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Ruptured aneurysm of the profunda femoris artery
Ruptured aneurysm of the profunda femoris artery J o h n W. Wiest, M.D., Dipankar Mukherjee, M.D., and T o s h i o Inahara, M.D.,
Portland, Ore. An unusual case of a ruptured aneurysm involving the profunda femoris artery is reported. This problem was managed by resection of the aneurysm and revascularization of the lower extremity with a polytetrafluoroethylene graft to the distal branches of the profunda femoris artery. The limited avad'able literature is reviewed. (J VAse SURG 1986; 4:406-9.)
Peripheral atherosclerotic aneurysms are most common in the popliteal artery (55%) followed by the c o m m o n femoral artery (42%). 1 Isolated aneurysms o f the profunda femoris artery are uncommon and comprise only 0.5% o f all peripheral artery aneurysms? Asymptomatic aneurysms are difficult to identify because o f their location deep within the muscles o f the thigh. Symptoms develop as a result o f compression o f the adjacent femoral nerve or vein, embolization o f atherosclerotic debris, acute or chronic thrombosis, or rupture. Aneurysm rupture creates a limb-threatening and potentially life-threatening situation. The clinical presentation and surgical management o f a rare case o f ruptured profunda femoris aneurysm are reported.
CASE REPORT An 80-year-old man was hospitalized for evaluation of a painful swollen left groin. Physical examination showed a large tender putsatile mass in the left groin and upper thigh with an obvious thrill and a loud bruit. A diminished pulse was palpable in the popliteal artery. Distal pulses were not palpable but the ankle-arm index was 0.5. Past medical history was relevant for the elective resection ofa 6 cm infrarenal abdominal aortic aneurysm and placement of a Dacron aortobi-iliac bypass graft 4 years before this admission. Angiography of the femoral vessels at the time showed early aneurysmal dilatation of the common and profimda femoral arteries (Fig. 1). The distal superficial femoral artery was occluded. Rupture of a femoral aneurysm was suspected because of the rapid onset of symptoms. The diagnosis was confirmed by ultrasound examination of the left groin and thigh, which showed a 10 cm pulsatile mass with a medial irregularity compatible with extravasated blood. From the Department of Surgery, St. Vincent Hospital and Medical Center. Reprint requests: Toshio Inahara, M.D., 9155 SW Barnes Road, Suite 206, Portland, OR 97225. 406
The patient was promptly taken to the operating room where control of the distal external lilac artery was obtained through a retroperitoneal approach. A longitudinal incision was made directly over the pulsatile mass and it was dissected free from surrounding structures. The common femoral vein was densely adherent to the aneurysm and was left undisturbed. Two small outflow vessels were identified and dissected free for distal control. The aneurysm involved the profunda femoris artery and measured 10 x 10 cm (Fig. 2). The common femoral artery was slightly dilated and the superficial femoral artery was normal in size but occluded distally. Proximal and distal occlusion clamps were placed after systemic heparinization was begun. The aneurysmal sac was opened, preserving the adherent common femoral vein, and a large laminated clot was removed. The shaft of the femur formed the posterior wall of the aneurysm and the rupture site was identified along the medial wall. The profimda femoris artery provided the sole source of blood supply to the lower extremity, which made vascular reconstruction mandatory. An 8 mm polytetrafluoroethylene graft was placed between the distal external iliac artery and the two branches of the distal profunda femoris artery. At the completion of the procedure, blood flow to the lower extremity was restored to the preoperative status with an ankle-arm index of 0.5. The early postoperative course had been uneventful. Angiography performed 10 days after operation shows the graft to be widely patent (Fig. 3).
DISCUSSION Atherosclerotic aneurysms o f the common femoral artery involved the orifice o f the profunda femoris artery in 56% o f cases reported by Cutler and Darling.3 However, aneurysmal dilatation o f the profunda femoris artery itself is uncommon and occurs in only 1% to 2.6% o f all femoral artery aneurysms. 2,4 This vessel is believed to be protected from dilatation by the muscular runnel formed by the adductor magnus. 2's'6 The natural history o f these aneurysms is unknown, but potential complications include
Volume 4 Number 4 October 1986
Ruptured aneurysm of the profunda femoris artery 407
Fig. 1. Angiograna done 4 years before this admission shows aneurysmal dilatation of the common and profunda femoral arteries.
