Case reports
Aneurysm of Lateral Circumflex Femoral Artery in Association with Multiple Atherosclerotic Aneurysms M . J . R . L a n c a s h i r e , M B , F R C S , R.B. G a l l a n d , M D , F R C S , Reading, England
Femoral aneurysms are uncommon and are frequently associated with other aneurysms, particularly those of the aorta and popliteal arteries. Other peripheral aneurysms are even more rare. As far as we are aware, only one aneurysm of the lateral circumflex artery has been previously described. We describe such an aneurysm in association with a common femoral aneurysm on the same side, an abdominal aortic aneurysm and an lilac aneurysm on the contralateral side. (Ann Vasc Surg 1992;6:289-291). KEY WORDS:
Aneurysm; lateral circumflex femoral artery.
CASE REPORT A 64-year-old man was referred with a rapidly enlarging swelling in his left groin. He was an ex-smoker, but had no previous history of myocardial infarction, angina, transient ischemic attacks or strokes. He did not suffer from intermittent claudication. In the past he had had a laminectomy for a prolapsed intervertebral disc, and a bladder neck incision complicated by a deep venous thrombosis. He was taking Verapamil for previously diagnosed hypertension. There was no relevant family history and no history of trauma. Examination revealed him to be normotensive, with no carotid bruits. There were no cardiac murmurs and an echocardiogram was normal. Abdominal examination was unremarkable, and palpation of his left groin revealed a 5 cm by 6 cm pulsatile swelling just below the inguinal ligament. The right femoral artery was enlarged, but there were no palpable popliteal aneurysms. Routine radiology and hematology, including erythro-
From the Department of Surgery, Royal Berkshire Hospital, Reading, England. Reprint requests: Mr. R.B. GalIand, Consultant Surgeon, Royal Berkshire Hospital, London Road, Reading, England.
cyte sedimentation rate, were normal. Ultrasound confirmed a left femoral aneurysm and also demonstrated a small abdominal aortic aneurysm. An intravenous digital subtraction arteriogram (IV DSA) showed an ectatic aorta with two small saccular aneurysms, one on the right side just above the bifurcation, and the other on the left below the renal artery. The right common femoral artery was ectatic, but on the left there was a common femoral aneurysm. Below and lateral to the femoral aneurysm, was a second, larger aneurysm (Fig. 1). No popliteal aneurysm was seen. Conventional arteriography confirmed that the second aneurysm was arising from the profunda femoris artery. At operation the lower aorta was considerably inflamed with the right ureter densely adherent to it, just posterior to the thin walled saccular aneurysm shown on the IV DSA. The right common iliac artery was also aneurysmal and the surrounding tissues were thickened and fibrous (subsequent culture of a biopsy of this area revealed no evidence of bacterial growth). The left groin was then exposed and the two aneurysms dissected out fully. The left common femoral aneurysm extended from the inguinal ligament, to the femoral bifurcation. The second aneurysm was found to arise from the lateral circumflex femoral artery (Fig. 2). The fight common femoral artery was slightly ectatic. The aneurysmat aorta was resected and bypassed with
289
290
ANEUR YSM OF LATERAL CIRCUMFLEX FEMORAL ARTERY
a
ANNALS OF VASCULAR SURGERY
b
Fig. 1. Intravenous digital subtraction arteriogram as described in text. (a) Aorta and iliac arteries. (b) External iliac and femoral arteries.
a 22 mm by 11 mm soft woven Dacron graft. The left lateral circumflex femoral aneurysm was excised with preservation of the profunda femoris artery. The left common femoral aneurysm was ligated at the inguinal ligament and then excised down to the bifurcation. The left limb of the graft was then anastomosed end-to-end to the common femoral bifurcation. On the right the graft was anastomosed end-to-side to the common femoral artery. Following this he made an uneventful recovery and was discharged home. He remains well one year later.
DISCUSSION F e m o r a l a n e u r y s m s are u n c o m m o n [1]. The majority o c c u r in elderly men and involve the c o m m o n femoral artery. H a l f of these a n e u r y s m s end before the c o m m o n femoral bifurcation and half extend into the p r o f u n d a femoris origin [2]. Isolated aneur y s m s o f the p r o f u n d a femoris artery account for less than 1% o f femoral a n e u r y s m s [1,3]. O t h e r a n e u r y s m s in this area are exceedingly rare. Most femoral artery a n e u r y s m s are atherosclerotic. H o w -
ever, false a n e u r y s m s , following previous reconstruction or t r a u m a are not u n c o m m o n . In the a b s e n c e of any o t h e r cause the p r e s u m e d etiology for patients under our care remains atherosclerotic. Femoral a n e u r y s m s are frequently bilateral (5070%) and are often associated with other a n e u r y s m s (50-85% with abdominal aortic a n e u r y s m s and 2545% with popliteal a n e u r y s m s ) [1-3]. The majority o f femoral a n e u r y s m s are a s y m p t o matic, being d i s c o v e r e d incidentally at routine examination, or during the investigation of other ane u r y s m s [1,2]. T h e y can give rise to s y m p t o m s due to nerve or venous c o m p r e s s i o n and can be painful if they enlarge quickly. Rupture is rare, the main complications being acute or chronic thrombosis (with an incidence of 3-32% at presentation) [1,2]. In addition claudication can precede the diagnosis of femoral a n e u r y s m , though this is frequently due to coexisting atherosclerotic occlusion [1]. It is widely a c c e p t e d that all but the very small femoral a n e u r y s m s , or those occurring in very unfit patients, should be excised and grafted. It has been
VOLUME 6 No 3 - 1992
A N E U R YSM OF LA TERAL CIRCUMFLEX FEMORAL A R T E R Y
291
The lateral circumflex femoral artery may be a branch of the profunda or may have a c o m m o n origin with the profunda at the bifurcation o f the c o m m o n femoral artery. A n e u r y s m s of the lateral circumflex artery are very rare. As far as we are aware, there is only one previous report of an isolated aneurysm, and this had ruptured on presentation. As in our case the lateral circumflex femoral artery was ligated without adverse effects. Providing that ligation can be achieved without compromising the profunda femoris artery, then ligation and resection is all that is likely to be needed to deal with these aneurysms.
