Case Report

Spontaneous Pseudoaneurysm of the Left Superficial Femoral

Artery: An Unusual Case Report and Review of Literature
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Krishna Vardhan M S S, Kapil Baliga1, Banushree Chandrasekhar Srinivasamurthy2

III Professional MBBS Student, Departments of 1Surgery and 2Pathology, Indira Gandhi Medical College and Research Institute, Puducherry, India
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Abstract
Pseudoaneurysms are rare to occur and the rarest to occur in those who have not undergone surgical/endovascular procedures like catheterization.
Such pseudoaneurysms are known as spontaneous pseudoaneurysms which are very less reported and reviewed. This generally occurs due
to underlying pathological causes, the most common being atherosclerotic disease. The most common clinical presentation is a femoral
artery pseudoaneurysm. Other less common presentations include aortic and visceral pseudoaneurysms. We describe here the occurrence of a
pseudoaneurysm in a patient who has no history of endovascular procedures in the past and has a pseudoaneurysm showing a secondary change
along with superadded infection of Acinetobacter baumannii. The case was radiologically diagnosed by a computed tomography scan of the
abdomen and thigh, after which a surgical excision of the pseudoaneurysm was performed and the specimen was sent for the histopathological
examination, which revealed secondary changes.

Keywords: Acinetobacter, endovascular procedures, femoral artery, secondary changes, spontaneous pseudoaneurysm

Introduction pseudoaneurysms include percutaneous hemodialysis,

A pseudoaneurysm, which as the name indicates, is a false
permanent abnormal dilatation of the vascular wall due to it’s
damage or weakening. This results in localized pooling of the
blood forming a hematoma with turbulent blood flow, which is
not covered by any layer of vascular wall unlike a true aneurysm
which is covered by all the three tunica layers of the vessel wall.
This hematoma may cavitate and establish communication with
the parent vessel wall. Thus, the wall of a pseudoaneurysm
consists only of an organized clot.[1] Whereas, an active
pseudoaneurysm generally develops a fibrin sac that contains
the actual pseudoaneurysm and also allows the extravasation of
the blood from the vessel to the contained area.[2] Furthermore,
the etiology of true aneurysms is degenerative in nature, whereas
pseudoaneurysms are of inflammatory or traumatic origin that
can cause thrombosis of vasa vasorum of tunica adventitia
leading to weakening of the vessel wall.[3] In recent times, due
to the increased access of the peripheral arteries, generally the
femoral artery, for diagnostic procedures and interventions,
pseudoaneurysms very commonly occur in these peripheral
arteries due to repeated damage or puncture and hence the most
common type being iatrogenic pseudoaneurysms which account
70%–80% of the incidence.[4,5] Other causes of iatrogenic
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intra‑aortic balloon pump placement, and other interventional
techniques.[6‑8] Noniatrogenic causes include trauma, injury by
tumor, Behcet’s disease, infection, vasculitis, inflammation,
and unknown etiology.
Since there is no history of trauma or any other risk factor
that could have led to the development of this condition,
we labeled the patient to have developed a femoral artery
spontaneous pseudoaneurysm. Spontaneous pseudoaneurysms
are rare and have been less reported till date.[9] It is more
frequently attributed to atherosclerotic changes in the vessels,
which weakens the walls, and hence, it can probably be a risk
factor for the development of pseudoaneurysm.[10‑12] It can
also occur secondary to the rupture of a true aneurysm, but
this mechanism is still not very clear.[13] We report a case of a
patient who developed a long‑standing pseudoaneurysm that
Address for correspondence: Dr. Krishna Vardhan M S S,
E‑mail: drkrishna318@gmail.com
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How to cite this article: Vardhan MS, Baliga K, Srinivasamurthy BC.
Spontaneous pseudoaneurysm of the left superficial femoral artery: an
unusual case report and review of literature. Indian J Vasc Endovasc Surg
2023;10:222-6.
Received: 11‑02‑2023 Accepted: 24‑04‑2023
Published Online: 23-10-2023

