The femoral neuralgia syndrome after arterial catheter trauma

The femoral neuralgia syndrome after arterial catheter trauma John W. HaUett, Jr., MD, Seth W. Wolk, MD, Kenneth J. Cherry, Jr., MD, Peter Gloviczki, MD, and Peter C. Pairolero, MD, Rochester, Minn. The increasing number of diagnostic angiograms and interventional vascular procedures has resulted in a heightened awareness of serious catheter-related vascular trauma. We reviewed 50 consecutive catheter injuries of the femoral artery that required surgical intervention and focused specifically on their long-term outcome. The most common traumatic lesion was femoral pseudoaneurysm (60%) followed by uncontrolled hemorrhage (23%) and arterial thrombosis (17%). The most frequent chronic complaint of these patients was the femoral neuralgia syndrome affecting 15 of 50 patients (30%). Typically, these patients complained of postcatheterization pain in the groin, which radiated down the anteromedial thigh (anterior femoral cutaneous nerves), and was associated with residual hyperesthesias. The neuralgia gradually improved in 6 weeks to I year in most patients. Chronic pain, however, necessitated multiple visits to a pain clinic or physical therapy unit in four patients (27%) and resulted in unemployment in three (20%). We conclude that current catheter-related arterial injuries are commonly associated with a chronic femoral cutaneous neuralgia syndrome that has not been emphasized previously. (J Vasc SvgG 1990;11:702-6.)

During recent long-term follow-up of catheterrelated femoral artery injuries, we recognized that the most common late problem after surgical repair was chronic groin and thigh pain. This persistent pain syndrome represented significant late morbidity for some individuals. Review of previous papers on femoral artery injuries after angiography revealed minireal late postsurgical follow-up in most series and no mention of this particular late sequela. Ha In this paper we describe the characteristics of the femoral neuralgia syndrome after angiographic catheter trauma, discuss its probable causes, and recommend measures to minimize and treat this relatively common complication.

We recently identified retrospectively 50 consecutive catheter-induced injuries of the femoral artery that occurred after diagnostic and therapeutic angiography and required surgical repair between 1986 and 1988 at the Mayo Medical Center. In this same 2-year period, diagnostic and therapeutic angiograms

were obtained in 8874 patients with cardiac problems and in 8344 patients with various peripheral vascular conditions. The following descriptive data on the entire 80 injuries and the neuralgia subset were collected: age, gender, indication for catheterization, nature o f the arterial injury, and type of operative management including anesthesia, surgical technique, and transfusion requirements. We talked directly with eveu late survivor by telephone or personal interview to delineate any long-term extremity problems. Followup ranged from a minimum of 12 months to a maximum of 36 months. When we discovered that the most common late problem (Table I) was persistent lower extremity pain, we ascertained in detail the location, severity, treatment, and current status of all patients with this particular complication. By use of the Pearson chi-square analysis and Fisher's exact test, we compared the characteristics of the patients with (n = 15) and without (n = 35) the femoral neuralgia syndrome after arterial catheter trauma.

From the Section of Vascular Surgery, Mayo Clinic. Presented at the Thirteenth Annual Meeting of the Midwestern Vascular Surgical Society, Chicago, I11., Sept. 29-30, 1989. Reprint requests: John W. Hallett, It., MD, Section of Vascular Surgery, The Mayo Clinic, Rochester, MN 55905. 24/6/19749

RESULTS Fifteen of the 50 patients (30%) with catheter injuries of the femoral artery experienced the femoral neuralgia syndrome. There were 12 women and three men with a mean age of 63 years (range 48 to 82

METHODS

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Table I. Late morbidity in 50 consecutive catheter-related injuries of the femoral artery (N = 50) No.(%) Femoral neuralgia syndrome Delayed wound healing Ischemic neuropathy of the foot New daudication Total

15 4 2 I 22

703

AV

(30%) (8%) (4%) (2%) (44%)

years). The characteristics were paroxysmal groin pain radiating down the anteromedial thigh toward the knee and associated with hyperesthesias of the thigh (Fig. 1). Only one patient noted quadriceps musde weakness. Patients rated the pain as severe in five cases and mild to moderate in the remaining I0.

