Surgical correction of a Pseudoaneurysm and Arteriovenous fistula in Common femoral artery and vein secondary to a stab injury in groin.
Case Study
A youngman of 23 yrs came to us from Ramu, Cox’s Bazar with complaints of pulsatile palpable swelling & pain in groin of right lower limb, difficulty in walking & swelling of right lower limb for 3 months. He had the history of multiple stab injury 3 months ago. He was stabbed in lateral side of right upper thigh. He was in shock and admitted in a local hospital for treatment. He was managed conservatively for bleeding and shock. After recovery he was
discharged from the hospital. But later he observed a gradually increasing tender pulsatile swelling in his right groin.He had some difficulties in walking or movement of right lower limb. He also felt gradually increasing thrill in the groin of the affected side. There was some sort of soft tissue infection at the site of penetrating injury, which later apprently healed following antibiotic treatment.
When the patient visited us, we found a pulsatile tensed cystic mass in right groin just lateral to the femoral arterial pulse .Another thrill was present just medial to the femoral artery over femoral vein and it was radiating upwards to the lower abdomen. His all peripheral pulses were present but lower in volume in comparison to opposite leg.
A continous machinery bruit was heard at the medial side of common femoral artery over femoral vein radiating to upwards to the lower abdomen. He was normotensive. Chest radiograph showed normal cardiac shadow. Duplex study revealed a cystic mass over and lateral to the Common femoral artery which was pulsatile. In color Doppler “to and fro” blood flow movement present in the cystic mass. A communication (fistula) between CFA and CFV
also noticed. CT Angiogram confirmed that the cystic mass was measured L 55 mm × T 40mm × AP 35 mm and was just proximal to the bifurcation of profunda and SFA. No evidence of arterial dissection was present. Peripheral angiogram showed the site and extension of the AV fistula.
Elective surgery was planned and performed to correct the lesion. Epidural regional anesthesia was given at L 2-3 level. Patient was in supine position. A longitudinal incision was given over the femoral artery site. Exposure of the external iliac, common femoral and superficial femoral arteries were done. Profunda femoris artery could not be visualized. Corresponding veins also exposed. Proximal controlled to the external iliac and distal controlled to the superficial femoral artery with silastic tape were taken. Profunda femoris artery could not be exposed as it was obscured by AV fistula. Site of the arteriovenous fistula was identified. Tape control of the vein just proximal and distal to the fistula were taken. All arteries were clamped. Then fistula tract was resected. Arterial and venous walls
were repaired with 6-0 prolene. No graft was needed. After that Profunda femoris artery was visualized and control was taken. Pseudoaneurysmal sack was exposed and freed from surroundings. Systemic heparinization was done with 10000 IU of unfractionated heparin IV. CFA, SFA, Profunda femoris arteries were clamped. Two large vascular clamps were applied between the femoral arteries and the aneurusmal sac. The sac was resected between the clamps. In order to avoid increasing risk of major hemorrhage or nerve injury, we did not excise the aneurysmal pouch completely. We limited the resection by preserving the adjacent tissues. Pseudoaneurysmal sack was opened and marsupialization done. Embolectomy of CFA, SFA & PFA were done with Fogharty embolectomy balloon catheter to confirm adeqaute antegrade and retrgrade flow. CFA was repaired with 6/0 prolene.
Wound was closed after proper hemostasis keeping a drain tube in situ. Distal pulses were intact .The post operative period was uneventful. As the pressure effect of pseudoaneurysm on femoral nerve relieved his pain and difficulties during walk disappeared. He was discharged from hospital on 9th POD. The patient made a good recovery and has been followed up for months. Post operative duplex vascular scan showed normal blood flow in CFA, SFA & Profunda femoris artery. He is still under our follow-up.
discharged from the hospital. But later he observed a gradually increasing tender pulsatile swelling in his right groin.He had some difficulties in walking or movement of right lower limb. He also felt gradually increasing thrill in the groin of the affected side. There was some sort of soft tissue infection at the site of penetrating injury, which later apprently healed following antibiotic treatment.
When the patient visited us, we found a pulsatile tensed cystic mass in right groin just lateral to the femoral arterial pulse .Another thrill was present just medial to the femoral artery over femoral vein and it was radiating upwards to the lower abdomen. His all peripheral pulses were present but lower in volume in comparison to opposite leg.
A continous machinery bruit was heard at the medial side of common femoral artery over femoral vein radiating to upwards to the lower abdomen. He was normotensive. Chest radiograph showed normal cardiac shadow. Duplex study revealed a cystic mass over and lateral to the Common femoral artery which was pulsatile. In color Doppler “to and fro” blood flow movement present in the cystic mass. A communication (fistula) between CFA and CFV
also noticed. CT Angiogram confirmed that the cystic mass was measured L 55 mm × T 40mm × AP 35 mm and was just proximal to the bifurcation of profunda and SFA. No evidence of arterial dissection was present. Peripheral angiogram showed the site and extension of the AV fistula.
Elective surgery was planned and performed to correct the lesion. Epidural regional anesthesia was given at L 2-3 level. Patient was in supine position. A longitudinal incision was given over the femoral artery site. Exposure of the external iliac, common femoral and superficial femoral arteries were done. Profunda femoris artery could not be visualized. Corresponding veins also exposed. Proximal controlled to the external iliac and distal controlled to the superficial femoral artery with silastic tape were taken. Profunda femoris artery could not be exposed as it was obscured by AV fistula. Site of the arteriovenous fistula was identified. Tape control of the vein just proximal and distal to the fistula were taken. All arteries were clamped. Then fistula tract was resected. Arterial and venous walls
were repaired with 6-0 prolene. No graft was needed. After that Profunda femoris artery was visualized and control was taken. Pseudoaneurysmal sack was exposed and freed from surroundings. Systemic heparinization was done with 10000 IU of unfractionated heparin IV. CFA, SFA, Profunda femoris arteries were clamped. Two large vascular clamps were applied between the femoral arteries and the aneurusmal sac. The sac was resected between the clamps. In order to avoid increasing risk of major hemorrhage or nerve injury, we did not excise the aneurysmal pouch completely. We limited the resection by preserving the adjacent tissues. Pseudoaneurysmal sack was opened and marsupialization done. Embolectomy of CFA, SFA & PFA were done with Fogharty embolectomy balloon catheter to confirm adeqaute antegrade and retrgrade flow. CFA was repaired with 6/0 prolene.
Wound was closed after proper hemostasis keeping a drain tube in situ. Distal pulses were intact .The post operative period was uneventful. As the pressure effect of pseudoaneurysm on femoral nerve relieved his pain and difficulties during walk disappeared. He was discharged from hospital on 9th POD. The patient made a good recovery and has been followed up for months. Post operative duplex vascular scan showed normal blood flow in CFA, SFA & Profunda femoris artery. He is still under our follow-up.
 |
| Fig-1 showing the scar of the stab injury |
 |
| Fig-2 CTAngiogram showing pseudoaneurysm of CFA and AV fistula. |
.jpg)