Incidence of femoral and popliteal artery aneurysms in patients with abdominal aortic aneurysms

Patients with abdominal aortic aneurysm have a high prevalence of popliteal artery aneurysms

Patients with abdominal aortic aneurysms (AAA) are more prone to develop popliteal artery aneurysms (PAA), but the prevalence is not well known. Our aim was to investigate the prevalence of PAA in patients with AAA, and to determine whether a certain risk factor profile is more commonly found in patients with concurrent aneurysms. All AAA patients (ICD code I71.3, I71.4) attending the outpatient clinic at the Karolinska University Hospital between 2011 and 2013 were included in the study cohort ( n=465); 48% (225) had been subjected to an ultrasound or computed tomography scan of their popliteal arteries. In these patients, three definitions of PAA were considered (⩾ 10.5, ⩾ 12, ⩾ 15 mm), although the overall analysis is based on PAA ⩾ 12 mm. The mean age was 70.7 years (SD 7.5), 89% were men, and the mean AAA diameter was 47 mm (SD 14). The prevalence of PAA was 19% ( n=43) by definition ⩾ 12 mm, and 11% ( n=25) with 15 mm. Claudication was more frequently found in AAA patients with PAA than patients without PAA. Sensitivity between clinical examination and radiology was 26%, and the specificity for clinical examination was 90%. In conclusion, owing to the high prevalence of PAA in AAA patients, described by us and others, the low cost and risks associated with ultrasound and the poor sensitivity at clinical examination, all women and men with AAA should undergo one radiological examination of their popliteal arteries.

Outcomes of Women Treated for Popliteal Artery Aneurysms

BACKGROUND

Popliteal artery aneurysms (PAAs) in women are rare and their outcomes compared with men with PAA are unknown. The purpose of this study was to compare the surgical outcomes of PAA of women with men.

METHODS

All patients who underwent PAA repair at a single institution from 1985 to 2013 were reviewed. All women with degenerative PAA treated during that time frame were matched on year of repair to men. Presentation, mode of repair, and outcomes were reviewed. Survival and amputation-free survival were evaluated by life table analysis.

RESULTS

During the study interval, 8 women with degenerative PAA underwent surgical treatment (1.6% of 485 total PAA repairs). The overall median follow-up was 5 years (range 1 month to 19 years), but the median follow-up was shorter for women than men (1.6 vs. 6 years, P = 0.04). At the time of repair, women were of similar age compared with men (73.5 vs. 71.7 years) and had similar aneurysm size (2.7 vs. 2.9 cm). Women had similar urgency (25 vs. 17.5% emergent) and symptomatic status (50% vs. 55% acute) even though 7 of the 8 women had a thrombosed PAA at the time of repair. Operative time, approach, graft type, and inflow and outflow sources were similar between genders. No women received endovascular repair (0% vs. 10%, P = 0.5). One patient of each gender underwent major amputation (one woman on post-operative day 158 and one man on post-operative day 3). Overall, women had lower survival and amputation-free survival at 2 years (51% vs. 100% and 20% vs. 94%, P < 0.01 for both, standard error 0.2).

CONCLUSIONS

PAA requiring intervention in women is a rare clinical occurrence. Although our series is limited, women requiring PAA repair had higher long-term mortality compared with men with a similar pathology and treatment strategy.

Cirurgia aberta e endovascular no tratamento de aneurisma de artéria poplítea: experiência de cinco anos do HCRP-FMRP-USP