knterior emoral LJtaneous

Indication for catheterization The most common indication for femoral catheterization in patients with femoral neuralgia had been diagnostic coronary angiography (n = 8, 53%), followed by coronary balloon angioplasty (n = 6, 40%), and one transvenous right ventricular biopsy associated with an adjacent femoral artery injury. Although 14% (7/50) of all femoral artery injuries among the 50 patients in the study were caused by peripheral angiography or angioplasty, none of the patients with the femoral neuralgia syndrome had peripheral arterial studies or intervention. Type o f injury Pseudoaneurysm was by far the most common traumatic lesion associated with subsequent femoral neuralgia (13/15, 87%). One patient had femoral artery thrombosis, and one other was operated on to control ongoing hemorrhage. Pseudoaneurysm occurred more frequently in those patients with femoral neuralgia syndrome than it did in those patients who did not have neuralgia (87% versus 60%,p = 0.064, NS). Operative management Over the 2-year study period, several different surgeons performed the various operations. Eight patients (53%) required general anesthesia whereas the remaining seven were managed under local anesthetic injection or regional epidural or spinal anesthesia. Nearly all (n = I3, 87%) of the patients had direct suture of the puncture site after hematoma evacuation. The one patient with femoral artery thrombosis underwent a Fogarty thrombocmbolec-

Fig. 1. Distribution of pain, paresthesias, and hyperesthesias in patients with femoral cutaneous neuralgia syndrome after catheter injury of the femoral artery.

tomy and arterial patch angioplasty. One other patient required a synthetic femoral interposition graft. Seven patients (47%) received homologous blood transfusions in the operating room or in the early postoperative period. No specific mention was made in any operative report of problems with the adjacent femoral nerve. Late outcome The neuralgia gradually improved in 6 weeks to 1 year in all patients, but every patient was left with either some residual medial thigh paresthesias or hyperesthesias. Chronic pain neccssitated multiple visits to a pain clinic or physical therapy unit in four pa-

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H a l l e t t et al.

Table II. Type of catheterization associated with 50 catheter-related injuries of the femoral artery No femoral neuralgia N = 35 (%)

Type of catheter study Coronary angiogram Coronary balloon angioplasty Cardiac valvuloplasty Peripheral angiogram Peripheral balloon angioplasty Venticular biopsy Type of postcatheterization arterial lesion Pseudoaneurysm* Uncontrolled hemorrhage Thrombosis

14 9 5 4 3

(40) (26) (14) (11) (9)

Femoral neuralgia N = 15 (%)

p value

8 (53) 6 (40)

NS NS

1 (7) 21 (60) 8 (23) 6 (17)

13 (87) 1 (6.5) 1 (6.5)

0.064 NS NS

~q~here was a trend that those patients with chronic femoral neuralgia syndrome were more likely to have a pseudoaneurysm (87%) than patients who had no neuralgia (60%) (p = 0.064). NS, not significant.

Table III. Operative management of 50 catheter-related injuries of the femoral artery

Type of anesthesia General Local or regional Type of arterial repair Direct suture Thromboembolectomy -+ patch Graft interposition Blood transfusion Yes No

No femoral neuralgia

Femoral neuralgia,

p

N = 35 (%)

N = 15 (%)

value

24 (69) 11 (31)

8 (53) 7 (47)

NS NS

26 (74) 8 (23) 1 (3)

13 (87) 1 (6.5) 1 (6.5)

NS NS NS

24 (69) 11 (31)

7 (47) 8 (53)

0.144

NS, not significant. *There was a trend toward more blood transfusion in patients without chronic femoral neuralgia.

tients (27%) and resulted in unemployment in three patients (20%). Comparison with all femoral artery injuries The most striking difference between patients with postcatheterization femoral neuralgia syndrome and other patients sustaining postcatheterization femoral artery trauma but free from neuralgia was the predominance of pseudoaneurysms in the patients with neuralgia (n = 13, 87%). In all other respects the two groups did not differ significantly (Tables II and III). DISCUSSION Numerous articles and a reccnt monograph on iatrogcnic vascular injuries have focused on the etiology, management, and early complications of catheter-induced arterial trauma. 1~3 These reports emphasize the following immediate complications: major bleeding, arterial thrombosis and embolization, pseudoaneurysm, arterial dissection, arteriove-

nous fistula, contrast toxicity, and fragmentation of catheters. They rarely report any late follow-up beyond 30 days. In this study, which intentionally focused on long-term complications, we discovered that the chief chronic complaint of patients with catheter-related arterial trauma was a femoral neuralgia syndrome. The postcatheterization femoral neuralgia syndrome typically has the three components: paroxysmal posrtraumatic groin pain, radiating down the anteromediaI thigh (femoral cutaneous nerve distribution) (Fig. 1), and associated with hyperesthesias. The antecedent traumatic lesion is a femoral pseudoaneurysm in nearly every case. This neuralgia primarily involves the anatomic territory of the two anterior femoral cutaneous branches of the femoral nerve ~4,1s (Fig. 2). These cutaneous branches originate from the femoral nerve just below the inguinal ligament. The i n t e r m e d i a t e branch divides into two fibers that pierce the fascia lata in the anterior midline of the thigh over the sartorius musde. These fibers

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rein

Cutaneous brs.

