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Superficial femoral artery aneurysms: An unusual entity?
Superficial femoral artery aneurysms: An unusual entity? Fredric Jarrett, MD, Michel S. Makaroun, MD, Robert Y. Rhee, MD, and Daniel J. Bertges, MD, Pittsburgh, Pa Objective: The purpose of this study was to investigate the mode of presentation of superficial femoral artery aneurysms, their association with other arterial aneurysms, and their operative treatment. Method: Records of patients with superficial femoral artery aneurysms seen at our institution from 1990 to 2000 were reviewed retrospectively with attention to presenting symptoms, clinical examination, arteriographic findings, and operative management. Results: Eleven of 13 aneurysms (85%) were in men. Nine (69%) were associated with aortic or iliac aneurysms, and seven (54%) with femoral or popliteal aneurysms. Six patients (46%) presented with distal ischemia, four (31%) presented with a thigh mass, and three (23%) were discovered during investigation for other vascular problems. No ruptured superficial femoral artery aneurysms were seen. Eleven patients underwent successful aneurysm resection and bypass grafting. Two patients underwent amputation. There were no operative mortalities. Conclusions: Patients with superficial femoral artery aneurysms may present with distal ischemia, with a pulsatile thigh mass, with rupture and bleeding, or the aneurysms may be discovered during other investigations. The high incidence of complications suggests that resection and grafting should be performed electively, and the frequent association of aortoiliac or peripheral aneurysms mandates thorough investigation and follow-up. (J Vasc Surg 2002;36:571-4.)
Arteriosclerotic aneurysms of the superficial femoral artery (SFA) are said to be distinctly unusual, if not rare, entities. For this reason, their natural history and the frequency of their association with aortoiliac and other peripheral aneurysms are not known or understood. For example, it is unclear if SFA aneurysms have a natural history similar to that of aortic aneurysms, with a high incidence of rupture and a low incidence of thrombosis or embolism, or if the natural history of SFAs is similar to that of popliteal aneurysms, with a high incidence of thrombosis and distal embolization, a low incidence of rupture, and a marked preponderance in men. METHODS AND RESULTS We retrospectively reviewed records of all patients seen from 1990 to 2000 with lower extremity aneurysms at University of Pittsburgh Medical Center (UPMC) and the Pittsburgh Veterans Affairs Hospital. Thirteen patients with SFA aneurysms were identified. Eleven were men (85%): 7 of 9 at UPMC and 4 of 4 at the Veterans Affairs Hospital. Patients with false aneurysms secondary to trauma or with anastomotic aneurysms after previous arterial reconstructive procedures were excluded, although two From the Division of Vascular Surgery, University of Pittsburgh School of Medicine. Competition of interest: nil. Presented at the Fifteenth Annual Meeting of the Eastern Vascular Society, Washington, DC, May 4-6, 2001. Reprint requests: Fredric Jarrett, MD, UPMC Shadyside Medical Center, 5200 Centre Avenue, #705, Pittsburgh, PA 15232 (e-mail: [email protected]). Copyright © 2002 by The Society for Vascular Surgery and The American Association for Vascular Surgery. 0741-5214/2002/$35.00 ⫹ 0 24/1/125841 doi:10.1067/mva.2002.125841
patients found to have SFA aneurysms underwent arteriography because of femoral pseudo aneurysms. Patients with arteriomegaly or with extension of femoral or popliteal aneurysms into the adductor canal were likewise excluded. An aneurysm was defined as as a diameter of 2 or more times that of the host SFA. The average age of our patients was 75 years (range, 61-91 years). Nine patients (69%) had associated or past aortic or iliac aneurysms and seven (54%) had associated popliteal or common femoral aneurysms (Table I). Seventy-six percent of our patients were symptomatic with either limb-threatening distal ischemia or presentation with a painful thigh mass. There