222 © 2023 Indian Journal of Vascular and Endovascular Surgery | Published by Wolters Kluwer ‑ Medknow
 Vardhan, et al.: Spontaneous femoral artery pseudoaneurysm: A case report and literature review

has undergone secondary change superadded with an infection
by Acinetobacter baumannii.
Case Report
A 43‑year‑old male presented to the outpatient department with
complaints of swelling on the left inner thigh for the past 8 weeks.
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overlying skin looked normal and showed no discoloration. It
was pulsatile and noncompressible on palpation. Bruit was heard
on auscultation. No oral or genital ulcers, hypermobile joints,
or other physical findings to suggest connective tissue disease
could be observed. The differential diagnosis of a hematoma,
pseudoaneurysm, seroma, or infection/abscess was made. The
contrast‑enhanced computed tomography (CT) scan of the

The swelling was insidious in onset and progressive in size. The

abdomen and the thigh showed minor atherosclerotic changes
swelling was not associated with pain, numbness, discharge,
in the abdominal aorta and a low‑attenuated oval‑to‑round
fever, or weight loss. The patient is a known case of hypertension,
structure of size 6.1 cm × 5.2 cm with a homogeneous thrombus,
diagnosed a year back, and is not on antihypertensive drugs. He
arising from the superficial branch of the left femoral artery
has no history of any endovascular procedures or trauma. He
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indicative of a pseudoaneurysm [Figure 1]. Under epidural

is not on antiplatelet or anticoagulant drugs. He is a chronic
anesthesia, excision and repair were done, in which the
smoker, had been smoking since the last 15 years and claims to
pseudoaneurysm was first exposed and the femoral nerve was
have quit smoking 3 years ago. Family history of cardiovascular
separated, and then, an incision was made on the anterior wall
diseases was negative. On physical examination, there was
of the pseudoaneurysm exposing the contents of it, removing
a single swelling on the medial aspect of the left mid‑thigh
the thrombus [Figures 2 and 3]. Great saphenous vein (GSV)
which was not warm and tender, measuring 5 cm × 5 cm. The

Figure 1: CECT showing a low‑attenuated oval‑to‑round structure with Figure 2: Intraoperative image showing the exposed pseudoaneurysm
a thrombus, arising from the superficial branch of the femoral artery, with clamped clear proximal and distal superficial branch of femoral artery,
indicative of a pseudoaneurysm. CECT: Contrast‑enhanced computer between which exists the large globular pseudoaneurysm
tomography

Figure 4: Intraoperative image depicting the empty and corrected

Figure 3: Intraoperative image showing the same pseudoaneurysm, and pseudoaneurysm and interposition of reversed GSV. GSV: Great
separated femoral nerve, to avoid injury during the excision saphenous vein

