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A ruptured superficial femoral artery aneurysm: A case report
Journal des Maladies Vasculaires (2016) 41, 69—73
Disponible en ligne sur
ScienceDirect www.sciencedirect.com
CLINICAL CASE
A ruptured superficial femoral artery aneurysm: A case report Un anévrisme rompu de l’artère fémorale superficielle. À propos d’un cas H. Naouli ∗, H. Jiber , A. Bouarhroum Vascular surgery department, UHC Hassan II Fez, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, no 6, Lot Labrigui, route sidi-hrazem, Fès, Morocco Received 21 January 2015; accepted 14 August 2015 Available online 29 October 2015
KEYWORDS Superficial femoral artery; Aneurysm
MOTS CLÉS Artère fémorale superficielle ; Anévrisme
Summary True atherosclerotic aneurysms of superficial femoral artery (SFA) are rare and often associated with other peripheral or aortic aneurysms. We are reporting the case of a 78-yearold man who has been admitted with a ruptured superficial femoral artery aneurysm associated with bilateral popliteal artery aneurysm. The patient underwent successful aneurysm resection and bypass grafting. © 2015 Elsevier Masson SAS. All rights reserved. Résumé L’anévrisme athéroscléreux de l’artère fémorale superficielle est une entité rare ; son association avec d’autres localisations anévrismales aortiques ou périphériques est fréquente. Nous rapportons le cas d’un patient âgé de 78 ans admis pour un anévrisme rompu de l’artère fémorale superficielle associé à un anévrisme poplité bilatéral. Le traitement consistait en une résection du sac anévrismal avec interposition d’un greffon prothétique en PTFE. © 2015 Elsevier Masson SAS. Tous droits réservés.
Introduction Superficial femoral artery aneurysms are uncommon. Their relative rarity has been attributed to the protection provided by the surrounding musculature and the lack of
∗
Corresponding author. E-mail address: [email protected] (H. Naouli).
http://dx.doi.org/10.1016/j.jmv.2015.09.001 0398-0499/© 2015 Elsevier Masson SAS. All rights reserved.
bending stress [1]. This deep position in the thigh hides it from early detection and a rupture is often the first symptom [2].
Case report A 78-year-old man with known hypertension was admitted with a pulsatile hematoma in his right thigh that
70
H. Naouli et al.
Figure 1 Clinical photograph of the patient showing visible bruising in the anterior and medial aspect of his right thigh up to the groin. Vue préopératoire, ecchymose de la face antéro-interne de la cuisse droite s’étendant jusqu’à l’aine.
had progressively expanded in size and become markedly painful during the previous 3 days. The patient was a non-smoker and had neither diabetes mellitus nor hyperlipidemia or other peripheral arterial diseases. He was hemodynamically stable and not febrile. Upon physical examination, a pulsatile hematoma with visible bruising was present in the anterior and medial aspect of his right thigh up to the groin (Fig. 1). The lower right limb was not ischemic and had palpable pulses. Furthermore, bilateral popliteal pulsatile masses were found. Computed tomography angiography (CTA) revealed a fusiform aneurysm with a maximum diameter of 8 cm originating from the mid-portion of the SFA. It was partially thrombosed, surrounded by hematoma and had obviously ruptured (Fig. 2). A bilateral saccular aneurysm of the popliteal artery was also found of which the size was estimated to be 4,3 cm in diameter on the right and 3 cm on the left side, both with a laminated thrombus. The popliteal aneurysms were asymptomatic. CTA of the thoracic and abdominal aorta showed no abnormalities. Conventional arteriography was not performed, but CTA had not shown distal emboli. On the other hand, duplex ultrasound of supra-aortic vessels have found no significant atherosclerosis lesions. Three hours after arrival, the patient underwent an emergency surgical exploration through a medial approach permitting the resection of the aneurysm. The repair was performed using a 6 mm PTFE bypass graft (Fig. 3). The proximal anastomosis was end-to-end and the distal one end-to-end upstream of the ipsilateral popliteal aneurysm. On peroperative time, an i.v. bolus of unfractionated heparin was administrated just before clamping. Histologic examination and culture of the sac were negative. Postoperatively, the patient did well-receiving Aspirin in daily doses of 100 mg and preventive doses of LMWH (low molecular weight heparin). He was discharged 5 days later. The follow-up ultrasound Doppler at 6 months later revealed a satisfactory patency, and the aneurysm was no longer palpable.
Figure 2 Computed tomography angiogram of the lower limbs showing a ruptured true aneurysm of the right SFA (arrow). Angioscanner en reconstruction des membres inférieurs objectivant un anévrisme rompu de l’artère fémorale superficielle droite (flèche).
