An Unusual Complication of a ‘‘Blind’’

Femoral Embolectomy
Christos D. Karkos, Dimitrios G. Karamanos, Dimitrios N. Papadimitriou,
Filippos Demiropoulos, Neophytos Zambas, and Thomas S. Gerassimidis, Thessaloniki, Greece

Latrogenic pseudoaneurysms after femoral embolectomy are unusual and have been described
in the peroneal, posterior tibial, and popliteal arteries. We present an unusual case of such
a pseudoaneurysm originating from a medial superior genicular collateral vessel that was coming
off the proximal popliteal artery at an acute angle. It is likely that the embolectomy catheter had
accidentally entered this branch, which ruptured when the balloon was inflated. Transcatheter
coil embolization resulted in successful thrombosis of the pseudoaneurysm.

We report an unusual case of lower limb pseudoa-

neurysm developing after a femoral thromboembo-
lectomy that was performed with a Fogarty catheter
in a ‘‘blind’’ manner.

CASE REPORT
A 78-year-old man was admitted with a 10-hour long
acute ischemia of the left lower limb. He had been bed
bound for the previous 4 years because of a stroke
affecting the left side of the body. He had a known history
of arterial hypertension, coronary artery disease, and
chronic atrial fibrillation. He had previously been antico-
agulated with Sintrom (Novartis, Switzerland), but this
was stopped 2 years earlier because of gastrointestinal
bleeding. On examination, the patient was in atrial fibril-
lation and this was confirmed on the electrocardiogram.
The femoral pulse was palpable, but there were no distal
pulses. The leg was pale and cold with empty veins and
prolonged capillary refill. There was calf tenderness;
however, motor and sensory function could not be reli-
ably assessed because this was the neurologically affected
leg as a result of previous stroke. There were no audible

Fifth Department of Surgery, Aristotle University of Thessaloniki,

Hippocrateio Hospital, Thessaloniki, Greece.
Correspondence to: Christos D. Karkos, Fifth Department of Surgery,
Medical School, Aristotle University of Thessaloniki, Hippocrateio Fig. 1. CT angiography revealing a pseudoaneurysm
Hospital, Konstantinoupoleos 49, Thessaloniki 546 42, Greece, arising from a medial superior geniculate branch.
E-mail: ckarkos@hotmail.com
Ann Vasc Surg 2010; 24: 824.e15-824.e17
DOI: 10.1016/j.avsg.2010.02.029
signals on hand-held Doppler examination. The cause of
Ó Annals of Vascular Surgery Inc. ischemia was thought to be embolic in origin, and the
Published online: May 17, 2010 patient was taken to the operating room. A femoral

