A pseudoaneurysm (false aneurysm) is a swelling in an artery which does not contain all layers of the normal arterial wall. The swelling consists of adventitial tissue (the outermost layer) lined with layered thrombus (clot). Femoral pseudoaneurysms occur as a result of previous endovascular procedures (e.g. diagnostic arteriogram, angioplasty, cardiac catheterization), vascular trauma, or following open vascular surgery (e.g. aortobifemoral bypass, femoro‐popliteal bypass). Pseudoaneurysms following previous vascular surgery are often associated with vascular graft infection and require debridement (removal) of infected tissue and often complete or partial graft removal. This review will only consider pseudoaneurysms following endovascular procedures.

Pseudoaneurysms result from poor haemostasis (failure to control blood flow) at the time of the initial treatment, i.e. inadequate compression of the puncture site after withdrawing the catheter/sheath or failure to use a closure device. Frequently these patients are anticoagulated (receiving anti‐clotting therapy) or have a coagulopathy (clotting disorder) and this may compound the problem. Pseudoaneurysms are reported to occur in one per cent of diagnostic arteriograms and up to eight per cent of therapeutic endovascular interventions (Eternad‐Rezai 2003). Symptoms include pain, swelling and bruising in the groin area. Duplex ultrasound is the diagnostic test of choice and demonstrates a high velocity jet on colour flow imaging through a defect in the arterial wall. A proportion of small pseudoaneurysms may spontaneously clot over time and active observation is therefore an option. For those pseudoaneurysms that need treatment, surgery has traditionally been considered as the 'gold standard'. This may require simple suture of the defect after evacuation of the haematoma (blood‐filled swelling) or a patch angioplasty (surgical repair using a patch).

Ultrasound‐guided compression is now increasingly used as a therapeutic tool to avoid the need for surgery. Compression with the ultrasound probe at the site of communication between the false aneurysm and the native artery abolishes flow through the arterial wall allowing thrombosis of the aneurysm sac to occur. Patients will require effective analgesia and/or sedation in order to tolerate the procedure, which involves compression for 10 minutes at a time repeated for up to 60 minutes. Success rates of 63 to 88% have been reported (Morgan 2003).

A number of studies have reported successful thrombosis of femoral pseudoaneurysms using Duplex ultrasound‐guided percutaneous bovine thrombin injection (Edgerton 2002; Friedman 2002; Kruger 2003; Lonn 2002; Sackett 2000). This can be performed as an outpatient procedure. Thrombin in a concentration of 1000 U/ml is injected slowly into the pseudoaneurysm, with thrombosis frequently occurring within five seconds (Eternad‐Rezai 2003). The reported dose needed is between 20 U and 6000 U (Eternad‐Rezai 2003; Olsen 2002). A primary success rate of 95 to 98% has been reported (Maleux 2003; Mohler 2001). Thrombin injection can be associated with immediate complications such as thrombosis of the native artery, and rarely venous thrombosis. Delayed reperfusion of the aneurysm may occur in six per cent of cases (Olsen 2002). A potential problem with the use of bovine thrombin may be contamination with prions (protein‐related infectious agents, thought to be responsible for transmission of some degenerative diseases). One study has overcome this risk by using autologous thrombin prepared from patients' blood for treatment of pseudoaneurysms (Quarmby 2002).

A recent study described the use of para‐aneurysmal saline in the treatment of femoral pseudoaneurysms, i.e. injection of saline around the communication between the false aneurysm and the native artery, abolishing blood flow (Gehling 2003). Endovascular treatment methods such as coil embolization (using a coil to encourage formation of a blood clot, thus filling the aneurysm) or stent‐grafts (a prosthetic tube lying within the artery) have also been used to treat femoral pseudoaneurysms (Morgan 2003).

This review aims to explore the evidence for the efficacy of these treatment modalities in the treatment of femoral pseudoaneurysms.