was a striking male preponderance (85%) among patients with SFA aneurysms in our series, but less than the male preponderance (97%) usually seen with popliteal aneurysms. This preponderance was observed despite the fact that only 4 of 13 patients were from the Veterans Affairs Hospital. In 9 of 13 (69%) of our patients, the aneurysm was not palpable on physical examination, and, in fact, the four patients whose aneurysms were appreciated on physical examination were lean or had particularly large aneurysms allowing appreciation of a pulsatile mass deep to the thigh muscles (Figs 1 and 2). In one patient who underwent arteriography for limb-threatening ischemia that showed a SFA occlusion and no adequate run-off, the aneurysm had thrombosed and the correct diagnosis was made only during above-knee amputation (Fig 3). Although there were no ruptured SFA aneurysms in our own series, rupture occurred in 34% of the 38 cases reviewed from previous reports (Table II). We are unable to explain this disparity of observations between our experience and the reports cited. In the four patients with a painful or pulsatile thigh mass, an aneurysm was considered and arteriography was 571
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Table I. Characteristics of patients with superficial femoral artery aneurysms
Patient
Age/gender
Presentation/diagnosis
1 2 3 4 5 6 7 8 9 10
91/F 75/M 82/M 69/M 70/M 64/M 76/M 61/M 91/F 70/M
11 12 13
66/M 73/M 85/M
Thigh mass, symptomatic Ischemic foot Ischemic foot with ulcer Thigh mass on arteriogram Thigh pain on arteriogram Distal emboli Ischemic foot Thigh mass, pulsatile Thigh mass, symptomatic Femoral pseudoaneurysm* (AAA Repair 8 yrs Previously) Femoral aneurysm Ischemic foot on arteriogram Ischemic foot with gangrene
AAA/ iliac aneurysm
Femoral/popliteal aneurysm
— — ⫹ ⫹ ⫹ ⫹ ⫹ — — ⫹
— ⫹ ⫹ — — ⫹ ⫹ — — ⫹
Resection/PTFE Exclusion/PTFE Hyperbaric O2/amputation Resection/PTFE Resection/Hemashield Resection/prosthesis In situ GSV, Femoral posterior tibial Resection/prosthesis (Hemashield) Resection/prosthesis (Hemashield) Resection/L Fem-Pop with GSV
⫹ ⫹ ⫹
⫹ ⫹ —
Resection/prosthesis Resection/in situ GSV to distal popliteal Amputation
Procedure
AAA, Abdominal aortic aneurysm; GSV, greater saphenous vein; PTFE, polytetrafluoroethylene. *AAA repair 8 years earlier.
Fig 1. Computed tomographic scan of 91-year-old woman with a palpable and visible right superficial femoral artery aneurysm, measured as 7 cm in diameter. The contralateral leg shows no evidence of aneurysm formation.
recommended. In the remaining nine patients, arteriography was prompted by complaints and symptoms of distal ischemia (six patients), asymptomatic femoral pseudoaneurysms (two patients), or thigh pain without a palpable mass on examination (one patient). Of the six patients who presented with distal ischemia, one had a nonhealing ulcer and a second had a gangrenous foot, two had fresh clot in tibial vessels on arteriography, one had physical findings of distal emboli, and one had an acutely cool, cyanotic foot. No patients had symptoms of venous compression or compression of adjacent nerves. Aneurysm size was not always stated in arteriogram reports but ranged from 3 cm to 10
cm. When the size was stated, it notoriously underestimated the true size of the aneurysm because of the presence of laminated thrombus. Ultrasound scanning, which can more accurately measure aneurysm size, was not routinely obtained after an SFA aneurysm was identified by arteriography. In eleven patients, repair was accomplished by conventional techniques of partial or complete aneurysm resection and grafting, and prosthetic grafts (eight cases) were the most commonly employed conduit, as the SFA seemed to offer a convenient size match for a 6 mm to 8 mm graft. Three patients underwent reconstruction with use of au-
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Jarrett et al 573
Fig 2. Arteriogram in the same patient showing a 2.5-cm fusiform superficial femoral artery aneurysm at the mid-thigh level, the difference in size measurements being the result of laminated thrombus.