Discussion Atherosclerotic aneurysms of SFA (SFAAs) are said to be distinctly unusual, if not rare, entities [3]. To the best of our knowledge, only 103 cases of true SFA aneurysms have been published, and the majority are represented by single case reports or small case series (Table 1). In fact, only 3% of
Figure 3
PTFE bypass graft of the SFA.
Vue opératoire, exclusion de l’anévrisme avec interposition.
Author
Year
no of patients
Presentation Asymptomatic
Rupture
Size (cm)
Procedure (n)
Complications (%)
Follow-up
Endograft (2) Graft (4): ePTFE, Dacron, GSV PTFE (3) Dacron (3) GSV (3) Amputation (1) Dacron (1) GSV (4) Dacron (2) GSV (2) Ligation (1) PTFE (16) GSV (5)
Anastomotic pseudoaneurysm
56 months Clinical examination US Doppler Did well perioperatively
Piffaretti et al. [13]
2011
6
6
0
5.1
Jarrett et al. [3]
2002
13
3
0
6.5
Kremen et al. [26]
1981
8
0
5
NR
Cutler and Darling [17]
1973
5
NR
NR
NR
Perini et al. [4]
2014
27
10
7
5.4
Case reports (no of patients ≤ 3) [1,27,28]
1967—2011
44
NR
27
8.5
PTFE (19) Dacron (3) GSV (5) Stent-graft Viabahn (1) ePTFE (2)
Our case
2014
8
PTFE
Total
1
Ruptured
Unsuccessful treatment with hyperbaric oxygen (amputation) One death due to respiratory failure Ischemic but viable limb Amputation (2) Graft thrombosis (1) Hematoma (1) Infection (1) DVT (1) Lymph leak (1) Contained aneurysm rupture Myocardial infract Renal failure Lymph leak Wound necrosis Limb loss Stroke —
Did well NR
A ruptured superficial femoral artery aneurysm: A case report
Table 1 Case series (> three patients) and case reports reported in literature. Séries de cas (> trois patients) et cas rapportés dans la littérature.
Clinic and US Doppler at 1, 3, 6, 12 months and yearly
21 days—24 months
Did well at 12 months
104
71
72 all aneurysms are femoral [4]. SFAAs have been estimated to account for 15% of all femoral artery aneurysms [5]. They were most often seen in elderly men, predominantly affected the right lower extremity [5], and were most often located on the distal third of the artery (59%) [4]. SFAAs are bilateral in 18% and are often associated with aneurysms at other sites in 27—69% [1]. In their studies, Baird et al. observed a coexisting abdominal aortic aneurysm in 60% of cases [6], while Dent et al. noted that 83% of patients with peripheral aneurysms had multiplicity [7]. In a more recent series, Savolainen et al. diagnosed the presence of an abdominal aortic aneurysm in 55% of cases, while popliteal aneurysms were found or later operated on in 66% of cases [8]. Conversely, previous data underlined that only 12% of patients with abdominal aortic aneurysms have coexisting femoral or popliteal aneurysms [9]. Most available reviews report a rupture prevalence of 30—50% among patients presenting SFAAs [1]. Farinon and al. reported thrombosis and distal ischemia in 19%, and distal embolization in 14% [10] although less common than with popliteal aneurysm (63%) [11,12]. SFAAs occur deep within the muscular structures in the thigh and present at a late stage with symptoms, including localized pain or a pulsatile mass [5]. They may sometimes be difficult to palpate even when they reach a large size [2], and usually remain undetected until rupture takes place [10]. Therefore, the first symptom is most frequently rupture (26% vs 3% for popliteal aneurysms) [13]. This is a clear and important distinction from aneurysms in other lower extremity locations. In order to conclude the physical examination, it is mandatory to evaluate the state of the abdominal aorta and the contralateral limb in all patients with SFA aneurysms. The clinical diagnosis of an SFA aneurysm is difficult. The available literature reports that in about two-thirds of these patients, the aneurysm is not evident on physical examination, unless the patients are lean or the aneurysms very large [3]. In the literature, the most often reported diagnostic tool is angiography [1]. Angiography is advisable in multiple aneurysmal lesions or in distal occlusive disease for visualizing runoff, before reconstruction [14]. Computed tomographic angiography (CTA) is an accurate and effective diagnostic method for tracking size, configuration, and extravasation of blood into the soft tissue of the thigh [15]. Furthermore, it can be easily used to size the endograft if endovascular exclusion is planned [4]. For these reasons, Perini et al. recommend CTA as the first choice diagnostic tool [4]. Ultrasound is considered a better test to precisely determine aneurysm diameter [3]. MRI can be of diagnostic utility or of discriminatory value when other tests are inconclusive [16]. The indications for repair of SFA aneurysms follow the same basic principles applicable to the repair of aneurysms in any other locations: remove the embolic source, prevent or treat rupture, eliminate any mass effect, and restore limb perfusion [1]. Repair is indicated for every symptomatic case, but there is no agreement on asymptomatic cases [1,2,17,18]. Perini and al. suggest treating an asymptomatic aneurysm of the SFA if its diameter is ≥ 20 mm, if surgical risk is not elevated, and if the aneurysm is known to have been enlarged [4]. Other authors, however, propose to wait until the diameter reaches 25 mm [1].
