Enormous Articular Hemorrhage Following Arthroscopy, Total Joint Replacement and other Surgical Operations in Hemophilic Patients due to Arterial Pseudoaneurysms: Diagnosis and Treatment



Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain


Pseudoaneurysms in hemophilic patients are unusual. We must have a suspicion when the patient has suffered
an arterial trauma (following arthroscopy, total joint replacement and other surgical operations). Pseudoaneurysms
may take place in any anatomical zone where there has been trauma. The diagnosis must be verified by duplex
ultrasonography (US), standard angiogram, computed tomography angiogram or magnetic resonance angiography.
There are diverse alternatives for the management of arterial pseudoaneurysms. Small pseudoaneurysms can be
resolved with conservative noninterventional management. It includes outside pressing, US probe pressing or USguided
thrombin injections. In larger pseudoaneurysms, endovascular methods, such as coil embolization, are now
preferred. If the aforesaid methods are unsuccessful, standard surgical management with simple ligation or arterial
reconstruction must be carried out. We must suspect a pseudoaneurysm when, following an arterial trauma, there
is severe bleeding that does not stop with appropriate management with intravenous injection of the insufficient
coagulation factor. The diagnosis has to be verified by imaging. Endovascular tmethods, such as coil embolization, are
now preferred by the majority of physicians. The diagnosis and managment of an arterial pseudoaneurysm must be
carried promptly to avert adverse events.
Level of evidence: III


1. Rodriguez-Merchan EC. Pseudoaneurysms in
haemophilia. Blood Coagul Fibrinolysis. 2013;
2. Ferreira V, Matos A, Rego D, Gonçalves J, Teixeira G,
Antunes I, et al. Percutaneous treatment pseudoaneurism
of the hand in hemophilic patient. Rev Port
Cir Cardiotorac Vasc. 2017;24(3-4):178.
3. Lokey HA, Phelps DB, Boswick 3rd JA. Traumatic false
aneurysm of the hand in hemophilia. J Trauma. 1978;
4. Fields JM, Saluja S, Schwartz DS, Touloukian RJ, Keller
MS. Hemophilia presenting in an infant as a radial
artery pseudoaneurysm following arterial puncture.
Pediatr Radiol. 1997; 27(9):763.
5. Harkin DW, Connolly D, Chandrasekar R, Anderson
M, Blair PH, Hood JM, et al. Radial artery mycotic
pseudoaneurysm in a haemophiliac: a potentially fatal
complication of arterial catheterization. Haemophilia.
2002; 8(5):721-4.
6. Clerico C, Benatar M, Dumontier C. Radial artery
pseudoaneurysm: a rare complication after
arthroscopic treatment of a volar wrist ganglion in a
hemophilia patient. Chir Main. 2014; 33(5):361-3.
7. Vora S, Ibrahim T, Rajadurai VS. Radial artery
pseudoaneurysm in a neonate with hemophilia A.
Indian Pediatr. 2014; 51(11):921-3.
8. Thomas BP, Fouzia NA, Raveendran S, Pallapati SR, 
Abraham A, Srivastava A. Management of hemophilic
cysts and pseudotumors of the hand in bleeding
disorders: a case series. J Hand Surg Am. 2018;
9. Gopal A, Aranson N, Woo K, Clavijo L, Shavelle DM.
Recalcitrant peroneal artery pseudoaneurysm in a
patient with hemophilia B. Cardiovasc Revasc Med.
2013; 14(6):359-62.
10. Kickuth R, Anderson S, Peter-Salonen K, Lämmle B,
Eggli S, Triller J. Hemophilia A pseudoaneurysm in a
patient with high responding inhibitors complicating
total knee arthroplasty: embolization: a cost-reducing
alternative to medical therapy. Cardiovas Intervent
Radiol. 2006; 29(6):1132-5.
11. Kotwal RS, Acharya A, O’Doherty D. Anterior tibial
artery pseudoaneurysm in a patient with hemophilia:
a complication of ankle arthroscopy. J Foot Ankle Surg.
2007; 46(4):314-6.
12. Sadat U, Naik J, Hayes PD. Surgical complications in a
hemophilia patient with factor VIII inhibitor and their
endovascular management. Vasc Endovascular Surg.
2008; 42(2):168-72.
13. Saarela MS, Tiitola M, Lappalainen K, Vikatmaa P,
Pinomäki A, Alberty A, et al. Pseudoaneurysm in
association with a knee endoprothesis operation in an
inhibitor‐positive haemophilia A patient–treatment
with local thrombin. Haemophilia. 2010; 16(4):686-8.
14. Park JJ, Slover JD, Stuchin SA. Recurrent hemarthrosis
in a hemophilic patient after revision total knee
arthroplasty. Orthopedics. 2010; 33(10):771.
15. Kumar R, Pruthi RK, Kobrinsky N, Shaughnessy WJ,
McKusick MA, Rodriguez V. Pelvic pseudotumor and
pseudoaneurysm in a pediatric patient with moderate
hemophilia B: successful management with arterial
embolization and surgical excision. Pediatric Blood
Cancer. 2011; 56(3):484-7.
16. Drew M, Yu JC, Michaels LA. Arterial pseudoaneurysms
in haemophilia: conservative treatment with
observation and factor replacement. Haemophilia.
2011; 17(3):550-2.
17. Rodriguez‐Merchan EC, Jimenez‐Yuste V, Gomez‐
Cardero P, Rodriguez T. Severe postoperative
haemarthrosis following a total knee replacement in
a haemophiliac patient caused by a pseudoaneurysm:
early treatment with arterial embolization. Haemophilia.
2014; 20(1):e86-9.
18. Chamseddin KH, Kirkwood ML. Anterior tibial artery
pseudoaneurysm following ankle arthroscopy in a
hemophiliac patient. Ann Vasc Surg. 2016; 34:269-e17.