CASE REPORT pseudoaneurysm, penetrating trauma
A P s e u d o a n e u r y s m of the Superficial Femoral A r t e r y as a Late C o m p l i c a t i o n of a Stab Wound Limited arteriography based on clinical indications has become increasingly popular. We present the case of a patient with pseudoaneurysm formation of the superficial femoral artery as a late consequence of a lateral stab wound to the thigh. This case demonstrates the need for postinjury follow-up to identify missed injuries before they are limb threatening. [Weibke EA, Lipsett PA: A pseudoaneurysm of the superficial femoral artery as a late complication of a stab wound. Ann Emerg Med August 1991; 20:916-9• 7.] INTRODUCTION Injuries to the c o m m o n femoral artery (CFA} resulting in pseudoaneurysm formation complicate at least 1% of all elective percutaneous catheterization procedures.l Pseudoaneurysms of the deep and superficial femoral arteries resulting from blunt or penetrating trauma are less common, and pseudoaneurysms of the superficial femoral artery (SFA) as a late complication of stab wounds have not been described. We present an unusual case of a bilobed pseudoaneurysm of the SFA that developed after a stab wound to the lateral thigh.
Eric A Weibke, MD Pamela A Lipsett, MD Baltimore, Maryland From the Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland. Received for publication September 19, 1990. Revision received February 4, 1991. Accepted for publication March 19, 1991. Address for reprints: Pamela A Lipsett, MD, Department of Surgery, The Johns Hopkins Hospital, Harvey 803, Baltimore, Maryland 21205.
CASE REPORT A 45-year-old man sustained multiple stab wounds to the left chest and lateral left thigh in a domestic argument. Evaluation revealed a left hemopneumothorax and a nonexpanding moderate h e m a t o m a of the lateral thigh. No bruit was present. Femoral, popliteal, dorsal pedis, and posterior tibial pulses were intact and symmetric, and ankle-brachial indexes (ABIs) were 1.0 bilaterally. The patient underwent tube thoracostomy. Due to the lateral entry of his stab wound and a normal examination (with the exception of the hematoma), arteriography was not performed. In follow-up six weeks later, the patient complained of mild numbness of the medial thigh. The hematoma was resolving, but a deficit was noted in the left dorsalis pedis pulse. A loud bruit and a thrill were noted. His ABIs were now 1.1 on the right and 0.8 on the left. Arteriography demonstrated a large bilobed pseudoaneurysm of the SFA (Figure 1), presumably from a through-and-through stab wound. The injured arterial segment was resected (Figure 2) and reconstructed with an interposition 6 - m m polytetrafluoroethylene graft, with two large hematomas evacuated. The postoperative course was unremarkable with ABIs measuring 1.1 bilaterally at follow-up. DISCUSSION Arterial injury may result in a simple hematoma formation, transection of the vessels with arteriovenous communication, or pseudoaneurysm formation. Pseudoaneurysms m a y typically present in a delayed fashion weeks to months after blunt or penetrating trauma. The majority of pseudoaneurysms requiring operation occur as complications of percutaneous CFA catheterization. One report describes pseudoaneurysms complicating 0.6% of diagnostic cardiac catheterizations and 11.5% of intra-aortic balloon placements, with an overall incidence of 1% of all percutaneous femoral procedures.~ Pseudoaneurysms can develop after both blunt and penetrating injuries to arteries and commonly present
20:8 August 1991
Annals of Emergency Medicine
916/135
PSEUDOANEURYSM Weibke & Lipsett
FIGURE 1. Arteriogram revealing bi-
lobed pseudoaneurysm of the SFA. Common femoral and profunda fernotis arteries were normal. FIGURE 2. Intraoperative photograph revealing through-and-through injury to SFA (forceps through defect) and large amount of clot evacuated from pseudoaneurysm. in a delayed fashion. 2-5 Such complications of orthopedic procedures as hip replacement and such orthopedic injuries as femur fractures resulting in pseudoaneurysm of the common, ~ deep, 7 and superficial 4 femoral arteries have been reported. Studies summarizing peripheral arterial trauma, both civilian s and military, 9 show that the SFA accounts for 14% and 57% of the injuries, respectively. Pseudoaneurysm formation of the SFA after stab wounds has not been described. Controversy surrounds the appropriate evaluation of potential vascular injury after civilian trauma. Routine exploration in the stable patient without localizing "hard" signs of vascular injury (eg, pulse deficit, distal ischemia, bruit, thrill, or large or expanding hematoma) has been abandoned in lieu of exclusion angiography.m, 11 Several studies have questioned the need for arteriography even in this setting. 1o l.~ Recently, in a randomized, prospective, controlled trial, Dennis et al demonstrated that only 48 arteriographic abnormalities were present in 254 patients with 318 potential injuries, l"- Of these injuries, ,32 {10%) occurred to major arteries, and only six patients (1.8%) required operation. Dennis et al suggested that routine arteriography should be used selectively for p r o x i m i t y injuries caused by a shotgun or those involving the thoracic inlet. Using their criteria and avoiding arteriography, only two of 254 injuries requiring operation would be missed. A l t h o u g h not available in this case, an alternative to exclusion arteriography may be color flow duplex Doppler examination. Studies eval-