Fig 3. Arteriogram in an 85-year-old man showing superficial femoral artery occlusion with only collateral vessels and no run-off vessels shown at the thigh level. At amputation, performed because of ischemic ulceration, he was found to have a thrombosed superficial femoral artery aneurysm.
Table II. Superficial femoral artery aneurysms, 1972 to 2001 Reference Hardy and Eadie (13), 1972 Ormstad and Solheim (14), 1975 Kremen et al (4), 1981 Celi et al (15), 1984 Cieslik et al (16), 1989 Parra et al (17), 1989 Bonelli et al (18), 1991 Mayall et al (19), 1991 Rigdon and Monajjem (5), 1992 Vasquez et al (20), 1993 Attalah et al (21), 1995 Farinon (22), 1995 Dimakakos et al (6), 1998 Present study, 2001 Total
Aneurysm(s)
Rupture
1 1 7 1 1 1 2 3 2 1 2 1 2 13 38
— 1 3 — — 1 2 — 1 — 2 1 2 — 13 (34%)
togenous saphenous vein because of associated distal occlusive or aneurysmal disease and the need to construct the distal anastomosis below the knee where our preference is for autogenous saphenous vein. One patient underwent
Thrombosis/ embolism — — 3 — — — — 1 1 1 — — — 6 12 (26%)
Other aneurysms — 1 2 — — — — — — — 1 — 1 10 15 (39%)
amputation after presenting with an ischemic foot and no satisfactory runoff vessels; his thrombosed aneurysm was not recognized preoperatively on physical examination or arteriography, but was discovered during performance of
JOURNAL OF VASCULAR SURGERY September 2002
574 Jarrett et al
an above-the-knee amputation. One patient underwent amputation after unsuccessful treatment of ischemic ulcers with local care and hyperbaric oxygen. All patients survived surgery (Table I). DISCUSSION Aneurysms located in the SFA have always been thought to be most unusual entities. A report by Graham et al1 of 172 arteriosclerotic femoral aneurysms did not mention SFA aneurysms, nor did the reviews by Levi and Schroeder2 or Baird et al.3 Although Kremen et al4 described seven atherosclerotic SFA aneurysms, most reports of this entity in the surgical literature are of only one or two cases. A report by Rigdon and Monajjem5 of two SFA aneurysms included a literature review of 17 SFA aneurysms in 14 patients. Forty percent were associated with abdominal aortic aneurysms, 27% were associated with other peripheral aneurysms, and 35% had ruptured. In their 1998 report of two ruptured SFA aneurysms, Dimakakos et al6 included a review of 28 patients with 30 aneurysms, 33% associated with abdominal aneurysms, 14 of 30 (46.6%) that had ruptured, and 5 of 30 (16.6%) that had thrombosed. However, five of these were common femoral aneurysms with extension into the SFA and should not be included in these series. Cutler and Darling7 describe 63 procedures on arteriosclerotic femoral aneurysms, none of which were isolated SFA aneurysms. Although Adiseshiah and Bailey8 and Zanetti9 reported three additional cases and one additional case, respectively, information regarding presentation of these aneurysms was not available in these reports and they are not included in the series tabulated (Table II). The high incidence of associated abdominal and peripheral aneurysms among patients with SFA aneurysms mandates appropriate investigation at the time of diagnosis and subsequent follow-up to include periodic surveillance for the appearance of other aneurysms. We have recommended yearly duplex scanning on our patients, as has been our practice with other peripheral aneurysms. Thus far, no additional SFA aneurysms have been identified on followup. The associated high incidence of multiple aneurysms in our series was not seen in the two women, both over age 90 years, who had no other associated peripheral aneurysms, whereas only one of the 11 men in our series had no other associated aneurysms. Dent et al,1 in their series of multiple arterial aneurysms likewise reported that multiple aneurysmal disease was seen almost exclusively in men, with only 1 woman among the 57 patients reported. Because SFA aneurysms may occlude and the aneurysm may not be identified on arteriography, its true incidence may be underappreciated, as such patients may present with a presumed thrombotic occlusion of an atherosclerotic SFA when in fact their occlusion is the result of a thrombosed aneurysm. Resection of a superficial femoral artery aneurysm may be easily accomplished and reconstruction performed with a prosthetic graft if no distal abnormalities requiring grafting are present. When occlusive or aneurys-
