Jornal Vascular Brasileiro

Rupture of a popliteal artery aneurysm: case report and review of the literature for the past 50 years
(Portuguese PDF version)

Ricardo Soffiatti Mesquita Oliveira, Daniela Aliperti Ferreira, Júverson Alves Terra Júnior, Roberto da Mata Lenza, Antonio Carlos de Assis Filho, Wilson Nunes ^*

* Vascular and Endovascular Surgery, Department of Cardiovascular Diseases, Hospital Clínico y Facultad de Medicina, Pontificia Universidad Católica de Chile.

Correspondence:
Ricardo Soffiatti Mesquita Oliveira
Av. Frei Paulino, 30
CEP 38025-180 - Uberaba, MG, Brazil
E-mail: soffiatti@uol.com.br

ABSTRACT

Rupture is a rare complication of the popliteal artery aneurysm. We report a case of a 75-year-old patient with acute pain and a right lower limb edema who was unable to ambulate. The diagnostic investigation through physical examination, ultrasound, computed tomography, and arteriography revealed the presence of a ruptured popliteal artery aneurysm. The patient was submitted to revascularization, had uneventful postoperative course and recovered with total function of his limb.

Key-words: ruptured aneurysm, popliteal artery, revascularization.

J Vasc Br 2005;4(1):105-110

The most common complication of the popliteal artery aneurysm is the acute artery occlusion.^1,2 Rupture is a rare event and only 10 cases have been reported since 1981 in a review study performed by Illig et al.³ and a total of 120 cases (incidence of 2.92%) from 1953 to 2003 in our review. We report a case of rupture of a supragenicular popliteal artery aneurysm.

CASE REPORT

A 75-year-old patient, male, was admitted to the emergency department of the Hospital Escola - Faculdade de Medicina do Triângulo Mineiro, reporting strong pain with a painful edema extending from the right lower limb extremity to the inferior third of the thigh, making ambulation impossible. At physical examination, he was hemodynamically normal, with no alterations of the red series, absent pedal pulse and presence of a hard, pulsating tumor of approximately 8 cm in the popliteal fossa. The ultrasound (US) of the inferior third of the thigh and popliteal fossa revealed a packed ruptured aneurysm with a 6-cm diameter confirmed by computed tomography (CT) (Figure 1). The arteriography showed the aorta with no alterations, enlargement of the superficial femoral artery with diffuse atheromatosis, but with no significant obstructive injuries, right popliteal artery with important aneurysmatic dilatation and a popliteal artery drainage through collateral circulation at the anterior and posterior musculature of the leg (Figure 2) (Figure 2 only reveals the presence of aneurysmatic dilatation of the supragenicular popliteal artery in which we could not identify a contrast overflow). There is no image of the leg in order to identify leg artery obstruction. A femoro-popliteal bypass was then performed, with an 8-cm polytetrafluoroethylene (PTFE) prosthesis, supragenicular, with latero-terminal proximal (with ligature of the artery distal to the anastomosis) and termino-terminal distal anastomosis. The postoperative evolved uneventfully and the patient was discharged on the eighth day, with total preservation of limb functions.

Figure 1 - Contrast-enhanced computed tomography: distal third of the right thigh. Ruptured popliteal artery aneurysm with extensive hematoma in the popliteal fossa.

Figure 2 - Arteriography of right lower limb, contrasting the femoral artery and the popliteal aneurysm.

DISCUSSION

Of peripheral arteries, after the aorto-iliac system, the popliteal artery represents the most common site of aneurysms.^2,3 The central portion of the artery, adjacent to the knee, was the most affected site, rarely showing extension to the distal segment.⁴ Its association with other sites of aneurysmatic formation is observed in great part of cases, especially in the bilateral involvement of the popliteal artery (50%), aortic aneurysm (1/3) and femoral artery aneurysm (1/4).³ The aneurysm reported by us was located on the proximal portion of the popliteal artery and the patient presented another small dilatation of the femoral artery. A particularity of popliteal and femoral aneurysms is the great disproportion of their incidence regarding gender. We found a predominance of 94.4% (844 male:50 female) in our review, similar to a review done by Inahara et al.⁵, who found an incidence of 98% in males (467 male:12 female).Symptoms may be unspecified, but usually represent a clinical picture of ischemia.^2,6,7 Complications frequently occur, several times followed by limb loss.¹ Claudication, pain, edema, stiffening of muscles, and alterations in local temperature and sensitivity may occur.^2,3,6,8 We verified that the patient presented history of claudication for approximately 2 years (probably as a consequence of distal embolizations, which are frequent in the popliteal artery aneurysm). The dilatation dimensions present a close relation to the disease symptoms, being observed by Whitehouse et al.⁸ in a study of 88 aneurysms. Prognosis does not depend only on the dilatation size, but also whether there is previous complication to the treatment and the nature of the complication.

