Annals of Vascular Surgery
Volume 24, Issue 4 , Pages 553.e13-553.e16, May 2010

Delayed Presentation of Popliteal Pseudo-aneurysm Following Soccer Football Injury

  • Y.C. Chan

      Affiliations

    • Corresponding Author InformationCorrespondence to: Y.C. Chan, MB, BS, BSc, MD, FRCS(England), FRCS(General Surgery), Division of Vascular and Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, South Wing, 14th Floor K Block, Queen Mary Hospital, Pokfulam Road, Hong Kong.
    • ,
  • A.C. Ting
    • ,
  • K.X. Qing
    • ,
  • S.W. Cheng

Division of Vascular and Endovascular Surgery, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong

published online 25 January 2010.

Article Outline

Development of pseudo-aneurysm of the popliteal artery usually results from trauma, infection, or iatrogenic causes after orthopedic operations. This is to our knowledge the first reported case in the world's literature of a delayed presentation of a large above-knee popliteal artery pseudo-aneurysm following a soccer football injury. The pseudo-aneurysm severely compressed the native artery, and open exploration with surgical vein-patch repair of the artery was chosen in preference to endovascular stent-graft in view of the compressive symptoms and large size of the chronic pseudo-aneurysm. This case highlights the importance of imaging such as duplex ultrasound, computed tomography, or magnetic resonance angiography if symptoms persist after sports injury.

 

Traumatic pseudo-aneurysm of the popliteal artery is rare and may result from penetrating or blunt trauma, endovascular surgery,1 invasive diagnostic or surgical orthopedic procedures, or perigenicular neoplasia.2 If it occurs after sports injury, the impact of the mechanical force must be significant.3, 4 Since the popliteal artery is a deep-seated structure, it is not uncommon for the patient to present late, with the presence of a mass or compression symptoms.

We present the case of a patient who presented with a large above-knee popliteal artery pseudo-aneurysm 6 months after blunt trauma sustained during a soccer football game. This was successfully managed with open exploration, evaculation of the large pseudo-aneurysm, and vein-patch repair of the arterial defect.

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Case Report 

A 15-year-old boy with an aspiration to become a professional footballer sustained injury to the left knee while playing a competitive soccer football game at school. The precise mechanism of injury was unclear, but he noticed immediate and progressively worsening pain and swelling above and medial to the left knee and was unable to continue with the game. Emergency left femur and knee radiograph did not show any fractures or joint dislocation. He was managed conservatively with rest, ice pack, compression, physiotherapy, and simple analgesia.

Despite the improvement in the pain, he noticed a progressive swelling over the medial aspect of the distal left thigh. However, he did not seek any medical attention until 6 months later, when the swelling was obviously much bigger and was associated with some discomfort on flexing the left knee. He presented to the orthopedic surgeons, and on clinical examination, the left knee was found to be normal but there was a pulsatile expansile mass of about 12 × 8 cm in the medial aspect of the left thigh. A magnetic resonance angiogram confirmed the presence of a large pseudo-aneurysm arising from the above-knee popliteal artery, severely compressing the artery (Fig. 1).

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  • Fig. 1 

    Magnetic resonant angiogram of the distal left thigh (A–D: cranial to caudal) showing the large pseudoaneurysm arising from the above-knee popliteal artery, severely compressing the artery. The popliteal artery distal to the pseudoaneurysm was normal.

Different treatment options were discussed with the patient and his parents. As the pseudo-aneurysm was very large and compressing the popliteal artery, endovascular stent-grafting may not be successful and then had the risk of thrombosis or migration. The patient opted for open surgical repair with resection of the pseudo-aneurysm. During the operation, a percutaneous antegrade angiogram was performed of the left leg, which confirmed the position of the neck of the pseudo-aneurysm and the presence of distal run-off vessels. The above popliteal artery was exposed via the medial approach, and after adequate proximal and distal control, the sac was entered. The contents of the pseudo-aneurysm were evacuated, and the arterial defect was freshened longitudinally and repaired with a long saphenous vein patch (Fig. 2). The patient remained well and was discharged on postoperative day 5. His follow-up outpatient appointment confirmed successful treatment and uneventful recovery, and postoperative Duplex ultrasonic examination showed a patent popliteal artery.

