C Özbek, U Yetkin, K Ergüne?, T Güne?, T Gökto?an, A Gürbüz
aneurysm, atherosclerotic, eptfe graft, superficial femoral artery
C Özbek, U Yetkin, K Ergüne?, T Güne?, T Gökto?an, A Gürbüz. Giant Atherosclerotic Aneurysm of the Superficial Femoral Artery in Hunter's Canal. The Internet Journal of Thoracic and Cardiovascular Surgery. 2007 Volume 11 Number 2.
Isolated true atherosclerotic aneurysm of the superficial femoral artery is uncommon. Early diagnosis and management are necessary to protect the extremity function and vitality.
In this study we're presenting an original case of a giant superficial femoral aneurysm in Hunter's canal not associated with aortic, proximal femoral or popliteal aneurysms.We report our diagnostic approaches and our successful revascularization with ringed expanded polytetrafluoroethylene graft interposition.
Open surgical repair should always be the first choice of treatment. The prognosis after surgery is favourable. And less invasive methods must be reserved for rare and complicated patients.
True “arteriosclerotic” aneurysms of the superficial femoral artery, not associated with generalized dilatation of the common femoral or popliteal artery, are relatively rare(1). They are most often identified in elderly males(2). True femoral aneurysms were originally classified by Cutler and Darling in 1973 as type 1 and type 2 according to their relationship to the common femoral bifurcation. Case reports of isolated superficial and profunda femoral artery aneurysms have been published, but these are exceedingly rare(3).
Isolated superficial femoral artery aneurysms are rare and occur at an older average age than do other peripheral aneurysms, but their incidence is anticipated to increase with this growing segment of the population. In the absence of evidence of syphilitic, other infectious, immunologic, inflammatory, or connective-tissue disorders, these and other aneurysms are considered arteriosclerotic in origin, despite the absence of diffuse arteriosclerosis in many cases and controversy regarding the role of arteriosclerosis in their cause(1).
Individualized operative approaches are based on aneurysmal involvement of the superficial femoral or profunda femoris arteries, as well as the presence or absence of coexisting extremity occlusive disease. Aneurysm excision and interposition or bypass graft reconstruction are favored over direct end-to-end reanastomosis(3).
A 82 years old man admitted to our clinic for progressive left thigh medial tumor,function loss and pain in the last 2 days. His left leg was slightly cold and peripheral pulses were hardly determined when compared with the other leg.There was pulsation on the mass and a murmur was heard correlated with systolic thrill.Ankle/arm index was 140/140=1 at right and 80/140=0.55 at left.Except the 29% hematocrit result,routine biochemical tests,bleeding and coagulation timing tests were resulted normal.Lower extremity arterial and venous colored Doppler ultrasonography(CDUSG) showed a giant fusiforme aneurysm in Hunter's canal and organized thrombus areas with various concentrations at 1/3 distal part of left thigh (Figures 1 and 2). Venous structures were normal.
Lower extremity angiography showed a fusiforme aneurysm in Hunter's canal,distal to left superficial femoral artery(Figure 3). He went under operation.
He was operated under endotracheal general anesthesia and in supine position.Aneurysm was determined with skin incision paralel to left femoral artery course.Proximal and distal parts of superficial femoral artery were freed with attentive dissection and holding with the nylon tapes. After administering 1cc heparin (=5.000 IU) intravenously,bleeding was controlled with vascular clamps.Aneurysm capsule of was opened and organized thrombus masses were removed (Figure 4 ).Femoral vein and saphenous nerve near the artery were compact.
Aneurysmal segment was resected. Patency was constructed with 8mm ringed expanded polytetrafluoroethylene (Vascutek Terumo seal PTFE vascular prosthesis,T7008ES) tube graft interposition (Figures 5 and 6).A closed drainage system was placed in the sac of giant aneurysm and capitonated and the incision was closed.
Microbiological culture results of saccular material was negative and pathological examination showed the atherosclerotic aneurysm.
True isolated atherosclerotic aneurysm of the superficial femoral artery is a rare pathology(4). Review of 17 “arteriosclerotic” superficial femoral artery aneurysms in 14 patients whose cases were reported in the literature revealed a complication at presentation in 65%, rupture in 35%, thrombosis in 18%, and distal emboli in 12%. However, limb salvage was 94% and there were no perioperative deaths(1).
True femoral artery aneurysms are attributed to weakening of the arterial wall due to atherosclerosis. True femoral artery aneurysms are relatively rare and are found in elderly smoking men. Aortic aneurysms are approximately 10 times more common. Distal embolization occurs in 0-26% of cases. Acute thrombosis occurs in around 15% of cases. Rupture is uncommon and varies between 10% and 14%(3). This number emphasizes the need of a complete angiological investigation in patients with aneurysms(5). CDUSG's advantages are low cost,utility in various treatment choices and low time spending.In addition to diagnosis it gives detailed information about pseudoaneurysms dimensions,morphology,neck anatomy, flow and relation with adjacent vessels(2). The review of the literature emphasizes the great latency of the disease and the high incidence of complication at presentation, as well as, echosonographic diagnostical advantages over angiography(6).
Femoral artery aneurysms that are symptomatic or larger than 2.5 cm should be repaired in order to prevent limb-threatening complications, such as rupture, thrombosis, or embolization(2). Therapeutic interventions include open surgical repair, ultrasound guided compression, thrombin injection under ultrasound, coil embolization and endovascular repair with stent-graft (2,7). Open repair is the standard method of treatment and should be preceded by evaluation for coexisting aortoiliac or popliteal aneurysms, assessment of superficial femoral artery patency, and determination of the point of origin of the deep femoral artery relative to the aneurysm sac(2). In open repair,resection + graft interposition is the simplest and successfull method.Preferred conduit is e-PTFE(8). Autogenous vein grafts have advantages only if there is infection (2,8). After surgical treatment the prognosis is favourable(6).5-year patency rate for open repair of femoral arterial aneurysms is 85% (8).
Generally, endovascular repair methods are preferred when conventional methods are too risky or technically impossible to be used (2). Although it is technically possible to place stent for femoral or popliteal pseudoaneurysms, its patency rate is between 43% and 87%, which is not satisfactory (2,9,10).
In conclusion; early recognition and surgical repair are recommended for patients with aneurysms of the superficial femoral artery greater at least twice the normal vessel size. Elective surgical treatment is associated with little risk to the patients and avoids the need for operation in the setting of limb-threatening ischemia(6).
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