Traumatic Pseudoaneurysm in a Wrestler Alan J. A n n e n b e r g , M D , Patrick S. V a c c a r o , MD, Wilhelm A. Zuelzer, MD, Columbus, Ohio
An 18-year-old man sought treatment for a pulsatile mass in the medial distal thigh four years after he had sustained blunt trauma during a wrestling match. Investigation, which included magnetic resonance imaging and arteriography, showed the mass to be a pseudoaneurysm, which should be considered in the differential diagnosis of masses resulting from direct, blunt trauma. At exploration, a pseudoaneurysmic thrombus in the superficial femoral artery was evacuated and the vessel was repaired with an interposition graft of reversed saphenous vein, followed by complete recovery of the patient. (Ann Vasc Surg 1990;4:69-71) KEY WORDS:
Pseudoaneurysm; trauma; arteries.
area of his previous site of injury. He denied any recent trauma. The pain was exacerbated by activity. Examination disclosed a 6 x 8 cm pulsatile mass with an associated bruit on the posteromedial aspect of the left lower thigh (Fig. 1). The popliteat artery and distal vessels at the ankle were palpable, but the pulses were significantly diminished compared to the opposite leg. A roentgenogram of the left femur showed an 8 cm indistinct oval rim of calcification overlying the posteromedial aspect of the distal femur. Nuclear magnetic resonance imaging of this extremity demonstrated findings consistent with a pseudoaneurysm of the distal superficial femoral artery at the level of the adductor canal (Fig. 2). There was some cortical erosion of the femur. Intraarterial digital vascular imaging demonstrated a hi-lobed pseudoaneurysm of the distal superficial femoral artery with a systolic jet of contrast filling the aneurysm (Fig. 3). Exploration of the medial aspect of the left lower thigh by means of a longitudinal incision demonstrated a 6 x 8 cm posttraumatic superficial femoral artery pseudoaneurysm with extensive thrombus. During the exploration, the adductor canal appeared markedly narrowed, resulting from a hypertrophied tendinous insertion of the adductor magnus into the distal femur. The pseudoaneurysm was just proximal to this area of narrowing. After proximal and distal control of bleeding was secured, the thrombus was evacuated and the vessel repaired, using an interposition graft of reversed saphenous vein. The patient's postoperative recovery was uneventful and he was discharged on the fifth postoperative day.
Blunt arterial injury incurred during participation in athletics is rare, particularly in the a b s e n c e o f o r t h o p e d i c t r a u m a . M a n y have d e s c r i b e d traumatic p s e u d o a n e u r y s m s in the civilian p o p u l a t i o n [1,2] but m o s t such injuries o c c u r in an industrial or automobile accident, usually in association with o r t h o p e d i c fractures or dislocations. We report a traumatic superficial femoral a r t e r y p s e u d o a n e u r y s m resulting f r o m a wrestling injury without associated o r t h o p e d i c injury.
CASE REPORT An 18-year-old white man sought treatment because of an expanding mass on the medial aspect of his left lower thigh. He had sustained a direct blow to the medial distal thigh, with subsequent swelling and pain in a wrestling match approximately four years earlier. He consulted his local physician after the injury because of some mild swelling in his lower thigh and knee. Roentgenograms made at this time were apparently normal. The knee swelling resolved, but he noted some persistent fullness in his left lower thigh. Approximately two months before, the patient developed thigh pain and noted a mass in the
From the Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio. Reprint requests: Patrick S. Vaccaro, MD, 300 East Town Street, Columbus, Ohio 43215. 69
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ANNALS OF VASCULAR SURGERY
Fig. 1. Large mass on posteromedial distal left thigh.
DISCUSSION Extensive reports of peripheral vascular trauma, resulting from the Vietnam conflict, have contributed substantially to the management of blunt arterial injury [3]. In the civilian population, approximately 17% of arterial injuries result from blunt trauma [1] and are caused by fracture-dislocation, acute traction, or contusion of bony structures. Blunt trauma to the superficial femoral artery has been noted to cause as many as 20% of all blunt vascular injuries [4]. Superficial femoral artery pseudoaneurysms resulting from blunt trauma have been previously described in the civilian population [2]. These arise from intimal tears with extension through the media and adventitia. The injury is followed by the development of pulsatile hematomas that remain in communication with the lumen of the injured artery. Eventually these hematomas develop fibrous encapsulation. Occasionally it is difficult to detect the communication between pseudoaneurysm and the parent artery arteriographically. Two arteriographic signs that may help identify the parent artery are the systolic jet and diastolic washout sign. These find-
Fig. 2. Transverse view of nuclear magnetic resonance imaging study demonstrating pseudoaneurysm with thrombus (arrow).
