K.V

55 year old gentleman, underlying diabetes mellitus, hypertension and coronary artery disease with history of recent angioplasty to right coronary artery done via right femoral artery, presented two weeks later with painful right groin swelling for one week with pus discharge but no fever. He took a course of antibiotics but the swelling was increasing in size. He was admitted, started on intravenous antibiotics and treated as infected right groin hematoma to rule out pseudoaneurysm or abscess.

Ultrasound right groin: Right groin hematoma with subcutaneous edema and focal deep vein thrombosis of right common femoral vein, no pseudoaneurysmUltrasound one week later: Subcutaneous hematoma in right groin and no communication with right common femoral arteryCT angiogram of abdomen and lower limbs: Distal right external iliac artery leak compressing adjacent external iliac vein, the area of contrast pooling measuring 1.8X2.5X2.1cmCRP 63.9Blood culture: No growthSwab culture: MSSA

Contrast leak from the distal right external iliac artery/proximal right common femoral artery forming a focal area of collection in connection with main artery likely a pseudoaneurysmNo significant atherosclerotic disease/stenosis of right common iliac, external iliac and common femoral arteries up till the femoral artery bifurcation Left common femoral artery normal

Percutaneous transluminal angioplasty (PTA) of right common femoral artery pseudoaneurysmLeft femoral artery puncture under fluoroscopy, 6 French femoral sheath was inserted. Terumo long soft wire was manipulated from left into right common iliac artery then right common femoral artery and 6Fr JR catheter advanced into right common iliac artery and angiogram taken. Pseudoaneurysm with contrast leak identified at right common femoral artery. The existing femoral sheath was converted into a larger sheath followed by a 0.018 guidewire and Trailblazer support catheter into right common femoral artery. The Armada35 8.0X40X80mm balloon was inflated up to 8 ATM across the pseudoaneurysm to ensure its occlusion upon full balloon inflation and decide stent placement. COVERA™Vascular Covered Stent (Bard Peripheral Vascular Inc.) 9X60mm was delivered to right common femoral artery and deployed across the pseudoaneurysm. Post stenting, repeat angiogram showed no more contrast  leakage at the site of pseudoaneurysm. Angiogram also taken for left common femoral artery and left femoral puncture site closed with proglide. 

This case illustrates the need for high index suspicion of pseudoaneurysm in the setting of persistent groin hematoma post-catheterization despite delayed appearance of hematoma. There is limitation in the sensitivity of ultrasound doppler in detecting pseudoaneurysm in some cases. The incidental finding of focal common femoral vein DVT may be due to the compression effect of the superficial hematoma over the vein (provoked DVT). Several treatment options for pseudoaneurysm have been utilized to avoid the risks of open surgery. Percutaneous endovascular treatment using a covered stent maybe a safe and feasible method for the treatment of pseudoaneurysm.