Case Report : Aneurysm of the most proximal (medial) branch of the Profunda Femoris Artery
Ahmed Elshiekh MBBCH MRCS, Nicholas Matharau BSc MBChB PhD FRCSI FRCS
University Hospital Coventry and Warwickshire
True profunda femoris artery aneurysm (PFAA) is a very rare condition estimated to present only 0.5% of the peripheral aneurysms and 1-2.6% of femoral aneurysms. Although, it is relatively uncommon amongst all femoral artery aneurysms (1-2.6 %) , it is more likely to rupture than other peripheral aneurysms. In this case report we are presenting a very rare case of aneurysm of the most proximal (medial) branch of the Profunda Femoris Artery in an 85 years old male .Successful surgical ligation was performed with no complications related to surgery at two years follow up .
True profunda femoris artery aneurysm (PFAA) is a very rare condition estimated to present only 0.5% of the peripheral aneurysms and 1-2.6% of femoral aneurysms (1). This may be explained by the fact that it lies in a deep anatomical position being deeply impeded in the muscles of the thigh (2).PFAAs are associated with synchronous aneurysms in 65-75% of cases, most frequently in the popliteal artery (3).
The nature of the anatomy of the profunda being deep to the muscles imposes a diagnostic challenge especially in asymptomatic patients. PFAAs could present with symptoms of local venous and nerve compression, which may cause venous congestion distally and local pain. Complications such as distal embolism, limb-threatening ischemia, and rupture are as well occasionally associated with PFAAs. (4)
One of the studies with the largest number of femoral aneurysms published was done in Mayo clinic in USA and included 17 PFAAs in 15 patients. According to this study, the locations of the Aneurysms were found to be as shown in table 1. (1).
Table 1 relation of PFA aneurysm to CFA bifurcation and its location.
In this case report we are presenting a very rare case of aneurysm of the most proximal (medial) branch of the Profunda Femoris Artery. No case reports as to the knowledge of the authors have reported aneurysm of this branch of the profunda femoris artery.
An 85 year old male who presented with left lower limb claudication pain with subsequent US scan showing a thrombosed popliteal artery aneurysm on the left lower limb . Because of the often bilateral nature of these aneurysms an Magnetic Resonance Angiography (MRA) was organised and showed a right-sided aneurysm in a very uncommon site which is the most proximal branch of the profunda femoris artery (the medial branch) (figure 1). Angiography followed confirming the presence of the aneurysm in that very uncommon site (figure 2).The diameter of the aneurysm was noted to be 3 cm. No other Aneurysms other than the previously known left sided popliteal aneurysm were found.
The patient had a past medical history of polymyalgia rheumatica, hypercholesterolemia, Gastro-oesophageal reflux disease, sciatica and hypercholesterolemia. He had previously undergone right hip replacement surgery and a left partial knee replacement.
His regular medications included Simvastatin, Aspirin, Prednisolone, Alendronic acid, Adcal-D3 and Lansoprazole. He was an ex-smoker having stopped smoking 34 years ago and was not known to be diabetic or hypertensive. There was no past medical history of ischemic heart disease, hypercholesterolemia or diabetes.
On examination, he had no abdominal scars, no palpable abdominal aortic aneurysm and his PFA aneurysm was easily palpable in the right proximal thigh.
Figure 1 (left) MRA scan showing aneurysm of first branch of Right PFA.
Figure 2 (right) CT angiography of Right Femoral artery showing aneurysm of the first branch of PFA.
The case was discussed in the vascular surgery Multi-Disciplinary Meeting (MDT) and the patient was counselled about conservative versus operative management and his choice was to proceed with surgery. Elective operation was done in which an oblique right groin incision was used to access the CFA for control and to access PFA aneurysm outflow vessels. CFA, Superficial Femoral Artery (SFA) and 3 PFA branches were dissected out followed by the aneurysm. The superficial femoral vein was found to be densely adherent to, and almost obstructed by the aneurysm itself. The aneurysm was dissected out from the sub-sartorial position with sharp dissection of dense adhesions. A focal area of very thin aneurysm wall and localised blowout was found, then the runoff vessels were dissected out and aneurysm ligated proximally and distally using 6mm nylon tape. The sac was afterwards opened and enclosed thrombus removed. Decompression of Superficial Femoral Vein (SFV) was immediately noted.
Postoperative recovery went well with no evidence of change in perfusion status of the leg or any new symptoms other than a superficial seroma that needed operative drainage with wound left open to heal by secondary intention with application of negative pressure dressing. Two year follow up at outpatient clinic followed with no complications related to the surgery to date.
The rate of spontaneous rupture of profunda femoris artery aneurysm has been reported to be higher than other peripheral artery aneurysms by 30 to 45 % (1, 10).
Open aneurysmal repair remains the most common approach for treatment of femoral artery aneurysms and although endovascular treatment has been reported there is no evidence for it (9).
Criteria for repair has been suggested in 2008by Harbuzariu et al as they suggested that all high-risk patients with PFAA >2 cm should have elective repair (1).Whilst this is a logical and pragmatic risk-stratification based on received wisdom for intervention with peripheral aneurysms, there is no evidence in support of this. Other authors have used a higher threshold for intervention as Igari et al in their five case reports although they admit that this threshold is not evidence based (11). This was largely debated by Lawrence et al as their paper suggested that the threshold for repair of pooled femoral artery aneurysms should be 3.5 cm and that intra-luminal thrombus is an additional indication for elective repair. However, most of the patients included in their study had common femoral artery or superficial femoral artery aneurysms with very little number of patients included who had PFAA. Thus the results should be viewed cautiously in the case of profunda femoris artery aneurysms (5). Furthermore, rupture of 1.5 cm profunda femoral artery aneurysm has been reported (1). So, up to date there is no strong evidence in the literature that supports a threshold level for risk stratification.
Femoral artery pseudoaneurysm has been reported in literature following hip replacement (13). The fact that the patient had previously had hip replacement arouses the possibility of iatrogenic injury. However, on intra-operative examination the aneurysm was found to be a true rather than a false aneurysm making it unlikely.
Furthermore, the patient had never had intravenous access through the right groin. This excludes pseudoaneuryms due to femoral access for endovascular interventions which has been shown to have a higher rate than that of the true aneurysm, possibly due to the large number of interventions taking place with the advancement of the endovascular treatments (6, 7, 8).
Compression of the femoral vein causing deep vein thrombosis or venous congestion and lower limb swelling has been described in the literature (14). In our case although the patient did not present with symptoms of venous compression, the aneurysm was found intraoperatively to significantly compress the superficial femoral artery. Potentially, this could progress to symptomatic venous compression should the aneurysm enlarge in size, a finding which has previously been reported ( 15 ) .
A localised swelling postoperatively was initially thought to be degenerative aneurysymal sac that was tied off operatively. However on re-operation it was found to be a seroma rather than an aneurysmal sac as the collection was found to be superficial to the deep fascia.
Aneurysm of a branch of the profunda femoris artery is a rare entity that could be present in patients with other types of aneurysm. It is relatively uncommon amongst all femoral artery aneurysms (1-2.6 %) but are more likely to rupture than other peripheral aneurysms. Operative management by simple ligation was shown to be safe on both 30 day follow up and up to a two year follow up period.
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