At admission, he was complaining of spasm in the right foot, difficulty in walking erect, and distension in the right lower abdominal quadrant. Physical examination revealed a pulsatile mass in the right lower quadrant. An arterial Doppler ultrasonography showed a 53x28 mm pseudoaneurysm in right external iliac artery (Figure 1). Closure of aneurysm by compression and thrombin injection under ultrasonographic guidance failed. Thus, a surgical intervention was scheduled. Meanwhile, the aneurysm continued to grow in size. The patient was taken into operation under general anesthesia in appropriate position. A right flank and femoral incisions were made and joined. Femoral artery was exposed first, followed by aneurysm exploration via retroperitoneal approach (Figure 2). Near-full thickness injuries and dissections were detected in many parts of right external iliac artery up to the level of internal iliac artery. Following control of the iliac arteries with a vascular tape, aneurysmectomy was performed after 5000 IU intravenous heparin injection. A 90x50 mm pseudoaneurysm sac was removed (Figure 3). As severely dissected, the external iliac artery was excised. Since the common iliac artery was extremely fragile, we planned to perform an aortofemoral bypass by means of the abdominal incision. Abdominal aorta was controlled by abdominal incision. Aorto-femoral bypass was performed via retroperitoneal approach using a 6 mm polytetrafluoroethylene graft. Surgical layers were closed anatomically. Postoperative course was uneventful.

Figure 1: Doppler ultrasonographic view of pseudoaneurysm.

Figure 2: Intraoperative view of pseudoaneurysm.

Figure 3: Sac of pseudoaneurysm (90x50 mm).

Furthermore, endovascular therapy has some challenges related to iliofemoral access, despite the ever improving logistics provided by advancing stent graft technology and delivery platforms. Murray et al.[8] in a systematic review of studies on endovascular access techniques performed between 1994 and 2005, reported that majority of access problems are brought about by overly tortuous iliac arteries, circumferential vessel wall calcification, severe vessel obstruction, and small vessel caliber. It is usually not possible to use covered endovascular stent grafts, since there is a significant size mismatch between the common and external iliac arteries.[9]

The success and complication rates of non-surgical treatments of this pathology are heavily dependent on the width and length of pseudoaneurysm neck.

In conclusion, conventional surgical approach remains the gold standard for the management of pseudoaneurysms, although endovascular techniques and ultrasonographically-guided vessel compression and thrombin injection are increasingly used.[10,11] The primary surgical approach should be aneurysmectomy and arterial reconstruction. End-to-end anastomosis or primary repair with an appropriate graft should be performed, where possible.

Declaration of conflicting interests
The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding
The authors received no financial support for the research and/or authorship of this article.

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