1. Pseudoaneurysm of Lower Extremity Robert Benzl MS4 August 2013 Jordan Tasse MD, Konrad Bienia MD

2. 82 y/o female L THA in 5/2011, c/b periprosthetic fracture, s/p plate fixation, c/b infection and stem loosening, s/p proximal femoral replacement as single stage revision with chronic suppressive abx therapy on 6/12/2013. 7/19/2013, on routine follow up she was noted to have left thigh swelling. Patient stated she had not been taking suppressive antibiotics as recommended. Patient was started on Bactrim. 8/2/13, patient presented to OSH for acute onset left thigh pain/swelling/anemia (Hb to 7.8). Pt transferred the night of 8/5/13 to Rush after initial workup and management. Patient History 2

3. Labs 8/5/13: – WBC 11.6, Hb 8.7 (s/p 7 units pRBC) – platelets 146,000 – INR 1.2, ptt 24.6 – fibrinogen 309 – D-dimer 21,560 – Creatinine of 1.17 CXR 8/5/13: wnl VQ scan 8/2/13: For chest pain. Low probability for PE. LE Doppler 8/2/13: No DVT. Angiogram not obtained 2/2 elevated creatinine CT hip: 8/3/13: Large soft tissue density in post aspect of thigh 13.9X8.3X30. No fracture. OSH Findings 8/5/13 3

4. Left Thigh - Mid Diaphysis CT - Soft Tissue Window - Axial

5. Left Thigh - Mid Diaphysis CT - Soft Tissue Window - Axial

6. CONSTITUTIONAL: – awake, alert, cooperative, in pain. HEENT: – no JVD. LUNGS: – Good air entry, no added sounds. CARDIOVASCULAR: – Normal S1 & S2, no murmur. ABDOMEN: – Soft, nontender. L Lower ext: – In neutral position. healed lateral incision from hip along thigh, with significant surrounding ecchymosis and induration. Warm, tender to palpation. Maximal around hip. Unable to move extremity 2/2 pain. Pulses palpable. Physical Exam 6

7. Acute bleed/hematoma Soft tissue infection Femur fracture Arterial aneurysm Sarcoma DDx 7

8. Imaging Options 8 CT (soft tissue mass) LE Duplex US (negative for DVT)  X-Ray  Ultrasound  MRI  Angiography

9. Imaging X-Ray Femur MRN 6582667

10. Imaging X-Ray Left Femur (distal) MRN 6582667

11. Major X-Ray positives/negatives: Soft tissues demonstrate diffuse swelling Prosthetic components in their expected position. No periprosthetic fracture distal to the femoral rod. Periosteal reaction and callus formation and suggestion of a prior oblique femoral fracture. No radiopaque foreign bodies. Next diagnostic modality:  Ultrasound (bleed/hematoma highest on ddx). Imaging Options 11

12. Sample Hematoma Case (not our patient) There is well-defined collection noted in subcutaneous plane which is compressible. Lesion is anechoic with thin septa within. Thin but well-formed capsule is seen. http://radiopaedia.org/cases/soft-tissue-haematoma-of-thigh soft tissue density F 70. Blunt trauma to thigh - 15 days. C/o local swelling - 5 days. X-Ray Ultrasound

13. Left Lateral Thigh Ultrasound Heterogeneously echogenic mass within the subcutaneous tissues extending along the lateral left thigh from just below the hip to the level of the knee.

14. Left Lateral Thigh Ultrasound Color Doppler demonstrates no internal vascularity. No communicating vessels are demonstrated. Mass measures at least 20 centimeters in length by 15 cm in transverse dimension.

15. Imaging Options 15 Given clinical picture and diagnostic imaging thus far, there is high suspicion for a bleed into thigh compartment. Next chosen modality:  Angiography – can potentially localize bleed and offer therapeutic intervention.

16. Left External Iliac Artery Angiogram

21. Pseudoaneurysm located off of lateral branch from profunda femoris artery.

22. Left External Iliac Artery Angiogram Responsible vessel embolized with metallic coils (white arrow).

23. Pseudoaneurysms 23 Following arterial injury, communication may persist with hematoma and arterial lumen. The resulting hematoma is contained within surrounding soft tissues. Commonly found as pulsating soft tissue masses, diagnosed clinically or with color duplex ultrasound. Most commonly associated with prior interventional procedure that required arterial access. Incidence is linked in inadequate time of pressure applied for homeostasis following sheath removal. In our case, ultrasound study did not show arterial communication with the soft tissue mass, nor was it noted to be pulsating on exam. Angiography did demonstrate communication of arterial lumen with soft tissue space/hematoma.

24. Follow Up 24 IR drain placement via ultrasound guidance the next day. Continued improvement, wound cultures NTD. Patient dc’d to skilled nursing facility.