mal disease below the knee requires an anastomosis to a distal popliteal or tibial artery, our preference is to use autogenous saphenous vein as a single graft. This preference was consistent with the preference for autogenous saphenous vein in a large series of patients with popliteal aneurysm11,12 and with our preference for autogenous saphenous vein for reconstruction to the below-knee popliteal or tibial vessels for occlusive disease. REFERENCES 1. Graham LM, Zelenock GB, Whitehouse WM, Erlandson EE, Dent TL, Lindenauer SM, et al. Clinical significance of arteriosclerotic femoral artery aneurysms. Arch Surg 1980;115:502-7. 2. Levi N, Schroeder TV. Arteriosclerotic femoral artery aneurysms. A short review. J Cardiovasc Surg 1997;38:335-8. 3. Baird RJ, Gurry JF, Kellam J, Plume SK. Arteriosclerotic femoral artery aneurysms. CMAJ 1977;117:1306-7. 4. 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. 5. Rigdon EE, Monajjem N. Aneurysms of the superficial femoral artery: A report of two cases and review of the literature. J Vasc Surg 1992;16: 790-3. 6. 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. 7. Cutler BS, Darling RC. Surgical management of arteriosclerotic femoral aneurysms. Surgery 1973;74:764-73. 8. Adiseshiah M, Bailey DA. Aneurysms of the femoral artery. Br J Surg 1977;64:174-6. 9. Zanetti PP, Personnettaz E, Peradotto F, Rosa G, Battaglia C. Aneurisma dell’arteria femorale superficiale. (Aneurysm of the superficial femoral artery). Minerva Cardioangiol 1986;34:323-7. 10. Dent TL, Lindenauer SM, Ernst CB, Fry WJ. Multiple arteriosclerotic arterial aneurysms. Arch Surg 1972;105:338-44. 11. Vermilion BD, Kimmins SA, Pace WG, Evans WE. A review of one hundred forty-seven popliteal aneurysms with long-term follow-up. Surgery 1981;90:1009-14. 12. Anton GE, Hertzer NR, Beven EG, O’Hara PJ, Krajewski LP. Surgical management of popliteal aneurysms. Trends in presentation, treatment, and results from 1952 to 1984. J Vasc Surg 1988;3:125-34. 13. Hardy DG, Eadie DGA. Femoral aneurysms. Br J Surg 1972;59:614-6. 14. Ormstad K, Solheim K. Ruptured aneurysms of the superficial femoral artery. Scand J Thor Cardiovasc Surg 1975;9:181-2. 15. Celi S, Mandolfino T, Micali C, Castiglione N. Aneurisma dell’arteria femorale superficiale. Chir Ital 1984;36:260-5. 16. Cieslik R, Pasierbski J, Reizer E, Dmytrzak A. Tetniak tetnicy udowej powierzchownej zagrazajacy peknieciem. (Superficial femoral artery aneurysm with imminent rupture). Wiad Lek 1989;42:334-6. 17. Parra HH, Bark T, Swedenborg J. Ruptured atherosclerotic aneurysm of the superficial femoral artery, case report. Acta Chir Scand 1989;155: 493-4. 18. Bonelli U, Cerruti R, Arnuzzo L. Gli aneurismi dell’arteria femorale superficiale in fase di osservazioni personali. Minerva Chir 1991;46: 1071-3. 19. Mayall JC, Mayall RC, Mayall ACDG, Mayall LCDG. Peripheral aneurysms. Int Angiol 1991;10:141-5. 20. Vasquez G, Zamboni P, Buccoliero F, Ortolani M, Berta R, Liboni A. Isolated true atherosclerotic aneurysms of the superficial femoral artery. Case report and literature review. J Cardiovasc Surg 1993;34:511-2. 21. Atallah C, Al Hassan HK, Neglen. Superficial femoral artery aneurysm—an uncommon site of aneurysm formation. Eur J Vasc Endovasc Surg 1995;10:502-4. 22. Farinon AM, Rulli F, Muzi M. Ruptured aneurysm of the superficial femoral artery. Panminerva Med 1995;37:155-8. Submitted Jul 24, 2001; accepted Apr 12, 2002.
