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Isolated deep femoral artery aneurysm. Case report and literature review
(Portuguese PDF version)

Ilídio Almeida Lima¹, Marcelo Fernandes Lima², Marcos Velludo Bernardes¹

1. Vascular Surgeon. ANGIOMED - Angiologia de Manaus Ltda., Manaus, AM, Brazil.
2. Vascular Surgeon. Specialist in Vascular Surgery, SBACV. ANGIOMED - Angiologia de Manaus Ltda., Manaus, AM, Brazil.

Correspondence:
Marcelo F. Lima
Av. Joaquim Nabuco, 1359-B
CEP 69000-000 - Manaus - AM
Brazil
Tel.: +55 (92) 233.2230
Fax: +55 (92) 232.6956
E-mail: mlima@argo.com.br

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ABSTRACT

The authors report the case of an isolated atherosclerotic aneurysm of the deep femoral artery in a 34 year-old male patient who exhibits symptomology not related to the findings of the physical examination. The diagnosis was confirmed by a duplex scan, which revealed an aneurysm of the deep femoral artery with 8.36 cm. Due to the risk of complications established during a literature review, particularly rupture and embolization, surgical treatment was the method of choice. An arteriographic study was utilized to plan the operation since computed tomography and magnetic resonance angiography proved to be sufficient, and do not present the risks of the arteriographic procedure. Treatment consisted of the ligature and resection of the aneurysm with a solid postoperative evolution. as the patency of the femoral-popliteal segment shown by the image studies guarantees the absence of ischemic symptoms in these situations.

Key-words: femoral artery, aneurysm, surgery.
Palavras-chave: artéria femoral, aneurisma, cirurgia.

J Vasc Br 2003;2(4):333-38

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True aneurysms of the deep femoral artery are rare, corresponding to approximately 0.5% of all peripheral aneurysms.^1-15 However, they remain of great interest from a surgical point of view due to the vital importance of the deep femoral artery in collateral circulation of lower limbs, in cases of obstruction of the femoropopliteal segment, and due to its high tendency to complications, especially rupture, with a significant morbidity involved in the therapeutic process when performed in emergency situations.^{1,4,5,7-10,14,16}

CASE REPORT

A 54 year-old, Caucasian patient looked for medical care complaining of a moderately intense pain in his right calf, which had begun abruptly 72 hours before, and which was relieved with the use of a non-hormonal anti-inflammatory. The patient was concerned that his symptomology could be related to deep venous thrombosis (DVT), explaining that in the first day in which he experienced the pain he drove his automobile for more than six consecutive hours.

At physical examination, no clinical signs of DVT were identified. However, the palpation of arterial pulses evidenced a large, lateral pulsating tumor in the right femoral artery, with the preservation of the other pulses in both lower limbs. The patient stated that he had felt the presence of the tumor before, describing how it had gradually expanded over the past four years. He related the growth in tumor volume to a previous ipsilateral inguinal herniorrhaphy, with no intercurrent illnesses in the postoperative course, according to him.

Due to the clinical diagnosis of muscular pain originating in the right calf and the aneurysm of the right femoral artery, an arterial and venous duplex scan of the lower limbs was requested. The scan evidenced normal functioning of the venous system and an aneurysmatic dilatation of the right deep femoral artery with an estimated diameter of 8.37 cm, which contained a mural thrombus and flow with turbulence in its interior (Figure 1). In addition, a moderate arteriosclerosis in the transition of the superficial femoral artery to the popliteal artery was evidenced, with a preserved patency of the infrapopliteal vessels. However, these vessels did not present a normal blood flow, a finding that introduced the possibility of hypokinesis. The computed tomography (CT) confirmed the diagnosis, allowing for the observation of a great dilatation of the deep femoral artery immediately after its origin and a large quantity of thrombi in the interior of the aneurysmal sac (Figure 2).

Figure 1- Duplex scan showing dilatation of the deep femoral artery immediately after its origin, with a whirlpool flow in its interior.

Figure 2- Computerized tomography visualizing the presence of extensive mural thrombi in the interior of the aneurysmal sac.

