Delayed Diagnosis of a Late Vascular Complication after Total Hip Replacement
Article Outline
Abstract
We present a patient that was admitted with acute distal embolization in the popliteal and infragenicular arteries one year after total hip replacement. The embolization was caused by a pseudoaneurysm formed after a piece of bone cement had eroded the arterial wall. CT angiography failed to diagnose the pseudoaneurysm and it was eventually diagnosed intraoperatively. To our knowledge this is only the second report on this complication.
Keywords: Bone cement, Pseudoaneurysm, Embolization, Total hip replacement, Vascular complication
Introduction
Vascular complications in surgery are rare following total hip replacement (THR), delayed vascular complications even more so.1 Infrequency makes the diagnosis challenging. We report a case of a common femoral artery pseudoaneurysm complicated by distal embolization, a late complication one year after THR.
Report
A 75-year-old female with a history of right THR one year previously had complained of persistent discomfort in the hip and groin. Following a 10-day period of claudication she was admitted with acute-onset pain, pallor and paraesthesia. The femoral pulse was palpable, but the other pulses were not present in the right leg. Duplex ultrasound and multislice CT angiography confirmed popliteal and infragenicular arterial occlusion and patent common femoral, superficial femoral and profunda femoris arteries. Embolectomy was successfully performed through a below knee approach and she subsequently underwent an embolus work-up with a normal echocardiography and electrocardiogram. A second CT angiography revealed an intraluminal thrombus in the common femoral artery.
The artery was subsequently explored and arteriotomy exposed a large, circular, 1-cm defect in the artery with an intraluminal extension of thrombus from the pseudoaneurysm (Fig. 1). A free-lying piece of bone cement was found adjacent to the pseudoaneurysm and removed along with it. A short segment of the common femoral artery was resected and replaced by an 8-mm PTFE graft as the saphenous vein was of poor quality. The subsequent recovery was uneventful and the patient was discharged without any symptoms of claudication.
Figure 1
Common femoral artery with a circular defect in the arterial wall and protruding thrombus (arrow).
Discussion
Most arterial injuries will be apparent during or shortly following surgery, with pain, bleeding and/or ischemia due to thrombosis or emboli.2 Pseudoaneurysms may present late, as in the patient presented here: a piece of cement in close proximity to the femoral artery slowly eroded the arterial wall. Eventually intraluminal extension of the thrombus in the pseudoaneurysm led to arterial stenosis, claudication and finally embolization.
Arterial injury after THR is surprisingly rare considering the short distance from the rim of the acetabulum to the common femoral artery. In two large series the incidence of arterial injury was only 0.04–0.08% in total hip replacement,2, 3 with a somewhat higher incidence in revision surgery. Cement causing injury to the external iliac artery has been reported in a few cases, but to our knowledge this is only the second report on such an injury to the common femoral artery.1
An endovascular approach to this type of injury is feasible,4 but the long-term durability is a major concern as movement and metal fatigue may lead to stent failure. The common femoral artery is superficial, can be approached quickly and surgery may be performed under local anaesthesia. Therefore, in our opinion, open surgery is still the treatment of choice for injuries to this artery.
Persistent pain following THR is difficult to elucidate due to the multitude of extrinsic and intrinsic causes ranging from tendinitis to malignancy.5 Two multislice CT angiographies failed to diagnose the pseudoaneurysm, thus the patient underwent two operations, first for the embolectomy, later for a resection of the pseudoaneurysm. The piece of cement adjacent to the artery did not raise an alert, and artefacts from the hip prosthesis made it difficult to visualize the pseudoaneurysm on transverse images. Retrospectively, it can easily be appreciated on a sagittal reconstruction (Fig. 2).
Figure 2
CT angiography showing the pseudoaneurysm (arrow) and the adjacent piece of cement.
Even though vascular injury after THR surgery is rare, surgeons should be aware of this possibility when following up patients. Bone cement left in the soft tissues can give serious complications and the presence of this find on radiological exams combined with unexplained pain should alert the surgeon of the possibility for this rare complication.
Conflict of Interest
There is no conflict of interest.
Funding
N/A.
References
- . Faux anevrysme arteriel sur arthroplastie de hanche. a propos d'un cas. Revue de chirurgie orthopedique et reparatrice de l'appareil moteur. 2004 Jun;90(4):365–368
- . Acute arterial complications associated with total hip and knee arthroplasty. Journal of Vascular Surgery. 2003 Dec;38(6):1170–1177
- . Predictors of lower extremity arterial injury after total knee or total hip arthroplasty. Journal of Vascular Surgery. 2008 Apr;47(4):803–807discussion 7–8
- Endovascular repair of a pseudo-aneurysm of the common femoral artery after revision total hip arthroplasty. Emergency Radiology. 2007 Sep;14(4):233–236
- . The painful total hip replacement. Clinical Orthopaedics and Related Research. 2004 Mar;(420):18–25
PII: S1533-3167(09)00027-2
doi:10.1016/j.ejvsextra.2009.07.003
© 2009 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
- Delayed Diagnosis of a Late Vascular Complication after Total Hip Replacement , 28 August 2009