H. Naouli et al. Another justification of earlier intervention is that morbidity and mortality rates associated with elective surgery are better compared to emergency procedures [19]. Saccular aneurysms should generally be operated on when the diagnosis is made in accordance with the treatment of saccular aneurysms elsewhere [2]. Several methods of SFA aneurysms repair have been described. Aneurysmectomy and reconstruction with a prosthetic graft is the most performed treatment for this type of lesion, followed by exclusion with surgical bypass [4]. Leon et al. reported, in their literature review, a preference for the use of vein over prosthetic for bypass conduit. In their practice, they reconstruct the SFA by using prosthetic grafts if no distal abnormalities are present. If occlusive or aneurysmal disease at the below-the-knee level requires an anastomosis to the distal popliteal or tibial arteries, they suggest to use an autologous saphenous vein [1]. The results of surgical treatment are similar to what is seen after femoropopliteal revascularization. When surgery is elective, 2-year venous graft patency rates are approximately 80%, compared to 65% when using PTFE grafts [20]. Endovascular treatment has been reported only three times: two patients whose SFA aneurysms were unruptured — described by Diethrich and Papazoglou — and one patient with a ruptured aneurysm, reported by Troitskii et al. [21,22]. Unfortunately, follow-up is unavailable for these cases [4]. Endovascular repair of SFA aneurysms makes intuitive sense, given that this artery does not cross a flexion point and is therefore not subject to repeated flexion or extension stress [1]. The durability of endovascular repair, as well as its benefits in terms of morbidity, mortality, hospital length of stay, and costs remains to be determined [15]. Rancic et al. have reported a small series of six patients treated by a hybrid technique over 5 years. This experience demonstrates that a less invasive technique under local anesthesia can be used to effectively treat even complex femoral artery aneurysms [23]. They used Viabahn endografts (Viabahn, Gore Inc., Flagstaff, AZ, USA) [23]. The self-expanding nitinol exoskeleton with longitudinal flexibility and shape memory makes this graft more resistant to deformation by mechanical forces [24]. The ultrathin expanded polytetrafluoroethylene (PTFE) with heparinbonded bioactive inner surface is responsible for a reduced risk of thrombosis [25]. The mid-term results are excellent; the patency rate was 100%, with no stent-graft migration, and no stent-graft occlusion at 29 months on follow-up [23]. Even if SFA aneurysms are operated on in an emergency context, outcomes are usually good with an early mortality of 4% and an estimated limb salvage rate at 5 years of 88%. The 62% estimated 5-year survival rate may be due to the fact that the population affected by SFAAs is significantly older at the time of operation [4].
Conclusion Degenerative aneurysms of the SFA display peculiar characteristics so that they differ from other peripheral aneurysms. In fact, they often grow to reach a considerable diameter before medical attention is sought, presenting with rupture or ischemia at diagnosis. The treatment is usually feasible, and long-term outcomes are good.
A ruptured superficial femoral artery aneurysm: A case report
Disclosure of interest The authors declare that they have no competing interest.
