What is the recommended treatment approach for a pseudoaneurysm of the profunda femoris artery following a neglected intertrochanteric fracture?

Management of Profunda Femoris Pseudoaneurysm Following Neglected Intertrochanteric Fracture

Symptomatic profunda femoris pseudoaneurysms following intertrochanteric fracture should undergo repair, with preoperative endovascular embolization followed by definitive surgical management being the recommended approach for complex cases requiring subsequent total hip arthroplasty. 1

Immediate Diagnostic Confirmation

• Obtain duplex ultrasound imaging immediately when pseudoaneurysm is suspected, as physical examination alone misses more than 60% of cases 1, 2
• The classic clinical triad includes thigh pain, bleeding/expanding hematoma, and unexplained anemia requiring blood transfusions 3, 4
• If duplex ultrasound is negative but clinical suspicion remains high, proceed to CT angiography or digital subtraction angiography for definitive diagnosis 4
• Monitor for progressive thigh swelling, pulsatile mass, distal limb ischemia, or compressive neuropathy 2, 3

Treatment Algorithm Based on Clinical Presentation

For Symptomatic Pseudoaneurysms (Class I Recommendation)

All symptomatic femoral artery pseudoaneurysms require repair regardless of size. 1 This includes:

• Expanding or painful thigh mass 3, 5
• Active bleeding or skin erosion 1
• Compressive symptoms (venous thrombosis, femoral nerve compression) 2
• Unexplained anemia requiring transfusions 3, 4

Endovascular Embolization as First-Line Treatment

• Endovascular coil embolization is the preferred initial intervention for profunda femoris pseudoaneurysms, particularly in poor surgical candidates or when definitive orthopedic surgery is planned 3, 4
• Thrombin injection achieves 93% success rate for catheter-related femoral pseudoaneurysms and can be considered for accessible lesions 1
• Multiple embolization sessions may be required to fully thrombose the pseudoaneurysm sac 4
• Digital subtraction angiography with coil embolization allows for immediate treatment during diagnostic procedure 3

Surgical Management Indications

Open surgical repair is necessary when: 1

• Endovascular treatment fails or is not feasible anatomically 4
• Infected pseudoaneurysm is present (requires extensive debridement) 1
• Rupture into retroperitoneal space or expanding rupture into soft tissue 2
• Definitive orthopedic reconstruction (total hip arthroplasty) is required 1

Surgical technique involves proximal and distal vessel ligation with pseudoaneurysm resection, removal of offending hardware (protruding screws), and assessment of limb viability 6

Staged Approach for Complex Cases

When total hip arthroplasty is needed after neglected intertrochanteric fracture:

1. Stage 1: Preoperative endovascular embolization to control the pseudoaneurysm and reduce bleeding risk 3, 4
2. Stage 2: Definitive orthopedic reconstruction once vascular stability is achieved 3

This staged approach minimizes catastrophic intraoperative hemorrhage during hardware removal and arthroplasty 3, 5

Critical Preventive Considerations

• Deep femoral artery pseudoaneurysms have higher rupture rates (33%) compared to other lower extremity pseudoaneurysms 1
• During intertrochanteric fracture fixation, avoid excessive screw penetration beyond the lateral femoral cortex 6, 7
• Maintain high clinical suspicion for vascular injury when patients develop progressive thigh swelling, unexplained anemia, or pulsatile masses postoperatively 3, 5

Common Pitfalls to Avoid

• Delayed diagnosis: The varied clinical presentations (from subtle swelling to life-threatening hemorrhage) often lead to diagnostic delays of weeks to months 3, 5
• Relying on physical examination alone: Always obtain imaging when vascular injury is suspected, as clinical examination is unreliable 1, 2
• Premature orthopedic intervention: Attempting total hip arthroplasty without addressing the pseudoaneurysm first risks catastrophic hemorrhage 3, 5
• Inadequate imaging: If duplex ultrasound is negative but clinical suspicion persists, escalate to CT angiography rather than dismissing the diagnosis 4

Expected Outcomes

• Endovascular embolization typically results in uneventful recovery with rapid mobilization 3
• Surgical outcomes depend on timing of intervention, with delayed diagnosis associated with prolonged hospitalization and reduced functional recovery 5
• Limb viability is generally preserved with either endovascular or surgical management when diagnosed promptly 6, 4