Arteriosclerotic aneurysms of the superficial femoral artery (SFA) are said to be distinctly unusual, if not rare, entities. For this reason, their natural history and the frequency of their association with aortoiliac and other peripheral aneurysms are not known or understood. For example, it is unclear if SFA aneurysms have a natural history similar to that of aortic aneurysms, with a high incidence of rupture and a low incidence of thrombosis or embolism, or if the natural history of SFAs is similar to that of popliteal aneurysms, with a high incidence of thrombosis and distal embolization, a low incidence of rupture, and a marked preponderance in men. METHODS AND RESULTS We retrospectively reviewed records of all patients seen from 1990 to 2000 with lower extremity aneurysms at University of Pittsburgh Medical Center (UPMC) and the Pittsburgh Veterans Affairs Hospital. Thirteen patients with SFA aneurysms were identified. Eleven were men (85%): 7 of 9 at UPMC and 4 of 4 at the Veterans Affairs Hospital. Patients with false aneurysms secondary to trauma or with anastomotic aneurysms after previous arterial reconstructive procedures were excluded, although two From the Division of Vascular Surgery, University of Pittsburgh School of Medicine. Competition of interest: nil. Presented at the Fifteenth Annual Meeting of the Eastern Vascular Society, Washington, DC, May 4-6, 2001. Reprint requests: Fredric Jarrett, MD, UPMC Shadyside Medical Center, 5200 Centre Avenue, #705, Pittsburgh, PA 15232 (e-mail: [email protected]). Copyright © 2002 by The Society for Vascular Surgery and The American Association for Vascular Surgery. 0741-5214/2002/$35.00 ⫹ 0 24/1/125841 doi:10.1067/mva.2002.125841
patients found to have SFA aneurysms underwent arteriography because of femoral pseudo aneurysms. Patients with arteriomegaly or with extension of femoral or popliteal aneurysms into the adductor canal were likewise excluded. An aneurysm was defined as as a diameter of 2 or more times that of the host SFA. The average age of our patients was 75 years (range, 61-91 years). Nine patients (69%) had associated or past aortic or iliac aneurysms and seven (54%) had associated popliteal or common femoral aneurysms (Table I). Seventy-six percent of our patients were symptomatic with either limb-threatening distal ischemia or presentation with a painful thigh mass. There was a striking male preponderance (85%) among patients with SFA aneurysms in our series, but less than the male preponderance (97%) usually seen with popliteal aneurysms. This preponderance was observed despite the fact that only 4 of 13 patients were from the Veterans Affairs Hospital. In 9 of 13 (69%) of our patients, the aneurysm was not palpable on physical examination, and, in fact, the four patients whose aneurysms were appreciated on physical examination were lean or had particularly large aneurysms allowing appreciation of a pulsatile mass deep to the thigh muscles (Figs 1 and 2). In one patient who underwent arteriography for limb-threatening ischemia that showed a SFA occlusion and no adequate run-off, the aneurysm had thrombosed and the correct diagnosis was made only during above-knee amputation (Fig 3). Although there were no ruptured SFA aneurysms in our own series, rupture occurred in 34% of the 38 cases reviewed from previous reports (Table II). We are unable to explain this disparity of observations between our experience and the reports cited. In the four patients with a painful or pulsatile thigh mass, an aneurysm was considered and arteriography was 571
