Angiosarcoma after Popliteal Aneurysm Exclusion Surgery. A Systematic Review


      Expansion after popliteal artery aneurysm exclusion with bypass is a common phenomenon. Popliteal angiosarcoma is seldom reported in literature and in most cases after popliteal artery aneurysm surgery. This paper aims to present the case of a popliteal angiosarcoma, initially diagnosed as late aneurysmal growth after exclusion surgery, to conduct a systematic review of popliteal angiosarcoma and assess any association between angiosarcoma and previous popliteal aneurysm surgery.


      We performed a secondary popliteal aneurysmorraphy through posterior approach for symptomatic aneurysm expansion in a 79-year-old woman, 9 years after medial femoropopliteal venous bypass and aneurysm exclusion. The postoperative course was complicated by recurrent hematomas and wound spillages requiring multiple revisions. Pathological analysis identified an angiosarcoma. Staging revealed bone invasion and pulmonary metastasis. Despite transfemoral amputation and adjuvant chemotherapy the patient died 8 months later.
      We performed a systematic review through MEDLINE on ‘primary’ and ‘secondary’ (with previous vascular surgery) angiosarcoma in popliteal artery aneurysm. Research was done using the terms ‘(hem) angiosarcoma’, ‘aneurysm’, ‘popliteal aneurysm or artery’, ‘femoral aneurysm or artery’. Other soft tissue sarcoma or nonpopliteal locations were excluded.


      Including this case, only 13 angiosarcomas in popliteal aneurysms are currently described. Two were reported without previous surgery considered as primary angiosarcoma and 11 after popliteal artery aneurysm surgery (secondary angiosarcoma). Patient age ranges from 8 months to 83 years with a male predominance (10/3). Nine of the 11 patients with secondary angiosarcoma were initially diagnosed as popliteal aneurysm expansion after previous bypass surgery, the 2 other secondary cases presented respectively with pain and inflammatory syndrome without expansion. All prior surgical exclusion was carried out by a medial approach. Interval with the index operation ranges from 3 months to 15 years. Death was reported in 8 of the 13 cases within the first year of diagnosis.


      Although seldom reported, popliteal angiosarcomas are mainly described after popliteal artery aneurysm exclusion surgery, raising suspicion on a potential association, yet causality cannot be demonstrated. Angiosarcoma should be included in the differential diagnosis of popliteal aneurysm growth or unexpected outcome after exclusion bypass surgery. Systematic imaging and pathological studies should be undertaken to allow early diagnosis and treatment. Routine use of a posterior approach, with aneurysm resection, when feasible as initial popliteal artery aneurysm treatment, might reduce the risk of late sarcomatous transformation.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Annals of Vascular Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Grip O.
        • Mani K.
        • Altreuther M.
        • et al.
        Contemporary treatment of popliteal artery aneurysms in 14 countries: a vascunet report.
        Eur J Vasc Endovasc Surg. 2020; 60: 721-729
        • Ravn H.
        • Wanhainen A.
        • Björck M.
        Surgical technique and long-term results after popliteal artery aneurysm repair: results from 717 legs.
        J Vasc Surg. 2007; 46: 236-243
        • Kirkpatrick U.J.
        • McWilliams R.G.
        • Martin J.
        • et al.
        Late complications after ligation and bypass for popliteal aneurysm.
        Br J Surg. 2004; 91: 174-177
        • Mehta M.
        • Champagne B.
        • Darling R.C.
        • et al.
        Outcome of popliteal artery aneurysms after exclusion and bypass: significance of residual patent branches mimicking type II endoleaks.
        J Vasc Surg. 2004; 40: 886-890
        • Hart J.
        • Mandavilli S.
        Epithelioid angiosarcoma: a brief diagnostic review and differential diagnosis.
        Arch Pathol Lab Med. 2011; 135: 268-272
        • Mark R.J.
        • Poen J.C.
        • Tran L.M.
        • et al.
        Angiosarcoma: a report of 67 patients and a review of the literature.
        Cancer. 1996; 77: 2400-2406
        • Hasegawa T.
        Histological grading and MIB-1 labeling index of soft-tissue sarcomas.
        Pathol Int. 2007; 57: 121-125
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • et al.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        BMJ. 2009; 339: 332-336
        • Nocturne G.
        • Sellam J.
        • Miquel A.
        • et al.
        Is sarcoma a complication of arterial femoro-popliteal bypass?.
        Jt Bone Spine. 2010; 77: 358-360
        • Cristaudo A.
        • Steffen C.
