Limb Salvage Through Endovascular Repair of an Iatrogenic Superficial Femoral Artery Pseudoaneurysm Following Femoral Fracture Fixation

Vascular injury leading to pseudoaneurysm formation is a rare but potentially limb-threatening complication of lower limb trauma and postoperative recovery. We report a case of a 58-year-old man who developed progressive swelling of the right thigh one week after sustaining a road traffic accident and undergoing intramedullary nailing for a distal femoral shaft fracture. The swelling, initially presumed to represent a postoperative hematoma, progressed to cause severe tension and pain with early signs of threatened compartment syndrome. Upon transfer to our center, urgent surgical exploration for presumed hematoma evacuation revealed pulsatile bleeding suggestive of arterial injury. Computed tomography angiography, followed by invasive angiography performed the next morning, demonstrated a well-defined pseudoaneurysm arising from the superficial femoral artery, proximal to the knee joint. The following day, definitive endovascular repair was performed via an antegrade right femoral approach. A 7 × 80 mm covered stent graft (Covera™ Plus Vascular Covered Stent; BD-Bard Peripheral Vascular Inc., Tempe, AZ, USA) was deployed across the arterial defect and post-dilated with a 7 × 40 mm Ultraverse™ PTA balloon (BD-Bard Peripheral Vascular Inc., Tempe, AZ, USA), achieving complete exclusion of the pseudoaneurysm while maintaining normal distal perfusion. The procedure was completed under local anesthesia without complications. Postoperatively, the patient demonstrated rapid clinical improvement with marked reduction in thigh swelling, pain, and compartmental tension. Follow-up imaging confirmed stent patency and complete exclusion of the pseudoaneurysm. At three months, he had full functional recovery and was able to bear weight independently. This case underscores the importance of recognising vascular injury as a cause of progressive postoperative limb swelling, particularly when accompanied by increasing pain and tension suggestive of impending compartment syndrome. Early vascular imaging, including computed tomography angiography followed by confirmatory invasive angiography when necessary, is crucial for accurate diagnosis. Endovascular covered stent grafting provides a safe, minimally invasive, and limb-saving alternative to open surgery, allowing rapid hemostasis, preservation of arterial flow, and excellent long-term outcomes.