True Profunda Femoris Aneurysms" Are They More Dangerous than Other Atherosclerotic Aneurysms of the Femoropopliteal Segment? W.F. Tait, MD, R.K. Vohra, PhD, H.M.H. Carr, FRCS, G . J . L . T h o m s o n , M D , M . G . W a l k e r , C h M , Manchester, England
Three cases of true aneurysms of the profunda femoris artery are reported along with a review of 17 other cases in the literature. These aneurysms are rare and commonly present with rapid enlargement or rupture (9/20), the risk of rupture being higher than those affecting the femoral or popliteal arteries. All patients underwent successful surgical treatment except for one who required amputation. The diagnosis of an aneurysm of the profunda femoris artery must be considered in all patients with a pulsatile swelling in the groin. Surgical treatment is mandatory, and it carries a low mortality as well as a low risk of amputation. (Ann Vasc Surg 1991 ;5:92-95). KEY WORDS:
Aneurysm; profunda femoris artery.
symptom was of intermittent claudication affecting his left calf after walking a distance of about 400 yards. He had previously been referred to the vascular clinic in 1984 when he was found to have bilateral common femoral and bilateral popliteal aneurysms. He subsequently underwent surgical repair of both common femoral and right popliteal aneurysms. Arteriography showed that the left popliteal aneurysm was thrombosed. He had been hypertensive for seven years and t h i s was controlled with Atenolol. The exact nature of the swelling in the right groin was uncertain and an arteriogram was performed. This showed an aneurysm of the proximal portion of the right profunda femoris artery measuring 3 cm in diameter and a further aneurysm arising more distally in the right profunda femoris artery measuring 2.2 cm (Fig. 1). The right superficial femoral artery was occluded. In January 1989 the profunda femoris artery aneurysms were resected and continuity established using a Dacron graft. The patient is currently well and his graft remains patent:
We report three cases of atherosclerotic aneurysms of the profunda femoris artery and have identified a further 28 cases from the world literature [1-21]. True aneurysms affecting this artery are rare and we have studied their clinical features and risk of complications in comparison to aneurysms of the common femoral artery and the popliteal artery,
CASE REPORTS
Patient No. 1 A 76-year-old man was noted to have an asymptomatic swelling in his right groin at the vascular outpatient clinic in August 1988. He had suffered from peripheral vascular disease for several years and at this examination his only
Patient No. 2
From the Department of Vascular Surgery, Manchester Royal Infirmary, Manchester, England. Reprint requests: Mr. W.F. Tait, Senior Registrar, Department of Vascular Surgery, Manchester Royal Infirmary, Manchester MI3 9WL, England.
A 69-year-old man who had been admitted in May 1989 with a right hemiplegia was found to have an asymptomatic swelling in his right groin. He was hypertensive at 220/140 mmHg. In 1986 he had undergone emergency 92
VOLUME 5
No
1-
1991
T R U E P R O F U N D A PT~MORLS A N E U R Y S M S
93
I
Fig. 1, Arteriogram showing two profunda femoris artery aneurysms in Patient 1. repair of a ruptured aneurysm of his left superficial femoral artery. While making a good recovery from his stroke, the swelling in his fight groin increased in size dramatically. An arteriogram showed a 6 x 8 cm aneurysm of his right profunda femoris artery (Fig. 2) in addition to small aneurysms of aorta, right internal iliac artery, and right popliteal artery. The right superficial femoral artery was patent. The profunda femofis artery aneurysm was resected and ligated but no reconstruction was carried out. He remains well three months postoperatively.
Patient No. 3
A 75-year-old man was admitted in March 1990 with an acutely ischemic left leg. Clinical examination revealed a large aneurysm in the left groin. He had previously presented in 1979 with bilateral popliteal aneurysms which had required surgical treatment. In his left leg the popliteal aneurysm had been ligated and the popliteal artery reconstructed using a saphenous vein graft. On this occasion an arteriogram showed a 6 • 4 cm aneurysm of the proximal portion of the profunda femoris artery with thrombosis of the superficial femoral artery and the vein
Fig. 2. Subtraction arteriogram showing large profunda femoris artery aneurysm (arrows) in Patient 2. graft (Fig. 3). Surgery was carried out the aneurysm and reconstruction of the artery using a Dacron prosthesis. His cessfully salvaged and he remains well
with resection of profunda femoris left leg was sucto date.
