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Symptomatic popliteal venous aneurysm causing a footdrop
Symptomatic popliteal venous aneurysm causing a footdrop Frank Hoexum, MD,a Domenique M. J. Müller, MD,b Willem (Pim) van Ouwerkerk, MD, PhD,b and Jan D. Blankensteijn, MD, PhD,a Amsterdam, The Netherlands Symptomatic aneurysms of the popliteal vein are uncommon, with the majority resulting in thromboembolic complications. Neurologic symptoms are extremely rare. We present a case of a 53-year-old man with a footdrop resulting from a saccular popliteal venous aneurysm. Compression of the peroneal nerve caused the neurologic deficit. After aneurysmectomy and lateral venorrhaphy, the patient regained full strength of his lower leg muscles. Neurologic complications caused by a popliteal venous aneurysm should be considered in patients with a swelling in the popliteal fossa and a neurologic deficit of the lower extremity. (J Vasc Surg Cases 2016;2:130-3.)
Popliteal venous aneurysms (PVAs) are rare. Symptoms caused by PVAs are in the majority of cases thromboembolic (eg, pulmonary embolism, deep venous thrombosis). Arterial complications are uncommon and neurologic symptoms are exceedingly rare. The subject of our case report consented to the publication of this report. CASE REPORT A 53-year-old man was referred to our institution because of a footdrop on his left side and the inability to extend his left hallux. Several years before, his left knee was injured during sporting activities, with ligamentous injuries and a torn meniscus. Arthroscopy was performed with removal of the damaged cartilage. His recovery was complicated by a pulmonary embolism, which was thought to be a coincidence of postoperative immobilization. Computed tomography pulmonary angiography revealed the pulmonary embolism; no duplex scan of the lower extremity was performed. An oral anticoagulant was prescribed for secondary prevention. In the last 5 months before referral, he has experienced an intermittent footdrop. He also complained about coincidental lower back pain. Magnetic resonance imaging of his back excluded spinal nerve root compression. His back pain faded over time, but he kept his footdrop and paralysis of the extensor hallucis longus. Besides the paralysis, he had a sensory loss at the anterolateral side of his lower leg and the dorsum of his left foot. His complaints worsened when sitting on the toilet but not when sitting in a chair. His complaints seemed to improve in the week before his referral,
and he was able to slightly extend his left hallux. Inspection revealed a local swelling in the popliteal fossa of his left knee (Fig 1). Physical examination confirmed the paralysis of the anterior tibial muscle, a paresis of the extensor hallucis longus muscle of grade 4 on the Medical Research Council scale, and hypesthesia of the anterolateral side of his left lower leg. Reflexes were symmetrical. Magnetic resonance imaging of the left knee showed, besides a bucket-handle tear of his medial meniscus and a torn lateral meniscus, a saccular aneurysm of the popliteal vein with a close relationship to the tibial nerve and peroneal nerve (Fig 2). The peroneal nerve had a slightly increased intensity, matching a neuritis. An additional electromyographic investigation showed denervation and reinnervation of the muscles innervated by the peroneal nerve. Because of his complaints and the risk of thromboembolic complications of the aneurysm, we performed an open repair. With an S-shaped posterior approach, the tibial and peroneal nerves were carefully dissected free from the aneurysm. An aneurysmectomy and lateral venorrhaphy were performed to decrease the diameter of the popliteal vein to normal (Fig 3). No perioperative complications occurred. Recovery was uneventful and he could be discharged, after resuming oral anticoagulants, on the fourth postoperative day. Follow-up in the outpatient clinic showed no signs of recurrence on duplex ultrasound examination. He experienced full recovery of his lower leg muscle strength with normal sensibility. After 6 months, his oral anticoagulants were discontinued. At 13 months of follow-up, no recurrent pulmonary embolism was diagnosed.
DISCUSSION From the Department of Vascular Surgerya and Department of Neurosurgery,b VU Medical Center. Author conflict of interest: none. Correspondence: Frank Hoexum, MD, Department of Vascular Surgery, VU University Medical Center, De Boelelaan 1117, PO Box 7057, Amsterdam 1007 MB, The Netherlands (e-mail: frankhoexum@hotmail. com). The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 2468-4287 Ó 2016 The Authors. Published by Elsevier Inc. on behalf of Society for Vascular Surgery. This is an open access article under the CC BY-NCND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.jvscit.2016.05.002
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PVAs are rare. Until 2006, only 147 cases had been reported in the literature.1 A thorough search of the literature added up to about 200 cases in total. The true incidence of PVA is not clear because of the lack of population-based studies. Two large series in which duplex ultrasound scans of the lower extremities were performed during the analysis of various venous symptoms revealed a PVA in 0.1% and 0.2% of all patients.2 Because of selection bias, these figures cannot be extrapolated to the general population. The exact etiology is unknown; trauma, inflammation, congenital weakness (eg, elastin insufficiency in the vessel wall), and localized degenerative
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Fig 1. Preoperative photographs. Swelling is obvious in the left popliteal fossa (A).
