Femoral pseudoaneurysms are a known complication following vascular access procedures. Both surgical and nonsurgical options are available for repair but open surgical repair has remained a robust technique for challenging anatomy and pseudoaneurysm characteristics especially when other treatments have failed. ^{1– 3} In patients unsuitable for open repair, endovascular options can be considered, specifically, covered stent placement or embolization ^{1, 2, 4} however this is subject to neck anatomy, location of the pseudoaneurysm and proximity to the femoral bifurcation. This case demonstrates a novel technique combining endovascular techniques with Perclose ProStyle (Abbott Vascular, Abbott Park, IL), a suture-mediated closure system, which can provide an effective and less invasive alternative to traditional repair.

A 91-year-old woman presented to the emergency department with a large pulsatile right groin mass 10 days following an elective coronary angiogram for consideration of transcatheter aortic valve implantation (TAVI). Her background was significant for severe aortic stenosis, peripheral arterial disease, type 2 diabetes mellitus, hypertension, hyperlipidaemia, atrial fibrillation, first degree heart block, previous left nephrectomy, gastro-oesophageal reflux disease, and osteoarthritis. She was independent from home alone with weekly cleaning services and mobilised with a walking stick. On examination, there was significant bruising and swelling tracking from groin to ankle. Blood tests revealed a normal platelet count and coagulation panel. The patient was on therapeutic anticoagulation for her atrial fibrillation with apixaban 2.5 mg twice a day which was not ceased throughout her admission due to high stroke risk. Doppler ultrasound confirmed the presence of a 35 mm diameter pseudoaneurysm arising from the right superficial femoral artery with a short and relatively wide neck measuring 2.9 mm in diameter ( Figure 1).

The pseudoaneurysm was initially successfully treated by direct injection of 600U of thrombin under ultrasound guidance but progress ultrasound demonstrated recurrence approximately 24 hours later. Open surgical repair under a general anaesthetic was deemed too high-risk given her age and comorbidities following a perioperative anaesthetic review. Therefore, a novel endovascular Perclose-assisted antegrade retrograde approach was utilised for the treatment of her recurrent large right femoral pseudoaneurysm.

Ipsilateral right common femoral antegrade approach (due to extreme tortuosity of the left external iliac artery) with insertion of a soft glidewire into the pseudoaneurysm over a 5Fr sheath. Digital subtraction angiography demonstrated the pseudoaneurysm arising from the proximal superficial femoral artery (SFA) 1cm distal to the femoral bifurcation ( Figure 2). Direct percutaneous puncture of the pseudoaneurysm was performed, establishing 5Fr sheath access. A soft glidewire was introduced which was negotiated into the proximal superficial femoral artery and common femoral artery retrograde ( Figure 3). Wire exchange was performed for a Bentson wire and a Perclose ProStyle (Abbott Vascular, Abbott Park, IL) was used for closure of the SFA puncture site that caused the pseudoaneurysm. Final digital subtraction angiography revealed complete resolution of the pseudoaneurysm with a widely patent superficial femoral artery and patent iliac segment ( Figure 4). Closure of the antegrade 5Fr sheath was also obtained. Anticoagulation was recommenced the same day following the procedure. Repeat ultrasound 24 hours later demonstrated a thrombosed right groin pseudoaneurysm ( Figure 5) and she was discharged uneventfully the following day.

With increasing numbers of percutaneous intervention, there are rising numbers of femoral pseudoaneurysms with an incidence ranging from 0.05% to 2% after diagnostic catheterisation or from 2% to 6% after coronary or peripheral intervention. ⁵ The strongest predictors of femoral pseudoaneurysm formation are due to punctures below the common femoral artery, female gender, hypertension and the use of antithrombotic medications. ⁶ Methods of repair include compression, direct thrombin injection or selective embolization/stenting and open surgical repair. Traditional open surgical exploration and repair is generally considered in refractory femoral pseudoaneurysms but carries a significant risk of complications including and in patients with substantial comorbidities as in this case.

Our case presented a successful use of a refractory iatrogenic proximal superficial femoral pseudoanerysm on anticoagulation, avoiding the need for open surgery and associated risks of wound infections, bleeding, and prolonged recovery time and length of hospitalisation.

From a technical perspective, our case precluded the use of current endovascular interventions (i.e. embolisation and stenting) for the treatment of femoral pseudoaneurysms. This is due to the proximity to the common femoral bifurcation and profunda femoris artery origin and difficulty maintaining a proper seal due to its wider neck. Thus, an novel endovascular solution was necessary in this patient due to her age and comorbidities. ProStyle (Abbott Vascular, Abbott Park, IL)-assisted endovascular repair was an effective treatment for this patient given the above considerations. A small number of case series have been utilising other vascular closure-devices including AngioSeal and VASCADE. ^{6– 8} While ProStyle-assisted endovascular repair is effective in this case, its limitations its in use and applicability include its potential for failure in very small or diseased arteries and long-term outcomes in femoral pseudoaneurysms following trauma or infection.

Perclose ProStyle-assisted femoral artery pseudoaneurysm repair is a minimally invasive endovascular alternative to open surgery for the treatment of refractory pseudoaneurysms that can be considered in comorbid patients unfit for open surgical repair. Future research directions into utilising vascular closure devices in endovascular femoral pseudoaneurysm repair may be useful in these patient cohorts.

Ethics were not required for this study.

Written informed consent for the publication of the case report and any associated images was obtained from the patient.