DISCUSSION Atheroscterotic aneurysms of the profunda femoris a r t e r y a r e rare a n d e s t i m a t e d to a c c o u n t f o r 0.5% o f all p e r i p h e r a l a t h e r o s c l e r o t i c a n e u r y s m s [12]. F a l s e a n e u r y s m s o f this a r t e r y a r e m u c h m o r e common and many have been reported after t r a u m a , the m a j o r i t y b e i n g i a t r o g e n i c [22-26]. A l t h o u g h 28 o t h e r c a s e s o f p r o f u n d a f e m o r i s a r t e r y a n e u r y s m s w e r e identified in the l i t e r a t u r e in a d d i t i o n to o u r c a s e s , o n l y in 17 w e r e the d a t a sufficiently d e t a i l e d for a n a l y s i s [1-15]. All w e r e d u e to a t h e r o s c [ e r o s i s . T h e m e a n age o f the g r o u p w a s 65 y e a r s with a p r e p o n d e r a n c e o f m e n o v e r w o m e n . T h e s e a n e u r y s m s w e r e often a s s o c i a t e d with o t h e r p e r i p h e r a l a n e u r y s m s : five p a t i e n t s h a v -
94
ANNALS OF
TRUE PROFUNDA FEMOR1S A N E U R YSMS
VASCULARSURGERY
CFA
PA
FA
}
Fig. 4. Most common modes of presentation of aneurysms affecting the femoropopliteal segment. There were 262 cases of common femoral artery, 19 profunda femoris artery and 270 popliteal artery aneurysms. A = asymptomatic or minor local symptoms, R = rupture or rapid enlargement, TE = thrombosis or thromboembolism.
Fig. 3. Arteriogram showing profunda femoris artery aneurysm in Case 3.
ing one other aneurysm and four patients having three or more. Patients were initially seen with rupture in six cases and thromboembolism in two. The remaining 12 cases were asymptomatic atthough in four of these, rapid enlargement had occurred. The outcome of treatment was largely successful, whether by a combination of ligation and resection alone (10/20) or reconstruction (10/20). One patient required a below-knee amputation, and another died 12 days following his operation from a cardiac cause. The greatest difficulty most authors experienced was in diagnosing the condition accurately because the aneurysms were hidden deep in the thigh, the implication being that they remain unsuspected until they have reached such a size that rupture is likely. Ultrasound, computed tomography scanning and arteriography in isolation or in combination may be employed in order to establish the diagnosis. In comparison to profunda femoris artery aneurysms, femoral artery aneurysms are most often asymptomatic and only rarely present with thromboembolism or rupture [16,18,27] (Fig. 4). Their reputation is one of being relatively benign and the
outcome of surgical treatment if required is good. On the other hand, popliteal artery aneurysms have a more sinister reputation with a very high rate of thrombosis or thromboembolism [28-30] (Fig. 4). While rupture is less common, the risk of losing a limb in a patient with a popliteal aneurysm is 20% or higher [28-30]. The true incidence of profunda femoris artery aneurysm is undoubtedly underestimated. Some cases are likely to have gone undetected because of their hidden location. Nonetheless some conclusions may be reached from those cases we have been able to study. Profunda femoris aneurysms may be asymptomatic, but on presentation about half will have enlarged rapidly or ruptured, t h i s danger being greater than for femoral or popliteal aneurysms. It remains unclear whether the incidence of thromboembolism in profunda femoris artery aneurysms is really so low because this complication is unlikely to affect the viability of the leg unless a superficial femoral artery occlusion is also present. However, it appears that the likelihood of an amputation being required for a profunda femoris artery aneurysm is much less. In conclusion, it is important to consider the diagnosis of a profunda femoris artery aneurysm when dealing with an aneurysm in the groin. The dangers of these aneurysms have been demonstrated as have the beneficial effects of surgery. Operation should therefore be employed in all cases unless a significant contraindication exists.
REFERENCES 1. AMBROSINI A, TARDITO E. Gli aneurismi dell'arteria femorale profunda. Presentazione di due casi. Minerva Chir 1971 ;26:646-652. 2. BANCH1NI E, CAPOCASALE E. Rara sede di aneurismi periferici: aneurismi della a femorale profunda. Astratto da Acta Bio-Medica de l'Atenco-Parmense 1982;53:285-288.
