A femoral pseudoaneurysm is one of the most common complications of endovascular procedures [1]. As endovascular intervention has become widely spread, there has been a notable increase in complications associated with vascular access sites. The incidence of vascular access site complications is between 0.2–1.4% [2,3]. Femoral pseudoaneurysmal complication rates range from 0.1% in diagnostic procedures to up to 7.7% in therapeutic procedures [3]. The rupture of a femoral pseudoaneurysm can result in life-threatening conditions due to massive blood loss, although this occurrence is very rare, with limited publications to date. Herein, we present a case of a fatal femoral pseudoaneurysm rupture after endovascular intervention.

A patient in their early 90s was admitted to the emergency department with a sudden attack of left-sided weakness, dysarthria, and drowsy mentality 5 hours before arrival. The patient had a previous history of hypertension, dyslipidemia, coronary artery disease, and dementia. He was on medical treatment with a daily dose of cilostazol 200 mg, atorvastatin 20 mg, donepezil 5 mg, perindopril 5 mg, torasemide 5 mg, carvedilol 6.25 mg, and digoxin 0.125 mg. On arrival, his neurologic examination revealed dysarthria, left facial palsy, left sensory deficit, right gaze preference, and left hemiparesis (power grade 3/5) with a National Institutes of Health Stroke Scale score of 8. Brain magnetic resonance image (MRI) and computed tomography angiography (CTA) showed early ischemic changes in the right middle cerebral artery territory and an occlusion at the cavernous segment of the right internal carotid artery. Brain perfusion CT analyzed using the RAPID software (iSchemaView) showed a core volume of 0 mL and penumbra volume of 116 mL. The decision was made for immediate intra-arterial mechanical thrombectomy.

In the neuroendovascular suite, the procedure was performed under local anesthesia. The Seldinger technique using a micro-puncture access set was used to establish access to the right femoral artery, and an 8 Fr vascular sheath was inserted. Cerebral angiography of the right common carotid artery showed occlusion of the right cavernous segment of the internal carotid artery. Subsequently, an attempt was made to deliver an 8 Fr Cerebase DA guiding catheter (Cerenovus). However, due to severe tortuosity in the right common femoral artery and the abdominal aorta, coupled with the patient’s tall stature (177 cm), the catheter, even after being fully delivered, could only be positioned in the aortic arch just distal to the right innominate artery. A further attempt was made to access the occlusion site using a 135 cm long Esperance 6 F aspiration catheter (Wallaby Medical) and a 150 cm long Phenom 21 microcatheter (Medtronic). This attempt was also unsuccessful due to the instability of the guiding catheter and the challenging anatomy of the type 3 aortic arch. After 1 hour and 40 minutes, the decision was made to cease the procedure, and the femoral puncture site was closed using a Perclose ProGlide (Abbott Vascular). Brain MRI performed the following day revealed an infarction in the territory of the right middle cerebral artery. Aspirin 100 mg was added to the existing regimen of cilostazol 200 mg. The patient was monitored in the stroke unit, where neurological symptoms remained stable without any signs of deterioration. Additionally, there were no indications of infection or bulging at the site of the femoral puncture.

On the third day after procedure, the patient exhibited a sudden change in mental status, presenting with drowsiness. The patient’s vital signs indicated a severe drop in blood pressure, measuring 63/42 mmHg. Physical examination revealed a pronounced mass in the right inguinal region, accompanied by swelling of the right thigh and ecchymosis. A subsequent CTA of the lower extremities was performed, revealing a 4.1×2.9 cm right superficial femoral artery pseudoaneurysm with active extravasation (Fig. 1). Medical management, which included manual compression, hypotensive resuscitation, and transfusion of red blood cells, was immediately performed.

The patient was immediately arranged for emergency surgery. In the operating room, a 3 mm defect at 3 cm below bifurcation in the anterior wall of the right superficial femoral artery, accompanied by a massive hematoma, was observed. Pledget suture repair was performed, followed by evacuation and irrigation of the hematoma. After the surgery, the patient initially regained stable vital signs, but soon developed multiple organ failures, including the kidneys and liver, leading to persistent hemodynamic instability. Despite aggressive medical intervention, the patient expired the following day.

A pseudoaneurysm, also known as a false aneurysm, arises from damage to the arterial wall, leading to the formation of a hematoma that remains locally confined and is characterized by turbulent blood flow. Distinct from a true aneurysm, the wall of a pseudoaneurysm is composed of fibrin and platelet interconnections and lacks any of the arterial wall layers [4]. The most frequent clinical manifestation of a pseudoaneurysm occurs as a femoral pseudoaneurysm subsequent to accessing the femoral artery for endovascular procedures [4].

The incidence rate of a femoral pseudoaneurysmal complication depends on the type of procedure, with a 0.1% to 1.5% occurrence for diagnostic procedures and a potential increase up to 7.7% for therapeutic procedures [3]. The most typical symptom of a femoral pseudoaneurysm is a painful, pulsatile mass. It is usually accompanied by swelling and severe bruising at the site of recent arterial puncture. Duplex ultrasonography (US) is the gold standard for the diagnosis of femoral pseudoaneurysms, with a reported sensitivity of 94% and a specificity of 97% [5]. The critical aspect of diagnosis lies in identifying the neck communicating between the sac and the affected artery, which is characterized by a “to-and-fro” waveform. CTA is also effective, providing detailed insights into the pseudoaneurysm, adjacent anatomy, and arterial inflow. In our case, due to the patient’s hemodynamic instability and a strong suspicion of a femoral pseudoaneurysm rupture, CTA was selected as the diagnostic method. It successfully provided an accurate diagnosis of the pseudoaneurysm’s size and the precise location of the extravasation.