Fig. 2. Operative photograph of left groin, taken from left side. (A) Common femoral aneurysm, (B) lateral circumflex femoral aneurysm, dissected free from its bed and rotated to the patient's right. Sling (C) is around main profunda femoris artery.
suggested that priority should be given to revascularization of the profunda femoris rather than the superficial femoral artery [2]. A successful clinical outcome is achieved for most asymptomatic aneurysms. H o w e v e r , in the presence of complications a satisfactory result is obtained in only about half of those patients operated upon [1,2].
mmm
REFERENCES 1. GRAHAM LM, ZELENOCK GB, WHITEHOUSE WM, et al. Clinical significance of arteriosclerotic femoral artery aneurysms. Arch Surg 1980;115:502-507. 2. CUTLER BS, DARLING RC. Surgical management of arteriosclerotic femoral aneurysms. Surgery 1973;74:764-773. 3. PAPPAS G, JANES JM, BERNATZ PE, SCHIRGER A. Femoral aneurysms. Review of surgical management. JAMA 1964 ;190:489-494. 4. QUERAL LA, FLINN WR, YAO JST, BERGAN JJ. Management of peripheral arterial aneurysms. Surg Clin North Am 1979;59:693-706. 5. FELDMAN AJ, BERGUER R. Rupture of isolated atherosclerotic aneurysm of lateral femoral circumflex artery. Surge~, 1981 ;90:914--916.
Aneurysm of Lateral Circumflex Femoral Artery in Association with Multiple Atherosclerotic Aneurysms M . J . R . L a n c a s h i r e , M B , F R C S , R.B. G a l l a n d , M D , F R C S , Reading, England
Femoral aneurysms are uncommon and are frequently associated with other aneurysms, particularly those of the aorta and popliteal arteries. Other peripheral aneurysms are even more rare. As far as we are aware, only one aneurysm of the lateral circumflex artery has been previously described. We describe such an aneurysm in association with a common femoral aneurysm on the same side, an abdominal aortic aneurysm and an lilac aneurysm on the contralateral side. (Ann Vasc Surg 1992;6:289-291). KEY WORDS:
Aneurysm; lateral circumflex femoral artery.
CASE REPORT A 64-year-old man was referred with a rapidly enlarging swelling in his left groin. He was an ex-smoker, but had no previous history of myocardial infarction, angina, transient ischemic attacks or strokes. He did not suffer from intermittent claudication. In the past he had had a laminectomy for a prolapsed intervertebral disc, and a bladder neck incision complicated by a deep venous thrombosis. He was taking Verapamil for previously diagnosed hypertension. There was no relevant family history and no history of trauma. Examination revealed him to be normotensive, with no carotid bruits. There were no cardiac murmurs and an echocardiogram was normal. Abdominal examination was unremarkable, and palpation of his left groin revealed a 5 cm by 6 cm pulsatile swelling just below the inguinal ligament. The right femoral artery was enlarged, but there were no palpable popliteal aneurysms. Routine radiology and hematology, including erythro-
From the Department of Surgery, Royal Berkshire Hospital, Reading, England. Reprint requests: Mr. R.B. GalIand, Consultant Surgeon, Royal Berkshire Hospital, London Road, Reading, England.