VOLUME 5 NO 1 - 1991
TRUE PROFUNDA FEMORIS ANEUR YSMS
3. BILLIG DM, JORDAN PH, DE BAKEY ME. Arteriosclerotic aneurysm of the profunda femoris m'tery: report of a case with successful surgical repair. Cardiovasc Rex Cent Bull 1968;6:139-141. 4. EASTCOTT HHG. Arterial surgery. London: Pitman, 1969, pp 314-316. 5. FELDMAN AJ, BERGUER R. Rupture of isolated athero sclerotic aneurysms of the lateral femoral circumflex artery. Surgery 1981 ;90:914-916. 6. FERRERO S, CARTIA Q, BELGRANO EA. Su di un caso de aneurisma dell'arteria femoral profunda. Minerva Cardioangiologica 1983:31:469-470. 7. HARDY DG, EAD1E DGA. Femoral aneurysms. BrJ Sz,Te 1972;59:614-616. 8. KARMODY AM, GALLOWAY JMD. Aneurysm of the profunda femoris artery. J R Coll Surg Edin 1972;17:261263. 9. RATTO G, SACCO A, CANEPA G, et al. Atherosclerotic aneurysm of the deep femoral artery. J Cardiovasc Sur~ 1984;25:574-576. 10. SYMES JM, EADIE DG. Solitary arteriosclerotic aneurysm of the profunda femoris artery. J Cardiavasc Surg, 1973;14: 220-222. 11. TARRICO A. Ruptured aneurysm of profunda femoris. N Y State J Med 1980;80:960-962. 12. VALIULIS AP, JOHNSTON KW. Isolated arteriosclerotic aneurysm of the profunda femoris artery. ,I Cardiovasc Sur;, 1980;21:498-500. 13. BJORCK C-G, BERQVIST D, LJUNGNER H, et al. Atherosclerotic aneurysm of the deep femoral artery. Acta Chit Scand 1987;153:137-142. 14. ROSENMAN JM, WYCHE D. True aneurysm of the profunda femoris artery. J Cardiovase Surg 1987;28:701-705, 15. WE1ST JW, MUKHERJEE D, INAHARA T. Ruptured aneurysm of the profunda IEmoris artery. J Vas'~ Sur,g 1986 ;4:406-409. 16. CUTLER BS, DARLING RC. Surgical management of arteriosclerotic femoral aneurysms. Sur~?ery 1973:74:764773. 17. PAPPAS G, JANES JM, BERNATZ PE, et al. Femoral
IWI
18. 19. 20. 21. 22. 23.
24.
25. 26. 27. 28. 29. 30.
95
aneurysms. Review of surgical management. JAMA 1964; 190:97-101. GRAHAM LM, ZELENOCK GB, WHITEHOUSE WM, et al. Clinical significance of arteriosclerotic femoral artery aneurysms. Arch Sur~ 1980;115:502-507. BAIRD RJ, GURRY JF, KELLAM J, et al. Arteriosclerotic femoral artery aneurysms. Can Med Assoc J 1977;117: 23061307. DENT TL, H N D E N A U E R SM, ERNST CB, et al. Multiple arteriosclerotic arterial aneurysms. Arch Surg 1972;105: 338-344. WELSH P. Aneurysms of the extremities. J Cardiovasc Surg 1973;17:305-306. WISHART GC, CUSCH1ERI RJ, ROBERTSON DAR, et al. Pseudo-aneurysm of the profunda femoris artery following a stab wound. Br J Surg 1987;74:804. BARNES DI, BROUDE HB. False aneurysm of the profunda femoris artery complicating fracture of the femoral shaft and treated by transcatheter embolization. S Afr M e d J 1985:67: 824-826. MACKENZIE DB, GROBBELAAR N J, VAN RENSBERG MN. False aneurysm of the profunda femoris artery as a late complication of upper femoral episiotomy. S Aft J Sur~,, 1983;2/:255-262. SCLAFAN! SJA, SHAFTAN GW. Transcatheter treatment of injuries to profunda femoris artery. A JR 1982;138:463466. QUERAL LA, FLINN WR, YAO JST, et al. Management of peripheral arterial aneurysms. Surg Clin N Am 1979;59: 693-706. ADISESHIAH M, BAILEY DA. Aneurysms of the femoral artery. Br J Surg 1977;64:174-176. GUVENKIK L, BLOOR K, CHARLESWORTH D. Popliteal aneurysm, sinister harbinger of sudden catastrophe. B r J Surg 1980:67:294-296. VERMILION BD, KIMMINS SA, PACE WG, et al. A review of 147 popliteal a~eurysms with long-term follow-up. Surgew 1981:90:1009-1014. SCHELLACK J, SMITH RB, PERDUE GD. Nonoperative management of selected popliteal aneurysms. Arch Surg 1987:122:372-375.