        Not just a popliteal aneurysm: a case of metastatic epithelioid angiosarcoma.
        EJVES Extra. 2012; 23: e50-e52
        • Villaescusa Catalán J.M.
        • Martín I.G.
        • Cagigal Cobo M.L.
        Popliteal angiosarcoma after bypass with autologous saphenous vein.
        Ann Vasc Surg. 2019; 55: 308.e1-308.e4
        • Kogon B.
        • Kabeer M.
        • Sawchuk A.P.
        • et al.
        Angiosarcoma presenting as an occluded popliteal artery pseudoaneurysm.
        J Vasc Surg. 1998; 27: 970-973
        • Bader T.
        • Strobel K.
        • Egger-Sigg M.
        • et al.
        FDG PET/MRI imaging of an angiosarcoma in a popliteal aneurysm and tibial head after popliteal graft.
        Clin Nucl Med. 2016; 41: e426-e427
        • Cherchi M.
        • Camparini S.
        Late presentation of popliteal angiosarcoma after previously treated popliteal artery aneurysm.
        Eur J Vasc Endovasc Surg. 2017; 54: 463
        • Chetouani A.
        • Perrin M.
        • Drouet C.
        • et al.
        Aneurysmal angiosarcoma associated with vascular graft revealed by 18F-FDG-PET imaging.
        Radiol Case Rep. 2017; 12: 413-415
        • Di Saverio G.
        • Magne J.L.
        • Farah I.
        • et al.
        Angiosarcoma associated with aneuvrysm of the popliteal artery.
        Eur J Vasc Endovasc Surg. 1995; 161: 53-55
        • Croft J.
        Aneurysm of the popliteal artery complicated with sarcoma.
        Trans Pathol Soc L. 1890; 41: 65-70
        • Werra U.E.M.
        • Petzold P.T.
        Epithelioid angiosarcoma of the popliteal artery- primary or secondary? A rare disease entity difficult to diagnose and easily overlooked-literature research and case report.
        Ann Vasc Surg. 2021; 74: 524.e1-524.e7
        • Fabian O.
        • Mokra D.
        • Masopust J.
        • et al.
        Primary angiosarcoma of the femoral artery in patient with kidney and liver polycystosis and multiple arterial aneurysms: report of the case and review of the literature.
        Cardiovasc Pathol. 2019; 39: 8-11
        • Garg M.K.
        • Satwik A.
        • Yadav A.
        • et al.
        Intimal sarcoma of the popliteal artery presenting as popliteal artery aneurysm: a rare case report.
        Indian J Vasc Endovasc Surg. 2018; 5: 111-114
        • Al-Robaie B.
        • Stephenson M.
        • Evans G.H.
        • et al.
        Angiosarcoma mimicking a recurrent carotid artery aneurysm.
        Ann Vasc Surg. 2011; 25: 1142.e19-1142.e23
        • Scholtz J.
        • Mishra M.M.
        • Simman R.
        Cutaneous angiosarcoma of the lower leg.
        Cutis. 2018; 102: 8-11
        • Turcotte R.E.
        • Ferrone M.
        • Lsler M.H.
        • et al.
        Outcomes in patients with popliteal sarcomas.
        Can J Surg. 2009; 52: 51-55
        • Choi S.Y.
        • Min S.K.
        • Kim K. Il
        • et al.
        Intimal angiosarcoma presenting with common femoral artery aneurysm.
        J Vasc Surg. 2012; 56: 819-821
        • Thalheimer A.
        • Fein M.
        • Geissinger E.
        • et al.
        Intimal angiosarcoma of the aorta: report of a case and review of the literature.
        J Vasc Surg. 2004; 40: 548-553
        • Young R.J.
        • Robin A.
        • Young J.
        • et al.
        Angiosarcoma Lancet Oncol. 2010; 11: 983-991
        • Cao J.
        • Wang J.
        • He C.
        • et al.
        Angiosarcoma: a review of diagnosis and current treatment.
        Am J Cancer Res. 2019; 9: 2303-2313
        • Oskrochi Y.
        • Razi K.
        • Stebbing J.
        • et al.
        Angiosarcoma and dialysis-related arteriovenous fistulae: a comprehensive review.
        Eur J Vasc Endovasc Surg. 2016; 51: 127-133
        • Morris R.
        • Lee C.J.
        Development of angiosarcoma in a saphenous vein graft after femoral to above-knee popliteal artery bypass.
        Ann Vasc Surg. 2018; 50: 299.e9-299.e13
        • Geller R.L.
        • Hookim K.