Fig 2. Magnetic resonance imaging scan, transverse section. a, T1 weighted. b, T2 weighted. A, Popliteal vein aneurysm (PVA); 1, peroneal nerve; 2, tibial nerve; 3, peroneal nerve with a slightly increased intensity, matching a neuritis.
changes have been suggested.3 Symptoms caused by the PVA are in the majority of cases thromboembolic (eg, pulmonary embolism, deep venous thrombosis).4 In our case, it could have been the cause of the pulmonary embolism that followed arthroscopy several years before his presentation. Local swelling, pain, and venous symptoms are other complaints patients frequently experience.5 Arterial symptoms are less common and can result in intermittent claudication and even cerebral arterial embolism in patients with a patent foramen ovale.6,7 Neurologic symptoms are exceedingly rare. We could identify only one case report similar to our case. Jang et al in 2009 reported on a 58-year-old man with a footdrop and sensory change in his right calf and foot.8 Although a variety of surgical
procedures have been described in the treatment of PVAs, aneurysmectomy and lateral venorrhaphy were performed in the majority of cases.5 Little is known concerning the postoperative use of anticoagulants.5 In the literature, most patients received oral anticoagulation for 3 to 6 months.9 Sessa et al recommended low-molecularweight heparin for 3 weeks after tangential aneurysmectomy and oral anticoagulation therapy for 3 months in the presence of risk factors for thrombotic complications or after complex surgical repair.5 Our patient was given oral anticoagulants after a pulmonary embolism several years before his aneurysm repair. Because we resolved the presumed cause of his pulmonary embolism, we prescribed oral anticoagulation for the duration of 6 months, after
132 Hoexum et al
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Fig 3. Surgical procedure, posterior approachdaneurysmectomy and lateral venorrhaphy. A, Popliteal venous aneurysm (PVA); G, lateral head of the gastrocnemius muscle; P, peroneal nerve; T, tibial nerve; V, reconstructed popliteal vein.
which it was discontinued. He has not experienced a recurrent pulmonary embolism during the follow-up period. No evidence-based recommendations are available concerning follow-up strategies. We recommend duplex ultrasound at 6 months and 12 months after surgery. If no increasing diameter is observed, further follow-up is not indicated. Publication of cases is needed to identify this rare course of symptoms of a PVA to establish the appropriate treatment. CONCLUSIONS Although neurologic complications of PVA are extremely rare, with only two reported cases to date, it should be considered in any patient with a swelling in
the popliteal fossa and a neurologic deficit of the lower leg or foot. REFERENCES 1. Bergqvist D, Björck M, Ljungman C. Popliteal venous aneurysmda systematic review. World J Surg 2006;30:273-9. 2. Franco G, Nguyen Khac G. Aneurysme vein eux de la fosse poplitée: exploration ultrasonographique. Phlebologie 1997;50:31-5. 3. Roche-Nagle G, Wooster D, Oreopoulos G. Popliteal venous aneurysm. Am J Surg 2010;199:e5-6. 4. Nasr W, Babbitt R, Eslami MH. Popliteal venous aneurysm: a case report and review of literature. Vasc Endovascular Surg 2007-2008;41:551-5. 5. Sessa C, Nicolini P, Perrin M, Farah I, Magne JL, Guidicelli H. Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and review of the literature. J Vasc Surg 2000;32:902-12.
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6. Hallstensson S, Ljungman C, Rudström H, Björck M, Bergqvist D. Claudication and pulmonary embolism can be caused by venous aneurysm. A case report illustrates difficulties with this unusual diagnosis. Lakartidningen 2005;102:1152-3. 7. Auboire L, Palcau L, Mackowiak E, Viader F, Le Hello C, Berger L. Ischemic stroke due to paradoxical embolism arising from a popliteal venous aneurysm. Ann Vasc Surg 2014;28:738.e15-7.