The atherosclerotic disease is the most common etiology in the popliteal aneurysm, although syphilis, trauma, and fungous infections are also reported as a causal factor.^2,7,9 In this case the patient did not have syphilis or fungous infections and did not report a trauma history. The difficulty of making a diagnosis at physical examination is due to an anatomical factor, since the artery is located at a deep site and covered by the fascia in the popliteal fossa. A palpable dilatation in this region suggests a diameter from 2.5 cm to 10 cm.⁵ The diagnostic suspicion of a ruptured aneurysm is confirmed by ultrasonography, computed tomography and/or arteriography, examinations that show the aneurysmatic formation and its possible complications. The tomography is seen by some authors as the best choice for being fast and non-invasive, as well as allowing the visualization of the aneurysm with associated hematoma.³

Complications frequently occur, several times representing the aneurysm's primary manifestation. Evans et al.¹⁰ reported the occurrence of complications previous to admittance in 70% of cases. Gifford et al.¹¹ in a study of 100 popliteal aneurysms, verified that artery occlusion was the most frequent complication, having occurred due to the complete occlusion of the aneurysm due to thrombi or peripheral emboli caused by mural thrombi. Such data were also verified by Inahara et al.⁵ in a study of 40 cases. Rupture is a rare complication and a literature review revealed a mean incidence of 2.5% (0%-16%), limb amputation being close to 100%.¹² Illig et al.³, in a review study, reported the occurrence of complications during a period of 41 years. Rupture was only found in 2.1% of cases. We found a mean incidence of 2.92% (0%-16%) in a review of the period from 1953 to 2003 (Table 1).

Table 1 - Review on ruptured popliteal artery aneurysm using MEDLINE and Lilacs as databases from 1953 to 2003

Year Reference PAA Rupture %

1953 Gifford et al.¹¹ 100 16 16%

1962 Friesen et al.¹³ 73 11 15.07%

1965 Edmunds et al.¹⁴ 98 3 3.06%

1966 Baird et al.¹⁵ 51 4 7.84%

1970 Wychulis et al.¹⁶ 233 6 2.58%

1971 Evans et al.¹⁰ 56 4 7.14%

1974 Buda et al.¹⁷ 86 5 5.81%

1974 Gaylis¹⁸ 55 2 3.64%

1976 Towne et al.⁴ 119 2 1.68%

1977 Alpert et al.¹⁹ 64 1 1.56%

1978 Inahara & Toledo⁵ 40 1 2.50%

1981 Vermillion et al.²⁰ 147 4 2.72%

1981 Szilagyi et al.²¹ 87 0 0%

1983 Graham et al.²² 52 2 3.85%

1983 Whitehouse et al.⁸ 88 0 0%

1983 Reilly et al.²³ 244 0 0%

1984 Kauffman et al.¹² 37 4 10.81%

1985 Downing et al.²⁴ 62 4 6.45%

1986 Raptis et al.²⁵ 61 0 0%

1986 Melliere et al.²⁶ 77 0 0%

1986 Anton et al.²⁷ 160 0 0%

1987 Bonamigo & Frankini²⁸ 38 5 3.88%

1987 Englund et al.²⁹ 103 4 2.11%

1987 Schellack et al.³⁰ 95 2 0%

1989 Farina et al.³¹ 50 0 0%

1989 Cole et al.³² 59 0 0%

1991 Shortell et al.³³ 51 0 1.72%

1991 Halliday et al.³⁴ 58 1 4.23%

1991 Dawson et al.³⁵ 71 3 2.38%

1993 Roggo et al.³⁶ 252 6 0%

1993 Ramesh et al.³⁷ 44 0 0%

1994 Lowell et al.³⁸ 161 0 0.5%

1994 Varga et al.³⁹ 200 1 0%

1994 Carpenter et al.⁴⁰ 54 0 2.13%

1996 Vieira⁴² 13 1 6.25%

1996 Miranda Jr⁴³ 32 2 13.16%

1997 Sie et al.⁶ 124 6 4.84%

1998 Razuk Filho et al.⁴⁴ 28 2 7.14%

1999 Moriya et al.⁴⁵ 24 0 0%

1998 Illig et al.³ 1 1 100%

1998 Hopton et al.⁴⁶ 1 1 100%

1998 Davidovic et al.⁷ 76 4 5.26%

1999 Timi et al.⁴⁷ 42 0 0%

2000 Ihlberg et al.⁴⁸ 1 1 100%

2001 Irace et al.⁴⁹ 75 2 2.67%

2001 Safar & Cina⁵⁰ 1 1 100%

2002 Kauffman & Puech-Leão⁹ * 105 1 0.95%

2002 Galland & Magee⁵¹ 92 0 0%

2002 Dorigo et al.⁵² 109 3 2.75%

2002 Matarazzo et al.⁵³ 27 1 3.70%

2003 Harder et al.¹ 36 0 0%

2003 Canbaz et al.⁵⁴ 2 1 50%

Total 4109 120 2.92%

1996 Vieira⁴² 13 1 6.25%

Although the clinical manifestation is not specific, rupture must be suspected in case of an elderly patient, male, with signs and symptoms of atherosclerosis associated to unspecific pain and edema in the popliteal region.³

Therefore, facing the high incidence of complications with imminent risk of affected limb loss, most authors have defended the elective surgical treatment of popliteal aneurysms, even when they are asymptomatic.⁹ Rupture, although rare, is a complication with a high index of amputations, whether it is primary or secondary to a non-revascularization of the ischemic area in the immediate postoperative period and should always be considered in cases of painful tumor of the popliteal fossa.

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