Resumo Contexto Aneurismas de artéria poplítea (AAPs) correspondem a 70,00% dos aneurismas periféricos. A indicação cirúrgica é para aneurismas com diâmetros maiores que 2,0 cm ou sintomáticos. O tratamento é feito por técnicas cirúrgicas convencionais ou endovasculares. Esta última tem ganho muitos adeptos, mas ainda não há consenso estabelecido sobre sua indicação. Objetivo Apresentar a experiência da Divisão de Cirurgia Vascular e Endovascular do Hospital das Clínicas de Ribeirão Preto da Universidade de São Paulo no tratamento dos AAPs. Método Foram revisados casos de reparo convencional e endovascular de AAPs tratados nos últimos cinco anos, avaliando dados demográficos, comorbidades, indicação cirúrgica, complicações pré e pós-operatórias precoces e tardias, tempo de internação e de perviedade em até um ano. Resultados Foram realizadas no período dez cirurgias endovasculares (CE) e 21 cirurgias abertas (CA). O grupo CE teve maior frequência de comorbidades. Houve maior frequência de pacientes sintomáticos no grupo CA (85,00%) do que no grupo CE (40,00%). O Grupo CE apresentou menor número de complicações clínicas e cirúrgicas. A idade entre os grupos e o tempo de internação de cada grupo não apresentaram diferença estatística. A perviedade primária em um ano no Grupo CE foi de 80,00%, enquanto no Grupo CA foi de 75,00%. Conclusão O tratamento endovascular para AAPs apresenta bons resultados, em termos de perviedade com taxas de complicações aceitáveis, em pacientes com risco cirúrgico elevado e anatomia favorável, justificando, assim, a necessidade de mais estudos controlados para modificar a posição da técnica endovascular como uma terapia alternativa para casos selecionados.

A ruptured superficial femoral artery aneurysm: A case report

True atherosclerotic aneurysms of superficial femoral artery (SFA) are rare and often associated with other peripheral or aortic aneurysms. We are reporting the case of a 78-year-old man who has been admitted with a ruptured superficial femoral artery aneurysm associated with bilateral popliteal artery aneurysm. The patient underwent successful aneurysm resection and bypass grafting.

Knee MRI: Vascular Pathology

OBJECTIVE

Patients who undergo knee MRI for presumed musculoskeletal disease can have unexpected vascular findings or pathology in the imaged field. Some vascular processes are limb threatening and affect treatment planning and patient outcome.

CONCLUSION

Unexpected vascular findings on knee MRI can range from incidental to symptomatic and can include such processes as variant anatomy, aneurysm, traumatic injury, and neoplasm. The assessment for vascular pathology should be a key component of every radiologist's search pattern when evaluating knee MRI.

Duplex Ultrasound Findings of Popliteal Artery Aneurysms With Acute Limb Ischemia

Popliteal artery aneurysms are rare, but they have the potential to be limb threatening as a result of thrombosis and distal embolization. Duplex sonography may be used to effectively detect popliteal artery aneurysms and determine patency of the runoff arteries. Findings may include dilatation of the popliteal artery during gray-scale imaging with intraluminal heterogeneous echoes indicating the presence of mural thrombus. Abnormal or absent Doppler signals in the more distal arteries with intraluminal heterogeneous echoes may indicate the presence of thrombus, likely from embolization. This case presents the duplex sonography findings of bilateral popliteal artery aneurysms in conjunction with lower extremity acute arterial thrombosis and an abdominal aortic aneurysm.

Vein graft aneurysms following popliteal aneurysm repair are more common than we think

True infrainguinal vein graft aneurysms are reported infrequently in the literature. We sought to identify the true incidence of these graft aneurysms after popliteal aneurysm repair and identify factors which may increase the risk of such aneurysms developing. Using a prospectively compiled database, we identified patients who underwent a popliteal aneurysm repair between January 1996 and January 2011 at a single district general hospital. Patients were routinely followed up in a graft surveillance programme. Out of 45 patients requiring repair of a popliteal aneurysm over a 15-year period, four (8.8%) patients developed aneurysmal graft disease. Of the patients who developed graft aneurysms, all had aneurysmal disease at other sites compared with 18 (45.0%) patients who did not develop graft aneurysms. Patients with graft aneurysms had a mean of 1.60 aneurysms elsewhere compared to 0.58 in patients with non-aneurysmal grafts ( P = 0.005). True vein graft aneurysms occur in a significant number of patients following popliteal aneurysm repair. Our data would suggest this to be more likely in patients who have aneurysms elsewhere and therefore a predisposition to aneurysmal disease. It may be appropriate for patients with aneurysms at other sites to undergo more prolonged post-operative graft surveillance.

Peripheral arterial aneurysms: open or endovascular surgery?

