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Surgical treatment of a pseudoaneurysm of the femoral artery secondary to a gunshot wound. Clinical case report
M. A.. Gómez-Álvareza, G. E.. Muñoz-Maldonadoa, R.. Salinas-Domíngueza, M.. Mercado-Floresb, J. A.. Tamez-del Bosquea
a General Surgery Services, “Dr. José Eleuterio González” University Hospital, Universidad Autónoma de Nuevo León, Monterrey, N.L., Mexico
b Radiology Services, “Dr. José Eleuterio González” University Hospital, Universidad Autónoma de Nuevo León, Monterrey, N.L., Mexico
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Introduction </span></p><p class="elsevierStylePara"> Trauma is the 3<span class="elsevierStyleSup">rd</span> leading cause of death among the general population&#46; Vascular injuries represent 3&#37; of everyday traumas with a high morbidity&#46; Extremity pseudoaneurysms are developed after penetrating trauma in 60&#37; of arterial injuries&#46; In 40&#37; of those cases&#44; the trauma is caused by a gunshot wound&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara"> In medical literature&#44; we are able to find a series of small amounts of cases&#59; however&#44; in a study by Yetkin et al&#46;&#44; they presented 8 patients with pseudoaneurysms located in the femoral&#44; popliteal and tibioperoneal arteries secondary to gunshot wounds&#46; They concluded that the diagnosis depends on the high rate of suspicion by the healthcare provider&#44; and the longer the diagnosis takes&#44; the more complications they may have&#44; up to loss of the limb&#46;<span class="elsevierStyleSup">2 </span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Case presentation </span></p><p class="elsevierStylePara"> We report a case of a patient&#44; male&#44; 18-year-old with a gunshot wound in the right lower extremity that was assessed in a different medical facility and was discharged without an evident vascular injury&#46; Four months after the incident&#44; the patient came to the General Surgery Department at our Hospital for a consultation with pain in the right lower extremity and a limited gait&#46; During physical examination a pulsatile tumor of 9 x 7 x 9 cm in the external face of the right thigh with the presence of a murmur in the femoral region was documented&#59; the rest of the extremity displayed palpable pulse with a good intensity &#40;Fig&#46; 1&#41;&#46;</p><p class="elsevierStylePara"><img alt="Figure 1 Lump in anterior side outside of right thigh&#46;" src="304v16n64-90367591fig1.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 1</span> Lump in anterior side outside of right thigh&#46;</p><p class="elsevierStylePara"> We performed an angiotomography showing an arterial aneurysm 10 x 8 x 7 cm originating from the superficial fe-moral artery with a continuity solution of 0&#46;58 cm&#44; which communicated with the deep femoral artery &#40;Figs&#46; 2 and 3&#41;&#46;</p><p class="elsevierStylePara"><img alt="Figure 2 Computed axial tomography in coronal section showing pseudoaneurysm of the superficial femoral artery&#46;" src="304v16n64-90367591fig2.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 2</span> Computed axial tomography in coronal section showing pseudoaneurysm of the superficial femoral artery&#46;</p><p class="elsevierStylePara"><img alt="Figure 3 3D recontruction of the pseudoaneurysm of the fe-moral artery&#46;" src="304v16n64-90367591fig3.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 3</span> 3D recontruction of the pseudoaneurysm of the fe-moral artery&#46;</p><p class="elsevierStylePara"> Our surgical strategy consisted of performing proximal and distal vascular control of the superficial femoral artery&#44; complete resection of the superficial femoral artery aneurysm &#40;Fig&#46; 4&#41; and placement of the inverted saphenous graft &#40;Fig&#46; 5&#41;&#46; The patient was discharged after a 7-day post-surgical stay&#44; with a good evolution without complications&#44; and after a follow-up period of a year of consultations&#44; the patient was reported as fully asymptomatic&#46;</p><p class="elsevierStylePara"><img alt="Figure 4 Pseudoaneurysm of the superficial femoral artery&#46;" src="304v16n64-90367591fig4.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 4</span> Pseudoaneurysm of the superficial femoral artery&#46;</p><p class="elsevierStylePara"><img alt="Figure 5 reversed saphenous graft in the femoral artery&#46;" src="304v16n64-90367591fig5.jpg"></img></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Figure 5</span> reversed saphenous graft in the femoral artery&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion </span></p><p class="elsevierStylePara"> Lower extremity pseudoaneurysms concur with global trauma statistics&#44; being more frequent in young male adults&#46; The pathophysiology consists of the result of the energy dissemination of the surrounding tissue&#44; the expansive wave&#44; projectile fragmentation or bone damaging the vascular wall&#44; injuring the endothelial and causing a thrombus&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara"> Chronic traumatic aneurysm is developed by the partial or complete absorption of the periarterial hematoma at a fibrous sac level which is surrounded by the adjacent tissue&#46; In general&#44; the term &#8220;traumatic aneurysm&#8221; is utilized to refer to pseudoaneurysms&#44; whether they are acute or