Treating Rare mid femoral pseudoaneurysm after chronic total occlusion revascularization.

Abstract Background: Arterial pseudoaneurysms (PSAs) are rare complications of endovascular procedures.They are characterized by a defect in vessel wall layers which may result in severe pain, nerve compression or even hemodynamic instability. Treatment is dependent on the size of the lesion with larger defects at higher risk for expansion or rupture. Typical treatments include manual compression, thrombin injection or open vascular repair.Usually PSAs arise at puncture sites in the common femoral artery (CFA). In this case report, we present a unique scenario of a PSA resulting from endovascular repair of mid-superficial femoral artery (SFA) chronic total occlusion by re-entry from the sub-intimal space. This case describes use of a Viabahn covered stent to occlude a mid SFA PSA successfully. Case information: 73-year-old male with a history of severe COPD, ischemic heart disease, and 30-year history of smoking presented with severe left lower extremity claudication progressively worsening over the last year. Due to comorbidities, he was deemed too high risk for surgical bypass and instead, underwent a complex intervention requiring complete revascularization with angioplasty and stenting from a transpedal approach with contrast staining of the subintimal space. One week post-operatively, he presented back in the ER with severe mid-thigh pain. Arterial Doppler showed the patent left SFA stent, with a large PSA in the mid-left SFA at the prior location of subintimal injury during revascularization. A decision was made to attempt percutaneous covered stent placement to occlude the neck of the PSA. A Viabahn stent was deployed successfully across the PSA and within the previously placed Supera stent without complication. Post-dilation was performed with excellent final angiographic result that showed patency of the SFA with successful exclusion of the PSA. The patient had immediate improvement in pain and was back to baseline one week later. Conclusions: Although rare, PSAs found in the mid-SFA are an ideal location for correction with covered stent. Covered stents offer low risk and high reward rates, and identify a viable new treatment modality that could potentially replace the need for open surgical repair in the correct patient population. Additionally, this minimally invasive approach could be a viable treatment option for PSAs in locations not easily amenable for standard methods of repair.