References [1] Leon Jr L, Taylor Z, Psalms SB, Mills Sr J. Degenerative aneurysms of the superficial femoral artery. Eur J Vasc Endovasc Surg 2008;35:332—40. [2] Atallah C, Al hassane HK, Neglèn P. Superficial femoral artery aneurysm — an uncommon site of aneurysm formation. Eur J Vasc Endovasc Surg 1995;10:502—4. [3] Jarrett F, Makaroun MS, Rhee RY, Bertges DJ. Superficial femoral artery aneurysms: an unusual entity? J Vasc Surg 2002;36:571—4. [4] Perini P, Jean-Baptiste E, Vezzosi M, Raynier JL, Mottini F, Batt M, et al. Surgical management of isolated superficial femoral artery degenerative aneurysms. J Vasc Surg 2014;59:152—8. [5] Mohan IV, Stephen MS. Peripheral arterial aneurysms: open or endovascular surgery? Prog CardioVasc Dis 2013;56:36—56. [6] Baird RJ, Gurry JF, Kellam J, Plume SK. Arteriosclerotic femoral artery aneurysms. Can Med Assoc J 1977;117:1306—7. [7] Dent TL, Lindenauer SM, Ernst CB, Fry WJ. Multiple arteriosclerotic arterial aneurysms. Arch Surg 1972;105:338—44. [8] Savolainen H, Widmer MK, Heller G, Gerber M, Carrel TP, Schmidli J. Common femoral artery—uncommon aneurysms. Scand J Surg 2003;92:203—5. [9] Diwan A, Sarkar R, Stanley JC, Zelenock GB, Wakefield TW. Incidence of femoral and popliteal artery aneurysms in patients with abdominal aortic aneurysms. J Vasc Surg 2000;31:863—9. [10] Farinon AM, Rulli F, Muzi M. Ruptured aneurysm of the superficial femoral artery. Panminerva Med 1995;37:155—8. [11] Rigdon EE, Monajjem N. Aneurysms of superficial artery: a report of two cases and review of the literature. J Vasc Surg 1992;16:790—3. [12] Shortell CK, DeWeese JA, Ouriel K, Green RM. Popliteal artery aneurysms: a 25-year surgical experience. J Vasc Surg 1991;14:771—9. [13] Piffaretti G, Mariscalco G, Tozzi M, Rivolta N, Annoni M, Castelli P. Twenty-year experience of femoral artery aneurysms. J Vasc Surg 2011;53:1230—6. [14] Glyne CAC. True and false aneurysms of the femoral artery. In: Bell PRF, Jamieson CW, Vaughan Ruckley C, editors. Surgical management of vascular disease. Philadelphia: WB Saunders Company; 1990. p. 859—64.
73 [15] Dimakakos PB, Tsiligiris V, Kotsis T, Papadimitriou JD. Atherosclerotic aneurysms of the superficial femoral artery: report of two ruptured cases and review of the literature. Vasc Med 1998;3:275—9. [16] Dobritz M, Lang W, Fellner FA. MR diagnosis of superficial femoral artery aneurysm, primarily misdiagnosed as soft tissue tumor. A case report. Magn Reson Imaging 2003;21:687—90. [17] Cutler BS, Darling RC. Surgical management of arteriosclerotic femoral aneurysms. Surgery 1973;74:764—73. [18] Mayall JC, Mayall RC, Mayall AC, Mayall LC. Peripheral aneurysms. Int Angiol 1991;10:141—5. [19] Siani A, Flaishman I, Napoli F, Schioppa A, Zaccaria A. Rupture of an isolated true superficial femoral artery aneurysm: case report. G Chir 2005;26:215—7. [20] Rutherford RB. Superficial femoral artery aneurysm. In: Rutherford RB, editor. Vascular Surgery. Philadelphia: WB Sauders; 2005. p. 1538—9. [21] Diethrich EB, Papazoglou K. Endoluminal grafting of aneurysmal and occlusive disease in the superficial femoral artery: early experience. J Endovasc Surg 1995;2:225—39. [22] Troitskii AV, Bobrovskaia AN, Orekhov Plu, Lysenko le R, Khabazov RI, Parshin Plu, et al. successful percutaneous endovascular treatment of a ruptured femoral aneurysm. Angiol Sosud Khir 2005;11:53—7. [23] Rancic Z, Pecoraro F, Pfammatter T, Mayer D, Veith FJ, Lachat M. Less invasive (common) femoral artery aneurysm repair using endografts and limited dissection. Eur J Vasc Endovasc Surg 2013;45:481—7. [24] Gupta K, Dougherty K, Hermman H, Krajcer Z. Endovascular repair of a giant carotid pseudoaneurysm with the use of Viabahn stent graft. Catheter Cardiovasc Interv 2004:64—8. [25] Virmani R, Kolodgie FD, Dake MD, Silver JH, Jones RM, Jenkins M, et al. Histopathologic evaluation of an expanded polytetrafluoroethylene-nitinol stent endoprosthesis in canine iliofemoral arteries. J Vasc Interv Radiol 1999;10:445—56. [26] Kremen J, Menzoian JO, Corson JD, Bush HL, LoGerfo FW. Atherosclerotic aneurysms of the superficial femoral artery: a literature review and report of six additional cases. Am Surg 1981;47:338—42. [27] Dighe S, Thomas P. Ruptured superficial femoral artery aneurysm treated by simple ligation. Singapore Med J 2008;49:e151—2. [28] Lee S, Kang SK, Oh HK, Kang MW, Yu JH, Na MH, et al. An isolated true aneurysm of the superficial femoral artery in a young woman — a case report. Korean J Thorac Cardiovasc Surg 2011;44:361—3.