Rupture of a femoral pseudoaneurysm is a life-threatening condition and must be promptly managed. However, there has been limited reporting in the literature, possibly due to the rarity of the condition or a reluctance to disclose such a significant complication. Previous literature on femoral pseudoaneurysm rupture is shown in Table 1 [6-11]. Spontaneous rupture of a femoral pseudoaneurysm rarely occurs in young patients with autoimmune diseases [6,7]. Patients experiencing rupture related to percutaneous vascular catheterization, as shown in Table 1, typically were older in age and presented symptoms such as acute pain and swelling in the groin area, accompanied by hemodynamic instability [8-11]. Also, in previous reported cases of rupture, most femoral pseudoaneurysms exceeded 5 cm in its longest diameter before rupturing, and surgery was the chosen treatment, primarily due to hemodynamic instability [6,8-11]. It is noteworthy that our patient did not experience any pain prior to the onset of shock. We suspect that the rupture led to massive bleeding, as indicated by the sudden drop in blood pressure, which in turn resulted in a drowsy mental state, preventing the patient from reporting any pain. Following the rupture, the femoral pseudoaneurysm was found to have a maximum diameter of 4.1 cm. Considering previously reported rupture cases, it is likely that the size of the femoral pseudoaneurysm was significantly larger prior to rupture.

The risk for vascular complications of arterial catheterization, including a femoral pseudoaneurysm, is attributed to procedural and patient factors. The risk is mostly influenced by procedural factors including the use of a larger arterial sheath (8 Fr or greater), high puncture above the inguinal ligament, low puncture of the superficial femoral or deep femoral artery, insufficient compression after arterial sheath removal, and prolonged sheath indwelling time and procedure duration [12,13]. Patient factors include hypertension, female gender, severe atherosclerosis, heavy arterial calcification, repeated catheterization, high division of femoral artery, advanced age, obesity, and concurrent use of anticoagulants and/or antiplatelets [14,15]. The risk of femoral pseudoaneurysm rupture has been rarely investigated. A study on 50 surgically treated femoral pseudoaneurysms from transfemoral arterial catheterization showed 12 ruptures and found that age, peripheral vascular disease, and high liver enzyme levels were risk factors [16]. Our patient presented with several risk factors: advanced age, hypertension, heavily calcified arteries, ongoing dual antiplatelet therapy, low puncture of the superficial femoral artery, use of a large 8 Fr arterial sheath, and an extended procedural duration. These combined factors significantly elevated the patient’s risk for the development and eventual rupture of a femoral pseudoaneurysm.

After the first introduction of vascular closure devices in the early 1990s, various devices have been developed to decrease the incidence of vascular complications, facilitate early patient mobility, and improve patients’ comfort after endovascular interventions. A recent systematic review revealed that, despite some controversy, the complication rates of most devices are comparable to those of manual compression [17]. However, in real-world practice, the safety and efficacy of vascular closure devices are largely influenced by factors such as patient characteristics (like obesity and anticoagulant use), device features, operator experience, and vessel characteristics. In our case, we used the Perclose ProGlide, a percutaneous suture device compatible with sheaths up to 8 Fr, employing a single device deployment method. Although a single device deployment was compatible, given the multiple risk factors present in our patient’s case, an alternative device, or the use of 2 Perclose ProGlides might have been a more suitable choice [18].

The management of a femoral pseudoaneurysm depends on the anatomical features of the femoral pseudoaneurysm and the clinical characteristics of the patient. Small femoral pseudoaneurysms (less than 2–3 cm) can be observed expecting self-resolution. Aggressive treatment should be considered for patients presenting with an expanding hematoma, significant pain, a short neck and/or large pseudoaneurysm, and those who are undergoing anticoagulation therapy. Treatment options include US-guided compression, US-guided thrombin injection, endovascular therapy using stent-graft, and surgical repair. Although recent first line therapy is US-guided minimal invasive therapy, surgical repair is considered for hemodynamic instability, rapid expansion of a pseudoaneurysm, concomitant distal ischemia or neurologic defect, mycotic pseudoaneurysm, compromised soft tissue viability, and failure of other treatments [19]. However, it should be noted that surgery is associated with considerable morbidity and mortality rates, reaching up to 71% and 2.1% respectively [20]. Given that our case demonstrated signs of pseudoaneurysm rupture accompanied by hemodynamic instability, surgery was selected as the treatment of choice.

In conclusion, the rupture of a femoral pseudoaneurysm represents a life-threatening condition, making the early detection of femoral pseudoaneurysms crucial. It is essential to assess risk factors that could lead to complications following arterial catheterization. For patients with risk factors, conducting regular physical examinations and duplex US screenings after endovascular procedures is recommended to prevent catastrophic events such as femoral pseudoaneurysm rupture.