Fig. 2. Profimda femoris aneurysm is exposed through a longitudinal groin incision. Outflow vessels are encircled with tape distally.
thrombosis, distal embolization, compression of adjacent nerves or veins, and rupture. The patient admitted with a ruptured atherosclerotic aneurysm of the profunda femoris artery is rare as reflected by the scarcity of information available in the literature. False aneurysms as a result of blunt trauma, 7'8 gunshot and stab w o u n d s , 9,1° o r iatrogenic injury from orthopedic procedures H-~3are more common and will not be considered here. The few cases available in the literature during the past 25 years are summarized herein. Control of hemorrhage and vessel ligation has been the most common method of management. A functional limb was usually salvaged but postoperative complications have been common. Jamieson and Carroll 14 reported a case in 1965 of a ruptured aneurysm that was initially misdiagnosed as ileofemoral t.hrombophlebitis. Management involved resection of the aneurysm with proximal and distal vessel ligation. The postoperative course was complicated by an infected wound he-
matoma and adjacent muscle necrosis. A partially functional limb was eventually salvaged after a prolonged hospital course. Karmody and G a l l o w a y is managed an 83-yearold man who had a swollen bruised thigh at admission; surgical exploration revealed a ruptured profunda femoris aneurysm. The vessel proximal to the aneurysm was ligated but the distal vessels were not investigated because of the patient's poor general condition. After operation, the aneurysm decreased in size and the limb remained viable but the patient died on the twelfth postoperative day. Cutler and Darling 3 reported a single case in a series of 63 femoral artery aneurysms managed surgically. Bleeding was controlled by vessel ligation but the involved limb ultimately required amputation. More recently, Tarrico 16 reported the case of a 72-year-old man who had a pulsatile right groin mass that surgical exploration revealed as a ruptured aneurysm. The proximal profunda femoris artery was ligated to control hemorrhage. The postoperative
408
Journal of VASCULAR SURGERY
Wiest,Mukherjee, and Inahara
and polytetrafluoroethylene have all been used successfully. Drainage and antibiotics may be helpful to avoid postoperative problems of hematoma and wound infection noted in the cases cited earlier. Surgical management of profunda femoris aneurysms even in the elective setting is associated with a high incidence of subsequent amputation? The frequent coexistence of atherosclerotic occlusive disease makes revascularization for limb salvage difficult and may challenge the creativity of the vascular surgeon. Prompt surgical intervention and control of rupture combined with a well-planned revascularization procedure is critical to optimize limb salvage and patient survival. REFERENCES
Fig. 3. Postoperative angiogram shows widely patent polytetrafluoroethylene graft. Distal anastomosis is to terminal bifurcation o f normal distal profunda femoris artery.
course was complicated by a wound hematoma and infection followed by rupture of the superficial femoral artery 25 days later. Bleeding was controlled and the limb was revascularized with a Dacron crossover femoropopliteal bypass graft. The patient was eventually discharged from the hospital with a functional limb. The rupture of an isolated atherosclerotic aneurysm of the first branch of the profunda femoris artery, the lateral femoral circumflex artery, has also been reported. 17 This 5 × 7 cm aneurysm was excised and the proximal and distal vessels ligated. The postoperative course was complicated by a wound hematoma. Although these aneurysms can be managed with vessel ligation in the presence of adequate collateral blood supply, they are best treated with resection and grafting 3 to maximize blood flow to the limb as was done in the case reported here. Autogenous saphenous vein, :8 human umbilical vein, :9 Dacron, z,3,2°