Peripheral arterial aneurysms are uncommon; for some aneurysm types, data are limited to case reports and small case series. There is no Level A evidence in most cases to determine the choice between open or endovascular intervention. The evolution of endovascular technology has vastly improved the armamentarium available to the vascular surgeon and interventionalists in the management of these rare and unusual aneurysms. The choice of operative approach will ultimately be determined on an individual basis, dependent on the patient risk factors, and aneurysm anatomy. After consideration, some aneurysms (femoral, subclavian, carotid and ECAA) fare better with an open first approach; renal, splenic and some visceral artery aneurysms do better with an endovascular first approach. In our practice PAAs are treated with an endovascular first approach. For these rare conditions, both open and endovascular therapy will continue to work in harmony to enhance and extend the capabilities of modern surgical management.

A popliteal aneurysm with upper thigh extension: a tip of the iceberg finding

A 75-year-old male patient was referred to our orthopaedic department due to progressive weakening of the left leg, noticed while going up and down stairs, and swelling of the thigh. An increase in swelling was noted in association with spicy food. Clinical examination showed a palm-sized non-pulsatile soft mass in the popliteal region and swelling in the posterior-lateral thigh. MRI revealed a space-occupying 40×15×10 cm mass extending into the upper thigh without infiltrating character. Angiography was negative. Open surgical biopsy was performed to rule out a soft tissue tumour, during which, connection to the popliteal artery was identified. The patient underwent excision of the aneurismal sac and a prosthetic graft was interplaced. On follow-up, the patient noticed a rapid increase in muscle strength; stairs were no longer a problem.

[Popliteal artery aneurysm: surgical and endovascular therapy]

Aneurysms of the popliteal artery are the most common form of peripheral aneurysm with an incidence of 70-80 %. An enlargement of the popliteal artery of more than 50% of the original diameter is defined as a popliteal artery aneurysm and is found mainly in male patients older than 65 years of age. The incidence is 1%, in 50% of cases is bilateral and in up to 50% in association with other large vessel aneurysms (e.g. abdominal aorta). Differential diagnoses are Baker's cyst, cystic adventitial disease, entrapment syndrome and epitheloid hemangioma. One third of all diagnosed popliteal artery aneurysms are asymptomatic incidental findings, whereas two thirds are conspicuous due to symptoms (acute or chronic ischemia, local compression, rupture). The indications for invasive treatment are given for patients with patent aneurysms at a diameter of more than 2 cm or if a thrombus is present within the aneurysm. Symptomatic popliteal artery aneurysms are always an indication for therapy. Treatment strategies are surgical techniques and endovascular interventions, which both have a similar outcome and graft patency in midterm results.

One-stage hybrid repair of multiple degenerative aneurysms

The development of multiple aneurysms in different segments of the arterial tree requiring treatment is a challenge for the vascular surgeon as their management often demands more than one surgical procedure. We report a case of a 71-year-old male suffering from multiple aneurysms in four different segments of the arterial tree in combination with disabling claudication of his left leg. The patient was managed in a single session with a combination of classic open surgical and endovascular techniques in order to treat his aneurysms and revascularize his leg. This case illustrates the prospect to combine classic open surgical and endovascular techniques for the optimal management of multileveled arterial pathology. Combined therapy simplifies management and allows the one-stage treatment of these patients, while minimizing the overall operative risk.

Aneurisma verdadeiro de artéria plantar medial: relato de caso

Os aneurismas periféricos merecem atenção pela sua baixa frequência e associação com outros aneurismas arteriais, principalmente o de aorta abdominal. O aneurisma de artéria plantar verdadeiro é ainda mais raro. A escassa literatura disponível concentra-se nos casos de pseudoaneurisma pós-traumático dessa artéria. Relata-se o caso de uma paciente do sexo feminino, 85 anos, com queixa de dor no pé direito ao deambular durante um ano, acompanhada de nódulo pulsátil em região plantar, próximo da base do primeiro pododáctilo. Não havia história prévia de trauma ou cirurgia na região plantar acometida. Realizou-se ecografia vascular e angiorressonância, que diagnosticaram aneurisma de artéria plantar. A paciente foi então submetida à aneurismectomia com ligadura das artérias nutricionais, apresentando boa evolução pós- operatória.

