Via Research Recognition Day Program VCOM-Carolinas 2025

Case Reports

Traumatic Peripheral Arterial Pseudoaneurysm with Associated AV Fistula following stab injury: Case Report and Review of Literature

Henry Knox, MS 1 , Paul Creger, DO 2 , Stephen McCloy, DO 2 , Faez Ayoob, MD 1. Edward Via College of Osteopathic Medicine – Carolinas Campus, Spartanburg, SC. 2. Spartanburg Medical Center, Department of General Surgery, Spartanburg, SC.

Introduction

Discussion

A pseudoaneurysm (PA) is a vascular abnormality following an insult to an arterial wall. These “false aneurysms” form when an arterial puncture site fails to heal. This incomplete seal leads to arterial blood leaking through the puncture site into neighboring tissues forming a pulsatile hematoma. Arteriovenous Fistulas (AVFs) are abnormal connections between an artery and vein. Most often found in military related injuries, AVFs are less common in civilians. Stab wounds and gunshot wounds are the most common causes of AVF formation. However, both abnormalities can result from iatrogenic injury secondary to peripheral artery catheterization, trauma (blunt or penetrating), or overlying inflammation and/or infection. In this case report, we discuss the association of the two pathologies and how their early diagnosis with diagnostic imaging and clinical decision making as well as early intervention are imperative for an optimal outcome. We present clinical, operative, radiographic, and histopathological findings to better understand this rare pathology. Our patient is a 72 year-old male who presented to the Emergency Department (ED) with pulsatile bleeding from a laceration to his leg from a stab wound. The ED provider closed the wound primarily, applied a pressure dressing and discharged the patient home. Approximately four weeks later, the patient returned to the ED reporting two weeks of increased swelling and erythema over the wound with an underlying pulsatile mass. After workup with CT angiogram with runoff, the patient was found to have a PA and AVF of the posterior tibial artery and vein as seen in Figure 1. The patient was taken to the OR for hematoma evacuation, evaluation of the PA, AVF ligation, and ligation of posterior tibial artery and vein as seen in Figure 2 and 3. Following ligation, retrograde flow was confirmed, and distal pulses were palpable Case Report

Early intervention with direct arterial repair and flow preservation has greatly reduced the rate of amputations. Many minor arterial injuries to the extremities are likely missed based on natural history & lack of standard screening. Late complications of missed arterial injuries include pseudoaneurysm, A-V fistula, and claudication following repair often a sign of hemorrhage or ischemia. Early surgical exploration and/or arteriography may result in fewer complications. Simultaneous repair of arterial and venous injuries resulted in fewer amputations and decreased edema post-op due to enhanced venous outflow. Endovascular repair has gained favor in the acute setting, however, open surgical repair remains the gold standard. Revascularization is done when possible and ligation where it is not. The decision to ligate depended on surgical evaluation, proximal and distal control of the vessels, intraoperative testing to ensure there is distal retrograde flow from collateral vessels and confirmation of distal perfusion. Conclusions Peripheral artery pseudoaneurysms and AVFs can arise from iatrogenic or traumatic causes. Both are amenable to treatment with open surgery or endovascular repair with comparable short- and long-term outcomes. Ligation of peripheral artery and/or vein is safe for the patient if appropriate evaluation has been completed to prevent critical limb ischemia post ligation.

Figure 1. CT angiogram of PA and AVF of posterior tibial artery and vein

Figure 2. Intra-operative visualization of PA and fistula after dissection .

References

1. Wang Y, et al. Management of traumatic peripheral artery pseudoaneurysm: A 10-year experience at a single center. Journal of Interventional Medicine . 2023;6: 29-34. 2. Zhao B, et al. Comparison of three different treatment methods for traumatic and Iatrogenic peripheral artery pseudoaneurysms. Orthopedic Surgery . 2022;14:1404-1412. 3. Henry JC, Franz RW. Pseudoaneurysms of the peripheral arteries. Int J Angiol . 2019;28:20 – 4. 4. Koza Y, Kaya U. Retrospective analysis of 120 cases of iatrogenic and traumatic peripheral arterial pseudoaneurysms. Eurasian J Med . 2020;52:180 – 4. 5. Asensio JA, et al. Traumatic penetrating arteriovenous fistulas: a collective review. Eur J Trauma Emerg Surg 2022; 48: 775 – 789. 6. Lenartova M, Tak T. Iatrogenic pseudoaneurysm of femoral artery: case report and literature review. Clin Med Res. 2003 Jul;1(3):243-7. doi: 10.3121/cmr.1.3.243. PMID: 15931315; PMCID: PMC1069051. 7. Sidawy, Anton N., Perler Bruce A. Elsevier Health Sciences; 2018. Rutherford’s Vascular Surgery and Endovascular Therapy, E -Book. 8. Bounssir A, Taghi H, Sedki N, Bakkali T, Lekehal B. Technical management of traumatic arteriovenous fistula: Tips and tricks. Int J Surg Case Rep. 2020;76:468-473. doi: 10.1016/j.ijscr.2020.10.016. Epub 2020 Oct 8. PMID: 33207412; PMCID: PMC7586047.

Figure 3. Intra-operative image showing results of ligation of posterior tibial artery and vein.

2025 Research Recognition Day

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