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8. Jang SH, Lee H, Han SH. Common peroneal nerve compression by a popliteal venous aneurysm. Am J Phys Med Rehabil 2009;88:947-50. 9. Aldridge SC, Comerota AJ, Katz ML, Wolk JH, Goldman BI, White JV. Popliteal venous aneurysm: report of two cases and review of the world literature. J Vasc Surg 1993;18:708-15. Submitted Mar 22, 2016; accepted May 9, 2016.
Popliteal venous aneurysms (PVAs) are rare. Symptoms caused by PVAs are in the majority of cases thromboembolic (eg, pulmonary embolism, deep venous thrombosis). Arterial complications are uncommon and neurologic symptoms are exceedingly rare. The subject of our case report consented to the publication of this report. CASE REPORT A 53-year-old man was referred to our institution because of a footdrop on his left side and the inability to extend his left hallux. Several years before, his left knee was injured during sporting activities, with ligamentous injuries and a torn meniscus. Arthroscopy was performed with removal of the damaged cartilage. His recovery was complicated by a pulmonary embolism, which was thought to be a coincidence of postoperative immobilization. Computed tomography pulmonary angiography revealed the pulmonary embolism; no duplex scan of the lower extremity was performed. An oral anticoagulant was prescribed for secondary prevention. In the last 5 months before referral, he has experienced an intermittent footdrop. He also complained about coincidental lower back pain. Magnetic resonance imaging of his back excluded spinal nerve root compression. His back pain faded over time, but he kept his footdrop and paralysis of the extensor hallucis longus. Besides the paralysis, he had a sensory loss at the anterolateral side of his lower leg and the dorsum of his left foot. His complaints worsened when sitting on the toilet but not when sitting in a chair. His complaints seemed to improve in the week before his referral,
and he was able to slightly extend his left hallux. Inspection revealed a local swelling in the popliteal fossa of his left knee (Fig 1). Physical examination confirmed the paralysis of the anterior tibial muscle, a paresis of the extensor hallucis longus muscle of grade 4 on the Medical Research Council scale, and hypesthesia of the anterolateral side of his left lower leg. Reflexes were symmetrical. Magnetic resonance imaging of the left knee showed, besides a bucket-handle tear of his medial meniscus and a torn lateral meniscus, a saccular aneurysm of the popliteal vein with a close relationship to the tibial nerve and peroneal nerve (Fig 2). The peroneal nerve had a slightly increased intensity, matching a neuritis. An additional electromyographic investigation showed denervation and reinnervation of the muscles innervated by the peroneal nerve. Because of his complaints and the risk of thromboembolic complications of the aneurysm, we performed an open repair. With an S-shaped posterior approach, the tibial and peroneal nerves were carefully dissected free from the aneurysm. An aneurysmectomy and lateral venorrhaphy were performed to decrease the diameter of the popliteal vein to normal (Fig 3). No perioperative complications occurred. Recovery was uneventful and he could be discharged, after resuming oral anticoagulants, on the fourth postoperative day. Follow-up in the outpatient clinic showed no signs of recurrence on duplex ultrasound examination. He experienced full recovery of his lower leg muscle strength with normal sensibility. After 6 months, his oral anticoagulants were discontinued. At 13 months of follow-up, no recurrent pulmonary embolism was diagnosed.
DISCUSSION From the Department of Vascular Surgerya and Department of Neurosurgery,b VU Medical Center. Author conflict of interest: none. Correspondence: Frank Hoexum, MD, Department of Vascular Surgery, VU University Medical Center, De Boelelaan 1117, PO Box 7057, Amsterdam 1007 MB, The Netherlands (e-mail: frankhoexum@hotmail. com). The editors and reviewers of this article have no relevant financial relationships to disclose per the Journal policy that requires reviewers to decline review of any manuscript for which they may have a conflict of interest. 2468-4287 Ó 2016 The Authors. Published by Elsevier Inc. on behalf of Society for Vascular Surgery. This is an open access article under the CC BY-NCND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). http://dx.doi.org/10.1016/j.jvscit.2016.05.002
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PVAs are rare. Until 2006, only 147 cases had been reported in the literature.1 A thorough search of the literature added up to about 200 cases in total. The true incidence of PVA is not clear because of the lack of population-based studies. Two large series in which duplex ultrasound scans of the lower extremities were performed during the analysis of various venous symptoms revealed a PVA in 0.1% and 0.2% of all patients.2 Because of selection bias, these figures cannot be extrapolated to the general population. The exact etiology is unknown; trauma, inflammation, congenital weakness (eg, elastin insufficiency in the vessel wall), and localized degenerative
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Fig 1. Preoperative photographs. Swelling is obvious in the left popliteal fossa (A).
