Endovascular management of iatrogenic complex multilobular femoral artery pseudoaneurysm with arteriovenous fistula: a rare case report

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Abstract
Purpose: Complications developing after interventional procedures performed via the femoral artery are usually limited to a single pseudoaneurysm (PA) sac; however, the coexistence of a multilobular complex PA with arteriovenous fistula (AVF) is an extremely rare clinical entity. In this case report, we present the endovascular management of this complex iatrogenic vascular injury that developed following atrial fibrillation (AF) ablation therapy. Case presentation: The patient, with a 25 year history of AF and medically refractory recurrent palpitations, underwent cardioversion; however, sustained rhythm control was not achieved. AF ablation was performed. Within several days after the procedure, the patient developed groin pain, swelling, hematoma, and an audible thrill, prompting re-evaluation and advanced imaging. Doppler ultrasonography (US) and Computed Tomography angiography (CTA) revealed a large-neck multilobular PA originated from superficial femoral artery (SFA) composed of multiple interconnected lobes, accompanied by a dynamic high-velocity early arteriovenous shunt at the same level. The patient underwent endovascular treatment and after confirmation of a suitable landing zone, a covered stent–graft was successfully deployed to exclude both the PA neck and AVF tract. At six-month follow-up, Doppler US demonstrated sustained stent patency, complete PA resolution, and no residual AVF. Conclusion: This case demonstrates the effectiveness of covered stent–graft repair in the management of rare but clinically significant vascular complications following femoral artery vascular access. The combination of a multilobular PA and AVF presents unique therapeutic challanges; however, endovascular treatment offers a minimally invasive and effective solution. Successful exclusion of both lesions in a single session highlights the value of contemporary endovascular techniques in managing complex vascular injuries.

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