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572 Jarrett et al
Table I. Characteristics of patients with superficial femoral artery aneurysms
Patient
Age/gender
Presentation/diagnosis
1 2 3 4 5 6 7 8 9 10
91/F 75/M 82/M 69/M 70/M 64/M 76/M 61/M 91/F 70/M
11 12 13
66/M 73/M 85/M
Thigh mass, symptomatic Ischemic foot Ischemic foot with ulcer Thigh mass on arteriogram Thigh pain on arteriogram Distal emboli Ischemic foot Thigh mass, pulsatile Thigh mass, symptomatic Femoral pseudoaneurysm* (AAA Repair 8 yrs Previously) Femoral aneurysm Ischemic foot on arteriogram Ischemic foot with gangrene
AAA/ iliac aneurysm
Femoral/popliteal aneurysm
— — ⫹ ⫹ ⫹ ⫹ ⫹ — — ⫹
— ⫹ ⫹ — — ⫹ ⫹ — — ⫹
Resection/PTFE Exclusion/PTFE Hyperbaric O2/amputation Resection/PTFE Resection/Hemashield Resection/prosthesis In situ GSV, Femoral posterior tibial Resection/prosthesis (Hemashield) Resection/prosthesis (Hemashield) Resection/L Fem-Pop with GSV
⫹ ⫹ ⫹
⫹ ⫹ —
Resection/prosthesis Resection/in situ GSV to distal popliteal Amputation
Procedure
AAA, Abdominal aortic aneurysm; GSV, greater saphenous vein; PTFE, polytetrafluoroethylene. *AAA repair 8 years earlier.
Fig 1. Computed tomographic scan of 91-year-old woman with a palpable and visible right superficial femoral artery aneurysm, measured as 7 cm in diameter. The contralateral leg shows no evidence of aneurysm formation.
recommended. In the remaining nine patients, arteriography was prompted by complaints and symptoms of distal ischemia (six patients), asymptomatic femoral pseudoaneurysms (two patients), or thigh pain without a palpable mass on examination (one patient). Of the six patients who presented with distal ischemia, one had a nonhealing ulcer and a second had a gangrenous foot, two had fresh clot in tibial vessels on arteriography, one had physical findings of distal emboli, and one had an acutely cool, cyanotic foot. No patients had symptoms of venous compression or compression of adjacent nerves. Aneurysm size was not always stated in arteriogram reports but ranged from 3 cm to 10
cm. When the size was stated, it notoriously underestimated the true size of the aneurysm because of the presence of laminated thrombus. Ultrasound scanning, which can more accurately measure aneurysm size, was not routinely obtained after an SFA aneurysm was identified by arteriography. In eleven patients, repair was accomplished by conventional techniques of partial or complete aneurysm resection and grafting, and prosthetic grafts (eight cases) were the most commonly employed conduit, as the SFA seemed to offer a convenient size match for a 6 mm to 8 mm graft. Three patients underwent reconstruction with use of au-
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Jarrett et al 573
Fig 2. Arteriogram in the same patient showing a 2.5-cm fusiform superficial femoral artery aneurysm at the mid-thigh level, the difference in size measurements being the result of laminated thrombus.
Fig 3. Arteriogram in an 85-year-old man showing superficial femoral artery occlusion with only collateral vessels and no run-off vessels shown at the thigh level. At amputation, performed because of ischemic ulceration, he was found to have a thrombosed superficial femoral artery aneurysm.
