Introduction

Nowadays, arterial aneurysms which have high rates of mortality and morbidity are classified as most severe vascular disease. Arteriosclerosis is frequently responsible for its etiology. It could be only one isolated aneurysm or double-aneurysms, even though symmetric (₁). Two symmetric superficial femoral artery (SFA) aneurysms in the same patient are rare. While the aneurysm in the proximal arteries sually ends with rupture, peripheral aneurysms frequently cause ischemia due to thrombosis and thrombo-embolic events (₂). An unusual case describing bilateral SFAs aneurysms with one of the aneurysms resulting in thrombosis, is presented in this article.

Case Report

A sixty-four-year-old male patient was hospitalized by the orthopedics and traumatology section of our hospital because of a fracture of the head of the left femur due to trauma. The patient was evaluated by the cardiovascular section. In the computerized tomography (CT), bilateral aneurysmatic dilatations of SFAs were found. The patient who rejected aneurysm surgery, was discharged after implantation of a femoral head prosthesis by the orthopaedics section.

Figure 1

Figure 1: Computerized tomographic scan of both thighs of the patient. True aneurysms of the superficial femoral arteries which have 5 cm external diameter are shown. Each aneurysm contain intraluminal excessive thrombi.

Three months later, the patient was referred to the emergency department with thigh pain and paleness of the left calf and foot. The patient underwent urgent surgery with the diagnosis of thrombosis of the left SFA aneurysm. Excision of the left SFA aneurysm was not possible because of the patient's bad and cachexic condition. A synthetic graft bypass between the common femoral and popliteal artery at its origin was performed following the ligation of the SFA and distal neck of the aneurysm which resulted in limb salvage. The patient who again rejected the surgery to the right SFA aneurysm was discharged at the 15th postoperative day with palpable distal pulses. The result of pathologic examination of the specimen sampled from aneurysmal wall was reported as atherosclerosis. Haematologic, infectious, metabolic and rheumatismal tests were negative.

Four months later, aneurysmatic dilatations (5 cm) and intraluminal thrombus (2 cm) in the right SFA were still shown at the CT. A fully thrombozed aneurysm and patent synthetic graft in the left thigh was also observed.

Figure 2

Figure 2: Latest tomographic view of the right and left thigh. Aneurysm of the right superficial femoral artery which contains excessive thrombi was shown as patent. Huge and fully thrombosed superficial femoral artery aneurysm was shown in the left thigh. Additionally, patent synthetic graft was shown in the posteromedial region of the thrombosed aneurysm.

Discussion

Aneurysms in peripheral arteries may be associated with such etiologic factors as syphilitic or other infectious arteritis, non-infectious immunologic or inflamatory arteritis, and connective tissue diseases, although atherosclerotic aneurysm are seen frequent (₃,₄). When there is no etiologic factor, arteriosclerosis is frequently accused even there is not any clear evidence (³,₅). Arteriosclerotic SFA aneurysms are very rare in the literature (₆,₇) . It was suggested that the SFA is more protected against the development of an aneurysm than the common femoral or popliteal arteries, with excellent muscular support and absence of bending stress (³,₈).

Conservative management is proposed in small and asymptomatic aneurysms (¹). Additionally, percutaneous endovascular stented graft insertion is an alternative treatment modality (₉). Acute surgical intervention should be performed if there is a high risk for rupture, thrombosis of the aneurysm or thrombo-embolic events in the distal arteries (¹,³,⁵). We aimed at the resection of the true aneurysm with surgical intervention because of the development of the acute ischemia following the thrombosis in this case. However, the patient was anemic, highly cachexic, and in bad general condition. For this reason, we preferred the ligation of the aneurysmal neck and perform an arterial bypass with synthetic graft for shortening the operation time, to avoid large exploration and diminish the bleeding. Although there was an operation indication owing to the large diameter of the aneurysm of right SFA, the operation could not be performed because of the patients rejection of the operation.

Correspondence to

Dr Suat CANBAZ, Trakya University, Medical Faculty, Department of Cardiovascular Surgery, Gullapoglu Campus, TR 22030 Edirne, Turkey Phone: +90 284 235 76 56 Fax: +90 284 235 06 65 E.mail: scanbaz@trakya.edu.tr