Three cases of true aneurysms of the profunda femoris artery are reported along with a review of 17 other cases in the literature. These aneurysms are rare and commonly present with rapid enlargement or rupture (9/20), the risk of rupture being higher than those affecting the femoral or popliteal arteries. All patients underwent successful surgical treatment except for one who required amputation. The diagnosis of an aneurysm of the profunda femoris artery must be considered in all patients with a pulsatile swelling in the groin. Surgical treatment is mandatory, and it carries a low mortality as well as a low risk of amputation. (Ann Vasc Surg 1991 ;5:92-95). KEY WORDS:
Aneurysm; profunda femoris artery.
symptom was of intermittent claudication affecting his left calf after walking a distance of about 400 yards. He had previously been referred to the vascular clinic in 1984 when he was found to have bilateral common femoral and bilateral popliteal aneurysms. He subsequently underwent surgical repair of both common femoral and right popliteal aneurysms. Arteriography showed that the left popliteal aneurysm was thrombosed. He had been hypertensive for seven years and t h i s was controlled with Atenolol. The exact nature of the swelling in the right groin was uncertain and an arteriogram was performed. This showed an aneurysm of the proximal portion of the right profunda femoris artery measuring 3 cm in diameter and a further aneurysm arising more distally in the right profunda femoris artery measuring 2.2 cm (Fig. 1). The right superficial femoral artery was occluded. In January 1989 the profunda femoris artery aneurysms were resected and continuity established using a Dacron graft. The patient is currently well and his graft remains patent:
We report three cases of atherosclerotic aneurysms of the profunda femoris artery and have identified a further 28 cases from the world literature [1-21]. True aneurysms affecting this artery are rare and we have studied their clinical features and risk of complications in comparison to aneurysms of the common femoral artery and the popliteal artery,
CASE REPORTS
Patient No. 1 A 76-year-old man was noted to have an asymptomatic swelling in his right groin at the vascular outpatient clinic in August 1988. He had suffered from peripheral vascular disease for several years and at this examination his only
Patient No. 2
From the Department of Vascular Surgery, Manchester Royal Infirmary, Manchester, England. Reprint requests: Mr. W.F. Tait, Senior Registrar, Department of Vascular Surgery, Manchester Royal Infirmary, Manchester MI3 9WL, England.
A 69-year-old man who had been admitted in May 1989 with a right hemiplegia was found to have an asymptomatic swelling in his right groin. He was hypertensive at 220/140 mmHg. In 1986 he had undergone emergency 92
VOLUME 5
No
1-
1991
T R U E P R O F U N D A PT~MORLS A N E U R Y S M S
93
I
Fig. 1, Arteriogram showing two profunda femoris artery aneurysms in Patient 1. repair of a ruptured aneurysm of his left superficial femoral artery. While making a good recovery from his stroke, the swelling in his fight groin increased in size dramatically. An arteriogram showed a 6 x 8 cm aneurysm of his right profunda femoris artery (Fig. 2) in addition to small aneurysms of aorta, right internal iliac artery, and right popliteal artery. The right superficial femoral artery was patent. The profunda femofis artery aneurysm was resected and ligated but no reconstruction was carried out. He remains well three months postoperatively.
Patient No. 3
A 75-year-old man was admitted in March 1990 with an acutely ischemic left leg. Clinical examination revealed a large aneurysm in the left groin. He had previously presented in 1979 with bilateral popliteal aneurysms which had required surgical treatment. In his left leg the popliteal aneurysm had been ligated and the popliteal artery reconstructed using a saphenous vein graft. On this occasion an arteriogram showed a 6 • 4 cm aneurysm of the proximal portion of the profunda femoris artery with thrombosis of the superficial femoral artery and the vein
Fig. 2. Subtraction arteriogram showing large profunda femoris artery aneurysm (arrows) in Patient 2. graft (Fig. 3). Surgery was carried out the aneurysm and reconstruction of the artery using a Dacron prosthesis. His cessfully salvaged and he remains well
with resection of profunda femoris left leg was sucto date.