Pattern of femoro-popliteal aneurysms in an African population

Objective: To describe the pattern of femoro-popliteal aneurysms in an African Kenyan population. Patients and methods: Records of African in-patients with diagnosis of femoral or popliteal aneurysms admitted at the Kenyatta National Hospital, Nairobi, Kenya, from January 1998 to December 2007 were examined for presentation, diagnosis, risk/comorbid factors, site, age, and gender distribution. Data were analyzed using SPSS 13.0 and presented using tables. Results: Femoro-popliteal aneurysms constitute 33 out of 96 of peripheral cases (34.4%). The most common presentations were pulsatile mass (48.5%) and pain and swelling (33.3%). Pain alone and bleeding occurred in 9.1% each. Diagnosis was performed through Doppler ultrasound (45.5%), angiography (30.3%) and ultrasonography (24.3%). Aneurysms were associated with trauma (51.5%), atherosclerosis (21.2%), smoking (9.1%) and hypertension (6.1%). Site distribution was common femoral (33.3%), superficial femoral (36.4%) and popliteal (30.3%). Mean age was 46 years (range 13-79 years); with 20 (60.6%) of them occurring in individuals aged 50 years and younger. Male:female ratio was 15:1. Conclusion: In the present study, femoro-popliteal aneurysms constituted less than 40% of peripheral aneurysms, and superficial femoral artery was the most common site. They occurred predominantly in males aged 50 years and younger and were associated mainly with trauma and atherosclerosis. Prevalence, site and age distribution of these aneurysms in the Kenyan population differs from that described in studies of Caucasian populations.

Aneurysms in the arteries of the upper extremity in a Kenyan population

BACKGROUND

Aneurysms in the arteries of the upper extremity are rare but important in predicting aortic aneurysms and their potential to thromboembolize and cause limb loss. Their localization, age, and gender distribution vary between countries depending on ethnic background and cause. These data are valuable in the management of aneurysms, but are largely lacking from the Kenyan population.

OBJECTIVE

This study aimed at examining the pattern of these aneurysms in a Kenyan population.

STUDY DESIGN

Retrospective.

SETTING

Kenyatta National Hospital, Kenya.

PATIENTS AND METHODS

Hospital records of aneurysms in upper limb arteries over 10 years from January 1998 to December 2007 were examined. Ethical approval was given by the Kenyatta National Hospital Ethics and Research Committee. Site, age, gender, and risk factors were recorded. Unconfirmed diagnoses were excluded. Results were analyzed using SPSS 11.50 and presented using tables.

RESULTS

Aneurysms of the upper extremity arteries comprise 34 (35.4%) out of 96 peripheral aneurysms. Of these, brachial artery was the most common site (35.3%), followed by brachiocephalic (11, 32.4%), subclavian (9, 26.5%), radial (1, 2.9%), and anterior interosseous (1, 2.9%). Trauma was the commonest predisposing factor (41.2%), followed by atherosclerosis and related comorbidities (32.4%), infection (11.8%), and autoimmune disease (8.8%). The mean age was 39.5 years (range: 13-79) with a variable gender distribution.

CONCLUSION

Aneurysms of the upper extremity arteries are not uncommon in the Kenyan population. They occur more commonly in individuals aged 50 years and less, and although most of them are traumatic, atherosclerosis constitutes a significant proportion. Prudent management of risk factors is recommended.

Review of Current Theories for Abdominal Aortic Aneurysm Pathogenesis

Atherosclerotic plaques are a feature of abdominal aortic aneurysms (AAAs). Atherosclerosis and AAA appear to share similar risk factors. These observations have led to the conclusion that AAAs are a consequence of advanced atherosclerosis.

This review explores current theories regarding the pathogenesis of AAA and their implications for treatment.

