Indian Journal of Vascular and Endovascular Surgery

CASE REPORT
Year
: 2021  |  Volume : 8  |  Issue : 4  |  Page : 366--368

Etiology and management of femoral artery pseudoaneurysm formation in patients of chronic kidney disease: A series of three cases


Vikas Deep Goyal1, Gaurav Misra2,  
1 Department of Surgery, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India
2 Department of Anesthesia, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh, India

Correspondence Address:
Vikas Deep Goyal
Department of Surgery, Shri Ram Murti Smarak Institute of Medical Sciences, Bareilly, Uttar Pradesh
India

Abstract

Hemodialysis access is not a common cause of femoral artery pseudoaneurysm (FAP) formation. FAP formation during dialysis access is due to inadvertent cannulation of the femoral artery instead of the femoral vein. The ruptured FAPs can lead to increased morbidity and mortality. We hereby share our experience of three cases of ruptured FAPs or with impending rupture after femoral hemodialysis access in patients of chronic kidney disease. Urgent intervention is usually required to prevent life-threatening complications in such patients.



How to cite this article:
Goyal VD, Misra G. Etiology and management of femoral artery pseudoaneurysm formation in patients of chronic kidney disease: A series of three cases.Indian J Vasc Endovasc Surg 2021;8:366-368


How to cite this URL:
Goyal VD, Misra G. Etiology and management of femoral artery pseudoaneurysm formation in patients of chronic kidney disease: A series of three cases. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2022 Oct 5 ];8:366-368
Available from: https://www.indjvascsurg.org/text.asp?2021/8/4/366/332051


Full Text



 Introduction



Hemodialysis access is not a common cause of femoral artery pseudoaneurysm (FAP) formation.[1] The management of such cases remains challenging in the background of chronic kidney disease (CKD). The ruptured pseudoaneurysms can become life-threatening if not treated preemptively.[2] The literature on ruptured pseudoaneurysms of the femoral artery in patients of CKD is limited.[1],[2],[3] Coronary interventions, endovascular interventions, trauma, infection, intravenous drug abuse, and anastomotic leakage are the other important causes of FAP formation.[4],[5] Our series of three cases highlight this complication of pseudoaneurysm formation after femoral hemodialysis access.

The etiology and patient profile of the cases are described individually. Informed consent from patients was taken. The cases are briefly discussed.

 Case Reports



Case 1

A 29-year-old female patient presented with swelling in the right thigh postdialysis through the femoral route. The swelling was pulsatile and large. The patient was suffering from CKD and had received hemodialysis through the femoral route 15 days back. Ultrasonography (USG) and Doppler study revealed a large aneurysm arising from the femoral artery. The patient had a very low hemoglobin level and her coagulation profile was also deranged. The patient was taken for urgent surgery under general anesthesia. The pseudoaneurysm was large, approximately 11 cm × 9 cm [Figure 1]a. After getting proximal and distal control [Figure 1]b, a longitudinal incision was given overlying the aneurysm to its whole extent. Large clots were removed [Figure 1]c. The pseudoaneurysm was excised at its neck and the rent in the superficial femoral artery was directly repaired with 6'0'polypropylene suture [Figure 1]d. The wound was closed after adequate hemostasis and placing suction drain a little away from the site of repair. The patient was kept in the intensive care unit for 1 day and was discharged on the 5th postoperative day in a stable condition with palpable pulsations in the operated limb.{Figure 1}

Case 2

The second patient was a 50-year-old female who underwent hemodialysis for CKD through the femoral route. The size of the pseudoaneurysm was approximately 7 cm × 6 cm [Figure 2]a and was arising from the superficial femoral artery. The repair was done similarly to the previous case [Figure 2]b and [Figure 2]c. The patient was mobilized on the 3rd postoperative day and was discharged on the 4th postoperative day with palpable pulsations in the operated limb distal to the site of repair.{Figure 2}