824.e15
824.e16 Case reports
Fig. 2. Intraoperative angiography A confirmed the
presence of a pseudoaneurysm arising from a medial
superior geniculate collateral. The mid- and lower popli-
teal artery was occluded, and the tibioperoneal trunk
reconstituted through collaterals. There is only one
embolectomy was performed under local anesthesia using
a 4F embolectomy catheter, which was easily advanced
down the crural arteries. It was necessary to pass the cath-
eter down three times before no further thromboembolic
material could be retrieved. On completing the procedure,
the lower limb perfusion had improved clinically, a popli-
teal pulse was easily palpable, and there were audible
signals on hand-held Doppler. In addition, the patient’s
pain had settled. As a result, a completion angiogram
was not performed. The patient did not develop any signif-
icant reperfusion phenomenon and there was no need for
fasciotomies. He was systemically anticoagulated with
subcutaneous Innohep (tinzaparin sodium, LEO Pharma,
Denmark). His postoperative course was uneventful and
he was discharged home with a warm foot and a palpable
popliteal pulse on the ninth postoperative day. The delay
in discharge was because of social reasons, awaiting
appropriate home arrangements to be made. Three days
after discharge, he was noted to have a painful, pulsatile
left calf swelling and a cold, numb foot. Colorflow duplex
scan and a computed tomography angiogram suggested
a large pseudoaneurysm originating from a medial supe-
rior geniculate collateral of the popliteal artery (Fig. 1).
The latter was occluded behind the knee and the tibioper-
oneal trunk was reconstituted through collaterals, the
only run-off vessel being the peroneal artery. A further
thrombectomy procedure was performed under local
anesthesia restoring patency of the thrombosed popliteal
artery. Angioplasty of the tibioperoneal trunk and of
Annals of Vascular Surgery
run-off vessel (peroneal artery). After repeat embolec-
tomy, the lower limb circulation was restored and
the pseudoaneurysm was selectively embolized with
coils B.
the peroneal artery was also necessary using a 3-mm 
4-cm angioplasty balloon. The collateral branch feeding
the pseudoaneurysm was selectively catheterized and
embolized with 3 coils (BALT, Anco Medical, Montmo-
rency, France), two 8  30 mm and one 6  30 mm
(Fig. 2). The patient had an otherwise uncomplicated
recovery. The swelling and pain gradually resolved and
follow-up colorflow duplex scanning at 1 month showed
successful pseudoaneurysm thrombosis.
DISCUSSION
Iatrogenic pseudoaneurysm because of intimal
damage from the embolectomy balloon is a rare
occurrence and has been described in the peroneal,
posterior tibial, and popliteal arteries.1,2 Most embo-
lectomy procedures are still performed ‘‘blind’’ as
opposed to using a guidewire and radiological guid-
ance.3,4 As a result, there is no control over the cath-
eter, which tends to pass down either the peroneal
or, less often, the posterior tibial artery. This is
because the former has the straightest course
down to the ankle from the popliteal artery. Care
must be taken not to overinflate the balloon in the
tibial arteries to avoid disrupting the integrity of
the arterial wall and creating a pseudoaneurysm.
This case was even more unusual in that the
Vol. 24, No. 6, August 2010
pseudoaneurysm was originating not from the main
popliteal or the tibial arteries, but from a medial
superior genicular collateral that was coming off
the proximal popliteal artery at an acute angle. It
is likely that, during one of the three passes down
the leg, the embolectomy catheter had accidentally
entered this branch, which ruptured when the
balloon was inflated. Presumably, because of the
small vessel diameter, bleeding into the surrounding
tissues was not initially clinically overt. However,
given that the main popliteal artery below the origin
of the vessel subsequently re-occluded, the perige-
nicular arteries became significant collaterals for
lower limb perfusion. As a result, the disrupted arte-
rial branch gave rise to a pseudoaneurysm which
gradually increased in size in the presence of antico-
agulation and became clinically apparent. We
believe that this was the most likely sequence of
events. Naturally, we cannot entirely exclude the
possibility that the embolectomy balloon never
went through the popliteal artery during the first
surgery, but went instead into the genicular branch.
The apparent temporary improvement of the leg
Case reports 824.e17
perfusion for 12 days after the first embolectomy
makes this less likely.
In conclusion, the occurrence of a pseudoaneur-
ysm related to the genicular arterial collaterals after
a femoral embolectomy is extremely unusual. Apart
from the rarity of this event, this case also represents
a first-class teaching lesson about the inadequacy of
thrombo embolectomies which are performed in
a ‘‘blind’’ manner and the usefulness of a completion
angiogram.
REFERENCES
1. Neary WD, Tottle AJ, Earnshaw JJ. False aneurysm of the
posterior tibial artery after femoral embolectomy. Eur J
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2. Sadat U, See T, Cousins C, Hayes P, Gaunt M. Peroneal artery
pseudoaneurysmda case report and literature review. BMC
Surg 2007;7:4.
3. Myhre H. The failed embolectomy. Br J Surg 2000;87:
136-137.
4. Myhre HO, Saether OD. Embolectomy for lower limb
ischaemia. In: Greenhalgh RM ed. Vascular and Endovascular
Surgical Techniques, an Atlas. 3rd ed. London: WB Saunders,
1994. pp 285-291.