Disponible en ligne sur
ScienceDirect www.sciencedirect.com
CLINICAL CASE
A ruptured superficial femoral artery aneurysm: A case report Un anévrisme rompu de l’artère fémorale superficielle. À propos d’un cas H. Naouli ∗, H. Jiber , A. Bouarhroum Vascular surgery department, UHC Hassan II Fez, Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, no 6, Lot Labrigui, route sidi-hrazem, Fès, Morocco Received 21 January 2015; accepted 14 August 2015 Available online 29 October 2015
KEYWORDS Superficial femoral artery; Aneurysm
MOTS CLÉS Artère fémorale superficielle ; Anévrisme
Summary True atherosclerotic aneurysms of superficial femoral artery (SFA) are rare and often associated with other peripheral or aortic aneurysms. We are reporting the case of a 78-yearold man who has been admitted with a ruptured superficial femoral artery aneurysm associated with bilateral popliteal artery aneurysm. The patient underwent successful aneurysm resection and bypass grafting. © 2015 Elsevier Masson SAS. All rights reserved. Résumé L’anévrisme athéroscléreux de l’artère fémorale superficielle est une entité rare ; son association avec d’autres localisations anévrismales aortiques ou périphériques est fréquente. Nous rapportons le cas d’un patient âgé de 78 ans admis pour un anévrisme rompu de l’artère fémorale superficielle associé à un anévrisme poplité bilatéral. Le traitement consistait en une résection du sac anévrismal avec interposition d’un greffon prothétique en PTFE. © 2015 Elsevier Masson SAS. Tous droits réservés.
Introduction Superficial femoral artery aneurysms are uncommon. Their relative rarity has been attributed to the protection provided by the surrounding musculature and the lack of
∗
Corresponding author. E-mail address: [email protected] (H. Naouli).
http://dx.doi.org/10.1016/j.jmv.2015.09.001 0398-0499/© 2015 Elsevier Masson SAS. All rights reserved.
bending stress [1]. This deep position in the thigh hides it from early detection and a rupture is often the first symptom [2].
Case report A 78-year-old man with known hypertension was admitted with a pulsatile hematoma in his right thigh that
70
H. Naouli et al.
Figure 1 Clinical photograph of the patient showing visible bruising in the anterior and medial aspect of his right thigh up to the groin. Vue préopératoire, ecchymose de la face antéro-interne de la cuisse droite s’étendant jusqu’à l’aine.
had progressively expanded in size and become markedly painful during the previous 3 days. The patient was a non-smoker and had neither diabetes mellitus nor hyperlipidemia or other peripheral arterial diseases. He was hemodynamically stable and not febrile. Upon physical examination, a pulsatile hematoma with visible bruising was present in the anterior and medial aspect of his right thigh up to the groin (Fig. 1). The lower right limb was not ischemic and had palpable pulses. Furthermore, bilateral popliteal pulsatile masses were found. Computed tomography angiography (CTA) revealed a fusiform aneurysm with a maximum diameter of 8 cm originating from the mid-portion of the SFA. It was partially thrombosed, surrounded by hematoma and had obviously ruptured (Fig. 2). A bilateral saccular aneurysm of the popliteal artery was also found of which the size was estimated to be 4,3 cm in diameter on the right and 3 cm on the left side, both with a laminated thrombus. The popliteal aneurysms were asymptomatic. CTA of the thoracic and abdominal aorta showed no abnormalities. Conventional arteriography was not performed, but CTA had not shown distal emboli. On the other hand, duplex ultrasound of supra-aortic vessels have found no significant atherosclerosis lesions. Three hours after arrival, the patient underwent an emergency surgical exploration through a medial approach permitting the resection of the aneurysm. The repair was performed using a 6 mm PTFE bypass graft (Fig. 3). The proximal anastomosis was end-to-end and the distal one end-to-end upstream of the ipsilateral popliteal aneurysm. On peroperative time, an i.v. bolus of unfractionated heparin was administrated just before clamping. Histologic examination and culture of the sac were negative. Postoperatively, the patient did well-receiving Aspirin in daily doses of 100 mg and preventive doses of LMWH (low molecular weight heparin). He was discharged 5 days later. The follow-up ultrasound Doppler at 6 months later revealed a satisfactory patency, and the aneurysm was no longer palpable.
Figure 2 Computed tomography angiogram of the lower limbs showing a ruptured true aneurysm of the right SFA (arrow). Angioscanner en reconstruction des membres inférieurs objectivant un anévrisme rompu de l’artère fémorale superficielle droite (flèche).