DISCUSSION Atheroscterotic aneurysms of the profunda femoris a r t e r y a r e rare a n d e s t i m a t e d to a c c o u n t f o r 0.5% o f all p e r i p h e r a l a t h e r o s c l e r o t i c a n e u r y s m s [12]. F a l s e a n e u r y s m s o f this a r t e r y a r e m u c h m o r e common and many have been reported after t r a u m a , the m a j o r i t y b e i n g i a t r o g e n i c [22-26]. A l t h o u g h 28 o t h e r c a s e s o f p r o f u n d a f e m o r i s a r t e r y a n e u r y s m s w e r e identified in the l i t e r a t u r e in a d d i t i o n to o u r c a s e s , o n l y in 17 w e r e the d a t a sufficiently d e t a i l e d for a n a l y s i s [1-15]. All w e r e d u e to a t h e r o s c [ e r o s i s . T h e m e a n age o f the g r o u p w a s 65 y e a r s with a p r e p o n d e r a n c e o f m e n o v e r w o m e n . T h e s e a n e u r y s m s w e r e often a s s o c i a t e d with o t h e r p e r i p h e r a l a n e u r y s m s : five p a t i e n t s h a v -
94
ANNALS OF
TRUE PROFUNDA FEMOR1S A N E U R YSMS
VASCULARSURGERY
CFA
PA
FA
}
Fig. 4. Most common modes of presentation of aneurysms affecting the femoropopliteal segment. There were 262 cases of common femoral artery, 19 profunda femoris artery and 270 popliteal artery aneurysms. A = asymptomatic or minor local symptoms, R = rupture or rapid enlargement, TE = thrombosis or thromboembolism.
Fig. 3. Arteriogram showing profunda femoris artery aneurysm in Case 3.
ing one other aneurysm and four patients having three or more. Patients were initially seen with rupture in six cases and thromboembolism in two. The remaining 12 cases were asymptomatic atthough in four of these, rapid enlargement had occurred. The outcome of treatment was largely successful, whether by a combination of ligation and resection alone (10/20) or reconstruction (10/20). One patient required a below-knee amputation, and another died 12 days following his operation from a cardiac cause. The greatest difficulty most authors experienced was in diagnosing the condition accurately because the aneurysms were hidden deep in the thigh, the implication being that they remain unsuspected until they have reached such a size that rupture is likely. Ultrasound, computed tomography scanning and arteriography in isolation or in combination may be employed in order to establish the diagnosis. In comparison to profunda femoris artery aneurysms, femoral artery aneurysms are most often asymptomatic and only rarely present with thromboembolism or rupture [16,18,27] (Fig. 4). Their reputation is one of being relatively benign and the
outcome of surgical treatment if required is good. On the other hand, popliteal artery aneurysms have a more sinister reputation with a very high rate of thrombosis or thromboembolism [28-30] (Fig. 4). While rupture is less common, the risk of losing a limb in a patient with a popliteal aneurysm is 20% or higher [28-30]. The true incidence of profunda femoris artery aneurysm is undoubtedly underestimated. Some cases are likely to have gone undetected because of their hidden location. Nonetheless some conclusions may be reached from those cases we have been able to study. Profunda femoris aneurysms may be asymptomatic, but on presentation about half will have enlarged rapidly or ruptured, t h i s danger being greater than for femoral or popliteal aneurysms. It remains unclear whether the incidence of thromboembolism in profunda femoris artery aneurysms is really so low because this complication is unlikely to affect the viability of the leg unless a superficial femoral artery occlusion is also present. However, it appears that the likelihood of an amputation being required for a profunda femoris artery aneurysm is much less. In conclusion, it is important to consider the diagnosis of a profunda femoris artery aneurysm when dealing with an aneurysm in the groin. The dangers of these aneurysms have been demonstrated as have the beneficial effects of surgery. Operation should therefore be employed in all cases unless a significant contraindication exists.
REFERENCES 1. AMBROSINI A, TARDITO E. Gli aneurismi dell'arteria femorale profunda. Presentazione di due casi. Minerva Chir 1971 ;26:646-652. 2. BANCH1NI E, CAPOCASALE E. Rara sede di aneurismi periferici: aneurismi della a femorale profunda. Astratto da Acta Bio-Medica de l'Atenco-Parmense 1982;53:285-288.
