Popliteal vein aneurysm: case report and review of the literature

Abstracts

Os aneurismas venosos são entidades raras, porém com potencialidade de causar complicações tromboembólicas. Na maioria das vezes, são encontrados incidentalmente, como achados de exame físico ou de imagem. Os aneurismas sintomáticos de veia poplítea são obrigatoriamente tratados por reparo cirúrgico, devido ao alto risco de recorrência de embolia pulmonar. A técnica mais utilizada é a aneurismectomia tangencial com venorrafia lateral. Na impossibilidade de se empregar essa técnica, faz-se a ressecção com reconstrução venosa. Os autores relatam o caso de uma paciente com aneurisma de veia poplítea, cujo diâmetro era de 47 mm, submetido a aneurismectomia tangencial e venorrafia lateral, com sucesso.

Aneurisma; veia; cirurgia

CASE REPORT

Popliteal vein aneurysm: case report and review of the literature

Fernando Thomazinho; Jose Antonio Morselli Diniz; Ramzi Abdallah El Hosni Junior; Carlos Alberto Morselli Diniz; Igor Schincariol Perozin

Hospital Evangélico de Londrina, Londrina, PR, Brazil

Correspondence

ABSTRACT

Venous aneurysms are considered to be a rare disease; however they can be a potential cause for the development of thromboembolism. They are mostly detected by physical examination or imaging exams. Symptomatic aneurysms of the popliteal vein must be surgically treated, due to high risk of recurrent pulmonary embolism. The most widely used procedure is tangential aneurysmectomy and lateral venorrhaphy. If not possible, the aneurysm should be removed and a venous reconstruction should be performed. The authors report a case of a patient with a popliteal vein aneurysm measuring 47 mm in diameter. Tangential aneurysmectomy and lateral venorrhaphy were successfully used for treatment.

Keywords: Aneurysm, vein, surgery.

Introduction

The term aneurysm is used to characterize a focal dilatation of blood vessels. It is often associated with artery dilatations, but these lesions can also occur in any part of the vascular system.¹

Venous aneurysms are not frequent and are usually incidental findings on physical examination or in imaging examinations. It rarely has clinical significance, except for popliteal vein aneurysms (PVA), which should be remembered as a rare cause of recurrent pulmonary embolism and deep venous thrombosis.^2-6 Most venous aneurysms have a congenital origin, although they may also be acquired by trauma, inflammatory processes and degenerative changes.⁷

Case report

We report on a 60-year-old female patient, Caucasian, retired, with complaint of pain similar to tiredness in the posteromedial aspects of her left leg, predominantly in the popliteal fossa. She was submitted to bilateral saphenous vein stripping 30 years ago, and has a healed ulcer in her left ankle. She has controlled hypothyroidism and no history of deep venous thrombosis or dyspnea.

On physical examination, there was presence of recurrent trunk varicose veins with mild dermatofibrosis and pigmented dermatitis in her left leg. She also had a small bulging in the left popliteal fossa when standing erect, which disappeared with limb elevation.

Color-flow Doppler ultrasound showed reflux in the deep venous system in the left lower limb, fusiform dilatation of the popliteal vein (Figure 1), with transverse diameters of 47 x 37 mm, and ectasia of the soleal vein and proximal posterior tibial vein. Ascending phlebography was also performed, which confirmed the findings (Figure 2).

The patient was submitted to tangential aneurysmectomy and lateral venorrhaphy (Figure 3) using posterior popliteal approach. She was discharged with prescription of oral anticoagulants for 90 days.

Control examination using serial Doppler showed patent deep venous system with popliteal artery vein measuring 12 x 13 mm during a 9-month follow up. There was improvement in the symptoms reported above.