Discussion Atherosclerotic aneurysms of SFA (SFAAs) are said to be distinctly unusual, if not rare, entities [3]. To the best of our knowledge, only 103 cases of true SFA aneurysms have been published, and the majority are represented by single case reports or small case series (Table 1). In fact, only 3% of
Figure 3
PTFE bypass graft of the SFA.
Vue opératoire, exclusion de l’anévrisme avec interposition.
Author
Year
no of patients
Presentation Asymptomatic
Rupture
Size (cm)
Procedure (n)
Complications (%)
Follow-up
Endograft (2) Graft (4): ePTFE, Dacron, GSV PTFE (3) Dacron (3) GSV (3) Amputation (1) Dacron (1) GSV (4) Dacron (2) GSV (2) Ligation (1) PTFE (16) GSV (5)
Anastomotic pseudoaneurysm
56 months Clinical examination US Doppler Did well perioperatively
Piffaretti et al. [13]
2011
6
6
0
5.1
Jarrett et al. [3]
2002
13
3
0
6.5
Kremen et al. [26]
1981
8
0
5
NR
Cutler and Darling [17]
1973
5
NR
NR
NR
Perini et al. [4]
2014
27
10
7
5.4
Case reports (no of patients ≤ 3) [1,27,28]
1967—2011
44
NR
27
8.5
PTFE (19) Dacron (3) GSV (5) Stent-graft Viabahn (1) ePTFE (2)
Our case
2014
8
PTFE
Total
1
Ruptured
Unsuccessful treatment with hyperbaric oxygen (amputation) One death due to respiratory failure Ischemic but viable limb Amputation (2) Graft thrombosis (1) Hematoma (1) Infection (1) DVT (1) Lymph leak (1) Contained aneurysm rupture Myocardial infract Renal failure Lymph leak Wound necrosis Limb loss Stroke —
Did well NR
A ruptured superficial femoral artery aneurysm: A case report
Table 1 Case series (> three patients) and case reports reported in literature. Séries de cas (> trois patients) et cas rapportés dans la littérature.
Clinic and US Doppler at 1, 3, 6, 12 months and yearly
21 days—24 months
Did well at 12 months
104
71
72 all aneurysms are femoral [4]. SFAAs have been estimated to account for 15% of all femoral artery aneurysms [5]. They were most often seen in elderly men, predominantly affected the right lower extremity [5], and were most often located on the distal third of the artery (59%) [4]. SFAAs are bilateral in 18% and are often associated with aneurysms at other sites in 27—69% [1]. In their studies, Baird et al. observed a coexisting abdominal aortic aneurysm in 60% of cases [6], while Dent et al. noted that 83% of patients with peripheral aneurysms had multiplicity [7]. In a more recent series, Savolainen et al. diagnosed the presence of an abdominal aortic aneurysm in 55% of cases, while popliteal aneurysms were found or later operated on in 66% of cases [8]. Conversely, previous data underlined that only 12% of patients with abdominal aortic aneurysms have coexisting femoral or popliteal aneurysms [9]. Most available reviews report a rupture prevalence of 30—50% among patients presenting SFAAs [1]. Farinon and al. reported thrombosis and distal ischemia in 19%, and distal embolization in 14% [10] although less common than with popliteal aneurysm (63%) [11,12]. SFAAs occur deep within the muscular structures in the thigh and present at a late stage with symptoms, including localized pain or a pulsatile mass [5]. They may sometimes be difficult to palpate even when they reach a large size [2], and usually remain undetected until rupture takes place [10]. Therefore, the first symptom is most frequently rupture (26% vs 3% for popliteal aneurysms) [13]. This is a clear and important distinction from aneurysms in other lower extremity locations. In order to conclude the physical examination, it is mandatory to evaluate the state of the abdominal aorta and the contralateral limb in all patients with SFA aneurysms. The clinical diagnosis of an SFA aneurysm is difficult. The available literature reports that in about two-thirds of these patients, the aneurysm is not evident on physical examination, unless the patients are lean or the aneurysms very large [3]. In the literature, the most often reported diagnostic tool is angiography [1]. Angiography is advisable in multiple aneurysmal lesions or in distal occlusive disease for visualizing runoff, before reconstruction [14]. Computed tomographic angiography (CTA) is an accurate and effective diagnostic method for tracking size, configuration, and extravasation of blood into the soft tissue of the thigh [15]. Furthermore, it can be easily used to size the endograft if endovascular exclusion is planned [4]. For these reasons, Perini et al. recommend CTA as the first choice diagnostic tool [4]. Ultrasound is considered a better test to precisely determine aneurysm diameter [3]. MRI can be of diagnostic utility or of discriminatory value when other tests are inconclusive [16]. The indications for repair of SFA aneurysms follow the same basic principles applicable to the repair of aneurysms in any other locations: remove the embolic source, prevent or treat rupture, eliminate any mass effect, and restore limb perfusion [1]. Repair is indicated for every symptomatic case, but there is no agreement on asymptomatic cases [1,2,17,18]. Perini and al. suggest treating an asymptomatic aneurysm of the SFA if its diameter is ≥ 20 mm, if surgical risk is not elevated, and if the aneurysm is known to have been enlarged [4]. Other authors, however, propose to wait until the diameter reaches 25 mm [1].