Surgical treatment for the aneurysm was deemed necessary. The patient decided to seek treatment in another hospital in his native city for family reasons. There, an magnetic resonance angiography study was undertaken (Figure 3) and surgical therapy was performed via ligature and resection of the aneurysm, without deep femoral artery reconstruction.

Figure 3- Magnetic angioresonance outlining the anatomy of the right deep femoral artery aneurysm. There is no evidence of aneurysmatic dilatations in other arteries.

DISCUSSION

In a bibliography review published in 2001, Nagy et al. ¹⁷ documented 51 cases of deep femoral artery aneurysms described in literature since 1960, adding to this total three cases from their personal experience. Paisley et al., ¹⁸ Di Marco et al. ¹⁹ and Johnson et al. ⁵ described the other cases that have been reported up until the time of the current review. Some authors affirm that the rarity of deep femoral artery aneurysms can be explained by the relative protection that this artery has against aneurysmatic dilatation through an actual muscular tunnel formed by the adductor magnus, ^{3,5,9,10,18,20-23} in addition to the asymptomatic character of this lesion, which is located deeply in the musculature of the thigh. Therefore, a diagnosis is only possible when the volume of the aneurysm is large enough to be noticed during the inspection and palpation or during clinical manifestations resulting from complications that suggests a possible sub notification of these aneurysms.^8,9,12,19,24

According to available literature, the first report of a deep femoral artery aneurysm was made by Pappas et al. ⁶ In 1964, this group compiled a list of 115 aneurysms of the femoral artery that were recorded at the Mayo Clinic (Rochester, Minnesota). One deep femoral artery aneurysm was found among this total (0.86%). The etiology of these aneurysms is, by a wide majority, atherosclerotic tic (75 to 90%). However, other etiologies, such as collagen diseases, autoimmunity diseases, arthritis and syphilis can be indicated in the origin of the process.^{1,4,6,8,10-12,14,16,21-27} In 1987, Templeton et al. ²¹ described two cases of mycotic deep femoral artery aneurysms secondary to bacterial endocarditis, with Streptococcus viridans and Streptococcus faecalis as the causal agents isolated in cultures on the wall of the aneurysms.

There is a clear predominance for the masculine sex, accounting for nearly 90% of the cases, and the average age is 71 years.^8,13,23,26 Patients with deep femoral artery aneurysms have other aneurysms identified in 20 to 45% of the cases, ^12,15,28 with the abdominal aorta, the popliteal artery and the common femoral arteries being the most frequent sites.^{3,5,6,8-10,15,16,19} The study of the coexistence of a bilateral deep femoral artery aneurysm was only performed on two occasions; by Bjorck et al. ¹⁴ and Raine et al., ¹² respectively. Rarer still is the occurrence of simultaneous aneurysms in the upper and lower limbs, as described in the report written by Defraigne et al., ³ whose patient presented an aneurysm of the common femoral artery, the deep femoral artery and right popliteal and of the axillary artery bilaterally.

The diagnosis of a deep femoral artery aneurysm should be proposed for patients who present a pulsatile tumor in the common femoral artery topography, with this tumor located in a position that is slightly lateralized. However, the tumor can also be located deep in the muscular mass of the thigh and have a volume that is so insufficient that it is not perceived by inspection and palpation, especially in patients with a large physical build. When the inspection and palpation do not provide evidence, the diagnosis will only be possible if the image methods used for investigations of other arterial pathologies in this anatomic sector find the asymptomatic deep femoral aneurysms. The diagnosis can also be made based on the appearance of symptoms caused by the compression of neighboring structures, for example, sciatic and femoral neuropraxia. ^4,22

Although Billig et al., ²⁸ Valiulis et al. ⁷ and Williams et al. ⁹ described thrombosis as the most frequent complication of these aneurysms, a review of the presented cases points to rupture as the most common complication. ^6,7,26,28 Distal embolization, probably due to the passage of debris and thrombotic material in a retrograde fashion toward the superficial femoral artery was described by Markland ²³ and Fluckiger et al. ²² Intense and painful edema that begins abruptly and is located in the inguinal region or in the upper third of the thigh is frequently found in the described cases and is due to the sudden expansion of the anuerysm.^1,2-4,^8,9,11,^19,21,22,^26,29