Discussion

The first publication on venous aneurysm was in 1915 by Osler, who reported a case of axillary vein dilatation.⁸ Later, in 1928, Harris^1,3 described a 5-year-old child with jugular vein aneurysm. Abbott³ described a case of superior vena cava aneurysm in 1950. In 1968, May & Nissel were the first to describe the PVA,⁸ and Dahl et al. were the first to report complications of PVA.⁸

There are no precise criteria as to vessel diameter to define a venous dilatation as aneurysmal. McDevitt proposed that such definition would be correct in case of a dilatation twice the normal size⁹ of the vessel. Sessa et al., in their review, disagreed with this definition and cited the criteria proposed by Maleti et al., who support the need of the diameter being three times the size of the normal popliteal vein.¹⁰

Differently from the arterial system, venous system aneurysms are rare and occur at any age, irrespective of gender.¹ There is no consensus in the literature about the most frequent location in venous aneurysms. Perler et al. claimed that they are more frequent in the upper limbs than in lower limbs¹¹; on the other hand, Casttle & Arous, in their review, showed that venous aneurysms are more frequent in the lower limbs.⁸

Legnani¹² reported that PVA are the most frequent in the lower limbs, followed by great saphenous vein aneurysms and venous aneurysms in the foot. In our country, Dourado et al. described two cases of venous aneurysms in the foot.¹³ Venous aneurysms in the upper limbs are usually associated with arteriovenous fistulas for hemodialysis.

Most venous aneurysms are likely to have a congenital origin,¹⁴ but they may also be a result of degenerative changes or local inflammatory processes,¹⁵ such as trauma and infection. They could also be associated with varicose veins, due to valve insufficiency, obstructive process or arteriovenous fistula.¹

Focal loss of normal conjunctive tissue components of the vein wall, due to a congenital failure in development or degenerative losses associated with age, or also to an inflammatory process, results in wall weakening, making it vulnerable to dilatation.¹⁶

Due to structural changes, venous aneurysms have two forms: fusiform or saccular. Such differentiation is important to determine the surgical strategy. Saccular PVA account for 75% of cases.¹⁷

A wide variety of clinical presentations of venous aneurysms is described in the literature.¹¹ Most cases of peripheral venous aneurysms only cause local discomfort,¹⁸ therefore they are asymptomatic, with incidental diagnosis¹¹ (in the case reported herein, the patient showed painful symptoms in the left lower limb). However, this nosological entity may be more commonly manifested by complications, such as deep venous thrombosis and pulmonary embolism.

Peripheral venous aneurysms can be detected by presence of soft subcutaneous mass, which disappears with limb elevation and increases with the Valsalva maneuver.¹⁹ Suspicion will be confirmed by vascular ultrasound, current method of choice¹⁷ for the definitive diagnosis; ascending phlebography and magnetic nuclear resonance are restricted to cases of abdominal or thoracic venous aneurysms.^20,21 However, Coffman et al.²² consider phlebography mandatory for a precise determination of venous anatomy before the surgery.

Such disease should be remembered in the differential diagnosis of lower limb masses, especially when there is change in size according to limb positioning.²³

Histological findings showed thickening in the vessel wall, endophlebosclerosis and endophlebohypertrophy, a process that could be compared to atherosclerosis.^1,24 They also showed intimal hyalinization associated with thrombi, in addition to intimal thickening and fibrosis, with marked reduction of smooth muscle cells in the medial layer, which may be thick or absent in different stages, with presence or not of internal elastic limiting lamina.^25,26 Adventitia is frequently fibrotic, with prevalence of elastic fibers. Inflammatory cells, especially present in thrombosis areas, are also found throughout the vein wall, in the aneurysmal area. There is prevalence of lymphocytes, with few neutrophils and rare eosinophils. Mast cells are present in the adventitia, and do not seem to be increased compared to sections of non-aneurysmal veins.²⁷

The most common complications in venous aneurysms are deep venous thrombosis, thrombophlebitis and recurrent pulmonary embolism.¹ Some authors reported that large venous aneurysms, as well as saccular aneurysms, have higher predisposition for thromboembolic complications,^28,29 although there is no clear evidence on the critical diameter or on aneurysm shape that may cause more complications. Chahlaoui et al.³⁰ reported a fatal case of a patient with multiple episodes of pulmonary embolism, with a small saccular aneurysm (20 x 20 mm); hence, conclusion is that small aneurysms can also be a risk.

