It would depend on the locattion of the pseudoaneurysm, whether it is associated with an open wound. Need more specifics.

The least invasive the better it is, I think. I found this one pretty cool...

https://dl.dropbox.com/u/2807265/24389_fta.pdf

I can talk about iatrogenic fem pseudoanerysms (from the cath lab): we always try, first, to manage them conservatively with long echo-guided compressions and subsequent apposition of Femostop (6-18 hours). Sometimes we try with para-conduit saline injection (for small conduits,

Agree, echo guided compression is best. If not then Thrombin and as said the technique described above seems very promising. Surgery only if you have to, and it often ends up with an open procedure due to lymphatic fistula or infection

Are we talking about traumatic pseudoaneurysms or post procedure pseudoaneursyms. Different animals.

Surgical treatment is the best and safest approach to femoral pseudoaneurysm. If it is iatrogenic a single suture in the hole is enough. If the reason of the pseudoaneyrysm is open wound because of trauma, then it is more difficult. You can;t use a synthetic graft. You have to use a vein, or a vein patch in order to restore the damage

Femoral artery pseudoaneurysms are the result of 1) previous femoral surgery (anastomostic pseudoaneurysms) or 2) postintervention aneurysms (after femoral catheterization) or 3) trauma (blunt or penetrating).

In the case presented here, since there may be also a bone fracture, I assume that the aneurysm is post traumatic. If so, the aneurysm has to be repaired with open repair or endovascular grafting. Note, that there may be a possibility of infection if the aneurysm is related to an open wound. In the last scenario, the aneurysm has to be repaired only by open repair using only autologous vein for possible arterial reconstruction.

I agree with you M Tachtsi as our experience with femoral artery pseudoaneurysm is quite good with surgical intervention as pubished in ANZ Journal Of Surgery....http://www.ncbi.nlm.nih.gov/pubmed?term=tiwary%20sk%2C%20femoral%20aneurysm. We usually do open surgical intervention as most of the cases seen by us were quite large and presented after a long duration when chances of success of radiological intervention were dismal.

Nice option D Mayer. Echo guided and Thrombin are definitely minimally invasive techniques but they have limitations. As i said my cases were mostly of large sizes and late presentation when only good option was open surgical intervention.

Definite intervention is must as told by R. Bittencourt as watchful observation may lead to rupture and catastrophe. So golden rule is intervention which may be radiological, endovascular or open. Mode of intervention should be decided by expertise available and choice of the patient.

Dear G Pinault , please go through all posts and clarify your view about management which is not very clear from your post.

I agree with B Courtese as far as mode of intervention is concerned.

Dear Satyendra, I totally agree with you and I would also offer open surgical treatment in a post-traumatic case like the one you described. Regards.

Very informative post by K Filis. Open surgical intervention is ideal mode of intervention in post traumatic femoral aneurysm. Intervention always done as chances of rupture is always.

Thanks dear Germano for sharing your views in post. We always did open surgical intervention. Small hole upto 3 mm we closed primarily with non absorbable monofilament sutures but bigger defects were covered with patch graft from autologous veins.

Small iatrogenic pseudoaneurysms < 2.5 cm from arterial puncture usually thrombose sponatneously (http://www.ncbi.nlm.nih.gov/pubmed/9152307). If they are larger or persist, thrombin injection with ultrasound guidance is best option. For larger pseudoaneurysms from blunt or penetrating trauma, open repair usually best, but covered stent grafts are an option depending on location and other patient risk factors.

Thanks Joseph Mills for post. As my all cases were post traumatic our intervention was open surgical management. In other causes and small aneurysms other modes of intervention are well established.

I agree Satiendra , in my experiece perform only open surgery for post-traumatic/iatrogenic pseudoaneurism,only one case I use Trombin during endovascular procedure.

Thanks Bruno for sharing your experiences in post regarding pseudoaneurysm.

Management of post femoral intervention pseudoaneurysm can be expectant (if less than 2.0 cm) or u/s guided compression or u/s guided thrombin injection. Traumatic pseudo-aneurysms (popliteal etc) can be managed endovascularly with covered stents if not in infected fields. Open traumatic wounds or infectious pseudo-aneurysms usually are handled with open repair with autogenous vein and soft tissue coverage.

A lot depends on the actual etiology of the pseudoaneurysm, but also the size and location are important in choosing the opttimal strategy.

In our experience, thrombin injection will only work in pseudoaneurysms with a relatively long and small aneurysmal neck, so predominantly for post catheterisation pseudoaneurysms.

Also we 're very hesitant in using covered stents in de common femoral artery but use it preferentially in the superficial femoral and popliteal artery.

We think large common femoral pseudoaneurysms are best treated surgically.

Ultrasound guided thrombin injection for those post angio

coverd stent for those with larg neck anastomotic pseudo aneurysm can be terated by endovascular means or by surgery

We usually treat pseudoaneurysms depending on their size. If the neck is small ultrasound guided thrombin injection with consecutive local pressure bandage is the first option. Otherwise open repair is the method of choice. Posttraumatic pseudoaneurysms are treated endovascularly if their location is a guidelines accepted area to treat.

Open surgical intervention is ideal treatment in post traumatic femoral aneurysm. The cause is often an endovascular procedure by femoral access. The patients have cardiopathy, need antitrombotic or anticoagulant drugs. If their size is > 2 cm, or the procedure are performed 3-4 days before, I think is better to operate when they are emodinamically stable.

I agree Capoano answer!!

We are using US guided manual compression firstly and in failed cases US guided thrombin injection.

