Ruptured superficial femoral artery aneurysm: case report and literature review

Abstracts

O aneurisma de artéria femoral superficial é um evento raro que costuma manifestar-se em pacientes com idade avançada, frequentemente associado a outros aneurismas, periféricos ou de aorta abdominal. O caso relatado refere-se a um paciente cujo aneurisma de artéria femoral superficial se apresentou roto e associado a um aneurisma de aorta abdominal. Foi submetido à revascularização cirúrgica fêmoro-poplítea mediante prótese de politetrafluoretileno, com sucesso. A revisão da literatura demonstra que embora haja uma tendência à manifestação aguda da doença, principalmente como ruptura, os resultados com o tratamento cirúrgico são excelentes.

Artéria femoral superficial; aneurisma roto; ruptura

CASE REPORT

Ruptured superficial femoral artery aneurysm: case report and literature review

Alexandre Faraco de Oliveira^I; Horácio de Oliveira Filho^II

^ICirurgião vascular. Ultrassonografista vascular. Professor, Curso de Medicina, Universidade do Planalto Catarinense (UNIPLAC), Lages, SC, Brazil

^IICirurgião vascular. Especialista em Angiologia e Cirurgia Vascular, SBACV

Correspondence

ABSTRACT

Superficial femoral artery aneurysm is rare and usually occurs in elderly patients, often associated with peripheral or abdominal aortic aneurysms. In the reported case, the patient presented with a ruptured superficial femoral artery aneurysm associated with an abdominal aortic aneurysm. A successful femoropopliteal bypass was performed using a polytetrafluorethylene graft. Literature review shows that, despite the tendency for acute onset of the aneurysm, primarily with a rupture, surgical results are excellent.

Keywords: Superficial femoral artery, ruptured aneurysm, rupture.

Introduction

Superficial femoral artery aneurysm is rare. As an isolated injury, it has been described as responsible for only 0.5% of peripheral aneurysms; it is even less frequent in its acute form, due to local rupture or to thrombosis of the aneurysm.^1-3

In this study, a case of isolated ruptured superficial femoral artery aneurysm repaired with conventional surgery is reported and a literature review is presented.

Case report

An 87-year-old male patient, land worker and smoker, presented to the doctor's office reporting pain and increased volume on the right thigh which had begun 48 hours before.

Previous history: the patient reported that as his first medical visit and denied any previous complaint related to lower limbs, edema or claudication. He denied history of arterial hypertension and diabetes melitus. At physical examination, he was pale, presented with tachycardia (110 bpm) and hypotension (100 x 60 mmHg). Lower limbs: left limb, without any apparent alteration, with all palpable pulses and a reduced range of motion; right limb, ecchymosis from the thigh joint up to the scrotum, a pulsatile bulge from the inguinal ligament until the distal third of the thigh, with thrills on the mid-third of the anterior thigh, femoral pulse was palpable and all the others were not.

A color Doppler ultrasound examination was performed on the right lower limb; it revealed a large superficial femoral artery aneurysm on the mid-third (Figure 1), with 3.45 cm in transverse diameter, with turbulent and hypokynetic flow inside and a rupture in the medial aspect.(Figure 2). Laboratory tests revealed intense anemia (Hb: 6,7; Ht: 20,4).

The patient underwent immediate surgery, during which a large isolated ruptured superficial femoral artery aneurysm was found with large amounts of blood surrounding the muscle and subcutaneous tissues, especially in the medial aspect. (Figure 3) The procedure included femoropopliteal revascularization with an 8 mm polytetrafluorethylene graft, both proximal and distal end-to-end anastomoses and partial resection of the aneurysm sac. (Figure 4) Autologous great saphenous vein was not used because it was thin and fibrous.

At follow-up 30 days after the surgery, the patient did not report any complaint and was walking normally. Arterial duplex scanning was perfomed, revealing graft patency without any other aneurysms in the lower limbs. The patient had a suprarenal abdominal aortic aneurysm with 5.76 cm in the largest diameter. Examination of the material collected from the aneurysm wall did not reveal any bacterial growth or alterations in the arterial structure suggestive of diseases other than arteriosclerosis.