H. Naouli et al. Another justification of earlier intervention is that morbidity and mortality rates associated with elective surgery are better compared to emergency procedures [19]. Saccular aneurysms should generally be operated on when the diagnosis is made in accordance with the treatment of saccular aneurysms elsewhere [2]. Several methods of SFA aneurysms repair have been described. Aneurysmectomy and reconstruction with a prosthetic graft is the most performed treatment for this type of lesion, followed by exclusion with surgical bypass [4]. Leon et al. reported, in their literature review, a preference for the use of vein over prosthetic for bypass conduit. In their practice, they reconstruct the SFA by using prosthetic grafts if no distal abnormalities are present. If occlusive or aneurysmal disease at the below-the-knee level requires an anastomosis to the distal popliteal or tibial arteries, they suggest to use an autologous saphenous vein [1]. The results of surgical treatment are similar to what is seen after femoropopliteal revascularization. When surgery is elective, 2-year venous graft patency rates are approximately 80%, compared to 65% when using PTFE grafts [20]. Endovascular treatment has been reported only three times: two patients whose SFA aneurysms were unruptured — described by Diethrich and Papazoglou — and one patient with a ruptured aneurysm, reported by Troitskii et al. [21,22]. Unfortunately, follow-up is unavailable for these cases [4]. Endovascular repair of SFA aneurysms makes intuitive sense, given that this artery does not cross a flexion point and is therefore not subject to repeated flexion or extension stress [1]. The durability of endovascular repair, as well as its benefits in terms of morbidity, mortality, hospital length of stay, and costs remains to be determined [15]. Rancic et al. have reported a small series of six patients treated by a hybrid technique over 5 years. This experience demonstrates that a less invasive technique under local anesthesia can be used to effectively treat even complex femoral artery aneurysms [23]. They used Viabahn endografts (Viabahn, Gore Inc., Flagstaff, AZ, USA) [23]. The self-expanding nitinol exoskeleton with longitudinal flexibility and shape memory makes this graft more resistant to deformation by mechanical forces [24]. The ultrathin expanded polytetrafluoroethylene (PTFE) with heparinbonded bioactive inner surface is responsible for a reduced risk of thrombosis [25]. The mid-term results are excellent; the patency rate was 100%, with no stent-graft migration, and no stent-graft occlusion at 29 months on follow-up [23]. Even if SFA aneurysms are operated on in an emergency context, outcomes are usually good with an early mortality of 4% and an estimated limb salvage rate at 5 years of 88%. The 62% estimated 5-year survival rate may be due to the fact that the population affected by SFAAs is significantly older at the time of operation [4].
Conclusion Degenerative aneurysms of the SFA display peculiar characteristics so that they differ from other peripheral aneurysms. In fact, they often grow to reach a considerable diameter before medical attention is sought, presenting with rupture or ischemia at diagnosis. The treatment is usually feasible, and long-term outcomes are good.
A ruptured superficial femoral artery aneurysm: A case report
Disclosure of interest The authors declare that they have no competing interest.