A systematic literature search was conducted using the search terms abdominal aortic aneurysm, atherosclerosis, pathogenesis, and systemic disease. Articles were categorized according to the association of AAAs with atherosclerosis, arteriomegaly, peripheral aneurysm, systemic expression, genetics, autoimmunity, oxidative stress, and systemic disease. Twenty-nine articles reporting changes in the systemic vasculature associated with AAA and 12 articles examining the shared risk factor hypothesis were identified.

There is insufficient evidence to confirm that AAAs are the result of advanced atherosclerosis. The bulk of evidence points to AAA disease being a systemic disease of the vasculature, with a predetermined genetic susceptibility leading to a phenotype governed by environmental factors.

Popliteal Aneurysms: Does Size Matter ?

When considering the management of popliteal aneurysms, not only the size but also the nature, symptoms and state of collateral and distal circulation must be taken in to account. We present a patient who required operative management of a symptomatic 3cm popliteal aneurysm of the left leg whilst a conservative approach chosen for the right leg which had an asymptomatic 17 × 13.1 cm popliteal aneurysm, the largest of its kind reported within the English literature.

Arterial vascular disease in women

BACKGROUND

Arterial disease in women will become a major issue in the near future.

METHODS

A systemic review of existing literature was retrospectively conducted to collect information on the three most common entities of vascular disease: carotid atherosclerotic, abdominal aortic aneurismal, and lower extremity arterial occlusive disease.

RESULTS

Vascular disease is either underdiagnosed or undertreated in women. Whether regarding cerebrovascular disease, aortic aneurysmal disease, or atherosclerosis affecting the lower extremities, natural history, clinical and physiologic patterns are different in women vs men. Current biomedical devices create challenges in endovascular procedures performed in women. Furthermore, indications for treatment of vascular disease are derived from large studies where women are often underrepresented; and, thus, may not be applicable in female vascular patients.

CONCLUSIONS

Better understanding of the gender differences in vascular disease with focused randomized trials, biomedical research, and identification of gender specific medical and social risk factors will improve the clinical outcomes in female patients.

Screening for popliteal aneurysms should not be a routine part of a community-based aneurysm screening program

Introduction

Several studies have found an increased incidence of peripheral aneurysms in patients with an abdominal aortic aneurysm (AAA). The aim of this study was to determine whether screening for popliteal aneurysms should be part of an AAA screening programme.

Setting

A community-based AAA screening programme

Methods

The diameters of the internal abdominal aorta and both popliteal arteries were assessed by B-Mode ultrasound in a subgroup of the screened population. An AAA was defined as an infrarenal aortic diameter >29 mm. A popliteal aneurysm was defined as a popliteal diameter >19 mm.

Results

Information was available for 283 subjects, 112 subjects with a small AAA, and 171 subjects with a normal aorta. No popliteal aneurysms were found in the subjects with a normal aorta. Three popliteal aneurysms were found in patients with a small AAA. Scanning both popliteal arteries took an experienced sonographer on average three times as long as scanning for an AAA (5 vs 15 minutes).

Conclusion

Popliteal artery aneurysms are seen in less than 3% of men with a small AAA and not at all in men with a normal aortic diameter. It is therefore not cost effective to include screening for popliteal aneurysms in population screening for AAA.

A Contemporary Review of Popliteal Artery Aneurysms

Popliteal artery aneurysms account for 85% of all peripheral aneurysms and are frequently associated with abdominal aortic aneurysms. Up to 75% of all popliteal artery aneurysms are discovered in symptomatic patients who present with arterial insufficiency, leg swelling, or pain. Popliteal artery aneurysms can be diagnosed with duplex ultrasonography. Aneurysm repair should be considered for all symptomatic patients with rest pain or limb-threatening symptoms. Asymptomatic aneurysms larger than 2 cm should also be treated to prevent the development of limb-threatening ischemia and assure better surgical bypass graft patency and longer freedom from amputation. Conventional aneurysm repair consists of either opening the aneurysm sac and interposing a bypass graft or aneurysm ligation combined with bypass grafting. If the aneurysm sac is left intact, side branch perfusion may persist and the aneurysm may continue to enlarge and can rupture. Endovascular popliteal aneurysm repair has not demonstrated clinical equipoise to standard surgery but may be advantageous in select high-risk patients.