Table II. Superficial femoral artery aneurysms, 1972 to 2001 Reference Hardy and Eadie (13), 1972 Ormstad and Solheim (14), 1975 Kremen et al (4), 1981 Celi et al (15), 1984 Cieslik et al (16), 1989 Parra et al (17), 1989 Bonelli et al (18), 1991 Mayall et al (19), 1991 Rigdon and Monajjem (5), 1992 Vasquez et al (20), 1993 Attalah et al (21), 1995 Farinon (22), 1995 Dimakakos et al (6), 1998 Present study, 2001 Total
Aneurysm(s)
Rupture
1 1 7 1 1 1 2 3 2 1 2 1 2 13 38
— 1 3 — — 1 2 — 1 — 2 1 2 — 13 (34%)
togenous saphenous vein because of associated distal occlusive or aneurysmal disease and the need to construct the distal anastomosis below the knee where our preference is for autogenous saphenous vein. One patient underwent
Thrombosis/ embolism — — 3 — — — — 1 1 1 — — — 6 12 (26%)
Other aneurysms — 1 2 — — — — — — — 1 — 1 10 15 (39%)
amputation after presenting with an ischemic foot and no satisfactory runoff vessels; his thrombosed aneurysm was not recognized preoperatively on physical examination or arteriography, but was discovered during performance of
JOURNAL OF VASCULAR SURGERY September 2002
574 Jarrett et al
an above-the-knee amputation. One patient underwent amputation after unsuccessful treatment of ischemic ulcers with local care and hyperbaric oxygen. All patients survived surgery (Table I). DISCUSSION Aneurysms located in the SFA have always been thought to be most unusual entities. A report by Graham et al1 of 172 arteriosclerotic femoral aneurysms did not mention SFA aneurysms, nor did the reviews by Levi and Schroeder2 or Baird et al.3 Although Kremen et al4 described seven atherosclerotic SFA aneurysms, most reports of this entity in the surgical literature are of only one or two cases. A report by Rigdon and Monajjem5 of two SFA aneurysms included a literature review of 17 SFA aneurysms in 14 patients. Forty percent were associated with abdominal aortic aneurysms, 27% were associated with other peripheral aneurysms, and 35% had ruptured. In their 1998 report of two ruptured SFA aneurysms, Dimakakos et al6 included a review of 28 patients with 30 aneurysms, 33% associated with abdominal aneurysms, 14 of 30 (46.6%) that had ruptured, and 5 of 30 (16.6%) that had thrombosed. However, five of these were common femoral aneurysms with extension into the SFA and should not be included in these series. Cutler and Darling7 describe 63 procedures on arteriosclerotic femoral aneurysms, none of which were isolated SFA aneurysms. Although Adiseshiah and Bailey8 and Zanetti9 reported three additional cases and one additional case, respectively, information regarding presentation of these aneurysms was not available in these reports and they are not included in the series tabulated (Table II). The high incidence of associated abdominal and peripheral aneurysms among patients with SFA aneurysms mandates appropriate investigation at the time of diagnosis and subsequent follow-up to include periodic surveillance for the appearance of other aneurysms. We have recommended yearly duplex scanning on our patients, as has been our practice with other peripheral aneurysms. Thus far, no additional SFA aneurysms have been identified on followup. The associated high incidence of multiple aneurysms in our series was not seen in the two women, both over age 90 years, who had no other associated peripheral aneurysms, whereas only one of the 11 men in our series had no other associated aneurysms. Dent et al,1 in their series of multiple arterial aneurysms likewise reported that multiple aneurysmal disease was seen almost exclusively in men, with only 1 woman among the 57 patients reported. Because SFA aneurysms may occlude and the aneurysm may not be identified on arteriography, its true incidence may be underappreciated, as such patients may present with a presumed thrombotic occlusion of an atherosclerotic SFA when in fact their occlusion is the result of a thrombosed aneurysm. Resection of a superficial femoral artery aneurysm may be easily accomplished and reconstruction performed with a prosthetic graft if no distal abnormalities requiring grafting are present. When occlusive or aneurys-