VOLUME 4 No 1 - 1990
TRA UMA TIC PSEUDOANEUR YSM
Fig. 3, Digital vascular imaging of pseudoaneurysm demonstrating systolic jet of contrast medium (arrow).
71
main arterial segment, the pseudoaneurysm can be explored. If the defect in the artery is small, primary closure is the treatment of choice. If a large defect exists, an interposition graft using autogenous or synthetic material is effective in reestablishing vascular integrity [2-4,10]. In this particular patient, a narrowed adductor canal in the area of injury may have contributed to the development of a pseudoaneurysm of the distal superficial femoral artery. The adductor canal outlet syndrome has been characterized by several authors [Ill and is most often associated with occlusion of the distal superficial femoral artery. A plausible but hypothetical explanation for the development of this pseudoaneurysm is that blunt trauma associated with the scissors-like action of the adductor magnus and vastus medialis on the superficial femoral artery, particularly during an athletic event, may have resulted in an intimal tear within the vessel with subsequent development of a pseudoaneurysm.
REFERENCES ings relate to the blood flow in and out of the lumen of the pseudoaneurysm [5,6]. Recently, several investigations have shown the value of duplex scanning in the diagnosis of peripheral pseudoaneurysm demonstrating sensitivities and specificities greater than 94% [7,8]. A duplex scanning "to-and-fro" sign has been described in association with femoral artery pseudoaneurysm due to blood flow into the pseudoaneurysm during systole and out during diastole [9]. A high degree of clinical suspicion is an absolute necessity in the diagnosis and management of posttraumatic vascular trauma. Distal pulses may be present in up to 10% of patients with vascular injuries [10]. The presence of persistent swelling without resolution, pulsation within a hematoma, or the presence of a bruit indicate a possible posttraumatic pseudoaneurysm and justify duplex scanning and arteriography. Definitive operative management of a superficial femoral artery pseudoaneurysm is best carried out through a longitudinal incision in the medial distal thigh over a suspected pseudoaneurysm. With proximal and distal control of bleeding from the
1. BOLE P, PURDY R, MINDA R. Civilian arterial injuries. Ann Surg 1976;183:13-23. 2. NORRIS C, ZLOTNICK A, SILVA W. Traumatic pseudoaneurysms following blunt trauma. J Trauma 1986;26:480482. 3. RICH N, BAUGH J, HUGHES C. Acute arterial injuries in Viet Nam: 1000 cases. J Trauma 1970;10:359-362. 4. STURM J, BODILY K, ROTHENBERGER D. Arterial injuries of the extremities following blunt trauma. J Trauma 1980;20:933-936. 5. KREIPKE D, HOLDEN R, MASS J. Two angiographic signs of pseudoaneurysms. Radiology 1982;144:79-82. 6. ENGE l, AAKHUS T, EVENSEN A. Angiography in vascular injuries of the extremities. Acta Radiologica Diagn 1975;16: 193-199. 7. COUGHLIN B, PAUSHER D. Peripheral pseudoaneurysms: evaluation with duplex ultrasound. Radiology 1988; 168: 33%342, 8. HELVIE M, RUBIN J, SILVER T, KRESOWIK T. The distinction between femoral artery pseudoaneurysms and other causes of groin masses: value of duplex doppler sonography. A JR 1988;150:1177-1180. 9. ABO-YOUSEF M, WIESE J, SHAMMA A. The "toand-fro" sign: duplex doppler evidence of femoral artery pseudoaneurysm. A JR 1988;150:632-634. 10. PERRY M, THAL E, SHIRES G, Management of arterial injuries. Ann Surg 1971;173:403-408. t 1. BALOJI M. DEWEESE J. Adductor canal outlet syndrome. JAMA 1981;245:167-170.
