Management of traumatic arterial pseudoaneurysms as a result of limb trauma

CT Angiography of the Upper Extremities: Review of Acute Arterial Entities

Historically, evaluation of the upper extremity vasculature was performed using digital subtraction angiography. With the advancement of cross-sectional imaging and submillimeter isotropic data acquisition, CT angiography (CTA) has become an excellent noninvasive diagnostic tool for evaluation of the vasculature of the upper extremities. CTA allows quick evaluation of vessel patency and irregularity and achievement of the anatomic detail needed in preoperative planning. When interpreting CTA of the upper extremities, radiologists must be familiar with the normal vascular anatomy, common vascular anomalies, and pitfalls or artifacts that may mimic or mask abnormality. In this review, the authors provide an overview of the utility of CTA of the upper extremities. Also discussed are CTA techniques and the use of several newer technologies including dual-energy and photon-counting detector CT. The utility of CTA in patients with upper extremity trauma is explored, with a focus on assessing vascular injury. Other vascular abnormalities including infection, acute limb ischemia, and vasculitis are discussed. It is imperative for radiologists to be accustomed to CTA of the upper extremities in diagnosing acute vascular abnormalities and to recognize common pitfalls and mimics of these abnormalities. ©RSNA, 2025 Supplemental material is available for this article.

Pseudoaneurysms of lower limb of orthopaedic traumatological origin: a literature review and our experience of 18 cases

INTRODUCTION AND AIMS

Arterial pseudoaneurysm is a rare yet potentially life-threatening complication that can arise as a late sequelae of penetrating injuries or orthopaedic procedures. We aim at sharing our institutional experience of managing 18 cases of lower limb arterial pseudoaneurysms in orthopaedic practice and to provide technical tips for emergency management of severe bleeding. A comprehensive literature review resulting from fractures and orthopaedic surgeries is also presented.

RESULTS

The study group consisted mainly of male patients with a mean age of 48.5 years. The mean duration between injury and pseudoaneurysm diagnosis was 86.7 days. CT angiography and USG Doppler were the main diagnostic modality. Among the cases, five resulted from fracture fragments and 13 from iatrogenic injuries. Surgical interventions varied based on the artery involved and included excision and ligation, bypass grafting with dacron or vein graft, primary repair, and amputation in two cases. Complications included one patient with blowout at the anastomotic site and another case of deep infection. The literature review encompassed 108 cases of pseudoaneurysm of lower limb associated with fractures and iatrogenic injuries during orthopaedic procedures. Clinical manifestations varied widely which included painful swelling, pulsatility, bleeding, and neurological deficits. CT angiography was the most utilized diagnostic modality, while therapeutic embolization was the most common treatment method.

CONCLUSION

Iatrogenic arterial injuries contributed to more than 60% of the cases as per the literature review. The most frequent mechanisms related to instrumentation were the placement of the third and fourth screws of the DHS plate, and the distal screw of a short nail in treating pertrochanteric fractures. This can be avoided by external rotation and abduction of the limb during distal screw insertion. A high index of clinical suspicion is needed especially when bleeding from the hardware site is noted. A swelling in the previously operated site should raise a suspicion of pseudoaneurysm and incision and drainage must be avoided without further imaging (Duplex USG or CT angiography). This study highlights the importance of cautious surgical techniques to minimize the occurrence of vascular injuries during orthopaedic surgeries.

Successful Surgical Management of Post-traumatic Superficial Femoral Artery Pseudoaneurysm With Delayed Presentation

Pseudoaneurysms of the superficial femoral artery are uncommon and typically iatrogenic. The majority of publications on this topic that have been published in English literature are case reports. It is unclear how often arterial pseudoaneurysms (APAs) caused by limb trauma occur, and their treatment is not standardised. A review of the literature usually follows the presentation of a case report, but no recent update with reliable data has been published. In this case study, a 24-year-old patient who had a piece of iron lodged in the middle third of his thigh and a pulsatile mass that revealed a pseudoaneurysm of the superficial femoral artery is described. The patient underwent an emergency operation without employing a venous graft. We directly sutured the arterial lesion, with positive outcomes.

