Behavior-driven management of femoral artery pseudoaneurysms: two contrasting case reports and literature review

Introduction and importance: Femoral artery pseudoaneurysms (FAPs) remain a frequent complication of percutaneous catheterization. Conventional algorithms based solely on lesion diameter may overlook clinical instability. Case presentation: We report two contrasting cases: a 6-mm FAP in a patient on dual antiplatelet therapy, complicated by hemoglobin drop, infection, and Angio-Seal failure requiring staged reconstruction, and a 27-mm FAP in an anticoagulated patient successfully treated with early surgical repair and uneventful follow-up. Clinical discussion: These cases demonstrate that dynamic lesion characteristics such as duplex flow patterns, skin integrity, antithrombotic burden, and closure device performance provide superior guidance for therapeutic decision-making compared with size thresholds alone. Conclusion: A behavior-driven framework may allow earlier recognition of high-risk lesions and guide timely intervention. Prospective multicenter validation is warranted.