mmm
An 18-year-old man sought treatment for a pulsatile mass in the medial distal thigh four years after he had sustained blunt trauma during a wrestling match. Investigation, which included magnetic resonance imaging and arteriography, showed the mass to be a pseudoaneurysm, which should be considered in the differential diagnosis of masses resulting from direct, blunt trauma. At exploration, a pseudoaneurysmic thrombus in the superficial femoral artery was evacuated and the vessel was repaired with an interposition graft of reversed saphenous vein, followed by complete recovery of the patient. (Ann Vasc Surg 1990;4:69-71) KEY WORDS:
Pseudoaneurysm; trauma; arteries.
area of his previous site of injury. He denied any recent trauma. The pain was exacerbated by activity. Examination disclosed a 6 x 8 cm pulsatile mass with an associated bruit on the posteromedial aspect of the left lower thigh (Fig. 1). The popliteat artery and distal vessels at the ankle were palpable, but the pulses were significantly diminished compared to the opposite leg. A roentgenogram of the left femur showed an 8 cm indistinct oval rim of calcification overlying the posteromedial aspect of the distal femur. Nuclear magnetic resonance imaging of this extremity demonstrated findings consistent with a pseudoaneurysm of the distal superficial femoral artery at the level of the adductor canal (Fig. 2). There was some cortical erosion of the femur. Intraarterial digital vascular imaging demonstrated a hi-lobed pseudoaneurysm of the distal superficial femoral artery with a systolic jet of contrast filling the aneurysm (Fig. 3). Exploration of the medial aspect of the left lower thigh by means of a longitudinal incision demonstrated a 6 x 8 cm posttraumatic superficial femoral artery pseudoaneurysm with extensive thrombus. During the exploration, the adductor canal appeared markedly narrowed, resulting from a hypertrophied tendinous insertion of the adductor magnus into the distal femur. The pseudoaneurysm was just proximal to this area of narrowing. After proximal and distal control of bleeding was secured, the thrombus was evacuated and the vessel repaired, using an interposition graft of reversed saphenous vein. The patient's postoperative recovery was uneventful and he was discharged on the fifth postoperative day.
Blunt arterial injury incurred during participation in athletics is rare, particularly in the a b s e n c e o f o r t h o p e d i c t r a u m a . M a n y have d e s c r i b e d traumatic p s e u d o a n e u r y s m s in the civilian p o p u l a t i o n [1,2] but m o s t such injuries o c c u r in an industrial or automobile accident, usually in association with o r t h o p e d i c fractures or dislocations. We report a traumatic superficial femoral a r t e r y p s e u d o a n e u r y s m resulting f r o m a wrestling injury without associated o r t h o p e d i c injury.
CASE REPORT An 18-year-old white man sought treatment because of an expanding mass on the medial aspect of his left lower thigh. He had sustained a direct blow to the medial distal thigh, with subsequent swelling and pain in a wrestling match approximately four years earlier. He consulted his local physician after the injury because of some mild swelling in his lower thigh and knee. Roentgenograms made at this time were apparently normal. The knee swelling resolved, but he noted some persistent fullness in his left lower thigh. Approximately two months before, the patient developed thigh pain and noted a mass in the
From the Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio. Reprint requests: Patrick S. Vaccaro, MD, 300 East Town Street, Columbus, Ohio 43215. 69
T R A U M A TIC P S E U D O A N E U R YSM
70
ANNALS OF VASCULAR SURGERY
Fig. 1. Large mass on posteromedial distal left thigh.
DISCUSSION Extensive reports of peripheral vascular trauma, resulting from the Vietnam conflict, have contributed substantially to the management of blunt arterial injury [3]. In the civilian population, approximately 17% of arterial injuries result from blunt trauma [1] and are caused by fracture-dislocation, acute traction, or contusion of bony structures. Blunt trauma to the superficial femoral artery has been noted to cause as many as 20% of all blunt vascular injuries [4]. Superficial femoral artery pseudoaneurysms resulting from blunt trauma have been previously described in the civilian population [2]. These arise from intimal tears with extension through the media and adventitia. The injury is followed by the development of pulsatile hematomas that remain in communication with the lumen of the injured artery. Eventually these hematomas develop fibrous encapsulation. Occasionally it is difficult to detect the communication between pseudoaneurysm and the parent artery arteriographically. Two arteriographic signs that may help identify the parent artery are the systolic jet and diastolic washout sign. These find-
Fig. 2. Transverse view of nuclear magnetic resonance imaging study demonstrating pseudoaneurysm with thrombus (arrow).
