Profunda femoris artery aneurysms: Association with aneurysmal disease and limb ischemia
Article Outline
Objectives
Because there is a paucity of data about management and outcome of true profunda femoris artery aneurysms (PFAAs), we reviewed our 21-year experience with surgical repair of PFAAs.
Methods
Clinical data from the 15 patients who underwent repair between 1985 and 2006 were retrospectively reviewed.
Results
Fifteen men had 17 PFAAs (mean diameter, of 3.4 cm). Three had an acute presentation with rupture (n = 2) or acute limb ischemia (n = 1), one had local tenderness, and 11 were asymptomatic. Sizes of the ruptured PFAAs were 1.5 and 7.5 cm. Eleven patients (73%) had synchronous aneurysms, most frequently in the popliteal artery (n = 7). Three of the asymptomatic patients required an emergency operation because of acute lower extremity ischemia caused by thrombosis of a synchronous popliteal aneurysm (n = 2) or for a ruptured iliac aneurysm (n = 1). Aneurysmectomy with graft interposition between the common femoral and PFA was used in 15 repairs. Ligation alone was used for one aneurysm, and another was treated by partial aneurysmectomy with primary repair. There were no deaths, graft thrombosis, or limb loss at 30 days. At a mean follow-up of 28 months (range, 3 to 108 months), one patient required above knee amputation 2 years after aneurysm ligation, and another patient presented with a recurrent aneurysm. Long-term graft patency was 100%.
Conclusions
PFAAs are rare but often occur with synchronous aneurysms. One-third of patients presented with complications of limb ischemia or rupture caused by their PFAA or synchronous aneurysms. Good-risk patients with a PFAA >2 cm should undergo elective repair. Aneurysmectomy with femoral interposition graft is a durable repair.
Profunda femoris artery aneurysms (PFAAs) are rare and account for only 0.5% of peripheral aneurysms and 1% to 2.6% of femoral aneurysms.1, 2. It has been postulated that aneurysmal change in this location is rare because several muscles cover the PFA and the arterial wall has a rich muscle layer with few elastic fibers.3, 4, 5 The rarity of PFAAs has precluded a definitive study of the true natural history, and the clinical behavior of these aneurysms is estimated by reviewing case reports of the management of patients with a PFAA. In this article we evaluate the results of our >20-year experience with the surgical management of PFAA, with emphasis on the associated aneurysmal disease, intraoperative aspects, and risk of limb ischemia.
Methods
From January 1985 to June 2006, 17 PFAAs in 15 patients were operated on at the Mayo Clinic (Rochester, Minn). Data pertaining to these patients were retrospectively collected and organized according to demographics, preoperative risk factors, clinical and diagnostic evaluation, intraoperative findings and early (≤30 days postoperatively) and long-term outcome. This study was approved by the Mayo Clinic Institutional Review Board.
Inclusion criteria were aneurysmal dilatation of at ≥1.5 times the diameter of the adjacent normal caliber artery, isolated to the PFA and its branches, with or without involvement of the common femoral artery bifurcation. This was based on preoperative imaging and intraoperative findings. Only true aneurysms of the PFA were included; patients with traumatic pseudoaneurysms of the PFA such as after femoral catheterization or orthopedic procedures or patients with pseudoaneurysms after previous revascularization procedures involving the PFA or the common femoral bifurcation were not included.
Results
Demographic data and preoperative risk factors
All treated patients were men, and their mean age was 65 years (range, 17 to 85 years). Comorbidities included a history of smoking in 8 patients (53%), arterial hypertension in 7 (47%), hyperlipidemia in 4 (27%), diabetes mellitus in 2 (14%), coronary artery disease in 3 (20%), and chronic obstructive pulmonary disease in 6 (40%). At least one synchronous aneurysm in another location or a history of repaired aneurysm in another location was noted in 11 patients (74%; Table I). Three of these patients had associated aneurysms in two other locations.
Table I. Associated aneurysms location in the 15 patients with profunda femoris artery aneurysms
| Location | Patients, No. (%) |
|---|---|
| Popliteal | 7 (47) |
| Aortoiliac | 5(33) |
| Common iliac | 2(13) |
| Internal iliac | 1(6) |
Clinical and diagnostic evaluation
Two patients (13%) presented with contained rupture of the PFAA resulting in sudden onset of localized pain. One patient (6%) presented with right groin pain but no rupture. One patient (6%) presented with acute lower extremity ischemia caused by thrombosis of the PFAA in the setting of a chronically occluded ipsilateral superficial femoral artery. The PFAA was asymptomatic in 11 patients (73%); however, two patients presented with acute lower extremity ischemia caused by a thrombosed coexistent ipsilateral popliteal artery aneurysm and one presented with a ruptured common iliac artery aneurysm. Overall, six patients (40%) required an emergency operation. Two PFAAs were discovered incidentally during evaluation for lower extremity claudication. A femoral pulsatile mass was present in 10 patients (66%).
The imaging modalities used in the evaluation of these patients were duplex ultrasonography, angiography, and computed tomography. Location of the 17 PFAAs is summarized in Table II.