VOLUME 5 NO 1 - 1991
TRUE PROFUNDA FEMORIS ANEUR YSMS
3. BILLIG DM, JORDAN PH, DE BAKEY ME. Arteriosclerotic aneurysm of the profunda femoris m'tery: report of a case with successful surgical repair. Cardiovasc Rex Cent Bull 1968;6:139-141. 4. EASTCOTT HHG. Arterial surgery. London: Pitman, 1969, pp 314-316. 5. FELDMAN AJ, BERGUER R. Rupture of isolated athero sclerotic aneurysms of the lateral femoral circumflex artery. Surgery 1981 ;90:914-916. 6. FERRERO S, CARTIA Q, BELGRANO EA. Su di un caso de aneurisma dell'arteria femoral profunda. Minerva Cardioangiologica 1983:31:469-470. 7. HARDY DG, EAD1E DGA. Femoral aneurysms. BrJ Sz,Te 1972;59:614-616. 8. KARMODY AM, GALLOWAY JMD. Aneurysm of the profunda femoris artery. J R Coll Surg Edin 1972;17:261263. 9. RATTO G, SACCO A, CANEPA G, et al. Atherosclerotic aneurysm of the deep femoral artery. J Cardiovasc Sur~ 1984;25:574-576. 10. SYMES JM, EADIE DG. Solitary arteriosclerotic aneurysm of the profunda femoris artery. J Cardiavasc Surg, 1973;14: 220-222. 11. TARRICO A. Ruptured aneurysm of profunda femoris. N Y State J Med 1980;80:960-962. 12. VALIULIS AP, JOHNSTON KW. Isolated arteriosclerotic aneurysm of the profunda femoris artery. ,I Cardiovasc Sur;, 1980;21:498-500. 13. BJORCK C-G, BERQVIST D, LJUNGNER H, et al. Atherosclerotic aneurysm of the deep femoral artery. Acta Chit Scand 1987;153:137-142. 14. ROSENMAN JM, WYCHE D. True aneurysm of the profunda femoris artery. J Cardiovase Surg 1987;28:701-705, 15. WE1ST JW, MUKHERJEE D, INAHARA T. Ruptured aneurysm of the profunda IEmoris artery. J Vas'~ Sur,g 1986 ;4:406-409. 16. CUTLER BS, DARLING RC. Surgical management of arteriosclerotic femoral aneurysms. Sur~?ery 1973:74:764773. 17. PAPPAS G, JANES JM, BERNATZ PE, et al. Femoral
IWI
18. 19. 20. 21. 22. 23.
24.
25. 26. 27. 28. 29. 30.
95
aneurysms. Review of surgical management. JAMA 1964; 190:97-101. GRAHAM LM, ZELENOCK GB, WHITEHOUSE WM, et al. Clinical significance of arteriosclerotic femoral artery aneurysms. Arch Sur~ 1980;115:502-507. BAIRD RJ, GURRY JF, KELLAM J, et al. Arteriosclerotic femoral artery aneurysms. Can Med Assoc J 1977;117: 23061307. DENT TL, H N D E N A U E R SM, ERNST CB, et al. Multiple arteriosclerotic arterial aneurysms. Arch Surg 1972;105: 338-344. WELSH P. Aneurysms of the extremities. J Cardiovasc Surg 1973;17:305-306. WISHART GC, CUSCH1ERI RJ, ROBERTSON DAR, et al. Pseudo-aneurysm of the profunda femoris artery following a stab wound. Br J Surg 1987;74:804. BARNES DI, BROUDE HB. False aneurysm of the profunda femoris artery complicating fracture of the femoral shaft and treated by transcatheter embolization. S Afr M e d J 1985:67: 824-826. MACKENZIE DB, GROBBELAAR N J, VAN RENSBERG MN. False aneurysm of the profunda femoris artery as a late complication of upper femoral episiotomy. S Aft J Sur~,, 1983;2/:255-262. SCLAFAN! SJA, SHAFTAN GW. Transcatheter treatment of injuries to profunda femoris artery. A JR 1982;138:463466. QUERAL LA, FLINN WR, YAO JST, et al. Management of peripheral arterial aneurysms. Surg Clin N Am 1979;59: 693-706. ADISESHIAH M, BAILEY DA. Aneurysms of the femoral artery. Br J Surg 1977;64:174-176. GUVENKIK L, BLOOR K, CHARLESWORTH D. Popliteal aneurysm, sinister harbinger of sudden catastrophe. B r J Surg 1980:67:294-296. VERMILION BD, KIMMINS SA, PACE WG, et al. A review of 147 popliteal a~eurysms with long-term follow-up. Surgew 1981:90:1009-1014. SCHELLACK J, SMITH RB, PERDUE GD. Nonoperative management of selected popliteal aneurysms. Arch Surg 1987:122:372-375.
