European Journal of Cardiovascular Medicine

Peripheral arterial pseudoaneurysms (PAPs) are false aneurysms characterized by a disruption in the arterial wall, resulting in a hematoma contained by surrounding tissue that maintains continuity with the arterial lumen. Unlike true aneurysms involving all three arterial layers, PAPs lack a complete vessel wall, rendering them more prone to rupture, thrombosis, and distal embolization.

With the increasing frequency of endovascular and catheter-based procedures, the incidence of PAPs has risen, particularly due to iatrogenic causes. Studies consistently report femoral artery pseudoaneurysms as the most common type, often resulting from post-catheterization vascular access. For instance, Koza and Kaya found 83.3% of PAPs in their cohort to be iatrogenic, while Jaiswal et al. reported 46.9%. Trauma and intravenous drug use are also recognized causes, particularly in regions with high rates of interpersonal violence or substance abuse, as highlighted by Randimbinirina et al.

Clinically, PAPs typically present as a pulsatile mass, often accompanied by localized pain, a palpable thrill, or skin changes such as necrosis. While the femoral artery is most frequently involved, radial and brachial artery pseudoaneurysms are increasingly reported due to wider adoption of trans radial access in cardiovascular interventions.

Duplex ultrasound remains the first-line diagnostic tool given its high sensitivity and bedside utility. Computed tomography angiography (CTA) provides superior anatomical detail in complex cases or when planning surgical intervention. Management depends on size, location, symptoms, and risk of complications. Small, asymptomatic PAPs may resolve spontaneously or with ultrasound-guided compression. Larger, symptomatic, or complicated pseudoaneurysms often require surgical repair, although minimally invasive techniques such as thrombin injection and endovascular stenting are emerging options.

Despite advances in diagnostic and therapeutic modalities, robust data guiding optimal management remain limited, especially in resource-limited settings. Most existing literature is based on small, retrospective case series, limiting the generalizability of findings.

This multicenter retrospective study aims to bridge this gap by analyzing the clinical profile, etiology, management strategies, and outcomes of PAPs treated at tertiary care centers in Northern India. Through systematic documentation and outcome tracking, this study seeks to inform evidence-based practices tailored to high-burden, resource-constrained environments.

Study Design and Setting

This retrospective observational study was conducted at two tertiary care centers in Eastern India.This study aimed to evaluate the clinical profiles, underlying etiologies, treatment modalities, and outcomes of patients diagnosed with peripheral arterial pseudoaneurysms (PAPs).

This study was designed to reflect real-world clinical practice and management patterns.

Study Duration

This study included patients treated between January 2020 and December 2023. Follow-up data were collected up to June 2024 to ensure adequate evaluation of clinical outcomes and late complications.

Study Population

A total of 43 patients with a confirmed diagnosis of peripheral arterial pseudoaneurysm were included. The diagnosis was based on clinical examination andall patients underwent CT angiography

Inclusion Criteria

Adult patients aged 18 years and above, who were diagnosed with a peripheral arterial pseudoaneurysm and underwent either conservative or surgical management at one of the study centers, were included. Patients were eligible only if they had complete clinical and imaging documentation and had given consent for follow-up, either prospectively or via telephonic review.

Exclusion Criteria

Patients with pseudoaneurysms involving visceral arteries, those with known connective tissue disorders associated with vascular fragility, or those with incomplete medical or imaging records were excluded. Additionally, patients who were lost to follow-up before initiation of definitive treatment were not included in the final analysis.

Data Collection

Data were extracted from inpatient case records, operative notes, imaging archives, and discharge summaries. A structured proforma was used to capture patient demographics (age, sex, and comorbid conditions such as diabetes, hypertension, coronary artery disease), clinical features at presentation (including pulsatile mass, pain, thrill, bleeding, skin changes, fever), underlying etiology (iatrogenic, traumatic, or due to intravenous drug abuse), anatomical location (femoral or radial artery), and imaging modality used. Treatment details including the type of conservative or surgical approach, intraoperative findings, and postoperative course were recorded. Outcomes assessed included complications such as limb ischemia, wound-related issues, need for reoperation, and mortality. Follow-up status was also documented.