The diagnostic confirmation should be performed by evaluating the image of the aneurysm. Simple radiography can provide evidence for parietal calcification in the topography of the deep femoral artery. ²¹ The arteriography, although extremely useful for correct surgical planning, frequently fails to show aneurysmatic dilatation of the deep femoral artery, whether this be due to the presence of mural thrombi or thrombosis of the vessel lumen. ^{5,12,16-19,21,22} Ultrasonographic study through a duplex scan provides a high level of sensitivity for indicating of identifying aneurysmatic dilatation in addition to being a safe, non-invasive and low-cost method. ^5,23 However, its specificity in correctly localizing the center of the aneurysmatic dilatation is low, with various reports of incorrect aneurysm location. ^1,3,6,^12,18 The computerized tomography provides information about the diameter of the aneurysm, its entirety and the degree of parietal calcification and presence of mural thrombi, in addition to providing information about its relationship with neighboring structures. The tomography was suggested by Roseman & Wyche ¹¹ to be an adequate method in the outlining of these aneurysms in comparison with the arteriography. We agree with this affirmation, principally with the availability of the helicoidal three-dimensional computerized tomography, which gives more value to the information supplied by the conventional computerized tomography. The magnetic resonance angiography (MRA) is another diagnostic method that has been widely utilized as a substitute for angiography in the investigation of vascular pathologies. Its standard of quality is constantly increasing due to the constant improvement of the equipment used. The patient who was studied in this case was submitted to surgical intervention with information based on the combination of a duplex scan, computerized tomography and MRA, which proved to be sufficient for surgical planning. There was no need to submit the patient to an arteriographic study, as it presents the potential for complications already well established in literature.

Cutler & Darling ¹⁰ reported three interventions in deep femoral artery aneurysms that resulted in amputations. Both patients had associated popliteal or tibial occlusions, and both were submitted to ligature of the deep femoral artery. Only one patient submitted to a femoral-popliteal bypass with Dacron maintained functionality of the limb for nine months. Valiulius ⁷ and Ratto et al. ¹⁵ described two cases where the patients were submitted to ligature and resection of the aneurysm in which the distal arteries were patent, without hemodynamic repercussions for the lower extremities. Billig et al. ²⁸ reported a case of simultaneous reconstruction of aneurysms in the common femoral artery, the deep femoral artery, and the ipsilateral popliteal artery with Dacron, with excellent postoperative results. Other accounts of reconstruction of the deep femoral artery after aneurysm resection were made by Symes & Eadie, ²⁶ Wiest et al., ²⁹ Templeton & Barros D'Sa, ²¹ Markland, ²³ Schulze & Chester, ¹ Raine et al., ¹² Levi & Schroeder, ⁸ Dorrucci et al., ⁴ Di Marco & Felloni ¹⁹ and Johnson et al., ⁵ all describing a positive postoperative evolution. The first cast of a deep femoral artery aneurysm treated by endovascular technicians was described by Paisley et al. ¹⁸ in 2001. In this case, a covered Cragg stent was used to remove the aneurysm with follow-up after one year showing the preserved patency of the vessel without any sign of problems with the aneurysmal sac.

As a result of its rarity, the natural history of deep femoral artery aneurysms is not well known and the experience of surgical treatment is limited. The significant morbidity associated with urgent surgical treatment had lead to a consensus for the elective repair of asymptomatic deep femoral artery aneurisms.^{3,6,8,10-12,21,28}

The appropriate surgical method will essentially depend on the patency of the femoral-popliteal and distal segments. When there is patency of these segments, the ligature of the deep femoral artery can be safely undertaken. However, for the coexistence of hemodynamically significant stenoses or occlusions in these segments, the reconstruction of the deep femoral artery is required due to the vital importance of this vessel as a collateral channel to supply the lower extremity with the necessary blood flow to maintain the viability of the limb. Preference should be given to an autogenous material (greater saphenous vein) for vessel reconstruction.^{3,8,9,11,12,15,18,23,30} The use of a combined approach, including a change in the patient's position on the operating table for a posterior incision, may be necessary for the adequate distal control of the aneurysmatic deep femoral artery.

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