136/917
uating arterial anatomy m the presence of a h e m a t o m a have demonstrated abnormal arterial flow in a "to and fro" fashion suggestive of pseudoaneurysm formation. ~4,15 The efficacy, safety, and cost-effectiveness of this noninvasive test may make this preferable to exclusion arteriography for proximate injuries. We have used hard criteria for arteriography in penetrating proximity injury. As noted by m a n y authors, this is safe and cost-effective, lo l.~ However, if this policy is used, then a careful, knowledgeable, and thorough physical examination with diligent follow-up is essential. Although an initially unrecognized arterial injury secondary to penetrating proximity is u n c o m m o n , ensuring adequate follow-up will allow an excellent clinical outcome. Thus, primary reliance on a careful physical examination in patients with penetrating proximity trauma and adequate clinical follow-up will affect cost savings without additional morbidity.
SUMMARY We report the case of a patient with a pseudoaneurysm of the superficial femoral artery forming as a late consequence of a stab wound. With a careful physical examination, selective criteria for arteriography in proximity injuries can be used safely, provided adequate follow-up is ensured. REFERENCES I Skillman ]l, Kim D, Bairn DS: Vascular cnmplications
Annals of Emergency Medicine
of percutaneous femoral cardiac interventions. Inci deuce and operative repair. Arch SurJ~ 1988;12;3: 12(17-1212. 2. Engleman RM, Clements JM, Herrmann JB: Stab wounds and tramnatic false aneurysms in the extremities. J Trauma 1969;9:77-87. 3. Lmdfore O, Paukku P, Totterman S: A false aneurysm of the deep femoral artery. Actri Chir S t a n d 1982; 148:201-202. 4. Norris CS, Zlotnick R, Silva WE, et al: Traumatic pseudoaneurysm following b h m t trauma. I Trauma 1986;26:480-482 5. Squire A, Miller CM, Horowitz SF, et al: Femoral pseudoaneurysm following nonpenetrating trauma m a patient with aortic insufficiency. A m / Med 1985; 78:719-720. 6. Giacchetto 1, Gallagher II: False aneurysm of the common femoral artery secondary to migration of a threaded acetabnlar component. A case report and review of the literature Clin Orthop Rel Res 1988;Z:H: 91 96. 7. Orby C, Mertl P, Woestelandt T, et al: False aneurysm of the profunda femuris artery following an intertrochanterie fracture of the femur. A case report. Rev Chir Orthop 1988~74:585-587. 8. Drapanas T, Hewitt RL, Rudolph FW, et al: Civilian vascular injuries: A critical appraisal of three decades of management. Ann Surg 1970;172:351-360. 9. Rich NM, Baugh IH, Hughes CW: Acute arterial in juries in Vietnam: 100f) cases. ] Traltma 1970;10: 359-369 10. McCorkell SI, Harley SI, Morishima MS, et al: Indi~ cations of angiography in extremity trauma. A J R 1985;145:1245 1247. 11. Tohmeh AG, Perlcr BA: Angiography in the evalua tion of proximal arterial injury. Sitrg Gynec(l] Obstet 1990;170:117 120. 12. Dennis lW, Frykherg ER, Crump JM, et al: New per spectives on the management of penetrating trauma in p r o x i m i t y to m a j o r l i m b arteries. / V0sc Surg 1990;11:87-92. 13. Harding RR, McGahan IP, Blaisdell FW, et al: Stab wounds to the extremities: indications for angiography. Radiology 1987;162:465-467. 14 Abu-Yousef MM, Wiesse JA, Shamma AR: The to and fm sign: Duplex doppler evidence of femoral artery pseudoaneurysm. A I R 1988;150:632-634. 15 Rich NM, Hobson RW, Collins CI, It: Elective vascular reconstruction after trauma. AIH I SLtrg 1975; 130:712-719
20:8 August 1991
A P s e u d o a n e u r y s m of the Superficial Femoral A r t e r y as a Late C o m p l i c a t i o n of a Stab Wound Limited arteriography based on clinical indications has become increasingly popular. We present the case of a patient with pseudoaneurysm formation of the superficial femoral artery as a late consequence of a lateral stab wound to the thigh. This case demonstrates the need for postinjury follow-up to identify missed injuries before they are limb threatening. [Weibke EA, Lipsett PA: A pseudoaneurysm of the superficial femoral artery as a late complication of a stab wound. Ann Emerg Med August 1991; 20:916-9• 7.] INTRODUCTION Injuries to the c o m m o n femoral artery (CFA} resulting in pseudoaneurysm formation complicate at least 1% of all elective percutaneous catheterization procedures.l Pseudoaneurysms of the deep and superficial femoral arteries resulting from blunt or penetrating trauma are less common, and pseudoaneurysms of the superficial femoral artery (SFA) as a late complication of stab wounds have not been described. We present an unusual case of a bilobed pseudoaneurysm of the SFA that developed after a stab wound to the lateral thigh.