Definitions

Peripheral arterial pseudoaneurysm (PAP) was defined as a contained arterial wall disruption with blood flow between the arterial lumen and a surrounding hematoma or sac. Conservative management was considered successful if there was spontaneous thrombosis or resolution of the pseudoaneurysm with ultrasound-guided compression without need for surgery. Surgical success was defined by complete resolution of the lesion with limb preservation and no requirement for repeat intervention.

Management Protocol

Pseudoaneurysms smaller than 3 cm in size and without complications such as bleeding, infection, or necrosis were initially offered conservative treatment, which included clinical observation and serial imaging.

If spontaneous thrombosis occurred, no further treatment was required. In patients where conservative management failed or where the lesion was large, painful, infected, or causing skin compromise, surgical treatment was undertaken. Surgical techniques varied depending on the site, extent of vessel involvement, and patient comorbidities.

At the femoral site, options included arterial control with excision and either ligation or repair. In the radial location, primary repair was preferred, with arterial ligation used selectively. In one patient with a history of intravenous drug abuse and extensive vessel damage, graft reconstruction was performed.

Follow-up Protocol

Post-treatment follow-up was conducted at intervals of 2 weeks, 1 month, 3 months, and 6 months. Follow-up evaluation included clinical examination for wound healing, distal perfusion, and limb function. Doppler ultrasound was performed in selected patients to assess vascular patency and flow characteristics. Patients who failed to return for in-person follow-up were contacted via telephone to assess adverse events, limb salvage, or need for reintervention.

Statistical Analysis

Descriptive statistics were used to summarize patient demographics, clinical characteristics, and outcomes.Categorical data, such as sex, symptoms, etiology, site of involvement, and treatment modality, were expressed as counts and percentages.Continuous variables, such as age and lesion size, are presented as means and ranges.

Due to variability in sample sizes and methodologies across similar published studies, formal comparative statistical testing was not performed; instead, comparative interpretation was provided narratively in the discussion.

Table 1: Baseline Characteristics, Clinical Presentation, and Etiology (n = 43)

Demographic and Clinical Profile

In the present study comprising 43 patients, the mean age was 55 years, with a clear male predominance (72.1%). This reflects the typical demographic undergoing cardiovascular interventions and predisposed to vascular complications. Comorbid conditions were notably prevalent, with coronary artery disease being the most common (90.7%), followed by hypertension (51.2%) and diabetes mellitus (20.9%). A small proportion of patients had chronic kidney disease (2.3%) and chronic obstructive pulmonary disease (4.7%).

Presenting Symptoms and Etiology

The most frequent presenting symptom was a pulsatile mass, seen in 97.7% of cases, making it a nearly universal finding in this cohort. Pain was the second most common symptom, reported by 65.1% of patients. Other findings included thrill in 14%, fever in 4.7%, bleeding in 2.3%, and skin changes suggestive of necrosis or discoloration in 7%. The etiology was predominantly iatrogenic, accounting for 95.3% of cases, typically following catheter-based vascular interventions. Only one case each was attributed to trauma and intravenous drug abuse, highlighting the procedural nature of pseudoaneurysm development in this population.

Anatomical Distribution and Size

Femoral artery involvement was seen in 72.1% of patients, making it the most affected site, consistent with traditional femoral access routes in interventional cardiology. Radial artery pseudoaneurysms were identified in 27.9% of cases, likely reflecting increased use of transradial approaches. The size of pseudoaneurysms ranged from 2×2 cm to 19×10 cm. Conservative management was attempted in eight patients with pseudoaneurysms less than 3 cm in diameter. Among these, six underwent successful spontaneous thrombosis, one required ultrasound-guided compression, and one failed conservative therapy, necessitating surgical intervention.

