non-RCT.[¹] The incidence of pseudoaneurysm was 0.23%–2.04% (mean: 0.61%) in RCT and 0.03%–3.23% (mean: 0.19%) in non-RCT. Puncture-site haematoma and bleeding are the most common complication followed by pseudoaneurysm in cases of endovascular intervention.[⁵] In our institute, a total of 296 diagnostic procedures and 251 therapeutic endovascular interventions were done between 2020 and 2022. Femoral sheath was removed immediately in cases of diagnostic intervention and on 1^st post-operative day after therapeutic interventions. Haemostasis was usually achieved by manual compression for around 15 min. We found approximately 15 cases of puncture site haematoma and only one case of pseudoaneurysm. Routine screening ultrasound for puncture-site pseudoaneurysm was not done routinely.

A puncture-site pseudoaneurysm can be diagnosed on the basis of clinical symptoms such as pulsatile mass, bruit and local pain. Koza and Kaya reported puncture-site pseudoaneurysm after 8.3 days (2–21 days) after intervention on average.[⁶] In our patient, it was suspected when pulsatile growing swelling, bluish discolouration of skin and development of necrotic patch at puncture site on post-operative day 5. Screening of pseudoaneurysm can be done with ultrasound, but it is difficult in obese patients, so better to confirm with vessel echo. Hoke et al.[⁷] reported that a raised D-dimer level (D-dimer >0.67 μg/mL) and a low platelet count (<200,000/L) are useful serological markers of puncture-site pseudoaneurysm. In our case, platelet counts were found to be normal and D-dimer level was not done.

Risk factors of pseudoaneurysms include the following patient-related factors include advanced age, female gender, increased BMI and low platelet count. Procedure-related factors include antiplatelet therapy, large femoral sheath and insufficient haemostasis.[⁵] In our case, many risk factors were present, such as advanced age, female gender, obesity, large size sheath and therapeutic procedure.

Management options are observation, ultrasound-guided compression, ultrasound-guided thrombin injection and vascular repair.[⁴] Stone et al.[⁵] reported that pseudoaneurysms with a size of 3 cm or smaller are relatively likely to spontaneously thrombosed. On the other hand, treatment is necessary for large pseudoaneurysms and those continuing to enlarge, being symptomatic and not thrombosing through observation. Ultrasound-guided compression was tried in our case but was not successful. Percutaneous thrombin injection was not tried as there was the presence of infection and necrotic patch. Indications of vascular repair for pseudoaneurysm are enlarging haematoma, active bleeding and skin necrosis. In our case, indications of vascular repair were skin necrosis and active bleeding. Complications of surgical repair are infection and wound dehiscence, rebleeding, deep vein thrombosis and thromboembolism.[⁸]

CONCLUSION

Although the recently neuroendovascular procedure is gaining popularity, the incidence of access-site complications is relatively rare. Neurointerventionists should be aware of complications including hematoma, skin necrosis and pseudoaneurysm. Pseudoaneurysms at the puncture site can increase during observation, can bleed and may require curative repair.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.