Isolated atherosclerotic aneurysm of the superficial femoral artery - case report
(Portuguese
PDF version)
Cristiano
do Carmo Galindo1, Carlos Augusto Lima2, José Édson Cardoso3,
Geraldo Galindo Filho1, Vinícius Scalco Costa1, Fernando
Marcondes Penha1
1.
Medicine student.
2. MD, specialist in Angiology and Vascular Surgery.
3. PhD, specialist in Angiology and Vascular Surgery.
* Division
of Vascular Surgery of Hospital Marieta Konder Bornhausen, Itajaí,
State of Santa Catarina, Brazil.
Correspondence:
Cristiano do Carmo Galindo
Rua Timbó, 301/605
CEP 89012-180 - Blumenau - SC
Tel.: +55 47 340.2455 / 9101-6990
E-mail: crigalindo@al.furb.br
ABSTRACT
Isolated
atherosclerotic aneurysms of the superficial femoral artery are
rare. Due to their infrequency, we report an original case of superficial
femoral aneurysm without concomitant aneurysms. The literature review
emphasizes the great latency of the disease and the high incidence
of complications at presentation, risk factors, diagnostic difficulty
due to lack of information about its natural history, surgical indications
and the favorable prognosis after surgical treatment, with good
limb salvage rates.
Key-words:
aneurysm, femoral artery, surgery.
Palavras-chave: aneurisma, artéria femoral, cirurgia.
J
Vasc Br 2003;2(2):145-7
According
to the Subcommittee on Reporting Standards for Arterial Aneurysms, 1991,1
aneurysms are defined as a permanent and located dilation of an artery.
It has at least 50% of dilation compared with the expected normal diameter
for the artery in question. The expected diameter depends on some factors
such as patient's age, sex, physical condition and the method used.
Femoral aneurysms are classified as peripheral aneurysms. They are much
less frequent than aortic aneurysms.2,3
The isolated superficial femoral aneurysm has a very low incidence.2
It can be symptomatic or asymptomatic and diagnosed by palpation of
a pulsatile tumor in the inguinal region. This kind of aneurysm has
favorable prognosis after surgical treatment.
An original case of isolated aneurysm of the superficial femoral artery
is reported, and the literature reviewed.
CASE
REPORT
A 67-year-old woman has presented with a painless and pulsatile mass
in the right inguinal region for six months, associated with local itching.
She has no alterations of temperature, color, trophic or sensitivity
disorders or edema in the right lower limb. She has no history of cigarette
smoking, sedentary lifestyle, hypertension, hypercholesterolemia or
diabetes. On physical examination, she presented a palpable, pulsatile
and non-visible mass in the upper third of the right thigh. This mass
is painful to deep palpation and does not show evidence of rupture and
distal ischemia. The extremities are warm and symmetric with normal
distal pulses. She presents a discrete murmur in the right inguinal
region (+ / 4+).
Three months ago, the patient was submitted to ultrasonography, which
detected atheromatosis of the right lower limb arteries, associated
with a bulky aneurysm in the medial third of the right superficial femoral
artery (6.9 x 2.8 x 2.6 cm) without concomitant aneurysms in other arteries.
The patient underwent a surgical excision of the right superficial femoral
artery (Figure 1) and Dacron 6mm synthetic graft replacement (Figure
2). The pathoanatomical exam showed the atherosclerotic etiology of
the aneurysm.
After surgery, the patient showed no evidence of ischemic or embolic
complications during a 12-month follow-up period. Ultrasonographic exams
were performed at three, six and twelve months.
 Figure
1 - Anatomic location of the superficial femoral aneurysm measuring
6.9 x 2.8 x 2.6 cm in the perioperative period.
Figure
2 - Restoration of circulation with the Dacron 6mm graft used in our
patient.
DISCUSSION
Isolated
atherosclerotic aneurysms of the superficial femoral artery, as reported
herein, are rare. According to the literature this rarity occurs because
the superficial femoral artery is relatively more protected against
the development of aneurysms than the common femoral and popliteal arteries.
This occurs due to their excellent muscular support and absence of bending
stress.2
Most isolated aneurysms of the superficial femoral artery have traumatic
and mycotic origin .4 In the absence of
such clear etiologic factors, most of aneurysms have been considered
"atherosclerotic", even when there is little or no evidence
of atherosclerosis in other vessels.2
The natural history of superficial femoral aneurysm is not so clear
because few cases have been reported up to now. In a literature review
performed in 1995, only 21 aneurysms had been reported in 17 patients.5
Concomitant aneurysms were present in 69% of the cases and the association
with abdominal aortic aneurysm was the most frequently observed one
(40% of the cases). The average age was 77 years old (61-93 years old),
with prevalence of males (75%).2
Aneurysms of the superficial femoral artery usually manifest as a pulsatile
mass in the medial region of the thigh. It may be painful, but asymptomatic,
thus making the diagnosis an occasional finding. When the superficial
femoral artery is relatively deep into the thigh, the aneurysm usually
increases significantly before it is diagnosed. This hinders the recognition
of asymptomatic injuries.4 According to
Rigdon & Monajjen, 65% of the aneurysms appear through complications
such as rupture (35%), thrombosis (18%) and distal embolic events (12%).2
The diagnosis can be confirmed with ultrasonography, computed tomography
or magnetic resonance. Arteriography is reserved for the surgical planning.
Surgical treatment is indicated for all symptomatic aneurysms. Asymptomatic
aneurysms over 2.5 cm in diameter are treated with surgical resection
as well.4 The ultrasonographic finding of
thrombi covering the internal wall of the aneurysm is a sign of surgical
indication. Surgical treatment is indicated regardless of their size
because these thrombi are responsible for the main complications of
these aneurysms. The treatment consists of the resection of the aneurysm
rather than ligation of the proximal and distal artery and bypass of
the ligated segment.4 The limb salvage rate
was 94% and there were no perioperative deaths.3
Although the superficial femoral aneurysms are technically easy to resect,
with the restoration of circulation, the long-term reconstruction results
are not as efficient as they are for the common femoral aneurysm. This
happens because they are usually associated with multiple occlusive
and stenotic injuries. These lesions compromise the functioning of the
grafts in the medium and long term.
REFERENCES
1.
Johnson KW, Rutherford RG, Tilson MD, Shah DM, Hollier L, Stanley JC.
Suggested standards for reporting on arterial aneurysms. J Vasc Surg
1991;13:452-58.
2.
Rigdon EE, Monajjem N. Aneurysms of the superficial femoral artery:
a report of two cases and review of the literature. J Vasc Surg 1992;16:790-93.
3.
Vasquez G, Zamboni P, Buccoliero F, Ortolani M, Berta R, Liboni A. Isolated
true atherosclerotic aneurysms of the superficial femoral artery. J
Cardiovasc Surg 1993;34:511-12.
4.
Graham LM. Femoral and popliteal aneurysms. In: Rutherford RG, editor.
Vascular Surgery. Philadelphia: WB Saunders; 2000. p. 1345-1356.
5.
Brito CJ. Aneurismas periféricos. In: Maffei FHA, editor. Doenças
Vasculares Periféricas. Rio de Janeiro: MEDSI; 2002. p. 1149-1171.
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