cyte sedimentation rate, were normal. Ultrasound confirmed a left femoral aneurysm and also demonstrated a small abdominal aortic aneurysm. An intravenous digital subtraction arteriogram (IV DSA) showed an ectatic aorta with two small saccular aneurysms, one on the right side just above the bifurcation, and the other on the left below the renal artery. The right common femoral artery was ectatic, but on the left there was a common femoral aneurysm. Below and lateral to the femoral aneurysm, was a second, larger aneurysm (Fig. 1). No popliteal aneurysm was seen. Conventional arteriography confirmed that the second aneurysm was arising from the profunda femoris artery. At operation the lower aorta was considerably inflamed with the right ureter densely adherent to it, just posterior to the thin walled saccular aneurysm shown on the IV DSA. The right common iliac artery was also aneurysmal and the surrounding tissues were thickened and fibrous (subsequent culture of a biopsy of this area revealed no evidence of bacterial growth). The left groin was then exposed and the two aneurysms dissected out fully. The left common femoral aneurysm extended from the inguinal ligament, to the femoral bifurcation. The second aneurysm was found to arise from the lateral circumflex femoral artery (Fig. 2). The fight common femoral artery was slightly ectatic. The aneurysmat aorta was resected and bypassed with
289
290
ANEUR YSM OF LATERAL CIRCUMFLEX FEMORAL ARTERY
a
ANNALS OF VASCULAR SURGERY
b
Fig. 1. Intravenous digital subtraction arteriogram as described in text. (a) Aorta and iliac arteries. (b) External iliac and femoral arteries.
a 22 mm by 11 mm soft woven Dacron graft. The left lateral circumflex femoral aneurysm was excised with preservation of the profunda femoris artery. The left common femoral aneurysm was ligated at the inguinal ligament and then excised down to the bifurcation. The left limb of the graft was then anastomosed end-to-end to the common femoral bifurcation. On the right the graft was anastomosed end-to-side to the common femoral artery. Following this he made an uneventful recovery and was discharged home. He remains well one year later.
DISCUSSION F e m o r a l a n e u r y s m s are u n c o m m o n [1]. The majority o c c u r in elderly men and involve the c o m m o n femoral artery. H a l f of these a n e u r y s m s end before the c o m m o n femoral bifurcation and half extend into the p r o f u n d a femoris origin [2]. Isolated aneur y s m s o f the p r o f u n d a femoris artery account for less than 1% o f femoral a n e u r y s m s [1,3]. O t h e r a n e u r y s m s in this area are exceedingly rare. Most femoral artery a n e u r y s m s are atherosclerotic. H o w -
ever, false a n e u r y s m s , following previous reconstruction or t r a u m a are not u n c o m m o n . In the a b s e n c e of any o t h e r cause the p r e s u m e d etiology for patients under our care remains atherosclerotic. Femoral a n e u r y s m s are frequently bilateral (5070%) and are often associated with other a n e u r y s m s (50-85% with abdominal aortic a n e u r y s m s and 2545% with popliteal a n e u r y s m s ) [1-3]. The majority o f femoral a n e u r y s m s are a s y m p t o matic, being d i s c o v e r e d incidentally at routine examination, or during the investigation of other ane u r y s m s [1,2]. T h e y can give rise to s y m p t o m s due to nerve or venous c o m p r e s s i o n and can be painful if they enlarge quickly. Rupture is rare, the main complications being acute or chronic thrombosis (with an incidence of 3-32% at presentation) [1,2]. In addition claudication can precede the diagnosis of femoral a n e u r y s m , though this is frequently due to coexisting atherosclerotic occlusion [1]. It is widely a c c e p t e d that all but the very small femoral a n e u r y s m s , or those occurring in very unfit patients, should be excised and grafted. It has been
VOLUME 6 No 3 - 1992
A N E U R YSM OF LA TERAL CIRCUMFLEX FEMORAL A R T E R Y
291
The lateral circumflex femoral artery may be a branch of the profunda or may have a c o m m o n origin with the profunda at the bifurcation o f the c o m m o n femoral artery. A n e u r y s m s of the lateral circumflex artery are very rare. As far as we are aware, there is only one previous report of an isolated aneurysm, and this had ruptured on presentation. As in our case the lateral circumflex femoral artery was ligated without adverse effects. Providing that ligation can be achieved without compromising the profunda femoris artery, then ligation and resection is all that is likely to be needed to deal with these aneurysms.
Fig. 2. Operative photograph of left groin, taken from left side. (A) Common femoral aneurysm, (B) lateral circumflex femoral aneurysm, dissected free from its bed and rotated to the patient's right. Sling (C) is around main profunda femoris artery.
suggested that priority should be given to revascularization of the profunda femoris rather than the superficial femoral artery [2]. A successful clinical outcome is achieved for most asymptomatic aneurysms. H o w e v e r , in the presence of complications a satisfactory result is obtained in only about half of those patients operated upon [1,2].
mmm
REFERENCES 1. GRAHAM LM, ZELENOCK GB, WHITEHOUSE WM, et al. Clinical significance of arteriosclerotic femoral artery aneurysms. Arch Surg 1980;115:502-507. 2. CUTLER BS, DARLING RC. Surgical management of arteriosclerotic femoral aneurysms. Surgery 1973;74:764-773. 3. PAPPAS G, JANES JM, BERNATZ PE, SCHIRGER A. Femoral aneurysms. Review of surgical management. JAMA 1964 ;190:489-494. 4. QUERAL LA, FLINN WR, YAO JST, BERGAN JJ. Management of peripheral arterial aneurysms. Surg Clin North Am 1979;59:693-706. 5. FELDMAN AJ, BERGUER R. Rupture of isolated atherosclerotic aneurysm of lateral femoral circumflex artery. Surge~, 1981 ;90:914--916.