1. Crawford ES, DeBakey ME, Cooley DE. Surgical considerations of peripheral arterial aneurysms. Arch Surg 1959; 78:226-38. 2. Pappas G, Janes JM, Bernatz PE, Schirger A. Femoral aneurysms. JAMA 1964; 190:489-93. 3. Curler BS, Darling RC. Surgical management of arteriosclerotic femoral aneurysms. Surgery 1973; 74:764-73. 4. Dent TL, Lindenauer SM, Ernst CB, Fry WJ. Multiple arteriosclerotic arterial aneurysms. Arch Surg 1972; 105:33844. 5. Symes JM, Eadie DG. Solitary arteriosclerotic aneurysm of the profunda femoris artery. J Cardiovasc Surg (Torino) 1973; 14:220-2. 6. Billig DM, Jordan PH, DeBakey ME. Arteriosclerotic aneurysm of the profunda femoris artery: Report of a case with successful surgical repair. Cardiovasc Res Cent Bull 1968; 6:139. 7. Lindfors O, Pertti P, Totterman S. A false aneurysm of the deep femoral artery. Acta Chir Scand 1982; 148:201-2. 8. Squire A, Miller CM, Horowitz SF, Shane L, Jacobson II JH, Halperin JL. Femoral pseudoaneurysm following nonpenetrating trauma in a patient with aortic insufficiency. Am J Med 1985; 78:719-20. 9. Engelman RM, Clements JM, Herrmann lB. Stab wounds and traumatic false aneurysms in the extremities. J Trauma 1969; 9:77. 10. Loubeau JM, Bahnson HT. Traumatic false aneurysms and arteriovenous fistula of the profunda femoris artery: Surgical management and review of the literature. Surgery 1977; 81:222. 11. Bassett FH, Houck WS. False aneurysms of the profunda femoris artery after subtrochanteric osteotomy and nail-plate fixation. J Bone Joint Surg [Am] 1964; 46:583. 12. Dameron TB. False aneurysm of femoral profundus artery. resulting from internal fixation device (screw). J Bone Joint Surg [Am] 1964; 46:577. 13. Wolfgang GL, Barnes WT, Hendricks GL. False aneurysm of the profimda femoris artery resulting from nail-plate fixation of intertrochanteric fracture. A case report and review of the literature. Clin Orthop 1974; 100:143. 14. Jamieson WG, Carroll SE. Ruptured profunda femoral aneurysm presenting as thrombophlebitis. Med Serv J Canada 1965; 21:193-8.
Volume 4 Number 4 October 1986
15. Karmody AM, Galloway JM. Aneurysm of the profunda femoris artery. J R Coil Surg Edinb 1972; 17:261-3. 16. Taricco A. Ruptured aneurysm ofprofunda femoris. NY State J Med 1980; 80:960-2. 17. Feldman AJ, Berguer R. Rupture of isolated atherosclerotic aneurysm of lateral femoral circumflex artery. Surgery, 1981; 90:914-6. 18. Hardy DG, Eadie GA. Femoral aneurysm. Br J Surg 1972; 59:614-6.
Ruptured aneurysm of the profunda femoris artery 409
19. Ratto BG, Sacco A, Canepa G, Motta G. Atherosclerotic aneurysm of the deep femoral artery. J Cardiovasc Surg (Torino) 1984; 25:574-6. 20. Billig DM, Callow AD, Deterling RA. Surgical considerations in the management of lesions of the profunda femoris artery. Am J Surg 1970; 119:392-6.
Portland, Ore. An unusual case of a ruptured aneurysm involving the profunda femoris artery is reported. This problem was managed by resection of the aneurysm and revascularization of the lower extremity with a polytetrafluoroethylene graft to the distal branches of the profunda femoris artery. The limited avad'able literature is reviewed. (J VAse SURG 1986; 4:406-9.)
Peripheral atherosclerotic aneurysms are most common in the popliteal artery (55%) followed by the c o m m o n femoral artery (42%). 1 Isolated aneurysms o f the profunda femoris artery are uncommon and comprise only 0.5% o f all peripheral artery aneurysms? Asymptomatic aneurysms are difficult to identify because o f their location deep within the muscles o f the thigh. Symptoms develop as a result o f compression o f the adjacent femoral nerve or vein, embolization o f atherosclerotic debris, acute or chronic thrombosis, or rupture. Aneurysm rupture creates a limb-threatening and potentially life-threatening situation. The clinical presentation and surgical management o f a rare case o f ruptured profunda femoris aneurysm are reported.
