Acute thrombosis of isolated femoral artery aneurysm: case report

CASE REPORT

Acute thrombosis of isolated femoral artery aneurysm: case report

André Hideo Motoki^I; André Ricardo Girardi^I; Bruno Rick Ogata^I; Dionizio Baroni Júnior^I; Fernando Yoshio Lara Shimizu^I; Vitor Teixeira Liutti^I; Antônio Lacerda Santos Filho^II; Nelson Mesquita Júnior^III

^IMedical student (4th year), Faculdade Evangélica do Paraná (FEPAR), Curitiba, PR, Brazil.

^IIMSc., Surgical Clinic, Universidade Federal do Paraná (UFPR), Curitiba, PR, Brazil. Assistant professor, Angiology and Vascular Surgery, FEPAR, Curitiba, PR, Brazil.

^IIIMSc. in Surgical Clinic, UFPR, Curitiba, PR, Brazil. Assistant professor, Anatomy, Angiology and Vascular Surgery, FEPAR, Curitiba, PR, Brazil.

ABSTRACT

Common femoral artery aneurysms are rare; however, they are the second most frequent type of peripheral aneurysm, popliteal artery aneurysms being the most common. They usually have atherosclerotic ethiology. The complications of this aneurysm are thromboembolism and, more rarely, rupture. This article aimed at reporting the case of a 59-year-old male patient with complaint of sudden pain in his left leg associated with coldness, paleness and absence of pulses. Color Doppler ultrasound showed a thrombosed aneurysm of the common femoral artery. The patient was successfully submitted to aneurysm resection with reconstruction of the arterial bed.

Keywords: Aneurysm, femoral artery, thrombosis.

RESUMO

Aneurismas de artéria femoral são raros, porém são o segundo tipo mais freqüente de aneurismas periféricos, sendo o aneurisma de artéria poplítea o mais comum. Normalmente, são de etiologia aterosclerótica. As complicações deste aneurisma são representadas por embolia, trombose e, mais raramente, a rotura. O objetivo deste trabalho é relatar um caso de um paciente com 59 anos, masculino, com queixa de dor súbita em membro inferior esquerdo associado à frialdade, palidez e ausência de pulsos. O ecocolordoppler evidenciou a presença de aneurisma trombosado da artéria femoral comum. O paciente foi submetido, com sucesso, à ressecção do aneurisma, com reconstrução do leito arterial.

Palavras-chave: Aneurisma, artéria femoral, trombose.

Introduction

The first description of a surgical procedure for the treatment of a femoral artery true aneurysm was that by Sir Astley Cooper, who, in 1808, performed ligation of the external iliac artery to repair a femoral artery aneurysm. As an attempt to maintain arterial flow, Goyanes performed the first arterial reconstruction in Madrid, in 1906, using a venous graft, which was repeated by Horgarth Pringle in Glasgow, Scotland in 1913.¹ Femoral artery aneurysms are relatively rare, 10 times less frequent than aortic aneurysms. They are more frequent in male patients, older age, and smokers. Among peripheral aneurysms, femoral artery aneurysms are the second most frequent, after popliteal artery aneurysms, with 80% of peripheral aneurysms.^2,3

Ischemic complications of femoral aneurysms are the most common. Acute thrombosis occurs in about 15-32% of cases and results in acute ischemia, usually severe.⁴ However, if there is no major progression of thrombosis, there may be compensation by collateral circulation. In these cases, there is a common complaint of intermittent claudication.⁴

This study aims at describing a case of acute thrombosis of isolated femoral artery aneurysm submitted to surgical treatment.

Case report

J.J.M, a 59-year-old male patient, was admitted to the emergency room of Hospital Universitário Evangélico de Curitiba, and referred with complaint of sudden onset pain in the left lower limb associated with coldness during a 5-day course. The patient denies past history of intermittent claudication, angina or acute myocardial infarction. There were no more associated comorbidities, such as hypertension or diabetes. He also denied smoking or alcoholism.