Fig 2. Magnetic resonance imaging scan, transverse section. a, T1 weighted. b, T2 weighted. A, Popliteal vein aneurysm (PVA); 1, peroneal nerve; 2, tibial nerve; 3, peroneal nerve with a slightly increased intensity, matching a neuritis.
changes have been suggested.3 Symptoms caused by the PVA are in the majority of cases thromboembolic (eg, pulmonary embolism, deep venous thrombosis).4 In our case, it could have been the cause of the pulmonary embolism that followed arthroscopy several years before his presentation. Local swelling, pain, and venous symptoms are other complaints patients frequently experience.5 Arterial symptoms are less common and can result in intermittent claudication and even cerebral arterial embolism in patients with a patent foramen ovale.6,7 Neurologic symptoms are exceedingly rare. We could identify only one case report similar to our case. Jang et al in 2009 reported on a 58-year-old man with a footdrop and sensory change in his right calf and foot.8 Although a variety of surgical
procedures have been described in the treatment of PVAs, aneurysmectomy and lateral venorrhaphy were performed in the majority of cases.5 Little is known concerning the postoperative use of anticoagulants.5 In the literature, most patients received oral anticoagulation for 3 to 6 months.9 Sessa et al recommended low-molecularweight heparin for 3 weeks after tangential aneurysmectomy and oral anticoagulation therapy for 3 months in the presence of risk factors for thrombotic complications or after complex surgical repair.5 Our patient was given oral anticoagulants after a pulmonary embolism several years before his aneurysm repair. Because we resolved the presumed cause of his pulmonary embolism, we prescribed oral anticoagulation for the duration of 6 months, after
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Fig 3. Surgical procedure, posterior approachdaneurysmectomy and lateral venorrhaphy. A, Popliteal venous aneurysm (PVA); G, lateral head of the gastrocnemius muscle; P, peroneal nerve; T, tibial nerve; V, reconstructed popliteal vein.
which it was discontinued. He has not experienced a recurrent pulmonary embolism during the follow-up period. No evidence-based recommendations are available concerning follow-up strategies. We recommend duplex ultrasound at 6 months and 12 months after surgery. If no increasing diameter is observed, further follow-up is not indicated. Publication of cases is needed to identify this rare course of symptoms of a PVA to establish the appropriate treatment. CONCLUSIONS Although neurologic complications of PVA are extremely rare, with only two reported cases to date, it should be considered in any patient with a swelling in
the popliteal fossa and a neurologic deficit of the lower leg or foot. REFERENCES 1. Bergqvist D, Björck M, Ljungman C. Popliteal venous aneurysmda systematic review. World J Surg 2006;30:273-9. 2. Franco G, Nguyen Khac G. Aneurysme vein eux de la fosse poplitée: exploration ultrasonographique. Phlebologie 1997;50:31-5. 3. Roche-Nagle G, Wooster D, Oreopoulos G. Popliteal venous aneurysm. Am J Surg 2010;199:e5-6. 4. Nasr W, Babbitt R, Eslami MH. Popliteal venous aneurysm: a case report and review of literature. Vasc Endovascular Surg 2007-2008;41:551-5. 5. Sessa C, Nicolini P, Perrin M, Farah I, Magne JL, Guidicelli H. Management of symptomatic and asymptomatic popliteal venous aneurysms: a retrospective analysis of 25 patients and review of the literature. J Vasc Surg 2000;32:902-12.
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6. Hallstensson S, Ljungman C, Rudström H, Björck M, Bergqvist D. Claudication and pulmonary embolism can be caused by venous aneurysm. A case report illustrates difficulties with this unusual diagnosis. Lakartidningen 2005;102:1152-3. 7. Auboire L, Palcau L, Mackowiak E, Viader F, Le Hello C, Berger L. Ischemic stroke due to paradoxical embolism arising from a popliteal venous aneurysm. Ann Vasc Surg 2014;28:738.e15-7.
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8. Jang SH, Lee H, Han SH. Common peroneal nerve compression by a popliteal venous aneurysm. Am J Phys Med Rehabil 2009;88:947-50. 9. Aldridge SC, Comerota AJ, Katz ML, Wolk JH, Goldman BI, White JV. Popliteal venous aneurysm: report of two cases and review of the world literature. J Vasc Surg 1993;18:708-15. Submitted Mar 22, 2016; accepted May 9, 2016.