CASE REPORT An 80-year-old man was hospitalized for evaluation of a painful swollen left groin. Physical examination showed a large tender putsatile mass in the left groin and upper thigh with an obvious thrill and a loud bruit. A diminished pulse was palpable in the popliteal artery. Distal pulses were not palpable but the ankle-arm index was 0.5. Past medical history was relevant for the elective resection ofa 6 cm infrarenal abdominal aortic aneurysm and placement of a Dacron aortobi-iliac bypass graft 4 years before this admission. Angiography of the femoral vessels at the time showed early aneurysmal dilatation of the common and profimda femoral arteries (Fig. 1). The distal superficial femoral artery was occluded. Rupture of a femoral aneurysm was suspected because of the rapid onset of symptoms. The diagnosis was confirmed by ultrasound examination of the left groin and thigh, which showed a 10 cm pulsatile mass with a medial irregularity compatible with extravasated blood. From the Department of Surgery, St. Vincent Hospital and Medical Center. Reprint requests: Toshio Inahara, M.D., 9155 SW Barnes Road, Suite 206, Portland, OR 97225. 406
The patient was promptly taken to the operating room where control of the distal external lilac artery was obtained through a retroperitoneal approach. A longitudinal incision was made directly over the pulsatile mass and it was dissected free from surrounding structures. The common femoral vein was densely adherent to the aneurysm and was left undisturbed. Two small outflow vessels were identified and dissected free for distal control. The aneurysm involved the profunda femoris artery and measured 10 x 10 cm (Fig. 2). The common femoral artery was slightly dilated and the superficial femoral artery was normal in size but occluded distally. Proximal and distal occlusion clamps were placed after systemic heparinization was begun. The aneurysmal sac was opened, preserving the adherent common femoral vein, and a large laminated clot was removed. The shaft of the femur formed the posterior wall of the aneurysm and the rupture site was identified along the medial wall. The profimda femoris artery provided the sole source of blood supply to the lower extremity, which made vascular reconstruction mandatory. An 8 mm polytetrafluoroethylene graft was placed between the distal external iliac artery and the two branches of the distal profunda femoris artery. At the completion of the procedure, blood flow to the lower extremity was restored to the preoperative status with an ankle-arm index of 0.5. The early postoperative course had been uneventful. Angiography performed 10 days after operation shows the graft to be widely patent (Fig. 3).
DISCUSSION Atherosclerotic aneurysms o f the common femoral artery involved the orifice o f the profunda femoris artery in 56% o f cases reported by Cutler and Darling.3 However, aneurysmal dilatation o f the profunda femoris artery itself is uncommon and occurs in only 1% to 2.6% o f all femoral artery aneurysms. 2,4 This vessel is believed to be protected from dilatation by the muscular runnel formed by the adductor magnus. 2's'6 The natural history o f these aneurysms is unknown, but potential complications include
Volume 4 Number 4 October 1986
Ruptured aneurysm of the profunda femoris artery 407
Fig. 1. Angiograna done 4 years before this admission shows aneurysmal dilatation of the common and profunda femoral arteries.
Fig. 2. Profimda femoris aneurysm is exposed through a longitudinal groin incision. Outflow vessels are encircled with tape distally.
thrombosis, distal embolization, compression of adjacent nerves or veins, and rupture. The patient admitted with a ruptured atherosclerotic aneurysm of the profunda femoris artery is rare as reflected by the scarcity of information available in the literature. False aneurysms as a result of blunt trauma, 7'8 gunshot and stab w o u n d s , 9,1° o r iatrogenic injury from orthopedic procedures H-~3are more common and will not be considered here. The few cases available in the literature during the past 25 years are summarized herein. Control of hemorrhage and vessel ligation has been the most common method of management. A functional limb was usually salvaged but postoperative complications have been common. Jamieson and Carroll 14 reported a case in 1965 of a ruptured aneurysm that was initially misdiagnosed as ileofemoral t.hrombophlebitis. Management involved resection of the aneurysm with proximal and distal vessel ligation. The postoperative course was complicated by an infected wound he-
matoma and adjacent muscle necrosis. A partially functional limb was eventually salvaged after a prolonged hospital course. Karmody and G a l l o w a y is managed an 83-yearold man who had a swollen bruised thigh at admission; surgical exploration revealed a ruptured profunda femoris aneurysm. The vessel proximal to the aneurysm was ligated but the distal vessels were not investigated because of the patient's poor general condition. After operation, the aneurysm decreased in size and the limb remained viable but the patient died on the twelfth postoperative day. Cutler and Darling 3 reported a single case in a series of 63 femoral artery aneurysms managed surgically. Bleeding was controlled by vessel ligation but the involved limb ultimately required amputation. More recently, Tarrico 16 reported the case of a 72-year-old man who had a pulsatile right groin mass that surgical exploration revealed as a ruptured aneurysm. The proximal profunda femoris artery was ligated to control hemorrhage. The postoperative
408
Journal of VASCULAR SURGERY
Wiest,Mukherjee, and Inahara
and polytetrafluoroethylene have all been used successfully. Drainage and antibiotics may be helpful to avoid postoperative problems of hematoma and wound infection noted in the cases cited earlier. Surgical management of profunda femoris aneurysms even in the elective setting is associated with a high incidence of subsequent amputation? The frequent coexistence of atherosclerotic occlusive disease makes revascularization for limb salvage difficult and may challenge the creativity of the vascular surgeon. Prompt surgical intervention and control of rupture combined with a well-planned revascularization procedure is critical to optimize limb salvage and patient survival. REFERENCES
Fig. 3. Postoperative angiogram shows widely patent polytetrafluoroethylene graft. Distal anastomosis is to terminal bifurcation o f normal distal profunda femoris artery.