Eric A Weibke, MD Pamela A Lipsett, MD Baltimore, Maryland From the Department of Surgery, The Johns Hopkins Hospital, Baltimore, Maryland. Received for publication September 19, 1990. Revision received February 4, 1991. Accepted for publication March 19, 1991. Address for reprints: Pamela A Lipsett, MD, Department of Surgery, The Johns Hopkins Hospital, Harvey 803, Baltimore, Maryland 21205.
CASE REPORT A 45-year-old man sustained multiple stab wounds to the left chest and lateral left thigh in a domestic argument. Evaluation revealed a left hemopneumothorax and a nonexpanding moderate h e m a t o m a of the lateral thigh. No bruit was present. Femoral, popliteal, dorsal pedis, and posterior tibial pulses were intact and symmetric, and ankle-brachial indexes (ABIs) were 1.0 bilaterally. The patient underwent tube thoracostomy. Due to the lateral entry of his stab wound and a normal examination (with the exception of the hematoma), arteriography was not performed. In follow-up six weeks later, the patient complained of mild numbness of the medial thigh. The hematoma was resolving, but a deficit was noted in the left dorsalis pedis pulse. A loud bruit and a thrill were noted. His ABIs were now 1.1 on the right and 0.8 on the left. Arteriography demonstrated a large bilobed pseudoaneurysm of the SFA (Figure 1), presumably from a through-and-through stab wound. The injured arterial segment was resected (Figure 2) and reconstructed with an interposition 6 - m m polytetrafluoroethylene graft, with two large hematomas evacuated. The postoperative course was unremarkable with ABIs measuring 1.1 bilaterally at follow-up. DISCUSSION Arterial injury may result in a simple hematoma formation, transection of the vessels with arteriovenous communication, or pseudoaneurysm formation. Pseudoaneurysms m a y typically present in a delayed fashion weeks to months after blunt or penetrating trauma. The majority of pseudoaneurysms requiring operation occur as complications of percutaneous CFA catheterization. One report describes pseudoaneurysms complicating 0.6% of diagnostic cardiac catheterizations and 11.5% of intra-aortic balloon placements, with an overall incidence of 1% of all percutaneous femoral procedures.~ Pseudoaneurysms can develop after both blunt and penetrating injuries to arteries and commonly present
20:8 August 1991
Annals of Emergency Medicine
916/135
PSEUDOANEURYSM Weibke & Lipsett
FIGURE 1. Arteriogram revealing bi-
lobed pseudoaneurysm of the SFA. Common femoral and profunda fernotis arteries were normal. FIGURE 2. Intraoperative photograph revealing through-and-through injury to SFA (forceps through defect) and large amount of clot evacuated from pseudoaneurysm. in a delayed fashion. 2-5 Such complications of orthopedic procedures as hip replacement and such orthopedic injuries as femur fractures resulting in pseudoaneurysm of the common, ~ deep, 7 and superficial 4 femoral arteries have been reported. Studies summarizing peripheral arterial trauma, both civilian s and military, 9 show that the SFA accounts for 14% and 57% of the injuries, respectively. Pseudoaneurysm formation of the SFA after stab wounds has not been described. Controversy surrounds the appropriate evaluation of potential vascular injury after civilian trauma. Routine exploration in the stable patient without localizing "hard" signs of vascular injury (eg, pulse deficit, distal ischemia, bruit, thrill, or large or expanding hematoma) has been abandoned in lieu of exclusion angiography.m, 11 Several studies have questioned the need for arteriography even in this setting. 1o l.~ Recently, in a randomized, prospective, controlled trial, Dennis et al demonstrated that only 48 arteriographic abnormalities were present in 254 patients with 318 potential injuries, l"- Of these injuries, ,32 {10%) occurred to major arteries, and only six patients (1.8%) required operation. Dennis et al suggested that routine arteriography should be used selectively for p r o x i m i t y injuries caused by a shotgun or those involving the thoracic inlet. Using their criteria and avoiding arteriography, only two of 254 injuries requiring operation would be missed. A l t h o u g h not available in this case, an alternative to exclusion arteriography may be color flow duplex Doppler examination. Studies eval-
