Endovascular Management of a Deep Femoral Artery Perforating Branch Pseudoaneurysm after Total Hip Arthroplasty: A Case Study

Pseudoaneurysm of the profundal femoris artery (PFA) following total hip arthroplasty (THA) is a rare and unusual complication. Awareness of this complication and a high level of suspicion allow early diagnosis and treatment, thereby reducing the morbidity of this condition. We present a case of a pseudoaneurysm of a perforating branch of the PFA after revision THA which was treated successfully by selective coil embolization.


Introduction
Pseudoaneurysm of the PFA or its branches is an unusual and serious complication after THA. Vascular injuries are a rare complication after orthopedic surgery of the hip. Te complication rate is reported to be approximately 0.2-0.3% [1][2][3]. In a large series of >13,000 cases, an incidence of 0.04% in primary THA increasing to 0.19% in revision surgery was seen [4]. Such complications account for the third most common iatrogenic injury after those caused by catheterization and trauma [1]. Tey can result in signifcant mortality (7%) [5], amputation (1.6%), and persistent ischemia (7.3%) [4]. Tese complications can include thromboembolism, direct vessel laceration, pseudoaneurysm, and arteriovenous fstula formation. Etiologies are direct trauma from surgical instruments, joint manipulation and dislocation, protrusion of cement or screws, excessive retraction, and heat injury from the exothermic reaction generated during cement (methyl methacrylate) polymerization [1,3,[6][7][8].
Furthermore, there is an increased incidence in patients undergoing redo arthroplasty [9]. As stated by Del Prince et al, the prevalence of vascular injuries post redo arthroplasty ranged between 0.06 and 0.2%. Tese injuries are classifed into 2 groups: acute-onset vascular injury and delayed-onset vascular injury. Acute onset vascular injury may occur intraoperatively secondary to direct trauma from surgical instruments or cement. As mentioned by An et al., delayed vascular injury can result from postoperative trauma to vessels [10,11].
Vascular damage resulting from this procedure may present in many ways including pain, obvious bleeding, hemodynamic instability, anemia, a pulsatile mass, and limb ischemia [12]. De Boer et al. stated that the most common locations of pseudoaneurysms after THA are the external iliac artery and the common femoral artery [13]. Injuries and pseudoaneurysms of the PFA and its branches are very rare after THA as the artery is not close to the operation site [12,14]. Some cases resulting from chronic repeated trauma by a projecting screw were reported after intertrochanteric fracture treated by internal fxation with a dynamic hip screw plate [15,16].
Recent studies have concentrated on a pseudoaneurysm of the PFA that has been reported approximately two months after THA, in contact with a cement leak from the hole of the removed screw from the prior osteosynthesis of an intertrochanteric fracture [17,18].Öztürk et al. reported a pseudoaneurysm of the PFA after bipolar hemiarthroplasty, caused by the sharp edge of a fractured lesser trochanter [14].
In light of this, a risk factor for redo procedures is the presence of vascular damage due to THA, an uncommon complication for these injuries [2]. Because of its location deep in the thigh, pseudoaneurysm of the PFA often presents late with persistent pain and swelling. Patients may not present with the usual sign of a pulsatile mass [19]. Diagnosis of pseudoaneurysm is especially dependent upon suspicion because the symptoms and signs are nonspecifc which makes it a challenging process [4]. As a result, if there is persistent pain and swelling in the thigh after THA, additional vascular investigations should be performed. Noting that, it can be diagnosed by Doppler ultrasonography or computed tomography. Angiography, however, is needed for defnitive diagnosis and for endovascular repair if needed.
In this article, the authors present a case of a pseudoaneurysm of a perforating branch of the PFA following revision THA treated successfully by selective coil embolization.

