Pseudoaneurysm of the lateral circumflex femoral artery following direct anterior approach total hip arthroplasty—a case report

Total hip arthroplasty (THA) is a well-established procedure for end-stage hip osteoarthritis, with the direct anterior approach (DAA) gaining popularity among surgeons and patients alike. Given the close proximity of important vessels during this approach, vascular injury, including pseudoaneurysm formation, remains a rare but potentially serious complication. A systemic literature review by Alshameeri et al. showed two-thirds of vascular injuries were diagnosed intraoperatively or within the first post-operative week, and none were associated with the DAA.¹

However, there was one reported case of DAA THA with a pseudoaneurysm of the distal third of the external iliac artery and active bleeding of the proximal common femoral artery.² A separate article reported three cases of vascular injury of the common femoral artery following THA with DAA. It also highlighted that penetration or laceration was the most common form of vascular injury during THA, with the common femoral artery being the vessel most often affected.³

In both case reports they describe all patients undergoing open surgical repair of their common femoral artery injuries.^2,3

We report the case of a lateral circumflex branch of the profunda femoris artery pseudoaneurysm following DAA THA, managed by endovascular intervention with embolisation.

Case report

We present the case of an 88-year-old male who underwent primary left THA for osteoarthritis via DAA, with a background of peripheral vascular disease. The operation was uneventful, with an estimated blood loss of 150mL. He was mobilised post-operatively with routine venous thromboembolism prophylaxis and discharged.

He re-presented on day 5 post-surgery with thigh swelling and symptomatic anaemia, with haemoglobin dropping from 112 to 85g/L. He remained haemodynamically stable on initial review and throughout his hospital admission. Following full workup to rule out other causes, further imaging was organised. Initial ultrasound revealed a 19x4x9cm haematoma in the anterior compartment of the thigh. Subsequent computed tomography angiogram (CTA) showed contrast pooling, suggesting ongoing arterial bleeding with the possibility of a pseudoaneurysm. A further ultrasound was then obtained to better evaluate and differentiate the CTA findings. This showed bidirectional flow on colour Doppler imaging with swirling of blood, also known as the yin-yang sign.⁴ The ultrasound scan suggested that the pseudoaneurysm was most likely arising from the lateral circumflex branch of the profunda femoris artery.

On day 10 the patient underwent embolisation. Live fluoroscopy confirmed that the pseudoaneurysm was indeed arising from the lateral circumflex artery. The pseudoaneurysm was embolised with two coils. Following this intervention he made a full recovery with no further concerns and subsequently had an uneventful contralateral THA, also utilising the DAA.

Discussion

During superficial dissection for the anterior approach, the plane between the sartorius and tensor fascia latae is developed. The ascending branch of the lateral circumflex artery is consistently found through the bed of rectus femoris following superficial dissection. This is often ligated with surgical hand ties and diathermy.

In this case there was no apparent intraoperative vascular injury, and blood loss was within the expected range. The delayed presentation of this case suggests possible failure of ligation to the vessels as the cause of his pseudoaneurysm or inadvertent injury with medial retractor placement on pre-existing atherosclerotic vessels.

Those undertaking the DAA must be cognisant of the close proximity of the femoral neurovascular bundle. Meticulous superficial and deep dissection with haemostasis is paramount. Ligation of vessels done adequately and careful retractor placement during surgery can minimise vascular injuries during or post-THA.³ Noting the patient’s pre-existing atherosclerosis as part of their medical history is also vital in peri-operative planning and vascular assessments post-operatively. DAA THA is not contraindicated in patients with pre-existing vascular disease; they may need to be closely monitored in the post-operative period.

This case underscores the importance of monitoring for vascular complications following DAA THA, even in the absence of intraoperative concerns. Although vascular complications post-THA are rare, with a reported incidence of <0.2%,⁵ healthcare professionals should maintain a high suspicion for pseudoaneurysm formation in patients with unexplained post-operative pain, haematoma or haemoglobin decline. This case shows that endovascular embolisation remains a safe and effective treatment, enabling excellent recovery and functional outcomes. Endovascular embolisation is the preferred treatment modality for artery pseudoaneurysms, offering a minimally invasive approach with excellent outcomes. Early detection and intervention are crucial to prevent complications such as haematoma expansion, neurovascular compromise or limb ischaemia.