course was complicated by a wound hematoma and infection followed by rupture of the superficial femoral artery 25 days later. Bleeding was controlled and the limb was revascularized with a Dacron crossover femoropopliteal bypass graft. The patient was eventually discharged from the hospital with a functional limb. The rupture of an isolated atherosclerotic aneurysm of the first branch of the profunda femoris artery, the lateral femoral circumflex artery, has also been reported. 17 This 5 × 7 cm aneurysm was excised and the proximal and distal vessels ligated. The postoperative course was complicated by a wound hematoma. Although these aneurysms can be managed with vessel ligation in the presence of adequate collateral blood supply, they are best treated with resection and grafting 3 to maximize blood flow to the limb as was done in the case reported here. Autogenous saphenous vein, :8 human umbilical vein, :9 Dacron, z,3,2°
1. Crawford ES, DeBakey ME, Cooley DE. Surgical considerations of peripheral arterial aneurysms. Arch Surg 1959; 78:226-38. 2. Pappas G, Janes JM, Bernatz PE, Schirger A. Femoral aneurysms. JAMA 1964; 190:489-93. 3. Curler BS, Darling RC. Surgical management of arteriosclerotic femoral aneurysms. Surgery 1973; 74:764-73. 4. Dent TL, Lindenauer SM, Ernst CB, Fry WJ. Multiple arteriosclerotic arterial aneurysms. Arch Surg 1972; 105:33844. 5. Symes JM, Eadie DG. Solitary arteriosclerotic aneurysm of the profunda femoris artery. J Cardiovasc Surg (Torino) 1973; 14:220-2. 6. Billig DM, Jordan PH, DeBakey ME. Arteriosclerotic aneurysm of the profunda femoris artery: Report of a case with successful surgical repair. Cardiovasc Res Cent Bull 1968; 6:139. 7. Lindfors O, Pertti P, Totterman S. A false aneurysm of the deep femoral artery. Acta Chir Scand 1982; 148:201-2. 8. Squire A, Miller CM, Horowitz SF, Shane L, Jacobson II JH, Halperin JL. Femoral pseudoaneurysm following nonpenetrating trauma in a patient with aortic insufficiency. Am J Med 1985; 78:719-20. 9. Engelman RM, Clements JM, Herrmann lB. Stab wounds and traumatic false aneurysms in the extremities. J Trauma 1969; 9:77. 10. Loubeau JM, Bahnson HT. Traumatic false aneurysms and arteriovenous fistula of the profunda femoris artery: Surgical management and review of the literature. Surgery 1977; 81:222. 11. Bassett FH, Houck WS. False aneurysms of the profunda femoris artery after subtrochanteric osteotomy and nail-plate fixation. J Bone Joint Surg [Am] 1964; 46:583. 12. Dameron TB. False aneurysm of femoral profundus artery. resulting from internal fixation device (screw). J Bone Joint Surg [Am] 1964; 46:577. 13. Wolfgang GL, Barnes WT, Hendricks GL. False aneurysm of the profimda femoris artery resulting from nail-plate fixation of intertrochanteric fracture. A case report and review of the literature. Clin Orthop 1974; 100:143. 14. Jamieson WG, Carroll SE. Ruptured profunda femoral aneurysm presenting as thrombophlebitis. Med Serv J Canada 1965; 21:193-8.
Volume 4 Number 4 October 1986
15. Karmody AM, Galloway JM. Aneurysm of the profunda femoris artery. J R Coil Surg Edinb 1972; 17:261-3. 16. Taricco A. Ruptured aneurysm ofprofunda femoris. NY State J Med 1980; 80:960-2. 17. Feldman AJ, Berguer R. Rupture of isolated atherosclerotic aneurysm of lateral femoral circumflex artery. Surgery, 1981; 90:914-6. 18. Hardy DG, Eadie GA. Femoral aneurysm. Br J Surg 1972; 59:614-6.
Ruptured aneurysm of the profunda femoris artery 409
19. Ratto BG, Sacco A, Canepa G, Motta G. Atherosclerotic aneurysm of the deep femoral artery. J Cardiovasc Surg (Torino) 1984; 25:574-6. 20. Billig DM, Callow AD, Deterling RA. Surgical considerations in the management of lesions of the profunda femoris artery. Am J Surg 1970; 119:392-6.