Discussion

After a search in databases available in internet, the authors concluded that superficial femoral artery aneurysm is rare due to the few case reports and case series published.

The first case report on ruptured superficial femoral artery aneurysm, published in 1975, already argued that this situation is rare and is frequently associated with other aneurysms. It reported that femoropopliteal revascularization, preferably with autologous vein grafts, had good results in these cases.³

In 1981, Kremen et al.⁴ published a series of seven aneurysms from six patients and presented a literature review. They concluded that the disease affects elderly patients with advanced atherosclerosis and it usually presents as a mass, often with rupture. In this series, other peripheral aneurysms affected 50% of the patients and abdominal aortic aneurysms were present in 33% of the patients. The authors considered that aneurysm exclusion and femoropopliteal revascularization with autologous vein were the adequate treatment. In the end of the article, they argued that superficial femoral artery aneurysms should be surgically repaired, because, when untreated, they tend to rupture and occasionally serve as a source of emboli.⁴ Several other isolated case reports corroborate the conclusions of the series above mentioned both in terms of the rarety of the disease and the adequacy of the surgical treatment.^5-9

In 1992, Rigdon & Monajjem¹⁰ reported two cases with different presentations and outcomes: a rupture followed by revascularization and limb salvage and a thrombosis followed by limb loss, despite surgical revascularization. In their review of 17 cases in 14 patients, the authors identified acute presentations of the aneurysm in 65% of the cases (rupture in 35%, thrombosis in 18%, and distal emboli in 12%). There were no perioperative deaths, and limb salvage occurred in 94% of cases. Abdominal aortic aneurysm was discovered in 40%. The authors stressed the importance of further investigation to determine possible etiologies for the disease – infectious (syphilis, etc.), inflammatory, immunologic, connective-tissue disorders – before considering it arteriosclerotic in origin.¹⁰

Although femoropopliteal revascularization, preferably with autologous vein, has been showing excellent results, other techniques can be used. Dighe & Thomas¹¹ reported the case of a ruptured superficial femoral artery aneurysm in a patient with background of vascular disease previously submitted to surgical repairs of other aneurysms and whose popliteal artery was found too diseased for reconstruction; a proximal ligation was performed and adequate distal perfusion via collateral circulation was observed. The patient underwent simple ligation, without revascularization, and recovered with limb savage.¹¹

In the last years, endovascular methods have been suggested, so that patients with a high surgical risk can be treated with low morbidity and mortality. It can be substantially beneficial to patients who are in the seventh and eighth decades of life. The use of covered stents in the treatment of superficial femoral artery aneurysm was successful, but the long-term patency of such grafts has not been defined yet.¹² Recent studies reported the use of covered stents to repair spontaneous ruptures of the superficial femoral artery (without aneurysm), but fasciotomy may be necessary due to compartmental edema.^13,14

The reduced number of cases makes it difficult to draw any conclusion about the disease; however, the atherosclerotic etiology of superficial femoral artery aneurysms has been questioned due to its association with other aneurysms. It should also be considered that the real incidence of the disease may be concealed, because angiography tends not to reveal occluded aneurysms.^9,15 Reviews on the theme suggest that the superficial femoral artery aneurysm tends to present more as an aortic aneurysm (rupture) than as a popliteal aneurysm (thrombosis).^4,15,16 With the population living longer and the widespread use of arterial duplex scanning on lower limbs, there will probably be more opportunities to treat patients with superficial femoral artery aneurysms and to find answers to these and other questions. Although surgical treatment have showed satisfactory results (Table 1), the availability of endovascular techniques may contribute to reduce current morbidity rates.

References

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• ¹²
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Publication Dates

• Publication in this collection
  05 Jan 2010
• Date of issue
  Sept 2009

History

• Accepted
  12 June 2009
• Received
  27 Oct 2008