References [1] Leon Jr L, Taylor Z, Psalms SB, Mills Sr J. Degenerative aneurysms of the superficial femoral artery. Eur J Vasc Endovasc Surg 2008;35:332—40. [2] Atallah C, Al hassane HK, Neglèn P. Superficial femoral artery aneurysm — an uncommon site of aneurysm formation. Eur J Vasc Endovasc Surg 1995;10:502—4. [3] Jarrett F, Makaroun MS, Rhee RY, Bertges DJ. Superficial femoral artery aneurysms: an unusual entity? J Vasc Surg 2002;36:571—4. [4] Perini P, Jean-Baptiste E, Vezzosi M, Raynier JL, Mottini F, Batt M, et al. Surgical management of isolated superficial femoral artery degenerative aneurysms. J Vasc Surg 2014;59:152—8. [5] Mohan IV, Stephen MS. Peripheral arterial aneurysms: open or endovascular surgery? Prog CardioVasc Dis 2013;56:36—56. [6] Baird RJ, Gurry JF, Kellam J, Plume SK. Arteriosclerotic femoral artery aneurysms. Can Med Assoc J 1977;117:1306—7. [7] Dent TL, Lindenauer SM, Ernst CB, Fry WJ. Multiple arteriosclerotic arterial aneurysms. Arch Surg 1972;105:338—44. [8] Savolainen H, Widmer MK, Heller G, Gerber M, Carrel TP, Schmidli J. Common femoral artery—uncommon aneurysms. Scand J Surg 2003;92:203—5. [9] Diwan A, Sarkar R, Stanley JC, Zelenock GB, Wakefield TW. Incidence of femoral and popliteal artery aneurysms in patients with abdominal aortic aneurysms. J Vasc Surg 2000;31:863—9. [10] Farinon AM, Rulli F, Muzi M. Ruptured aneurysm of the superficial femoral artery. Panminerva Med 1995;37:155—8. [11] Rigdon EE, Monajjem N. Aneurysms of superficial artery: a report of two cases and review of the literature. J Vasc Surg 1992;16:790—3. [12] Shortell CK, DeWeese JA, Ouriel K, Green RM. Popliteal artery aneurysms: a 25-year surgical experience. J Vasc Surg 1991;14:771—9. [13] Piffaretti G, Mariscalco G, Tozzi M, Rivolta N, Annoni M, Castelli P. Twenty-year experience of femoral artery aneurysms. J Vasc Surg 2011;53:1230—6. [14] Glyne CAC. True and false aneurysms of the femoral artery. In: Bell PRF, Jamieson CW, Vaughan Ruckley C, editors. Surgical management of vascular disease. Philadelphia: WB Saunders Company; 1990. p. 859—64.
73 [15] Dimakakos PB, Tsiligiris V, Kotsis T, Papadimitriou JD. Atherosclerotic aneurysms of the superficial femoral artery: report of two ruptured cases and review of the literature. Vasc Med 1998;3:275—9. [16] Dobritz M, Lang W, Fellner FA. MR diagnosis of superficial femoral artery aneurysm, primarily misdiagnosed as soft tissue tumor. A case report. Magn Reson Imaging 2003;21:687—90. [17] Cutler BS, Darling RC. Surgical management of arteriosclerotic femoral aneurysms. Surgery 1973;74:764—73. [18] Mayall JC, Mayall RC, Mayall AC, Mayall LC. Peripheral aneurysms. Int Angiol 1991;10:141—5. [19] Siani A, Flaishman I, Napoli F, Schioppa A, Zaccaria A. Rupture of an isolated true superficial femoral artery aneurysm: case report. G Chir 2005;26:215—7. [20] Rutherford RB. Superficial femoral artery aneurysm. In: Rutherford RB, editor. Vascular Surgery. Philadelphia: WB Sauders; 2005. p. 1538—9. [21] Diethrich EB, Papazoglou K. Endoluminal grafting of aneurysmal and occlusive disease in the superficial femoral artery: early experience. J Endovasc Surg 1995;2:225—39. [22] Troitskii AV, Bobrovskaia AN, Orekhov Plu, Lysenko le R, Khabazov RI, Parshin Plu, et al. successful percutaneous endovascular treatment of a ruptured femoral aneurysm. Angiol Sosud Khir 2005;11:53—7. [23] Rancic Z, Pecoraro F, Pfammatter T, Mayer D, Veith FJ, Lachat M. Less invasive (common) femoral artery aneurysm repair using endografts and limited dissection. Eur J Vasc Endovasc Surg 2013;45:481—7. [24] Gupta K, Dougherty K, Hermman H, Krajcer Z. Endovascular repair of a giant carotid pseudoaneurysm with the use of Viabahn stent graft. Catheter Cardiovasc Interv 2004:64—8. [25] Virmani R, Kolodgie FD, Dake MD, Silver JH, Jones RM, Jenkins M, et al. Histopathologic evaluation of an expanded polytetrafluoroethylene-nitinol stent endoprosthesis in canine iliofemoral arteries. J Vasc Interv Radiol 1999;10:445—56. [26] Kremen J, Menzoian JO, Corson JD, Bush HL, LoGerfo FW. Atherosclerotic aneurysms of the superficial femoral artery: a literature review and report of six additional cases. Am Surg 1981;47:338—42. [27] Dighe S, Thomas P. Ruptured superficial femoral artery aneurysm treated by simple ligation. Singapore Med J 2008;49:e151—2. [28] Lee S, Kang SK, Oh HK, Kang MW, Yu JH, Na MH, et al. An isolated true aneurysm of the superficial femoral artery in a young woman — a case report. Korean J Thorac Cardiovasc Surg 2011;44:361—3.