Isolated Atherosclerotic Aneurysm of the Profunda Femoris Artery
Article Outline
True aneurysms of the profunda femoris artery are extremely rare in comparison to pseudoaneurysms of the same artery. In most cases they are accompanied by aneurysms of the abdominal aorta or peripheral vessels. The most common reason for aneurysmic dilatation of vessels is a generalized vascular degenerative process. An isolated true aneurysm of the profunda femoris artery due to atherosclerosis is markedly unusual. These aneurysms have a high incidence of complication; therefore surgical management is mandatory for all diagnosed cases regardless of whether they are symptomatic or not. We describe a case of a 73-year-old man with a large isolated atherosclerotic aneurysm of the profunda femoris artery. He presented with an enlarging, progressively debilitating mass in his upper thigh. Ultrasound and computed tomography-angiography demonstrated a 15 × 14 cm large aneurysm of the profunda femoris artery. The patient was successfully treated by aneurysm neck ligation and sac decompression.
True aneurysms of the femoral artery are relatively uncommon and attributed to weakening of the arterial wall due to atherosclerosis. Femoral aneurysms are often bilateral and frequently accompanied with aortic, iliac, and popliteal aneurysms.1, 2, 3, 4 They are sometimes diagnosed as a part of arteriomegaly, which is defined as diffuse vessel enlargement involving several arterial segments below the level of renal arteries.5 Patients presenting with femoral aneurysms are typically elderly men (>65 years old) with a decades-long history of smoking and hypertension. Although femoral aneurysms can remain asymptomatic lifelong, in the majority of cases they present with local symptoms due to enlargement, rupture, thrombosis, or embolization of distal vessels. Cutler and Darling classified femoral aneurysms according to their relationship to the common femoral artery bifurcation as type I and type II.6 Type I is confined to the common femoral artery, whereas type II aneurysms extend from common femoral to the proximal parts of the superficial and deep femoral artery. Isolated aneurysms of the profunda femoris artery (PFA) are exceedingly rare and account for 0.5% of all peripheral aneurysms.7 The diagnosis of small and asymptomatic aneurysms is very difficult because they are hidden deep in the thigh under the adductor muscles. Therefore, most of these aneurysms are disclosed after growing large and developing complications. Ultrasonography is an effective diagnostic tool to distinguish aneurysms from other groin masses, although computed tomography-angiography (CTA) remains the best imaging method to precisely define the exact site and length of arterial involvement. Due to the high incidence of complications, PFA aneurysms should be treated surgically once diagnosed, even if they are asymptomatic.8, 9
Case Report
A 73-year-old man was referred to the general surgeon for a suspected right-sided incarcerated groin hernia. The patient had had an inguinal hernia repair 8 years previously. He noticed a progressively enlarging mass during the last 3 months and suspected reappearance of the hernia. The swelling doubled in size during the last week and became debilitating painful. He was a former heavy smoker (40 cigarettes a day for 35 years) being treated for arterial hypertension (atenolol, fursemid), chronic obstructive pulmonary disease (teophylline), and chronic gastritis (ranitidine). There was no history of past or recent trauma of the groin or hip region or of vascular or orthopedic procedures. He practiced walking on regular daily basis and had no claudications. His family history revealed cardiovascular diseases.
An ultrasound examination showed a tumorous formation in the right groin that represented a large aneurysm of the femoral artery. It was connected to the common femoral artery by a short neck and extended laterally and distally, compressing adjacent structures and compromising venous circulation. Based on this finding, the patient was admitted to the vascular surgery department. On physical examination, the tense pulsating formation appeared to involve the groin and anterolateral aspect of the thigh. It was tender on palpation and even slight movements of the leg were painful. Sensory and motor functions of the extremity were intact. Both feet were warm with palpable femoral, popliteal, and dorsalis pedis pulses and absent posterior tibial pulses. The capillary refilling in toes was fast. The patient was circulatory stable. Red blood cell count, inflammatory parameters, and coagulation tests were within normal range. Serum tests for syphilis were negative. An urgent CTA showed a huge, partially trombosed aneurysm of the deep femoral artery (Fig. 1). The superficial femoral artery (SFA) was stretched over the medial aspect of the aneurysm and was patent as well as popliteal and anterior tibial arteries. Posterior tibial and peroneal arteries were not visible. There were no signs of aneurysmic dilation of the abdominal aorta, iliac arteries or lower extremity vessels except for the right PFA.
Fig. 1
CTA image of the profunda femoris artery aneurysm. SFA, superficial femoral artery; T, thrombosed part of the aneurysm; L, contrast-filled lumen of the aneurysm. Arrows indicate the size of the aneurysm.
Under general anesthesia, the right groin was explored through a medial longitudinal incision. A 15 × 14 cm aneurysm of the PFA was identified, involving the main trunk, beginning 10 mm after the origin of the vessel. After clamping the neck, the aneurysm was opened. Two-thirds of the cavity was filled with a thrombus. All branches were occluded and there was no back bleeding. The patent SFA allowed a simple PFA ligation and partial resection of the aneurysm without the need for vascular reconstruction. Histopathologic examination showed a typical atherosclerotic aneurysm. The culture of the thrombus from within the aneurysmal sac remained sterile.
The postoperative course was uneventful and the patient was discharged on the fifth postoperative day. During the 2-year follow-up, he remained free of symptoms.