Materials and Methods
Tis article presents a case study of a 50-year-old lady with no signifcant medical history who underwent a right THA for congenital hip dysplasia. Recurrent dislocations were the indication for revision THA after 6 years.
Two weeks postoperatively, during her stay at the rehabilitation center, she started complaining of severe, worsening pain localized to the right groin. Clinical neurologic and vascular examinations were normal. Radiographs showed satisfactory positioning of the hip prosthesis. Te orthopedic consultation revealed no orthopedic origin of her complaints. Duplex ultrasound showed a small pseudoaneurysm arising from the profunda femoris (ying-yang pattern on the color fow and to-and-fro waveform on the spectral doppler); no signs of venous thromboembolism were noted. A trial of ultrasound-guided compression was done without success. Computed tomography (CT) scan revealed a 14 × 22 mm pseudoaneurysm originating from a distal perforating branch of the right PFA ( Figure 1). Considering that no thrombin was available for an ultrasound-guided injection of the pseudoaneurysm, the endovascular repair was our treatment of choice.
Arteriography was done via left femoral artery retrograde access confrming the presence of the pseudoaneurysm (Figure 2(a)). Subsequently, selective catheterization of the distal perforating branch of the right PFA was performed using Progreat ™ microcatheter (Terumo Corporation, Tokyo, Japan) and successful embolization was achieved using 2 and 3 mm platinum coils (Balt Extrusion, Montmorency, France), placed distal and proximal to the neck of the pseudoaneurysm. Subsequent injection of the contrast medium demonstrated no fow into the pseudoaneurysm (Figure 2(b)). Following embolization, the patient had a gradual improvement of her symptoms. Te patient revealed that she had no pain, claudication, or swelling at follow-up 6 weeks later, and the control CT scan showed no recurrent vascular lesion over a 6-month period (Figure 3).

Results and Discussion
In our case, the pseudoaneurysm originated from a distal perforating branch of the PFA. Tere was no evidence of direct trauma from surgical instruments because it was far from the operation site; also, the injured artery was not in contact with a protrusion of cement, bone edge, or screws. During the operation on a redo case, the hip was moved out of place, which could have torn the blood vessel.
Moreover, the presentation was a nonspecifc groin pain 15 days postoperatively, which raised the suspicion of vascular complications and indicated a diagnostic procedure.
Doppler ultrasonography and a CT scan can be used to diagnose pseudoaneurysms in these cases. Angiography, however, was needed for a defnitive diagnosis and transcatheter treatment.
Open surgical repair of a pseudoaneurysm of the PFA can be difcult because of the location of the PFA, deep in the muscle compartment of the thigh. Transcatheter or ultrasound-guided percutaneous injection of thrombin, coil, or fbrin adhesive has been reported to occlude a similar pseudoaneurysm  [24]. Zhang et al. described 4 cases of successful embolization procedures done to deep femoral artery pseudoaneurysms after hip fracture surgery [25].
Successful embolization in our case was achieved using selective catheterization of the perforating branch of the PFA and coil embolization distal and proximal to the neck of the pseudoaneurysm to insure complete exclusion. Some opted for endovascular repair using a covered stent. [26] However, covered stent placement to seal the pseudoaneurysm was not feasible in our case, as it originated from a distal branch. A US-guided thrombin injection was not available at the time of intervention, although it could also have been considered a treatment option.  Case Reports in Medicine

Conclusion
Following THA, pseudoaneurysm of the PFA is quite rare. Early identifcation and treatment are made possible by knowledge of this consequence and a high degree of suspicion, particularly in redo surgeries. Since it is simpler to reach the deep femoral artery branches and less intrusive than open surgical repair, the endovascular repair was the authors' method of choice in this situation. Tis article presented a successful instance of selective coil embolization for the treatment of a pseudoaneurysm of a perforating branch of the PFA after revision THA. Tis technique was efective and will be useful in future situations similar to this.

Data Availability
All references are provided in the submitted document.

Conflicts of Interest
Te authors declare that they have no conficts of interest.

Authors' Contributions
Conception and design were performed by GB and EC; analysis and interpretation by GB, EC, and SN; data collection by GB and SN; writing the article by GB and SN; critical revision of the article by GB, EC, SN, and PS; fnal approval of the article by GB, EC, SN, and PS; statistical analysis and obtained funding were not applicable; overall responsibility by GB and EC.