Rapid Review·Cardiovascular
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Vascular: Peripheral
T2High yieldFemoral Artery Disease
Focus on
Three groin masses after (or without) a catheterization: a painful pulsatile mass with a systolic bruit days after femoral access is a pseudoaneurysm (thrombin injection); a continuous machinery bruit with leg swelling is an arteriovenous fistula (repair); a painless pulsatile mass in an atherosclerotic patient is a true femoral aneurysm (repair when > 3 cm or symptomatic).
Key takeaways
Overview
Why it matters
the femoral artery is the access site for most percutaneous procedures, so its complications are common exam material.A true aneurysm site
it is the second most common site of peripheral true aneurysm (after the popliteal).Telling them apart
all three lesions are a groin mass with a bruit.- Pain separates pseudoaneurysm (painful) from true aneurysm (painless).
- The bruit's timing separates fistula (continuous) from the others (systolic).
| Femoral artery pseudoaneurysm | Femoral arteriovenous fistula | Femoral artery aneurysm | |
|---|---|---|---|
| What it is | A hematoma outside the artery, in continuity with the lumen, bound only by fibrous tissue or adventitia (no true wall); the most common site of pseudoaneurysm | An iatrogenic channel between the femoral artery and vein | Dilation surrounded by all three wall layers |
| Cause | Femoral cannulation (about 1 percent of catheterizations; inadequate post-procedural compression is the strongest risk factor); trauma; spontaneous is very rare | Iatrogenic (most common): access for percutaneous procedures; penetrating trauma | Atherosclerosis and arterial wall weakening in older patients; may coexist with abdominal or thoracic aortic aneurysms |
| Presentation | Painful pulsatile groin swelling after the procedure, pain out of proportion, systolic bruit or thrill | Initially asymptomatic; vibratory sensation, continuous bruit and thrill in the groin (a pulsatile swelling may be present); chronic: limb edema, lower-extremity ischemia, high-output heart failure (High Output Heart Failure) | Painless pulsatile mass at the mid-inguinal point, sometimes thigh pain; acute limb ischemia if it thromboses; deep vein thrombosis or nerve compression; rupture with pain, ecchymosis and shock |
| Diagnosis | Duplex ultrasound; CT or magnetic resonance (MR) angiography if unclear | Doppler ultrasound | Duplex ultrasound; CT or MR angiography for size and planning |
| Management | Small and mild: observe; ultrasound-guided thrombin injection first line when 3 cm or more, symptomatic, or on anticoagulants; surgical repair in selected cases | Small: observe (many close); symptomatic, large or persistent: surgical repair | Small: observe; over 3 cm or symptomatic: open surgical repair (endovascular in selected cases) |
| Complications | Rupture, thromboembolism, infection, compression of adjacent structures | Distal ischemia, hyperdynamic circulation and high-output failure, arterial degeneration | Rupture, thromboembolism, infection, compression |
Pearls
The access-site complications
the Catheterization vascular complications separates them: hematoma (no bruit), pseudoaneurysm (systolic bruit), fistula (continuous bruit), distal ischemia, retroperitoneal bleed.A hematoma without a bruit
after catheterization it is just a hematoma.Femoral aneurysms come in company
check for an abdominal aortic aneurysm and popliteal aneurysms (bilateral in half).Prevention of access complications
Technique
puncture over the femoral head under ultrasound guidance, adequate compression or a closure device, bed rest, control of anticoagulation.Radial access
avoids most of them.The day after cardiac catheterization, a patient has a painful pulsatile groin swelling with a systolic bruit; duplex shows a 3.5 cm pseudoaneurysm. What is the first-line treatment, and what finding would suggest an arteriovenous fistula instead?
Femoral artery pseudoaneurysm over 3 cm: ultrasound-guided thrombin injection is first line. An arteriovenous fistula has a continuous bruit (not systolic) and, when chronic, limb edema and high-output heart failure.
How it's tested
Three days after coronary angiography a patient has a tender pulsatile groin mass with a systolic bruit: femoral pseudoaneurysm — duplex; ultrasound-guided thrombin injection if ≥ 3 cm or symptomatic.
Same patient but the groin is swollen and bruised without a mass, BP 88/50 and back pain: retroperitoneal hemorrhage from a high stick — CT, fluids and blood.
A continuous machinery murmur in the groin with a swollen warm leg months after femoral access: arteriovenous fistula — duplex, then repair.
A 72-year-old smoker with a painless pulsatile mass in the groin and a 5-cm abdominal aorta: femoral artery aneurysm (with AAA) — repair when ≥ 3 cm or symptomatic; check the popliteals.
Sudden cold pulseless foot in a man with a known femoral aneurysm: thrombosis or embolization — heparin and revascularization (Acute Limb Ischemia).
Go deeper
Guidelines: 2024 ACC/AHA Peripheral Artery Disease Guideline
Related Step 2 pages: Approach to Leg Pain & Ulcers, Acute Limb Ischemia, Abdominal Aortic Aneurysm, High Output Heart Failure, Acute Coronary Syndrome, Cholesterol Embolism Syndrome
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