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  • Fig. 2 

    After gaining proximal control by slinging the distal superficial femoral artery (A), the large pseudoaneurysm was opened longitudinally (B). The arterial defect was controlled digitally (C) and repaired with an autologous vein patch (D).

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Discussion 

Pseudo-aneurysms of the popliteal artery are rare entities, with an incidence of less than 3.5% of all popliteal aneurysms.5 Less than 100 cases of popliteal pseudo-aneurysms were reported by 2007,6 with most resulting from either penetrating or blunt trauma. If caused by iatrogenic means, they often occur as a consequence of orthopedic surgery (mostly knee surgery), acupuncture,7 or after percutaneous vascular procedures with inadvertent arterial perforation.1 This is to our knowledge the first reported case in the world's literature of a delayed presentation of a large pseudo-aneurysm arising from the above-knee popliteal artery following soccer injury, without any other major associated musculoskeletal injuries.

Soccer football injuries are not uncommon, with most being musculoskeletal strains, contusions, or bony fractures. A recent survey by the Union of European Football Associations (UEFA) found that a competitive footballer suffered on average two injuries per season, with the thigh, knee, and ankle being the most common locations.8 However, major vascular injury during football game without associated bony fracture or joint dislocation is very uncommon. There was one published case in the literature of a pseudo-aneurysm arising from the superolateral geniculate branch of the popliteal artery following a football injury, associated with dislocation of the knee joint.9 In this patient, we presume the force sustained during the initial football injury, either due to forceful external trauma or vigorous extension of the knee joint, was severe enough to disrupt the intima and media of the popliteal artery. Since the above-knee popliteal artery is located deep within the muscle group (consisting of muscles such as sartorius, vastus medialis, gracilis), covered by well-developed muscles in a footballer, any swelling in the medial lower thigh may not be clinically obvious at the time. Additional external compression would have tamponade off the hematoma. An alternative postulated mechanism would be that during the trauma, a small branch of the popliteal artery was avulsed from its origin, and this would continue to bleed and cause the pseudo-aneurysm. Of course, the pseudo-aneurysm was not imaged until 6 months later, by which time there was no reliable way to confirm the precise mechanism of injury.

There are many different treatment options for pseudo-aneurysms arising from the popliteal artery. Small pseudo-aneurysms can be observed only or treated by ultrasound compression,10 embolization, or fibrin injection. Endovascular treatment for traumatic injuries with stent-grafts has also gained popularity as an alternative treatment to open surgery. Piffaretti et al.11 reported on 10 patients who had peripheral vascular injuries successfully treated with different stent-grafts with no perioperative mortality or limb loss. Endovascular stent-grafts are effective in treating iatrogenic popliteal arterial injury following orthopedic operation.12

In this patient, we chose open repair over endovascular stent-grafts as the chronic pseudo-aneurysm was very large and was severely compressing the native artery. Endovascular device may be compressed or deformed or even thrombose in time. In addition, the large pseudo-aneurysm could not be removed, and the patient would be left with a large swelling in the medial lower thigh despite the successful exclusion of the pseudo-aneurysm. Although Reijnen et al.13 reported a case of successful stent-graft treatment of popliteal pseudo-aneurysm followed by ultrasound-guided evacuation of the hematoma, the pseudo-aneurysm was only present for 2 weeks and had a less solid content.

In conclusion, this is the first case to our knowledge in the world's literature of delayed presentation of a pseudo-aneurysm of the above-knee popliteal artery as a result of soccer trauma, and it was successfully treated with open exploration, repair of the artery with a vein-patch, and evacuation of the pseudo-aneurysm. We emphasize that unresolved symptoms following sports injury should be investigated and imaged with duplex ultrasound, computed tomography, or magnetic resonance angiography to rule out any arterial injury and to document any concomitant injuries. Although endovascular stent-graft repair is a less invasive option, open exploration and surgical repair should still be used if the pseudo-aneurysm is very large and compressing the adjacent artery.

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References 

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PII: S0890-5096(09)00340-9

doi:10.1016/j.avsg.2009.09.017

Annals of Vascular Surgery
Volume 24, Issue 4 , Pages 553.e13-553.e16, May 2010

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