Discussion
Aneurysms of the PFA are extremely rare.2, 3, 4, 10, 11, 12, 13, 14 It seems that its course deep inside the muscular compartment of the thigh protects this artery from different factors important for atherosclerotic degeneration. In contrast to heavily calcinated and narrowed common and superficial femoral arteries, PFA mostly remains soft and patent with signs of atherosclerotic degeneration limited only to its origin. This is attributed to the fact that it is working against low peripheral resistance and it is not involved in repeated bending as occurs with vessels located close to the joints like femoral or popliteal arteries. The majority of pathologic changes of this artery results from iatrogenic injuries secondary to diagnostic or therapeutic vascular or orthopedic procedures.15, 16 The usual consequence is a false aneurysm.
True aneurysms are practically always the result of a primary disease of vessel walls, with atherosclerosis being the most important as a natural attendant of aging. Other possible causes of arterial dilations are syphilitic and mycotic infections, metabolic dyscrasia with abnormal elastin production, and vasculitis as a part of an autoimmune disease.17, 18, 19 All of these mentioned pathologic processes usually involve vessels all over the body. Finding an isolated atherosclerotic aneurysm of the artery that is generally immune to atherosclerotic plaque formation is markedly unusual. The real incidence of true aneurysms of the PFA is undoubtedly underestimated. Smaller aneurysms of PFA are likely to stay undetected due to their deep location. The importance of PFA aneurysms lies in fact that approximately half of them will present with rupture or rapid enlargement, which predisposes them to rupture. That makes them more dangerous than aneurysms of the superficial femoral or popliteal artery.1, 20 However, the real incidence of thromboembolic complications, typical for popliteal aneurysms, remains unclear. Even if they occur, they mostly stay clinically silent because they do not affect the viability of the leg unless a SFA occlusion is also present.
Due to the scanty knowledge of the natural history and to the high incidence of complications, PFA aneurysms should be treated operatively once diagnosed. The aim of the surgery is to eliminate the aneurysm and to maintain or restore limb perfusion. The ideal surgical repair consists of aneurysm resection with graft replacement, using vein or prosthetic material.3, 7, 8, 9, 21 Flow restoration is mandatory in the case of SFA occlusion. An acceptable alternative is a femoropopliteal grafting procedure in addition to aneurysmal neck ligation. Simple ligation and resection is allowed only in cases of a patent SFA, as in our case. Minimally invasive techniques of transcatheter embolization have also been successfully used in the management of the ruptured PFA aneurysm and reported results were comparable to those of classic surgical procedures.22
References
- Clinical significance of arteriosclerotic femoral artery aneurysms. Arch Surg. 1980;115:502–507
- . Solitary arteriosclerotic aneurysm of the profunda femoris artery. J Cardiovasc Surg. 1973;14:220–222
- . True aneurysm of the profunda femoris artery. Literature review, differential diagnosis, management. J Cardiovasc Surg. 1987;28:701–705
- . Isolated atherosclerotic aneurysm of the profunda femoris artery. J Cardiovasc Surg. 1980;21:498–500
- Arteriomegaly: classification and morbid implications of diffuse aneurysmal disease. Surgery. 1983;93:700–708
- . Surgical management of arteriosclerotic femoral aneurysms. Surgery. 1973;74:764–773
- . Arteriosclerotic femoral artery aneurysms: A short review. J Cardiovasc Surg. 1997;38:335–338
- True profunda femoris aneurysms: Are they more dangerous than other atherosclerotic aneurysms of the femoropopliteal segment?. Ann Vasc Surg. 1991;5:92–95
- A. Isolated true atherosclerotic aneurysm of the profunda femoris artery. J Cardiovasc Surg. 1999;40:577–581
- . Isolated true atherosclerotic aneurysms of the deep femoral artery. Case report and literature review. J Cardiovasc Surg. 1996;37:17–20
- Rupture of a true profunda femoris artery aneurysm. Br J Surg. 1993;80:721–722
- . Atherosclerotic aneurysm of the deep femoral artery. Eur J Vasc Surg. 1992;6:450
- . Atherosclerotic aneurysm of the deep femoral artery. Eur J Vasc Surg. 1992;6:226
- Atherosclerotic aneurysm of the deep femoral artery. Acta Chir. Scand. 1987;153:137–142
- . Traumatic arteriovenous fistulas and false aneurysms. A review of 558 lesions. Surgery. 1975;78:817–828
- . A false aneurysm of the deep femoral artery. Acta Chir. Scand. 1982;148:201–202
- . Sci Am. 1982;247:110–123
- Vascular manifestations of Behçet′s disease. Int Angiol. 1989;8:145–150
- . Iliac and femoral aneurysms. In: Horrocs M editors. Arterial aneurysms. London: Butterworth Heinemann; 1995;
- A review of 147 popliteal aneurysms with long-term follow-up. Surgery. 1981;90:1009–1014
- . True aneurysm of the profunda femoris artery. EJVES Extra. 2001;21:1–2
- Management of ruptured true profunda femoris artery aneurysms. EJVES Extra. 2002;4:55–57
PII: S0890-5096(09)00337-9
doi:10.1016/j.avsg.2009.09.014
© 2010 Annals of Vascular Surgery Inc. Published by Elsevier Inc All rights reserved.