I would use ultrasound guided Thrombin injection and if it fails, I will fix it surgically.

Everything said so far is corect BUT the entire managemnet depends on the neck of the pseudo aneurysm , therefore if too large than injections compression and plusg wount work. the ideal is surgeery in such circumstances.

Distinguish the anatomic location.

Thrombin or ultrasound compression techniques are appropriate for common femoral PSA with small necks -- usually related to catheter interventions. The relevance to this description may be resuscitation or monitoring catheters in the common femoral artery.

However, if related to femoral fracture, these interventions are less likely to be useful and open, autogenous repair is appropriate.

Finallly, be particularly wary of the subgroup with local injection for illicit drug use as the approach, outcomes, and treatment are different.

I think timing is also a factor to take on account. In pseudo aneurysms that are promptly discovered ultrasound guided compression has very good results and cheap. Sometimes the treatment can be performed immediately following diagnosis

I think we have to distinguish the etiology of the femoral pseudoaneurysm.

- If it is subsequent to a percutaneous approach and it is located in the femoral bifurcation (common, superficial, profunda) the operative management should be in sequence: 1) ultrasound guided compression; 2) thrombin injection; 3) open surgery.

- If the pseudoaneurysm has origin from an arterial injury due to a bone fracture or during elective/emergent orthopedic surgery (such as hip arthroplasty) the arterial lesion is generally located in branches of the profunda femoris and so the only possible treatment is endovascular (coils, glue injection). Otherwise "wait and see".

You have to make sure it is not infected first! All of those who already injected it with thrombin could be looking at a huge abscess with unreconstructable melted femoral artery.

Traumatic pseudoaneurysms do not have this beautiful thin neck left after sheath removal (iatrogenic situation). The treatment should be open.

Traumatic pseudoaneurysm is best treated surgically. Having said that,currently ,with the increasing number of endovascular procedures worldwide, Iatrogenic aneurysms occur not uncommonly.Acute pulsating haematomas,the earliest in evolution of such lesions,particularly with drop in Hb. level and or distal ischemia mandate emergent surgery.

Lesser lesion upto 2 weeks from onset is eminently manageable with ultrasonic compression with excellent result.Beyond 2 weeks surgical M/t is needed.

Small 1to2 cms. aneurysms ,at least ,in 2 instances we have kept on close watch without intervention with no adverse sequlae since 2-3 years.

Major radiologic therapy of pseudoaneurysms remains ultrasound-guided thrombin injection (UGTI). Studies have shown that UGTI is more effective than ultrasound-guided compression used in the past. Although endovascular techniques and procedures including compression and thrombin injection under ultrasonographic guidance which failed in patient, are used in treatment of pseudoaneurysms, conventional surgical approach is still the best . The primary procedure in surgical approach should be aneurysmectomy and arterial reconstructive intervention. End-to-end anastomosis or primary repair with an appropriate graft should be chosen.

Surgical repair i think is better alternative because of

1) easily accessibility of femoral artery for repair

2) Patch or segment of proximal saphenous vein can be used for repair through the same incision.

3) Cost effective as compared to covered stents

4) autologus vein grafts/patch have better patency as compared to stents or prosthetic graft/ patche

5) Can be performed under regional anesthesia

we use US guided compression as first line treatment

Our group usually treat Traumatic pseudoaneurysm surgically.

I think that open surgery should be the best option .

Vikas Goyal said some of the reasons Why to prefer open access.

Considering only post-procedural (arterial catheterization):

1- If the Pseudoan. is recent (up to 48hs) and the patient is stable and without severe coronary disease I try ultrasound-guided compression.

2- If the Pseudoan. is older than 48hs, well capsulated, patient has pain, using antiplatelets drugs + LMWH, I prefer ecoguided thrombin injection

3- If infected, with cutaneous lesions or bleednig, surgical repair.

Before 1991, femoral pseudoaneurysms were treated surgically. Recently, the development of effective minimally invasive therapies has resulted in their use. Principles of surgery are: obtain control proximal and distal, open and evacuate the aneurysm sac, identify the puncture site, and repair with suture with local regional anesthesia. Percutaneous balloon occlusion via the contralateral femoral artery is an alternative, less invasive method to obtain iliac control. In the event of rupture or rapid expansion, especially in patients with hypotension and shock, the aneurysm sac is opened immediately with no attempt at proximal control. The hematoma is evacuated and hemostasis achieved by direct digital manual compression of the bleeding puncture site.

Endovascular Stent Grafting of a Deep Femoral Artery Pseudoaneurysm

Femoral artery pseudoaneurysms are best treated with the classical surgical method. Surgery is easy, effective and simple. Endovascular methods unnecessarily deploy some intravascular foreign substances permanently that may further cause unwanted tendency for endothelial proliferation. Additionally, the capsule of the pseudoaneurysm should be excised to treat the inguinal mass. This can also be achieved by the open surgical method. Beyond these issues, contralateral femoral artery puncture may cause an iatrogenic pseudoaneurysm while trying to treat the original site!

Dear Hamit ,

I sugest you to read this paper and references :

Article Endovascular Stent Grafting of a Deep Femoral Artery Pseudoaneurysm

Early post-cath: manual compression, better if US guided. Thrombin injection is an option.

Late, uncompressible, large, and high-flow: surgical repair.

Deep location and far from hip joint (i.e. SFA or EIA): covered-stents like Viabahn can be an option.

Post pci..anatomy dictates if amenable to thrombin injection (narrow neck and long track)..otherwise surgical repair..would stay away from covered stents in the femoral..they fracture and thrombose and are a bad idea