chronic&#46; Pseudoaneurysms must be treated as soon as possible&#44; because of their risk of rupture or thrombosis&#46;<span class="elsevierStyleSup">3</span> In our patient the diagnosis was made 4 months after the event&#46;</p><p class="elsevierStylePara"> The typical clinical picture starts with a lump with progressive growth and pain and limitation in the extremity&#8217;s functionality&#46; During physical examinations there may be tissue pallor and edema&#44; and pulsations and bruits over the lump&#46; Most often there is an absence or decrease of intensity of the distal pulse&#59; however&#44; this is a critical point&#46; In a study by Peck&#44; he concluded that it is possible to feel a distal pulse in 10&#37; of patients with a severe arterial injury&#44;<span class="elsevierStyleSup">4</span> just as with our patient&#46;</p><p class="elsevierStylePara"> The most common vascular injuries occur in the femoral arteries &#40;37&#46;3&#37;&#41;&#44; as it was in our case&#44; the popliteal arteries &#40;27&#46;8&#37;&#41; and the axillary and brachial arteries &#40;23&#46;5&#37;&#41;&#46;<span class="elsevierStyleSup">1 </span></p><p class="elsevierStylePara"> The diagnosis is made through physical examination and confirmed with an imaging study&#46; The first study used is the color Doppler ultrasound&#44; because it is a non-invasive method with excellent sensitivity and specificity which provides diagnostic&#44; but not therapeutic&#44; information&#46; Even though the &#8220;gold standard&#8221; is still the arteriography&#44; more importance has been given to non-invasive studies like the angiotomography with 3D reconstruction&#46; It is used because of its diagnostic and therapeutic evaluation&#59; it provides detailed information about the dimensions&#44; morphology and anatomy of the pseudoaneurysm&#46;<span class="elsevierStyleSup">5 </span>This was the study utilized in our case&#46;</p><p class="elsevierStylePara"> When an aneurysm is larger than 2&#46;5 cm&#44; it is considered &#8220;surgical&#8221; because of the risk of complications&#44; such as a thromboembolism or a rupture&#46; The surgical treatment includes open surgical repair&#44; compression and injection of thrombin guided by ultrasound&#44; embolization or endovascular repair with stent&#46;<span class="elsevierStyleSup">3&#44;5</span></p><p class="elsevierStylePara"> Endovascular repair is not used routinely for the treatment of femoral pseudoaneurysms&#46; In general&#44; it is used when the patient presents contraindications for conventional surgery&#46;<span class="elsevierStyleSup">6</span> Open surgical repair must be the first treatment option for late complications of arterial injuries such as fistulas and pseudoaneurysms&#44; using end-to-end anastomosis&#59; however when it is not possible&#44; an inverted saphenous venous graft should be used&#44; because it is more resistant to infection and has a longer duration&#44;<span class="elsevierStyleSup">7</span> as was done in our case&#46;</p><p class="elsevierStylePara"> Therefore&#44; we suggest our patients with penetrating wounds located over the vascular trajectory to rule out a vascular injury through an imaging study&#44; even when there is no clinical evidence of such injury&#46; The risk of not diag- nosing a vascular injury is the posterior emergence of an arterial-venous fistula or a pseudoaneurysm which can bring severe complications if not treated in time&#44; because they can cause massive bleeding and possibly loss of the limb&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conclusion </span></p><p class="elsevierStylePara"> Currently&#44; vascular injuries are rising with the increase in violence and crime within society&#46; Physical examination is not enough in order to diagnose vascular injuries&#59; therefore&#44; non-invasive and invasive methods must be used in order to exclude possible complications when necessary&#46; Despite all the advances in endovascular interventionism&#44; the first treatment option for this pathology is conventional surgery which consists of a resection of the pseudoaneurysm and reconstruction with an inverted saphenous graft or a prosthetic graft&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest </span></p><p class="elsevierStylePara"> The authors have no conflicts of interest to declare&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Funding </span></p><p class="elsevierStylePara"> No financial support was provided&#46;</p><hr></hr><p class="elsevierStylePara"> Received&#58; December 2013&#59; <br></br> Accepted&#58; January 2014</p><p class="elsevierStylePara"> &#42; Corresponding author&#58; <br></br> General Surgery Services&#44; <span class="elsevierStyleItalic"><br></br> &#8220;Dr&#46; Jos&#233; Eleuterio Gonz&#225;lez&#8221;</span> University Hospital&#46; <br></br> Francisco I&#46; Madero and Gonzalitos Avenue&#44; <br></br> Mitras Centro&#44; Z&#46;P&#46; 64460&#44; Monterrey&#44; N&#46;L&#46;&#44; Mexico&#46; <br></br> Telephone&#58; &#40;81&#41; 8346 7198&#46; Cell Phone&#58; 5566945497&#46; <span class="elsevierStyleItalic"><br></br> E-mail address</span>&#58; <a href="mailto&#58;mgomezuanl&#64;gmail&#46;com" class="elsevierStyleCrossRefs">mgomezuanl&#64;gmail&#46;com</a> &#40;M&#46; A&#46; G&#243;mez-&#193;lvarez&#41;&#46;</p>"
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ISSN: 16655796
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