On physical examination, the patient had a pale left lower limb with absence of pulses, with no changes in motor activity , but with paresthesia in the toes and slight increase in nonpulsatile volume in the left femoral region.

Color Doppler ultrasound showed aneurysmal dilatation with presence of an acute thrombus occluding the common femoral artery lumen. There was refilling in its bifurcation, with monophasic flow in the distal arterial tree. Doppler ultrasound of right lower limb arteries and aortoiliac territory showed absence of aneurysms and atheromatous plaques in its entire extension. Transesophageal echocardiogram ruled out presence of intracavitary thrombi.

The patient was submitted to a surgical treatment, in which presence of a 3 x 3 cm aneurysm was confirmed in the common femoral artery with no involvement of the bifurcation. The distal and proximal portions to the aneurysm had intact arteries. The aneurysm was then resected, distal thrombectomy (Figures 1 and 2) using a Fogarty catheter (which progressed through the distal arterial tree without difficulties) was performed, and a femorofemoral bypass was created using Dacron graft no. 10 with terminoterminal anastomoses (Figure 3), maintaining flow into superficial and deep femoral arteries. Anatomopathological study showed atherosclerotic etiology. The patient progressed well and was discharged on the fifth postoperative day. He is asymptomatic, with no intermittent claudication, patent bypass and present distal pulses. Follow-up time is 8 months, the patient is asymptomatic and pulses are present.

Discussion

Peripheral aneurysms are rare entities. When present in lower limbs, the popliteal artery and the common femoral artery are the first and second most affected arterial territories. As the disease progresses there may be complications, such as embolism, thrombosis and aneurysm rupture.^5,6 According to the literature, thrombosis in common femoral artery aneurysms occurs in 32% of cases.²

The most affected artery by aneurysms in femoral territory is the common femoral artery. The superficial femoral and deep femoral arteries are rarely affected by this disease.^2,6-9 Most of the times its origin is atherosclerotic, resulting from degenerative changes in the vessel wall mainly influenced by smoking.^1,2,5,6 Aneurysms are atherosclerotic when wall weakening is secondary to the atherosclerotic process. Such weakening can also occur secondary to chronic infections (such as mycotic and syphilitic aneurysms) or due to change in connective tissue (Behcet's disease, systemic lupus erythematosus, arteritis).^8-10 Atherosclerotic aneurysms are also considered as such in patients with dilatations that are not associated with moderate or advanced atherosclerotic disease in other vessels and that do not have other identifiable causes to justify arterial wall weakening.^7,11 Atherosclerotic aneurysms of the femoral artery account for more than 1/3 of all peripheral aneurysms.¹ However, aneurysms in femoral territory may have iatrogenic etiology, resulting from suture rupture or detachment of an anastomosed graft in the femoral artery, or that may be a consequence of catheterizations. Other factors include vibration of the wall and arterial fatigue, conditions that are related to stress of chronic movement during a forced flexion of the thigh and blood flow turbulence. Collagen diseases, mycotic and syphilitic chronic infections can also be associated with femoral artery aneurysm.^4,8,9

Femoral artery aneurysms can occur in combination with other aneurysms in 50% of cases. Their association with aortic aneurysm is found in 33-63.8% of cases; 18-72% can be bilateral.^1,3,4 In the reported case there were no other aneurysms.

This disease is asymptomatic in up to half of cases, but there may be local pain or symptoms resulting from lower limb ischemia.^1,3 Compression of nervous structures generates pain in the femoral region or anterior aspect of the thigh, or also a distal irradiation that may cause paresis in muscle groups. The femoral vein can be compressed, causing edema and/or other signs and symptoms of venous stasis.¹² Diagnosis of this type of aneurysm can be clinically performed by palpation of pulsatile bulging in the femoral artery and expansible in all directions, characterizing an arterial aneurysm.^1,2

According to Arroyo-Bielsa et al., of 68 femoral artery aneurysms found during a 14-year period, there was 10.2% of chronic thrombosis and 4.4% of acute thrombosis.¹