Case 3

The third patient was a 68-year-old male with similar complaints as in the above two cases. The size of the pseudoaneurysm was approximately 10 cm × 9 cm [Figure 3]a and was arising from the profunda femoris artery just at its junction with the superficial femoral artery. The repair was done similarly [Figure 3]b, [Figure 3]c, [Figure 3]d. The patient was mobilized on the 4th postoperative day and was discharged on the 5th postoperative day with palpable pulsations in the operated limb.{Figure 3}

All the patients were doing well and were free of any related symptoms clinically and radiologically at follow-up after 3 months and 6 months. Certain factors improve the patient outcome in such cases: (1) use of suction drain, (2) maintaining adequate compression over the operative site, (3) avoiding excision of the redundant skin flaps helps in the obliteration of the dead space, (4) antibiotic coverage for Gram-positive, Gram-negative, and anaerobic bacteria and according to culture results at least for 7 days, (5) strict control of diabetes mellitus with insulin therapy in diabetic patients, and (6) frequent dialysis to prevent edema formation helps in early recovery.

 Discussion



Radiocephalic arteriovenous fistula (AVF) is the most common mode of hemodialysis femoral access followed by AVF at other sites. Other means of vascular access are required many times when the fistula has not been formed or is immature or thrombosed. The other means of vascular access include the femoral vein, jugular vein, or subclavian vein. As the arteries run parallel and in close relation to the large vein, there are chances of inadvertent puncture or cannulation of the arteries instead of veins which can lead to pseudoaneurysm formation.

Risk factors associated with pseudoaneurysm formation are female sex, old age, inadequate compression after a femoral puncture, puncture of the superficial femoral artery, and use of large femoral sheaths.[5] The clinical findings suggestive of pseudoaneurysm are a palpable pulsatile mass, a palpable thrill with a bruit or murmur audible on auscultation over the swelling. Pre-operative diagnostic workup requires USG and Doppler study. The Computed Tomographic Angiogram (CTA) or Magnetic Resonance Angiogram (MRA) can provide an elaborative picture about the location and extension of the pseudoaneurysm which can further help in planning 0f the surgical approach.

The strategies which can be adapted to minimize the risk of femoral pseudoaneurysm formation are the use of USG guidance for vascular access and preferential choice of alternative sites like jugular or subclavian over the femoral route for the procedures. Choice of femoral vein access for hemodialysis should be reserved for emergency purposes only. The use of pressure dressing for a few hours over the puncture site after removal of the venous cannula can also minimize the risk of pseudoaneurysm formation.

Surgical intervention in cases of pseudoaneurysm is usually required when conservative treatment or endovascular intervention is not feasible.[6] Surgical closure is recommended where the pseudoaneurysms are large, have a wide neck, or there is evidence of infection within the aneurysm. Surgical options are resection of the aneurysm with the primary repair or with interposition or bypass grafts. Small femoral pseudoaneurysms are usually managed with Ultrasound-guided compression therapy (USGCT) or Ultrasound-guided thrombin injection (USGTI), whereas large aneurysms usually require surgical intervention. When the size of the pseudoaneurysm is small <2 cm, USGCT is usually effective. USGTI is another technique with a high success rate and can be done in patients in whom USGCT is ineffective.[7],[8] Endovascular management is another option in the management of patients with pseudoaneurysms preferably unruptured and with relatively small size. Endovascular management can be either with coil embolization or with stent-grafts. Stent grafts will require puncture of the contralateral femoral artery with large-sized sheaths with risk of pseudoaneurysm formation in the contralateral limb.

Management of FAPs in CKD patients requires a team approach comprising interventional radiologist, nephrologist, anesthetist, and vascular surgeon. Management principles include restriction of intravenous fluids, regulation of blood pressure, prevention and treatment of hyperkalemia, prevention of volume overload, and use of renal protective strategies. General, regional, or local anesthesia can be used depending upon the condition of the patient.

 Conclusion



Femoral hemodialysis access can lead to pseudoaneurysm formation if there is inadvertent puncture of the femoral artery. Urgent intervention is usually required in the management of ruptured FAPs or with impending rupture. The use of USG during venous access will minimize this complication.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for 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.

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