Scand J Thor Cardiovasc Surg 9: 181-182, 1975


Kari Ormstad and Kaare Solheim From the Department of Surgery, Telernark County Hospital, Skien, Norway

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(Submitted for publication November 4, 1974)

Abstracf. Femoral arterial aneurysms are rare, but their existence must be considered in cases of acute ischaemia of the leg or the occurrence of a pulsating swelling in the groin. Surgical intervention is mandatory, and venous autografts should be preferred to synthetic grafts. With adequate therapy, the prognosis is favourable, but the coexistence of multiple aneurysms should always be borne in mind. A successfully treated case of ruptured femoral aneurysm, combined with abdominal aortic aneurysm, is reported.

CASE REPORT A woman aged 75 was admitted to this hospital on January 17, 1974. Ten years previously she had been put on substitutional therapy with L-thyroxin-Na for myxoedema and has been euthyroid since. On the day of admission, while stretching up to reach a high shelf, she suddenly felt a sharp pain in the left groin as if something had bursted and was leaking into the thigh. She fainted and collapsed, but quickly regained consciousness. The summoned physician found that her blood pressure was 50/35 and pulse rate 140lmin. An expanding, tender swelling medially in the upper part of her left thigh was noted, and she was immediately taken to hospital. On admission she was pale, clammy, shivering and obviously suffering from great pain. Examination revealed blood pressure 150ll10, pulse rate 120/min and a bluish, tender, pulsatile swelling the size of half a football medially in the upper part of her left thigh. Peripheral pulses were absent distal to the swelling. In the abdomen, a round, pulsating mass was palpable in the left hypochondrium. The findings were interpreted as a ruptured femoral aneurysm and an intact abdominal aortic aneurysm. After resuscitation, surgical intervention was immediately carried out without further pre-operative investigations. The common femoral artery was exposed first to obtain proximal control. It was found almost normal and pulsating. Distally a huge haematoma of liquid and clotted blood was evacuated. Blood was spurting from a ruptured aneurysm on the superficial femoral artery 10 cm distal to the bifurcation. The aneurysm, 6 x 4 cm in size, was filled with recently formed thrombi. Clamps

were applied proximally and distally to the aneurysm which was left in place. The saphenous vein from the same leg was reversed and used to bypass the aneurysm. A strong pulse was obtained in the venous graft and distal to it. The postoperative course was complicated by wound necrosis, probably due to oedema, insufficient circulation and stasis. During the subsequent revisions, the venous graft could be seen pulsating, covered by only a fibrinous exudate in the depth of the wound. Secondary suture accomplished healing. Peripheral pulses were present, and the foot was pink and warm without oedema. Aortography prior to discharge revealed a tortuous aorta, patent renal arteries, an abdominal aortic aneurysm and open bypass. The patient was informed about the hazard of having an aortic aneurysm, but she refused further surgery.

DISCUSSION Femoral aneurysms are rare, representing 2.5 % of all peripheral aneurysms (Dent et al., 1972). Of all peripheral atherosclerotic aneurysms, 55 % are found in the popliteal region, whereas 3% are located in the thigh (Dent et al., 1972). The distribution of the latter is 80% in the common femoral, 15 % in the superficial femoral and 5 % in the deep femoral artery (Hardy & Eadie, 1972). The deep femoral artery differs from the superficial by its tendency to remain almost free from atheroma, despite extensive involvement of the other arterial segments, and by protection from dilatation by the muscular tunnel formed by the adductor magnus muscle. Since atherosclerosis is a generalised process involving all parts of the arterial tree, it might reasonably be expected that aneurysmatic degeneration would occur in multiple locations in the same patient. Several series from the last 15 years suggest that in 3 6 4 3 % of the patients with one aneurysm distal to the aorta-iliaca, multiple aneurysms are Scand J Thor Cardiovasc Surg 9

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K . Ormstad and K . Solheirn

coexisting (Crawford et al., 1961; Pappas et al., 1964; Bergan et al., 1969; Dent et al., 1972). Jackson (1969) states that in patients with aortic aneurysm, 20% have at least one more aneurysm. Dent et al. (1972) found multiple aneurysms in 3.9% of all patients admitted with any kind of aneurysmatic disease. Among 37 patients with femoral aneurysms, they found 35 patients (95 %) with at least one more aneurysm; 34 patients (92 %) had aneurysms in the aorto-iliac region and 22 patients (59%) had bilateral femoral aneurysms. Jackson (1969) also found that 55 % of femoral aneurysms are bilateral. These reports strongly suggest that multiple aneurysms should always be suspected when one aneurysm is encountered. In the present case, aortic aneurysm and femoral aneurysm coexisted. Angiography is mandatory for the diagnosis. Most aneurysms are asymptomatic and not readily accessible to clinical examination until they rupture or give rise to ischaemia from thrombosis or peripheral e-mbolization. Hardy & Eadie (1972) report seven cases, four of which presented acute claudication and three painful, pulsatile swelling in the groin. Hartung & Schlosser (1970) describe three cases, all of which presented acute ischaemia of the leg. None of these aneurysms were ruptured when the diagnosis was made. Surgical intervention is indicated as soon as a femoral aneurysm is diagnosed. Life-threatening haemorrhage occurs when it ruptures, and thrombosis or embolism may result in ischaemic gangrene and necessitate amputation. Tolstedt et al. (1961) estimate that 66% of these aneurysms will rupture or thrombose if left untreated. Nowadays, most vascular surgeons prefer to ligate the aneurysm at both ends, leave it in situ and

Scand J Thor Cardiovusc Surg 9

bypass it using a reversed autogenous vein graft. Earlier, Dacron grafts were used, even in peripheral vascular surgery, but this practice has been abandoned. Firstly, the risk of infection is considerably greater with synthetic grafts, and secondly, the small Dacron tubes may easily thrombose when used in the lower limbs. Prognosis. Hardy & Eadie (1972): their seven patients were alive and free from peripheral vascular symptoms 5-8 years postoperatively. Conclusion. Patients with femoral aneurysms should undergo vascular surgery as soon as the diagnosis is made. Autogenous vein grafts should be used instead of Dacron grafts. With early and adequate intervention the prognosis is favourable.

REFERENCES Bell, J. W., Radke, H. M. & Tolstedt, G. E. 1961. Late sequela of arteriosclerotic femoral aneurysms. Angiology 12, 601. Bergan, J. J., Kaupp, H. A. & Trippel, 0. H. 1969. Femoral aneurysmectomy, management of the profunda femoris artery. Angiology 20, 249. Bematz, P. E., Janes, J. M., Pappas, G . & Schirger, J. E. 1964. Femoral aneurysms. JAMA 190, 498. Crawford, E. S., DeBakey, M. E., Edwards, W. H. 1961. Peripheral arteriosclerotic aneurysm. J Amer Geriat SOC 9, 1. Dent, Th. L., Emst, C. B., Fry, W. J. & Lindenauer, M. 1972. Multiple arteriosclerotic arterial aneurysms. Arch Surg 105, 338. Eadie, D. G. A. & Hardy, D. G. 1972. Femoral aneurysms. Brir J Surg II, 614. Hartung, H. & Schlosser, V. 1970. Das Femoralarterienaneurysma als Ursache der akuten Extremititenischamie. Bruns’ Beirr Klin Chir 218, 346. Jackson, B. B. 1969. Surgery of acquired vascular disorders. Charles c. Thomas, Springfield, Ill.

Ruptured aneurysm of the superficial femoral artery.

Femoral arterial aneurysms are rare, but their existence must be considered in cases of acute ischaemia of the leg or the occurrence of a pulsating sw...
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