Surgery is the base of PVA treatment. In patients with thromboembolic complications, surgical treatment is mandatory and considered as the method of choice, only limited by clinical conditions,^{3-6,8,9,11-13,16,25,30,31-33} since anticoagulation alone in patients with pulmonary embolism is inefficacious, with high recurrence rates (80%).^3,5,32,34 Indication of surgical treatment in patients with asymptomatic PVA is contradictory. However, saccular aneurysms of any size and large fusiform aneurysms should be treated by surgery due to the high potential of future thromboembolic events.^16,25 Recurrent pulmonary embolism after surgery has never been reported. Small and asymptomatic fusiform aneurysms can be followed clinically by periodic Doppler ultrasounds.¹⁷

Tangential aneurysmectomy and lateral venorrhaphy is the most widely used surgical method and has been recommended for saccular aneurysms, but it can also be performed in fusiform aneurysms, as in our case. The technique was described by Aldridge et al.²⁷ and has good results.

Aneurysm resection and venous reconstruction are recommended when tangential aneurysmectomy cannot be performed due to risk of permanence of disease segment in the venous wall. This would be a more appropriate conduct for our patient; however, since there was no autogenous substitute for venous reconstruction, choice was for tangential aneurysmectomy. Graft reconstruction was rejected due to increased risk of occlusion. In the sample of Sessa,²⁵ three fusiform aneurysms were treated with tangential aneurysmectomy. There are several surgical options, such as aneurysm resection with terminoterminal anastomosis, resection with interposition of homologous autogenous venous graft, or polytetrafluoroethylene graft (PTFE). Other possibilities are venous bypass ligation, resection with venous transposition (tibioperoneal trunk into anterior tibial vein, medial gastrocnemius vein), resection without venous reconstruction and ligation.²⁵ Inferior vena cava filter should also be mentioned.²⁵

Although the ipsilateral great saphenous vein can be used as a substitute, this strategy should be avoided due to risk of losing an important collateral access in case there is thrombosis after surgical repair. The superficial femoral vein with competent valve can be used in the absence of saphenous vein.³³

Patency of popliteal vein reconstruction is little documented in the literature. Results of resection with terminoterminal anastomosis are not known. Long-term result seems to be satisfactory for reconstruction with venous patch or interposition of a saphenous graft, differently from use of synthetic and internal jugular vein grafts.³⁵

The fibrinolytic treatment has been used as initial part of the treatment in patients with pulmonary embolism. In the literature there are few cases treated by fibrinolysis before surgical repair.^6,14,35 This therapy reduces or eliminates the thrombi that may occasionally be inside the aneurysm, which could facilitate surgical repair.²⁶

The implantation of inferior vena cava filter²⁵ can also be an alternative for elderly, weakened patients, or in those contraindicated for anticoagulants, usually recommended in the postoperative period.

Conclusion

PVA is a rare occurrence and may cause serious thromboembolic complications. This disease should be considered in patients with episodes of recurrent pulmonary embolism and absence of risk factors for thromboembolism. Surgical treatment is indicated for all patients with symptomatic PVA, due to high risk of recurrent pulmonary embolism. Asymptomatic, but large or saccular PVA may also be treated by surgery. The most widely used treatment is tangential aneurysmectomy and lateral venorrhaphy. However, when this technique cannot be used, choice is for resection with reconstruction. Small aneurysms, such as those smaller than 20 mm and without thrombi, can be followed using serial Doppler ultrasound.

References

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Publication Dates

• Publication in this collection
  08 Dec 2008
• Date of issue
  Sept 2008

History

• Accepted
  01 Aug 2008
• Received
  25 Oct 2007