Indian Journal of Vascular and Endovascular Surgery ¦ Volume 10 ¦ Issue 3 ¦ July-September 2023 223
 Vardhan, et al.: Spontaneous femoral artery pseudoaneurysm: A case report and literature review
was identified and its harvesting was done. End‑to‑end
anastomosis of reversed GSV to cut ends of the superficial
femoral artery was done [Figure 4]. The removed clot of size
4 cm × 4 cm × 3.5 cm was sent for histopathological examination
and microbiological investigation. Two specimens were received
which were two gray‑brown irregular globular masses, one
measuring 3.3 cm × 2.3 cm × 1 cm and the other measuring
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2 cm × 1.4 cm × 0.5 cm, with adherent thickened arterial
wall [Figure 5]. The large mass on its outer surgical margin
and surface was painted with green acrylic paint [Figure 6].
Serial sectioning of 0.2 cm size of the large mass was done. Cut
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surface of the large mass looked gray‑white with recanalized
Figure 5: Specimens of the removed thrombi which were the contents of
the pseudoaneurysm. Globular specimens showing grayish‑white surface
with an irregular surface adhered to the arterial wall
Figure 6: Cut surface of the large clot showing regular, yellowish
soft‑to‑firm surface with areas of necrosis
a b
Figure 7: (a) Section showing dense mixed infiltrative material scattered in the myxoid fibrocollagenous stroma (H and E, ×10), (b) Section of the
specimen showing various layers of the arterial wall along with mixed dense infiltrative material (encircled area) indicating inflammation and necrosis
(H and E, ×4), (c) Section showing the outer border of the wall of the pseudoaneurysm and mixed dense infiltrate indicating inflammation (H and E, ×4)
224 Indian Journal of Vascular and Endovascular Surgery ¦ Volume 10 ¦ Issue 3 ¦ July-September 2023
vessels that were embedded. Serial sectioning of the small mass
was also done, and the cut surface looked gray‑brown to white
with recanalized vessels that were embedded. Microscopic
examination of the sections of both the masses shows mixed
dense infiltrate and myxoid fibrocollagenous tissue, underlying
the adipose tissue and skeletal muscle fibers [Figure 7a‑c]. The
fibrocollagenous stroma shows extreme areas of hemorrhage and
formation of granulation tissue [Figure 8]. Hemosiderin‑laden
macrophages were seen accompanied by fibrinous exudate
which indicates secondary change in the left femoral artery
[Figure 9a and b]. Microbiological investigation of the clot
showed the presence of many pus cells and a few Gram‑negative
coccobacilli [Figure 10]. The culture revealed the growth of A.
baumannii. The patient was under observation until the surgical
site healed and then discharged. The postrecovery period was
uneventful.
Discussion
Pseudoaneurysms are a rare entity that generally occur due
to any endovascular procedures, blunt, or penetrating trauma
and can be associated with bone fractures and orthopedic
procedures.[14‑17] However, spontaneous pseudoaneurysms
that are of unclear etiology are rarer in occurrence, and until
now, only 12 such cases have been published in the English
literature.[18] The occurrence of spontaneous pseudoaneurysms
has been attributed to atherosclerotic changes by several
authors.[10‑12] A few suggest it to be due to vasculitis or connective
tissue disorder if occurring in young adults.[18] Spontaneous
pseudoaneurysms are considered to be medical emergency, as
they pose a great risk of skin necrosis, spontaneous rupture,
infection, arteriovenous fistula formation, and distal venous
embolization. The patients usually present with complaints of
pulsatile swelling, pain, and rarely black color necrotized skin
lesion.[19] Hence, it is necessary to diagnose appropriately and
treat it quickly to prevent the aforementioned complications.
Our patient here presented only a single pulsatile swelling for
8 weeks with no pain and no skin discoloration or lesions. Since
there is no history of trauma or any other risk factor that could
have led to this condition, we labeled the patient to have evolved
a femoral artery spontaneous pseudoaneurysm. Since the
patient had this swelling for a long duration, it shows secondary
changes, i.e., inflammation and deposition of hemosiderin
c
 Vardhan, et al.: Spontaneous femoral artery pseudoaneurysm: A case report and literature review
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Figure 8: Section showing the granulation tissue with fibrocollagenous
stroma and extreme areas of hemorrhage (H and E, ×10)
a b
Figure 9: (a) Section showing hemosiderin‑laden macrophages and
fibrinous exudate (H and E, ×40), (b) Section showing the wall of
pseudoaneurysm and the fibrous stroma infiltrated by pigment‑laden
macrophages, suggestive of long‑standing hemorrhage (H and E, ×4)
Figure 10: Microscopic examination of the clot, showing the presence of
Gram‑negative coccobacilli, Acinetobacter baumannii (Gram Stain, ×100)
pigment‑laden macrophages. Therapeutic or treatment options
include open surgical repair, ultrasound‑guided compression,
and repair using stent grafts. However, in young adults, surgical
exploration is done to identify and evacuate the hematoma.
Indian Journal of Vascular and Endovascular Surgery ¦ Volume 10 ¦ Issue 3 ¦ July-September 2023
This is followed by the repair of the artery either by arterial
suturing or by graft interpositioning. In our case, we used
graft interposition to repair the artery, where an end‑to‑end
anastomosis of the reversed GSV to the cut ends of the
superficial femoral artery was done.
Conclusion
Spontaneous pseudoaneurysms, though very rarely
encountered, must be considered a differential diagnosis for
any pulsatile swelling. The use of CT, magnetic resonance
imaging, sonography, Doppler, and angiography may all be
valuable in the imaging of pseudoaneurysms. Despite its
rarity, we must be aware and make sure that we make a prompt
and quick diagnosis of such pseudoaneurysms, to prevent its
complications or morbidities. A surgeon must also be aware of
the different choices of treatments. However, we must never
forget that surgical exploration and correction is considered
the gold standard. According to the patient’s need, condition,
and affordability, an optimal treatment is to be selected.
Acknowledgment
We extend heartfelt gratitude to Dr. Nandita Shinkre Banaji,
Professor & HOD, Department of Microbiology, IGMCR&RI,
for her constant motivation and invaluable guidance. We would
also like to acknowledge the patient and the family for allowing
us to use the medical records in our case report and allowing
this case to be published.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form, the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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