Table II. Location of the 17 profunda femoris artery aneurysms
| Location | Aneurysms, No. (%) |
|---|---|
| Profunda femoris artery | |
| First portion | 10(58) |
| Second portion | 2(12) |
| On perforator branch | 1(6) |
| Involving common femoral artery bifurcation | 4(22) |
Thirteen aneurysms (76%) were confined to the PFA, and the other four (22%) were extending to the common femoral artery bifurcation. Ten PFAAs (58%) were located in the initial portion of the PFA, two (12%) were located after the take off of the first perforator branch, and one (6%) was on the second perforator branch of the PFA. Two patients had bilateral PFAAs. The mean diameter of the PFAAs was 3.4 cm (range, 1.5 to 7.5 cm). An ipsilateral occluded superficial femoral artery was associated with eight PFAAs (47%). The ipsilateral lower leg runoff was represented by two vessels for nine aneurysms (53%) and one vessel for eight aneurysms (46%).
Operative details
Five patients had undergone at least one previous operative intervention in the ipsilateral groin for revascularization procedures, but none of these involved the PFA or the common femoral artery bifurcation. Two of these patients had an aortobifemoral bypass for aneurysmal disease involving the aortoiliac arteries and the other three had a revascularization procedure for infrainguinal occlusive disease. Vascular control of the PFA was performed during some of these procedures. A vertical groin incision was performed in all cases. In one patient who had a 7.5-cm PFAA with rupture, a right lower quadrant incision for proximal control was performed. One of the two patients with bilateral PFAAs had simultaneous repair, and the other patient had sequential repair after a 1-year period.
For 15 of the PFAAs (88%), repair was by aneurysmectomy with graft interposition between the common femoral to the PFA (see Fig 1, Fig 2).One patient underwent a partial aneurysmectomy with primary repair of a second perforator branch profunda aneurysm. In another patient, an aneurysm located in the distal part of the PFA was treated by aneurysmectomy and ligation. In five aneurysm repairs (29%), the deep circumflex femoral arteries were reimplanted in the graft. Blood flow to the SFA was preserved if this vessel was patent. A synthetic graft (Dacron, DuPont, Wilmington, Del) was used in 14 PFAA repairs, and a reversed graft of great saphenous vein was used in the repair of a mycotic aneurysm after bacterial endocarditis.
Fig 1.
An intraoperative photo shows a 4.2-cm profunda femoris artery aneurysm.
Fig 2.
Intraoperative photo shows the repair of the profunda femoris artery aneurysm with Dacron interposition grafts.
Three patients had concomitant repair of a popliteal aneurysm during the same operation, two for acute thrombosis and one had an elective repair. Other single associated procedures were an aortobiiliac graft for a concomitant 4-cm right common iliac aneurysm, an aortobifemoral graft for an associated leaking 7-cm right common iliac aneurysm, and a femorofemoral crossover bypass for an associated occluded left external iliac artery.
The proximal clamp site was the common femoral artery in eight aneurysm repairs (44%), the proximal PFA in three (17%), and the external iliac artery in six (35%). The PFA distal to the aneurysm was controlled from within the aneurysmal sac with balloon occlusion catheters in 10 repairs (59%).
The mean operative time was 5 hours 24 minutes ± 2 hours 15 minutes. The average transfusion requirement was 700 mL of packed red blood cells.
The aneurysm pathology showed atherosclerotic changes in 14 of the resected aneurysms (82%). One aneurysm showed changes of medial fibromuscular dysplasia, and another aneurysm in a young patient with bacterial endocarditis showed inflammatory changes. A microbiologic examination was performed in only two cases, and both results were negative.
Early postoperative results
This series had 0% mortality, graft thrombosis, and limb loss ≤30 days after the operation. In-hospital mortality was 5% (1 of 15). This occurred in a patient who required a concomitant aortobifemoral bypass for a leaking right common iliac aneurysm. He had a complicated postoperative course with cholangitis, catheter sepsis, renal failure, and a prolonged requirement for ventilatory support. He died 3.5 months after his operation while still in intensive care unit as a result of ongoing sepsis. Transient renal failure and compartment syndrome developed postoperatively in another patient who presented with acute lower extremity ischemia as a result of a thrombosed PFAA and required emergency fasciotomies. Other single complications in the early postoperative period were a groin wound hematoma that was managed conservatively, a lymphatic leak in the groin requiring re-exploration, and a groin wound superficial abscess requiring incision and drainage.
Long-term results
The mean follow-up was 28 months (range, 3 to 108 months). Patients were seen for clinical examination and duplex ultrasound (DUS) imaging 3 months from the operation and every 6 months thereafter for 2 years. After that, once a year DUS imaging was performed.
Only one above knee amputation was recorded 2 years after the patient presented initially with a ruptured PFAA treated with aneurysmectomy and ligation. Another patient presented with a left thigh aneurysm 5 years after his second perforator branch profunda aneurysm was treated by partial aneurysmectomy with primary repair. This recurrent aneurysm was successfully embolized and no new PFAA was identified during follow-up in this patient. A groin seroma in a third patient was managed conservatively. No graft thrombosis was recorded during long-term follow up. Five of the 15 patients were still alive at the time of this review.