~udo~urysrn

Sartorius m. Intermediate and medial :utaneous nerves of thigh Sartori

Fig. 2. Anatomy of anterior cutaneous branches of the femoral nerve. The intermediate branches penetrate the sartorius muscle to supply the front of the thigh. The medial branches supply the medial thigh to the knee. often pass through the sartorius to reach the fascia. They are distributed downward over the front of the thigh as far as the knee. The other medial branch of the anterior cutaneous femoral nerve gives off twigs that pierce the fascia lata close to the saphenous fossa ovalis and supply the skin over the upper medial thigh. Others pierce the fascia lata in the middle and lower thirds of the thigh to become subcutaneous close to the greater saphenous vein and supply the anterior medial thigh as low as the knee. With one exception, the femoral motor intervention of the quadriceps muscle group was not a component of this femoral neuralgia in our 15 patients. The sparing of the motor components of the femoral nerve in this syndrome is intriguing and probably explained by the deeper and safer anatomic course of the motor fibers. In contrast, the cutaneous fibers pass more superficially into and through the sartorius muscle, which is usually compressed and stretched by the pseudoaneurysm. The cutaneous fibers are also more exposed to disturbance by electrocautery, selfretaining wound retractors, and suture closure. Several mechanisms of injury may disturb the cu-

Fig. 3. Mechanism of femoral neuralgia syndrome after catheter-induced pseudoaneurysm of the femoral artery. Compression, stretching, or late perineural fibrosis may disturb the cutaneous branches of the femoral nerve. taneous branches of the femoral nerve and result in the femoral' neuralgia syndrome that may follow catheter-related trauma of the femoral artery. Direct injury of the cutaneous branches of the femoral nerve by a misdirected percutaneous attempt at femoral artery puncture is one possibility. Stretching of the cutaneous nerve fibers by hematoma or pseudoaneurysm is a more likely cause since we have noted femoral neuralgia in patients with unoperated groin hematomas (Fig. 3). Operative stretching of the cutaneous branches by serf-retaining retractors may also contribute to the problem. In large pseudoaneurysms, these retractors often stretch the sartorius muscle through which some of these cutaneous branches pass. Direct or conducted heat injury by electrocautery is another possible mechanism of injury. Strangulation of nerve fibers by suture closure of the groin incision is also possible. Finally, some degree of nerve entrapment by incisional scar tissue may play a role. Since moit patients afflicted by postcatheterization femoral neuralgia had pseudoaneurysms, some type of stretch injury to the cutaneous branches of the femoral nerve seems to be the most probable cause. Can femoral neuralgia be prevented? This ques-

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tion is obviously the key inquiry to our findings, but it is not easy to answer. A certain degree of anterior femoral cutaneous neuralgia can occur after any groin incision over the femoral artery. For most patients it is transient. Since the femoral neuralgia noted after catheter-induced femoral pseudoaneurysms can follow a more severe course, the obvious solution is prevention of false aneurysms by better compression of the arterial puncture site after the catheter is removed from the femoral artery. Early repair ofpseudoaneurysms before they expand to large sizes, likewise, seems appropriate. Modifications of operative technique may also minimize the problem: avoidance of hot cautery near the cutaneous nerve branches, gentle use of self-retaining retractors, and nonstrangulating suture closure of the subcutaneous groin tissues. If femoralcutaneous neuralgia syndrome occurs, what is optimum management? First, the surgeon should inquire about any neuralgia in the early postoperative period and perhaps mention its possibility to the patient. If neuralgia occurs, the patient needs a reassuring explanation of its probable cause and the likelihood of gradual resolution. Severe neuralgia may require early and sustained intervention by a pain clinic. In some cases we have noted significant relief of peripheral neuralgias with low-dose tricyclic antidepressants at bedtime (e.g., amitriptyline 25 mg). Occasionally, a local femoral nerve block over a "pain point" will help. For those patients with neuralgias that impair ambulation or other activity (e.g., driving), physical therapy may be necessary. For all patients with catheter-related femoral neuralgia, reassurance and time are key ingredients for eventual recovery. The authors gratefiilly acknowledge the editorial assistance of Gall Prechel, the statistical analysis by James Naes-

sens, MPH, and Peter O'Brien, Phi), the anatomic illustrations by John Desley, and the critical review by Thomas C. Bower, MD. REFERENCES

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