Surgical Management and Outcomes

Surgical treatment was the mainstay in this cohort. Of the 31 femoral pseudoaneurysms, 30 underwent surgery, including two cases that required control at the common femoral artery and two that needed additional debridement for necrosis. One patient, with a history of intravenous drug use, received a vascular graft. Radial artery pseudoaneurysms were treated with primary repair in ten cases and arterial ligation in two. Complications were infrequent, with only three cases of skin necrosis reported. There were no incidences of limb ischemia or postoperative mortality, and outcomes were generally favorable. Of the total patients, 23 completed six months of follow-up, while five were lost to follow-up.

Peripheral arterial pseudoaneurysms (PAPs) are increasingly recognized as significant vascular complications, particularly in the context of rising interventional procedures. Our study, encompassing 43 patients from two tertiary care centers in Northern India, provides insights into the demographic patterns, clinical presentations, etiologies, and management outcomes of PAPs, with a focus on femoral and radial artery involvements.

Demographics and Etiology

The mean age of patients in our cohort was 55 years, with a male predominance (72.1%). A significant majority (95.3%) of the pseudoaneurysms were iatrogenic, primarily following cardiac catheterization procedures. This trend aligns with findings from Luther et al., who reported a substantial number of femoral arteries pseudoaneurysms post-catheterization. In contrast, a study by Sinha et al. highlighted trauma as a leading cause of PAPs in their series, indicating regional variations in etiology.

Clinical Presentation

Table D: Comparative Presentation of Symptoms Across Studies

Clinically, 97.7% of our patients presented with a pulsatile mass, and 65.1% reported pain at the site. Thrill was appreciable in 14% of cases, while skin changes, including necrosis, were observed in 7%. These findings are consistent with other studies where pulsatile masses and localized tenderness were predominant symptoms. However, the incidence of skin necrosis and bleeding was relatively lower in our cohort, possibly due to early detection and intervention.

Management Strategies

Management of PAPs in our study was stratified based on the size and location of the aneurysm. Conservative management was successful in 8 patients with pseudoaneurysms less than 3 cm, with spontaneous thrombosis observed in 6 cases. One patient required ultrasound-guided compression, and another failed conservative therapy, necessitating surgical intervention. Surgical exploration was performed in 30 femoral artery cases, with procedures including clot evacuation and arterial repair. Radial artery pseudoaneurysms were managed with primary repair in 10 cases and ligation in 2 cases. Notably, there was no postoperative mortality or limb ischemia reported.

Comparatively, Luther et al. reported a higher rate of surgical interventions, including ligation and excision, with a notable incidence of postoperative wound infections (36%) and limb amputations (8%) . The lower complication rates in our study may be attributed to prompt diagnosis and tailored management approaches.

Outcomes and Follow-Up

Out of the 38 patients who underwent treatment, 23 (60.5%) completed a 6-month follow-up without complications. The absence of postoperative mortality and limb ischemia underscores the efficacy of our management protocols. In contrast, studies focusing on traumatic pseudoaneurysms have reported higher complication rates, emphasizing the importance of etiology in prognostication.

Comparative Analysis with Other Studies

When juxtaposed with other regional studies, our findings highlight the evolving landscape of PAPs in India. The predominance of iatrogenic causes in our cohort reflects the increasing number of interventional procedures. In contrast, studies from regions with higher trauma prevalence report different etiological patterns. Furthermore, the success of conservative management in select cases aligns with global trends favoring less invasive approaches when appropriate.

Our study reinforces the significance of early detection and individualized management of peripheral arterial pseudoaneurysms. The favorable outcomes observed, including low complication rates and high treatment success, advocate for a stratified approach based on aneurysm characteristics and patient comorbidities. As interventional procedures continue to rise, awareness and prompt management of PAPs will be crucial in mitigating associated morbidities

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