Discussion
All patients in our series were men. Reviews of already published cases indicate that men seem to have PFAAs more frequently than women.6 Previous studies reviewing published PFAA cases suggested that 45% to 81% of these patients have other aneurysms,1, 2, 7, 8, 9 and 74% of patients in this present series had at least one synchronous aneurysm. These associated aneurysms can occur in the aortoiliac or especially the femoropopliteal segments, as 47% of patients had a synchronous or a history of repair of popliteal artery aneurysms. Because of this finding, we recommend that all patients found to have a PFAA be screened for aortoiliac and popliteal aneurysms with ultrasound imaging.
Our series was too small to draw any definitive conclusions about differences in behavior related to the proximal extent of the aneurysm. It is more difficult to identify aneurysms confined to the PFA on physical examination than those extending to the common femoral artery, theoretically allowing these PFAAs to become larger and potentially rupture. With the advent of computed tomography angiograms, it will likely be easier to identify isolated PFAAs.
All patients in our series underwent repair, and we did not have a separate group managed conservatively. As a result, an evidence-based recommendation for the size of an asymptomatic PFAA that should undergo repair could not be made. We think that a reasonable recommendation for repair of a PFAA is a 2-cm diameter. Although rupture occurred in a 1.5-cm aneurysm, by the same reasoning, 8% to 10% of abdominal aortic aneurysms <5.5 cm can rupture, yet we do not recommend repairing all abdominal aortic aneurysms.
Many published case reports were associated with rupture, and the reviews of these cases suggested that PFAAs have a higher spontaneous rupture rate of 30% to 45% than other peripheral aneurysms.6, 9, 10, 11, 12 The incidence of PFAA rupture in our series was 13%. This is similar to the 10% to 14% rates quoted for common femoral artery aneurysms.13, 14, 15 Of interest was that the two patients who presented with ruptured aneurysm were at the two extremes for the diameter of the deep femoral artery aneurysm, with 1.5 and 7.5 cm, respectively.
Although cited in the literature as potential risks associated with PFAAs, none of our patients had signs suggesting atheroembolism or deep venous compression.
Acute limb ischemia may be caused be a complication of the PFAA itself (rupture or thrombosis) or related to the coexistent vascular pathology. Surgical decisions need to be individualized by the cause of the ischemia, intraoperative findings, and the patient’s overall condition. We elected to repair the PFAA in all patients in this series, even in those who presented with an emergency condition unrelated to the PFAA itself. Although this increased the operative time, the unpredictable behavior of the PFAA and the significant morbidity induced by a complicated PFAA justifies this approach. Except for the patient with a leaking right common iliac artery aneurysm who had a complicated postoperative course, the other patients tolerated their procedures with minimal postoperative morbidity and no mortality.
Proximal control in most patients can be achieved through a groin incision. However, aneurysm size, rupture, or existing scarring may require a retroperitoneal approach for control of the external iliac artery, especially in emergency cases.
In earlier published case reports, ligation of the aneurysm was suggested as a possible treatment, especially for aneurysms located at the distal part of the PFA.16 Although not supported by data, most authors now recommend revascularization of the distal profunda after aneurysmectomy, especially in the setting of an occluded femoropopliteal segment. An ipsilateral occluded SFA was present in 47% of the aneurysms in our series, and distal profunda revascularization with graft interposition was used in 88% of repairs. Preserving adequate blood flow to the thigh and to important collateral circulation was one of the main goals of the operation; in five repairs, this required reimplantation of deep circumflex femoral vessels in the graft. This goal should be adapted to patient’s ability to tolerate a potentially longer procedure and to the existing associated occlusive pathology in the lower extremity.
Embolization may be an option when the PFAA is located on the distal portion or on the branches of the PFA, but we would reserve it for patients with a patent superficial femoral artery.
A Dacron graft was used in most patients (82%). In all femoral reconstructions for aneurysms, our practice is to use Dacron, typically 8 or 10 mm in diameter. We have had good results with this graft in the common femoral position, and therefore, we used it for PFAA reconstruction. All the grafts were patent at the time of the last follow-up and no graft infections were noted. Aneurysmectomy and ligation was performed in one patient who presented with rupture; this was the only patient who required an above knee amputation, which was done 2 years later, pointing again to the necessity of revascularization every time when feasible. The only patient in whom partial aneurysmectomy with primary repair was performed presented with a recurrent thigh aneurysm 5 years later, which was successfully embolized.
Conclusion
PFAA are rare, but often occur with synchronous aneurysms, and one-third present with complications of limb ischemia or rupture from the PFAA or synchronous aneurysms. The 13% incidence of rupture on presentation in this series was lower than the 30% to 45% suggested by articles reviewing published case presentations with PFAA. Because size alone may not be an adequate predictor of rupture risk, good-risk patients with PFAA >2 cm should have elective repair. Aneurysmectomy with femoral interposition graft is a durable repair and is recommended instead ligation alone owing to the frequency of concomitant SFA occlusion.
Author contributions
References
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Competition of interest: none.
CME article
PII: S0741-5214(07)01523-6
doi:10.1016/j.jvs.2007.09.040
© 2008 The Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.