        • Sullivan H.C.
        • et al.
        Cytologic features of angiosarcoma: a review of 26 cases diagnosed on FNA.
        Cancer Cytopathol. 2016; 124: 659-668
        • Jennings T.A.
        • Peterson L.
        • Axiotis C.A.
        • et al.
        Angiosarcoma associated with foreign body material: a report of three cases.
        Cancer. 1988; 62: 2436-2444
        • Burgert-Lon C.E.
        • Riddle N.D.
        • Lackman R.D.
        • et al.
        Angiosarcoma arising in chronic expanding hematoma five cases of an underrecognized association.
        Am J Surg Pathol. 2015; 39: 1540-1547
        • Staats P.
        • Tavora F.
        • Burke A.P.
        Intimal sarcomas of the aorta and iliofemoral arteries: a clinicopathological study of 26 cases.
        Pathology. 2014; 46: 596-603
        • Presacco S.
        • Agnes A.L.
        • Magalini S.
        • et al.
        Bleeding “Sarcomatosis” as a rare presentation of vascular graft-related angiosarcoma: case report and review of the literature.
        BMC Surg. 2020; 20: 1-9
        • Takamura K.
        • Kobayash H.
        • Rubin B.P.
        • et al.
        Aortic angiosarcoma in association with endovascular aneurysm repair: case report and review of the literature.
        Am J Case Rep. 2021; 22: e931740
        • Agaimy A.
        • Ben-Izhak O.
        • Lorey T.
        • et al.
        Angiosarcoma arising in association with vascular Dacron grafts and orthopedic joint prostheses: clinicopathologic, immunohistochemical, and molecular study.
        Ann Diagn Pathol. 2016; 21: 21-28
        • Pritsch T.
        • Bickels J.
        • Winberg T.
        • et al.
        Popliteal sarcomas: presentation, prognosis, and limb salvage.
        Clin Orthop Relat Res. 2007; 455: 225-233
        • Wood J.H.
        • Borkon M.J.
        • Schwartz H.S.
        • et al.
        Popliteal artery aneurysm simulating soft tissue sarcoma.
        J Gambl Issues. 2002; 7: 106-107
        • Sattout A.H.
        • Deolekar M.V.
        • Tait W.F.
        • et al.
        Femoral artery angiosarcoma presenting with distal embolization: report of a case.
        Surg Today. 2008; 38: 541-544
        • Wakely P.E.
        • Frable W.J.
        • Kneisl J.S.
        Aspiration cytopathology of epithelioid angiosarcoma.
        Cancer. 2000; 90: 245-251
        • Hottenrott G.
        • Mentzel T.
        • Peters A.
        • et al.
        Intravascular (“Intimal”) epithelioid angiosarcoma: clinicopathological and immunohistochemical analysis of three cases.
        Virchows Arch. 1999; 435: 473-478
        • Abraham J.A.
        • Hornicek F.J.
        • Kaufman A.M.
        • et al.
        Treatment and outcome of 82 patients with angiosarcoma.
        Ann Surg Oncol. 2007; 14: 1953-1967
        • Buehler D.
        • Rice S.R.
        • Moody J.S.
        • et al.
        Angiosarcoma outcomes and prognostic factors: a 25-year single institution experience.
        Am J Clin Oncol. 2013; 37: 473-479
        • Penel N.
        • Marréaud S.
        • Robin Y.M.
        • et al.
        Angiosarcoma: state of the art and perspectives.
        Crit Rev Oncol Hematol. 2011; 80: 257-263
        • Oxenberg J.
        • Khushalani N.I.
        • Salerno K.E.
        • et al.
        Neoadjuvant chemotherapy for primary cutaneous/soft tissue angiosarcoma: determining tumor behavior prior to surgical resection.
        J Surg Oncol. 2015; 111: 829-833
        • Penel N.
        • Bui B.N.
        • Bay J.O.
        • et al.
        Angiosarcomas and taxanes.
        Curr Treat Options Oncol. 2007; 8: 5269-5274
        • Heinhuis K.M.
        • Ijzerman N.S.
        • van der Graaf W.T.A.
        • et al.
        Neoadjuvant systemic treatment of primary angiosarcoma.
        Cancers (Basel). 2020; 12: 1-15
        • Björck M.
        • Earnshaw J.J.
        • Acosta S.
        • et al.
        Editor’s choice – European Society for Vascular Surgery (ESVS) 2020 clinical practice guidelines on the management of acute limb ischaemia.
        Eur J Vasc Endovasc Surg. 2020; 59: 173-218