Pseudoaneurisma e fístula arteriovenosa da artéria femoral profunda após rotura completa do músculo vasto medial: tratamento endovascular

Due to its anatomical characteristics, the deep femoral artery is protected from most vascular injuries. We report a case of a soccer player with pseudoaneurysm of a perforating branch of the deep femoral artery, associated with an arteriovenous fistula and secondary to complete rupture of the vastus medialis muscle. Magnetic resonance imaging showed muscle damage associated with a pseudoaneurysm and angiotomography confirmed the presence of a pseudoaneurysm associated with a deep arteriovenous fistula of a branch of the deep femoral artery. Endovascular treatment of the fistula was performed by embolization with fibrous microcoils and surgical drainage of the muscle hematoma. The patient recovered well, was free from clinical complaints on the 30th postoperative day and also after 1 year.

Late-onset pseudoaneurysms of lower limb arteries following late complications of orthopaedic constructs - Two cases and review of literature

INTRODUCTION & IMPORTANCE

Damage to the adventitial layer of an artery leads to pseudoaneurysm formation. Pseudoaneurysms caused by complications of orthopaedic constructs are rare.

CASE PRESENTATION & CLINICAL DISCUSSION

Case report 01. A 27-year-old male presented with acute bleeding from an external fixator pin site. He had defaulted follow-up due to covid pandemic and presented with malunited distal tibia fracture and loosened Schanz pins. CT angiogram revealed a pseudoaneurysm of the peroneal artery over the loosened pin site. The patient underwent exploration and ligation of the peroneal artery. Case report 02. 86-year-old female presented with a gradually enlarging lump on her left anteromedial thigh for three months duration. She underwent open reduction and internal fixation of ipsilateral femur fracture 17 months back. She was found to have a pseudoaneurysm of the superficial femoral artery caused by exposed screws following bony erosion. Exploration and repair of "neck" the pseudoaneurysm was performed and the recovery was uneventful.

CONCLUSION

Pseudoaneurysms are rare but carry devastating complications following various orthopaedic procedures. The common cause for the formation of pseudoaneurysms is trauma during surgery. But loosened Schanz screws and screws are also can be the cause. Early identification of a pseudoaneurysm and proper intervention will reduce morbidities.

Endovascular treatment of a post-traumatic pseudoaneurysm arising from a ruptured posterior tibial artery with Menox. A case report

Posterior tibial artery pseudoaneurysms are rare and can occur in the setting of trauma. Endovascular treatment of post-traumatic pseudoaneurysms has become a viable less-invasive method particularly in young patients in whom the presence of collaterals guarantees distal vascularization. We report an unusual case of a 16-year- old patient who sustained blunt trauma to his right lower extremity due to a bicycle injury and developed a delayed symptomatic pseudoaneurysm of the posterior tibial artery in the absence of tibia fracture. Superselective endovascular treatment with Ethylene Vinyl Alcohol Copolymer based liquid embolic system (Menox) was successfully performed, achieving exclusion of the pseudoaneurysm with preservation of the remaining vascularization of the lower limb.

Interventional radiology management of extremity pseudoaneurysms: a pictorial essay

Pseudoaneurysms are vascular abnormalities caused by a damaging force on an arterial wall, resulting in a persistent extravasation of blood into the surrounding tissue, which can be the result of infection, inflammation, trauma or any iatrogenic procedure. The incidence of extremity artery pseudoaneurysms is rising because of increased number of endovascular procedures. As a number of complications are associated with these false aneurysms, it is important to know the treatment modalities available. Ultrasound is the most common method of diagnosing extremity pseudoaneurysm because of their superficial location. Computed tomographic angiography is the next investigation of choice as it has three-dimensional capability and can help evaluate the vascular bed. Digital subtraction angiography is rarely used for diagnosis alone, and is used only when a therapeutic procedure is planned. Treatment of these pseudoaneurysms has shifted from open surgical procedures to minimally invasive treatment in recent years. The different techniques for tackling these lesions include ultrasound-guided compression, percutaneous thrombin or glue embolisation and endovascular coil or stent graft placement. In this pictorial essay, we review the different treatment modalities so that an interventional radiologist is aware of all the treatments he can offer when confronted with these lesions.