Classification of aneurysms in that territory can have two types: 1) only affecting the common femoral artery, with no involvement of the bifurcation; and 2) involving the bifurcation.^3,5,12

Although diagnosis of these aneurysms is eminently clinical, use of noninvasive methods, such as color Doppler ultrasound, contribute to diagnostic confirmation.^2,4,12,13 Other examinations, such as computed axial tomography, magnetic resonance and arteriography, are also useful.^2,5

Surgery is indicated for all symptomatic aneurysms with or without complications, as well as for asymptomatic measuring more than 2.5 cm in diameter.^7,11

In this case, the aneurysm was resected with insertion of a Fogarty catheter in the distal bed, with further placement of a terminoterminal Dacron graft in the femoral artery. In acute cases of limb ischemia, early etiological diagnosis is of great importance, both for disease prognosis and for choice of treatment.²

It can be concluded that, in addition to being an unusual aneurysm, thrombosis is rare, since its location tends to be diagnosed by the patient himself or by a physician on a routine examination before this complication is manifested. Good disease course is not the expected pattern due to prolonged ischemic time and absence of significant atherosclerotic disease.

References

• 1. Arroyo-Bielsa A, Rodríguez-Montalbán AI, Sáinz-González F, et al. Aneurismas ateroescleróticos de la arteria femoral común. Angiología. 1995;5:251-6.
• 2. Puech-Leão P, Kauffman P. Aneurismas arteriais. São Paulo: Byk; 1998.
• 3. Martínez-Ramos D, Villalba-Munera V, García-Calvo R, Miralles-Tena JM, Molina-Martínez J, Salvador-Sanchís JL. Trombosis venosa profunda como manifestación clínica inicial de un aneurisma de la arteria femoral común. Angiología. 2006;58:331-4.
• 4. Levi N, Schroeder TV. Arteriosclerotic femoral artery aneurysms: a short review. J Cardiovasc Surg (Torino). 1997;38:335-8.
• 5. Kolde E, Rocha MF, Franco FC, Ornato SJTA. Ruptura de aneurisma de arteria femoral. Cir Vasc Angiol. 1998;14:40-2.
• 6. Harbuzariu C, Duncan AA, Bower TC, Kalra M, Gloviczki P. Profunda femoris artery aneurysm: association with aneurysmal disease and limb ischemia. J Vasc Surg. 2008;47:31-5; discussion 34-5.
• 7. Galindo CC, Lima CA, Cardoso JE, Galindo Filho G, Costa VS, Penha FM. Aneurisma aterosclerótico isolado da artéria femoral superficial - relato de caso. J Vasc Bras. 2003;2:145-7.
• 8. Levi N, Schroeder TV. Rupture of true profunda femoris artery aneurysms. Two new cases. J Cardiovasc Surg (Torino). 1996;37:117-8.
• 9. Lima IA, Lima MF, Bernardes MV. Aneurisma isolado de artéria femoral profunda. Relato de caso e revisão bibliográfica. J Vasc Bras. 2003;2:333-8.
• 10. Koç Y, Güllü I, Akpek G, et al. Vascular involvement in Behçet"s disease. J Rheumatol. 1992;19:402-10.
• 11. Rigdon EE, Monajjen N. Aneurysms of the superficial femoral artery: a report of two cases and review of the literature. J Vasc Surg. 1992;16:790-3.
• 12. Maffei FHA, Lastória S, Yoshida WB, Rollo HA. Doenças vasculares periféricas. 3Ş ed. São Paulo: Medsi; 2002.
• 13. Corriere MA, Guzman RJ. True and false aneurysms of the femoral artery. Semin Vasc Surg. 2005;18:216-23.

Correspondence

Publication Dates

• Publication in this collection
  20 Feb 2009
• Date of issue
  Dec 2008

History

• Accepted
  19 Oct 2008
• Received
  19 Nov 2007