136/917
uating arterial anatomy m the presence of a h e m a t o m a have demonstrated abnormal arterial flow in a "to and fro" fashion suggestive of pseudoaneurysm formation. ~4,15 The efficacy, safety, and cost-effectiveness of this noninvasive test may make this preferable to exclusion arteriography for proximate injuries. We have used hard criteria for arteriography in penetrating proximity injury. As noted by m a n y authors, this is safe and cost-effective, lo l.~ However, if this policy is used, then a careful, knowledgeable, and thorough physical examination with diligent follow-up is essential. Although an initially unrecognized arterial injury secondary to penetrating proximity is u n c o m m o n , ensuring adequate follow-up will allow an excellent clinical outcome. Thus, primary reliance on a careful physical examination in patients with penetrating proximity trauma and adequate clinical follow-up will affect cost savings without additional morbidity.
SUMMARY We report the case of a patient with a pseudoaneurysm of the superficial femoral artery forming as a late consequence of a stab wound. With a careful physical examination, selective criteria for arteriography in proximity injuries can be used safely, provided adequate follow-up is ensured. REFERENCES I Skillman ]l, Kim D, Bairn DS: Vascular cnmplications
Annals of Emergency Medicine
of percutaneous femoral cardiac interventions. Inci deuce and operative repair. Arch SurJ~ 1988;12;3: 12(17-1212. 2. Engleman RM, Clements JM, Herrmann JB: Stab wounds and tramnatic false aneurysms in the extremities. J Trauma 1969;9:77-87. 3. Lmdfore O, Paukku P, Totterman S: A false aneurysm of the deep femoral artery. Actri Chir S t a n d 1982; 148:201-202. 4. Norris CS, Zlotnick R, Silva WE, et al: Traumatic pseudoaneurysm following b h m t trauma. I Trauma 1986;26:480-482 5. Squire A, Miller CM, Horowitz SF, et al: Femoral pseudoaneurysm following nonpenetrating trauma m a patient with aortic insufficiency. A m / Med 1985; 78:719-720. 6. Giacchetto 1, Gallagher II: False aneurysm of the common femoral artery secondary to migration of a threaded acetabnlar component. A case report and review of the literature Clin Orthop Rel Res 1988;Z:H: 91 96. 7. Orby C, Mertl P, Woestelandt T, et al: False aneurysm of the profunda femuris artery following an intertrochanterie fracture of the femur. A case report. Rev Chir Orthop 1988~74:585-587. 8. Drapanas T, Hewitt RL, Rudolph FW, et al: Civilian vascular injuries: A critical appraisal of three decades of management. Ann Surg 1970;172:351-360. 9. Rich NM, Baugh IH, Hughes CW: Acute arterial in juries in Vietnam: 100f) cases. ] Traltma 1970;10: 359-369 10. McCorkell SI, Harley SI, Morishima MS, et al: Indi~ cations of angiography in extremity trauma. A J R 1985;145:1245 1247. 11. Tohmeh AG, Perlcr BA: Angiography in the evalua tion of proximal arterial injury. Sitrg Gynec(l] Obstet 1990;170:117 120. 12. Dennis lW, Frykherg ER, Crump JM, et al: New per spectives on the management of penetrating trauma in p r o x i m i t y to m a j o r l i m b arteries. / V0sc Surg 1990;11:87-92. 13. Harding RR, McGahan IP, Blaisdell FW, et al: Stab wounds to the extremities: indications for angiography. Radiology 1987;162:465-467. 14 Abu-Yousef MM, Wiesse JA, Shamma AR: The to and fm sign: Duplex doppler evidence of femoral artery pseudoaneurysm. A I R 1988;150:632-634. 15 Rich NM, Hobson RW, Collins CI, It: Elective vascular reconstruction after trauma. AIH I SLtrg 1975; 130:712-719
20:8 August 1991
