2. History
• 21 year old male with history of gunshot injury in left thigh(May 2023) ,a
perforating wound with comminuted fracture shaft of femur post intramedullary
nailing presented with a pulsatile swelling over the medial aspect of mid-thigh
around one month after trauma , first noticed by the treating doctors.The swelling
was insideous in onset and progressive in nature and associated with pain on
movement
3. Examination findings
• A swelling of approximately 5x6cm, present over the
medial aspect of left mid thigh
• Pulsatile in nature
• No local rise of temperature
• Superior margin: 25cm from the level of pubic tubercle
• Inferior margin: 17cm from the level of tibial tuberosity
• Compressible
• Not fixed to underlying structures
• Left popliteal and Dorsalis pedis palpable
4. Investigations Done
Ultrasound screening of left thigh
Hypoechoic collection noted in intramuscular or
intermuscular plane in the anterior aspect of left lower thigh:
2.2x0.3x2cm approximately 0.8cc , suggestive of hematoma
or muscle tear
5. CT PERIPHERAL
ANGIOGRAM
• A well defined rounded collection measuring 6.12x3.6x4.7cm (CCxMLxAP)
noted in the intermuscular plane involving the medial aspect of left mid thigh,
showing progressive contrast pooling in subsequent phase
• There is communication with the left superficial femoral artery and displacing
the gracilis and sartorius muscles medially
• The common femoral artery appears normal with normal contrast
opacification
• The popliteal artery shows normsl luminal attenuation
No evidence of atheromatous changes or calcific plaques
• Multiple hyperdense metallic foreign bodies producing streak artefacts seen in
soft tissues of left lower limb
• Features are suggestive of pseudoaneurysm involving the left superficial
femoral artery
6.
7.
8. TREATMENT
Excision of pseudoaneurysm done under GA
Curved longitudinal incision given over the swelling in left thigh.The
pseudoaneurysm was exposed measuring approximately 8x9 cm.Left proximal and
distal superficial femoral artery secured .An A-V fistula( between SFA and SFV) just
proximal to the pseudoaneurysm ligated.The pseudoaneurysm is incised and blood
clots removed,aneurysm wall respected .Interposition was carried out between
proximal and distal of the left superficial femoral artery with saphenous vein
harvested from the opposite leg.Following bleeding control the layers were closed
appropriately,there was no complications either during or after operation.In the post
operative period the pulses in the left lower extremity were palpable
9.
10.
11.
12. Histopathology of excised specimen
• Gross : specimen consist of flap like tissue measuring 5x3x0.5 cm
• Microscopic : sections studied showed fibroadiposed tissue infiltrated by intense
mixed inflammatory cells,RBCs ,congested capillaries
• Smooth muscle and skeletal muscle fibre are also seen in the adjacent and
dissected by blood
• Features suggestive of pseudoaneurysm
13. Discussion
• Pseudoaneurysms and AV fistulas usually result from traumas
• The available liters reports penetration injury and firearm injury as
equally common cause of pseudoaneurysms
• Because of the fast progress of post traumatic pseudoaneurysms and
AV fistula when left untreated it can result serious complications like
rupture , secondary infection, neuropathy,distal embolus and
thrombosis ,early treatment or surgical intervention is usually
required
• In our case ,we performed resection of the pseudoaneurysm with
autologous reverse saphenous vein graft and repairing of the AV
fistula .There was no intraoperative and postoperative complications
14. Conclusion
• Post traumatic pseudoaneurysms and arteriovenous fistulas are the vascular
complications resulting from local traumas
• Because of the high risk of complications,early diagnosis and surgical treatment is
preferred in this condition
15. Reference
1. Erkut B, Karapolat S, Kaygin MA, Unlu Y. Surgical treatment of post-traumatic
pseudoaneurysm and arteriovenous fistula due to gunshot injury. Ulusal Travma ve
Acil Cerrahi Dergisi. 2007 Jul 1;13(3):248.
2. Daniel HE, Firmin A, Angele PO, Esthelle MN, Freddy B, Bernadette NN. Giant
pseudoaneurysm associated with arteriovenous fistula of the brachial and femoral
arteries following gunshot wounds: report of two cases. Case Reports in Vascular
Medicine. 2015 Feb 3;2015.
3. Algin A, Erdogan MO, Yusufoglu K, Findikli HA, Aydin H. Femoral artery
pseudoaneurysm due to a gunshot injury. J Pak Med Assoc. 2018 Jan 1;68:130-2.
4. Tank JC, Reilly BG, Ventimiglia AJ, Weiner SD. Pseudoaneurysm Formation from
a Prominent Orthopaedic Implant: Case Report and Literature Review. JBJS Case
Connector. 2013 May 22;3(2):e57.
