Pseudoaneurysms are well described. However, pseudoaneurysms of the superficial femoral artery are rare and usually iatrogenic.

We describe a case of a 27-year-old patient who presented a week after trauma with a piece of iron lodged in the middle third of the thigh, a beating mass revealing a pseudoaneurysm of the superficial femoral artery.

We present a case of a 27-year-old patient, with no specific medical history, including no known elastopathy, who, one week before admission, accidentally received a piece of an iron bar in the middle and inner third of the right thigh when he manually banged on a piece of iron.

A week later, the patient noticed a gradually increasing mass to the point of trauma and became larger. He noticed that the mass throbbed and was painful to the touch.

On clinical examination, the patient was hemodynamically and respiratory stable. There was a swelling in the middle third of the right thigh on the path of the superficial femoral artery, beating on sight and palpation and measuring approximately 50 mm. There was a thrill on palpation. There was no spontaneous bleeding.

In addition, there was no sign of limb ischemia, all pulses were well perceived. The Doppler ultrasound performed confirmed a pseudoaneurysm of the superficial femoral artery of approximately 60 mm with an aspect of arteriovenous fistula of approximately 0.5 cm with the femoral vein (Figure 1). The standard radiography of the limb made had objectified the radio-opaque projectile lodged in the muscular masses (Figure 2).

Given the size of the mass and the imminent risk of rupture, the patient underwent urgent surgery. We approached surgically on both sides of the mass and effectively controlled the superficial femoral artery (Figure 3) a big hematoma with several thrombi. Examination of the wall of the superficial femoral artery revealed a lesion of approximately 1.5 cm (Figure 4). The arterial wall was neither infected nor inflamed, so we performed a direct suture of the arterial defect without using a venous graft. Postoperative courses were uneventful. The patient was discharged at day 4 without any complications. The Doppler control showed a good flow. Short- and mid-term follow-up did not reveal a recurrence or other anomalies.

Pseudoaneurysm is a collection of blood formed as a result of a vascular wound and retained in the tissues surrounding the breached vessel [1]. Pseudoaneurysm of the femoral artery is uncommon [2].

The most common cause of femoral pseudoaneurysm is iatrogenic (endovascular procedures, anastomotic failure) with an incidence of 0.6–4.8% [3]. The pathophysiology of the pseudoaneurysms is particularly linked to the mechanism. It is a dissemination of energy with an expansive wave with fragmentation of the projectile that damages the endothelium [4].

Most traumatic arterial pseudoaneurysms in the extremities are usually caused by blunt trauma. However, penetrating by sharp objects, such as knives, forks, and piece of glass may cause wounds and vascular trauma [5].

Extremity pseudoaneurysms are developed after penetrating trauma in 60% of arterial injuries [6].

Depending on the size of the pseudoaneurysms, some can cause compression of the structures in the surrounding area and can cause skin ischemia, hemorrhage, and even necrosis [3]. Doppler ultrasonography remains the gold standard for diagnosis, as it can also evaluate the size, anatomy, and origin of pseudoaneurysms.

In some cases CT scan can be indicated if we do not have a perfect description of all the lesions. In our case, Doppler ultrasonography was enough. The main complication to fear is rupture of the pseudoaneurysm especially if the size is important.

Pseudoaneurysm may remain asymptomatic for a long time and manifest with the perception of a pulsatile mass or thrill [7]. Medical management included compressive dressing, anticoagulation reversal, hypotensive resuscitation, and transfusion of red blood cells and fresh frozen plasma [1],[8].

Indications for repair include rapid expansion, infection, skin or soft tissue necrosis, neuropathy, distal ischemia, pain, or rupture [2]. In our patient it was a rapid expansion, the mass appeared week after traumatism but we did not notice any local complication.

Small pseudoaneurysms (less than 3 cm) may spontaneously thrombose. A conservative treatment can be suggested with continuous Doppler surveillance [2].

Femoral artery pseudoaneurysms that are symptomatic or larger than 2.5 cm should be repaired in order to prevent limb-threatening complications, such as rupture, thrombosis, or embolization [2],[8].

The management of pseudoaneurysms is possible either surgical repair or endovascular treatment. Some authors reported the possibility of in situ injection of thrombin [4].

Treatment of these false aneurysms with a covered stent has also been described, of course if the anatomical conditions are acceptable [7].

We present this case especially because of the mechanism of trauma which is surprising. Although the cases of pseudoaneurysm of the post-traumatic femoral artery are reported in rare cases but this mechanism described in our patient is particular as well as the anatomical lesions which resulted from it.

In our case the size of the pseudoaneurysm was 6 cm, the surgery was the only option to avoid complications.

Femoral pseudoaneurysms after traumatism are very rare and had many different mechanisms. The size of the pseudoaneurysm and the symptoms give us an idea about how to proceed. For the big pseudoaneurysms, surgery is the best choice and gives us more visibility to control the proximal and distal of the artery and avoid rupture.