[Surgical treatment of a post-traumatic giant pseudoaneurysm of the axillary artery: a case report]

A false aneurysm of the axillary artery is an extremely rare complication of a lesion of this vessel. As few as several dozens of similar cases have been described in the available literature. We herein report a clinical case concerning surgical treatment of a 41-year-old patient who after a knife-inflicted injury had developed a 66x67 mm pseudoaneurysm of the axillary artery. The treatment consisted of several stages, thus requiring 2 hospitalizations. The first stage included an attempt to resect the aneurysm in an open fashion, followed by deployment of stent grafts in the axillary artery to exclude the aneurysm from circulation. The second stage consisted in elimination of the aneurysmal cavity, followed by decompression of the branches of the brachial plexus and the axillary vein. The patient was discharged on postoperative day 10 after the second surgical intervention.

Unusual Combination of a Fracture Monteggia Equivalent With Post-traumatic Radial Artery Pseudoaneurysm in a Child: A Case Report and Review of Literature

CASE

We report a unique case of a combination of forearm fracture and traumatic radial artery pseudoaneurysm in an 8-year-old child. The fracture pattern was a Monteggia equivalent with a mid-diaphyseal ulnar fracture and a radial neck fracture with displacement of the distal radial diaphyseal fracture fragment. The pseudoaneurysm, which probably developed after vigorous manipulation by a bonesetter, thrombosed spontaneously, and the fracture was managed nonoperatively with a good outcome.

CONCLUSION

Pseudoaneurysm of the radial artery is a rare phenomenon associated with fracture in a child. A history of vigorous manipulation of displaced fracture fragments in the vicinity of a major vessel should raise suspicion of this possible complication.

Proximal peroneal artery traumatic pseudoaneurysm following a compound proximal tibial shaft fracture managed with an external fixator: A case report

A case of post-traumatic proximal peroneal artery pseudoaneurysm following a proximal tibial shaft fracture, complicated by acute compartment syndrome, fixed using an external fixator, in a 22-year-old female is presented. She was investigated for sudden-onset bleeding from the external fixator pin site, 6 weeks after the initial injury, was anaemic and diagnosed with a pseudoaneurysm at lower limb angiography. Contrast leak from the site of pseudoaneurysm was noted and open surgery with ligation of the pseudoaneurysm was performed. This rare complication of a proximal tibial shaft fracture has to be considered in patients presenting with acute bleeding from the surgical site or from pin sites after a significant lag period and requires a high index of suspicion.

[Management of traumatic and iatrogenic arterial pseudoaneurysms in a tropical environment]

A false aneurysm or pseudoaneurysm (PA) is the formation of a pulsatile and encapsulated hematoma in communication with the lumen of a perforated artery. Its origin is different but most cases are associated with a traumatic event. Currently, the referenced treatment is endovascular surgery but it is not feasible for the majority of vascular surgeons working in a tropical environment. The aim of this study was to describe the diagnostic and therapeutic aspects of arterial PA (APA) encountered in our institution and to evaluate the place of open surgical technique in their management. This was a 30-month retrospective and descriptive study carried out in our institution (CHU-JRA, Antananarivo, Madagascar). Between 2012 and 2014, ten cases of APA were operated. There were 8 men with an average age of 30 years. The etiologies were accidental trauma (n=6) or iatrogenic vascular injury (n=4). Most patients had a painful and pulsatile swelling (n=8). The presence of a wound scar located on the swelling was observed in 5 patients. The false aneurysms were localized in the radial (n=3), femoral (n=2), brachial (n=2), carotid (n=2) and ulnar (n=1) arteries. The diagnosis was confirmed by ultrasound Doppler in all patients. The treatment was an open surgical procedure and consisted of lateral suture (n=4), resection with direct end-to-end anastomosis (n=1) or using autologous saphenous vein graft (n=2) or ligation (n=3). Postoperative courses and outcomes at last follow-up were uneventful with optimal patency rate.