mal disease below the knee requires an anastomosis to a distal popliteal or tibial artery, our preference is to use autogenous saphenous vein as a single graft. This preference was consistent with the preference for autogenous saphenous vein in a large series of patients with popliteal aneurysm11,12 and with our preference for autogenous saphenous vein for reconstruction to the below-knee popliteal or tibial vessels for occlusive disease. REFERENCES 1. Graham LM, Zelenock GB, Whitehouse WM, Erlandson EE, Dent TL, Lindenauer SM, et al. Clinical significance of arteriosclerotic femoral artery aneurysms. Arch Surg 1980;115:502-7. 2. Levi N, Schroeder TV. Arteriosclerotic femoral artery aneurysms. A short review. J Cardiovasc Surg 1997;38:335-8. 3. Baird RJ, Gurry JF, Kellam J, Plume SK. Arteriosclerotic femoral artery aneurysms. CMAJ 1977;117:1306-7. 4. 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. 5. Rigdon EE, Monajjem N. Aneurysms of the superficial femoral artery: A report of two cases and review of the literature. J Vasc Surg 1992;16: 790-3. 6. 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. 7. Cutler BS, Darling RC. Surgical management of arteriosclerotic femoral aneurysms. Surgery 1973;74:764-73. 8. Adiseshiah M, Bailey DA. Aneurysms of the femoral artery. Br J Surg 1977;64:174-6. 9. Zanetti PP, Personnettaz E, Peradotto F, Rosa G, Battaglia C. Aneurisma dell’arteria femorale superficiale. (Aneurysm of the superficial femoral artery). Minerva Cardioangiol 1986;34:323-7. 10. Dent TL, Lindenauer SM, Ernst CB, Fry WJ. Multiple arteriosclerotic arterial aneurysms. Arch Surg 1972;105:338-44. 11. Vermilion BD, Kimmins SA, Pace WG, Evans WE. A review of one hundred forty-seven popliteal aneurysms with long-term follow-up. Surgery 1981;90:1009-14. 12. Anton GE, Hertzer NR, Beven EG, O’Hara PJ, Krajewski LP. Surgical management of popliteal aneurysms. Trends in presentation, treatment, and results from 1952 to 1984. J Vasc Surg 1988;3:125-34. 13. Hardy DG, Eadie DGA. Femoral aneurysms. Br J Surg 1972;59:614-6. 14. Ormstad K, Solheim K. Ruptured aneurysms of the superficial femoral artery. Scand J Thor Cardiovasc Surg 1975;9:181-2. 15. Celi S, Mandolfino T, Micali C, Castiglione N. Aneurisma dell’arteria femorale superficiale. Chir Ital 1984;36:260-5. 16. Cieslik R, Pasierbski J, Reizer E, Dmytrzak A. Tetniak tetnicy udowej powierzchownej zagrazajacy peknieciem. (Superficial femoral artery aneurysm with imminent rupture). Wiad Lek 1989;42:334-6. 17. Parra HH, Bark T, Swedenborg J. Ruptured atherosclerotic aneurysm of the superficial femoral artery, case report. Acta Chir Scand 1989;155: 493-4. 18. Bonelli U, Cerruti R, Arnuzzo L. Gli aneurismi dell’arteria femorale superficiale in fase di osservazioni personali. Minerva Chir 1991;46: 1071-3. 19. Mayall JC, Mayall RC, Mayall ACDG, Mayall LCDG. Peripheral aneurysms. Int Angiol 1991;10:141-5. 20. Vasquez G, Zamboni P, Buccoliero F, Ortolani M, Berta R, Liboni A. Isolated true atherosclerotic aneurysms of the superficial femoral artery. Case report and literature review. J Cardiovasc Surg 1993;34:511-2. 21. Atallah C, Al Hassan HK, Neglen. Superficial femoral artery aneurysm—an uncommon site of aneurysm formation. Eur J Vasc Endovasc Surg 1995;10:502-4. 22. Farinon AM, Rulli F, Muzi M. Ruptured aneurysm of the superficial femoral artery. Panminerva Med 1995;37:155-8. Submitted Jul 24, 2001; accepted Apr 12, 2002.