VOLUME 4 No 1 - 1990
TRA UMA TIC PSEUDOANEUR YSM
Fig. 3, Digital vascular imaging of pseudoaneurysm demonstrating systolic jet of contrast medium (arrow).
71
main arterial segment, the pseudoaneurysm can be explored. If the defect in the artery is small, primary closure is the treatment of choice. If a large defect exists, an interposition graft using autogenous or synthetic material is effective in reestablishing vascular integrity [2-4,10]. In this particular patient, a narrowed adductor canal in the area of injury may have contributed to the development of a pseudoaneurysm of the distal superficial femoral artery. The adductor canal outlet syndrome has been characterized by several authors [Ill and is most often associated with occlusion of the distal superficial femoral artery. A plausible but hypothetical explanation for the development of this pseudoaneurysm is that blunt trauma associated with the scissors-like action of the adductor magnus and vastus medialis on the superficial femoral artery, particularly during an athletic event, may have resulted in an intimal tear within the vessel with subsequent development of a pseudoaneurysm.
REFERENCES ings relate to the blood flow in and out of the lumen of the pseudoaneurysm [5,6]. Recently, several investigations have shown the value of duplex scanning in the diagnosis of peripheral pseudoaneurysm demonstrating sensitivities and specificities greater than 94% [7,8]. A duplex scanning "to-and-fro" sign has been described in association with femoral artery pseudoaneurysm due to blood flow into the pseudoaneurysm during systole and out during diastole [9]. A high degree of clinical suspicion is an absolute necessity in the diagnosis and management of posttraumatic vascular trauma. Distal pulses may be present in up to 10% of patients with vascular injuries [10]. The presence of persistent swelling without resolution, pulsation within a hematoma, or the presence of a bruit indicate a possible posttraumatic pseudoaneurysm and justify duplex scanning and arteriography. Definitive operative management of a superficial femoral artery pseudoaneurysm is best carried out through a longitudinal incision in the medial distal thigh over a suspected pseudoaneurysm. With proximal and distal control of bleeding from the
1. BOLE P, PURDY R, MINDA R. Civilian arterial injuries. Ann Surg 1976;183:13-23. 2. NORRIS C, ZLOTNICK A, SILVA W. Traumatic pseudoaneurysms following blunt trauma. J Trauma 1986;26:480482. 3. RICH N, BAUGH J, HUGHES C. Acute arterial injuries in Viet Nam: 1000 cases. J Trauma 1970;10:359-362. 4. STURM J, BODILY K, ROTHENBERGER D. Arterial injuries of the extremities following blunt trauma. J Trauma 1980;20:933-936. 5. KREIPKE D, HOLDEN R, MASS J. Two angiographic signs of pseudoaneurysms. Radiology 1982;144:79-82. 6. ENGE l, AAKHUS T, EVENSEN A. Angiography in vascular injuries of the extremities. Acta Radiologica Diagn 1975;16: 193-199. 7. COUGHLIN B, PAUSHER D. Peripheral pseudoaneurysms: evaluation with duplex ultrasound. Radiology 1988; 168: 33%342, 8. HELVIE M, RUBIN J, SILVER T, KRESOWIK T. The distinction between femoral artery pseudoaneurysms and other causes of groin masses: value of duplex doppler sonography. A JR 1988;150:1177-1180. 9. ABO-YOUSEF M, WIESE J, SHAMMA A. The "toand-fro" sign: duplex doppler evidence of femoral artery pseudoaneurysm. A JR 1988;150:632-634. 10. PERRY M, THAL E, SHIRES G, Management of arterial injuries. Ann Surg 1971;173:403-408. t 1. BALOJI M. DEWEESE J. Adductor canal outlet syndrome. JAMA 1981;245:167-170.
mmm
