Pseudoaneurysm and subsequent venous thromboembolism after subintimal angioplasty for chronic total occlusion in the superficial femoral artery

Abstract Endovascular therapy (EVT) has been accepted as a minimally invasive treatment for peripheral artery disease, and its applicability has been widened with the development of techniques and devices. A long, totally occluded lesion in the superficial femoral artery (SFA) is one of the most challenging lesions for EVT due to technical difficulties in wire-crossing. Recently, intentional subintimal recanalization is often considered as an alternative option for long SFA occlusions. Previous studies have shown that subintimal approach achieved superior technical success rate and similar patency rate, compared to conventional intraluminal approach. However, there is limited information about complications of the treatment with subintimal approach. Deep vein thrombosis (DVT) due to direct compression by pseudoaneurysm in the SFA, which subsequently develops pulmonary embolism (PE), is considered as a rare complication of subintimal angioplasty for the occlusive SFA lesion. We herein present a case of a patient who developed pseudoaneurysm formation in the SFA after EVT. Although initial EVT was performed successfully with subintimal approach, DVT and PE were caused by the SFA pseudoaneurysm at sub-acute phase following the initial procedure. The pseudoaneurysm was treated with implantation of a covered stent sealing the entry point, disappearing with no endoleak.