ISSN: 2320-5407 Int. J. Adv. Res.

11(10), 266-273

Journal Homepage: - www.journalijar.com

Article DOI: 10.21474/IJAR01/17704

DOI URL: http://dx.doi.org/10.21474/IJAR01/17704

RESEARCH ARTICLE
LOWER EXTREMITY ARTERY ANEURYSMS AND THEIR MANAGEMENT-AN INSTITUTIONAL
EXPERIENCE

Vishal Bulla, N.Sritharan, P. Ilaya Kumar, Vella Duraichi, Jaya Chander, Vaisagh Remin, Ramya, Prathap
Kumar
1. Resident, Vascular Surgery,MMC,Chennai.
2. Professor,Vascular Surgery, MMC,Chennai
3. Asst.Professor,Vascular Surgery, MMC,Chennai
4. Junior Resident,Vascular Surgery, MMC,Chennai
……………………………………………………………………………………………………....
Manuscript Info Abstract
……………………. ………………………………………………………………
Manuscript History Objective: To study the clinical presentation, etiology and outcomes of
Received: 15 August 2023 Lower extremity aneurysms management at a teritiary care centre.
Final Accepted: 18 September 2023 Methodology: This is a retrospective study covering a period of 5
Published: October 2023 years from june 2018 to july 2023 conducted at the Institute of
Vascular Surgery, Madras Medical College, Chennai. Case sheets were
retrieved and reviewed from CMCHS database.
Inclusion criteria: Patients with true aneurysms and pseudoaneurysms
involving lower limb who were managed by surgery or endovascular
means were included in the study.
Exclusion Criteria: Pseudoaneurysms related to dialysis and Iliac
artery aneurysms Results There were 23 patients who presented with
aneurysms of the extremities that fell in the inclusion criteria. Of these
14 patients were male and 09 were female. Children (<18 years)
constituted 14.2 % of patients. Youngest- 7-month-old boy- Right PFA
Pseudoaneurysm Oldest - 72yrs old male- Left PFA Pseudoneurysm •
Major vessels involved were SFA-8/23(34.7%) and common femoral
artery 5/23(21.7%.). Complications developed in 4 of the 23 cases
(17.4%), which included recurrent pseudoaneurysm, surgical site
infection, post- operative hematoma and surgical site infection ending
up in AK amputation. Limb salvage rate was- 95.6% Amputation rate-
4% (1 patient).
Conclusion: Extremity artery aneurysms are uncommon. Majority are
pseudoaneurysms. Results of both open surgery and endovascular
management are excellent.

Copy Right, IJAR, 2023,. All rights reserved.

……………………………………………………………………………………………………....
Introduction:-
The most common cause of non-mycotic peripheral arterial aneurysms is atherosclerosis and all peripheral
aneurysms are uncommon when compared to aortic aneurysms. In descending order, the relative frequency of these
aneurysms is popliteal, femoral, subclavian or axillary, and carotid. Atherosclerotic peripheral aneurysms are
frequently associated with synchronous aortic, iliac, or splanchnic aneurysms. Reports on distal aneurysms
involving the, deep femoral, and tibial or peroneal arteries are limited to small series or case reports. Although true

266
Corresponding Author:- Vishal Bulla
Address:- Resident, Vascular Surgery,MMC,Chennai.
ISSN: 2320-5407 Int. J. Adv. Res. 11(10), 266-273

aneurysms have been reported in these areas, for the most , tibial, and peroneal aneurysms are secondary to trauma
or are mycotic in origin.1-3 Age and sex distribution of peripheral aneurysms are dependent on cause.

Atherosclerotic aneurysms tend to occur primarily in men older than 50 years of age, and aneurysms caused by
trauma are also more common in men, but occur at a younger age. Dent at al.(1)found that of those with a common
femoral aneurysm, 95% had a second aneurysm, 92% had an aortoiliac aneurysm, and nearly 60% had bilateral
femoral aneurysms. Conversely, the incidence of femoral and popliteal aneurysms in patients with an abdominal
aortic aneurysm is low and ranges from 3.1% to 14%.(2). Unlike aortic aneurysms, which tend to rupture, peripheral
aneurysms most commonly thrombose or give rise to distal arterial emboli and since there are rarely warning signs
before embolization, the mere presence of a peripheral aneurysm often suggests the need for repair. The two primary
objectives of treatment are exclusion of the aneurysm and restoration of arterial continuity, and in most cases, both
objectives can be achieved. In the rare cases that is not surgically accessible, exclusion alone may be required
Additional considerations include relieving associated compressive symptoms from the aneurysm and minimizing
the risk of late aneurysm expansion.

Methodology:-
This is a retrospective study covering a period of 5 years from june 2018 to july 2023 conducted at the Institute of
Vascular Surgery, Madras Medical College, Chennai.

Case sheets were retrieved and reviewed from Insurance schemes database.

Inclusion criteria:
Patients with true aneurysms and pseudoaneurysms involving lower limb who were managed by surgery or
endovascular means were included in the study.

Exclusion criteria-
Pseudoaneurysms related to dialysis accesand Iliac artery aneurysms

Discussion:-
The femoral artery is the most common location for pseudoaneurysm, with various causes including iatrogenic,
anastomotic, traumatic, and mycotic origins being frequently encountered. The increasing incidence of
pseudoaneurysms is primarily attributed to the expanded utilization of catheter-based interventions in cardiovascular
disease treatment, with pseudoaneurysms being reported in approximately 0.2% of all femoral arterial access
procedures. Longer procedures, larger-bore catheters, thrombolytic or anticoagulation therapy, and the use of
multiple catheters are considered risk factors for pseudoaneurysm development. Additionally, intravenous drug
misuse and the increased use of arterial closure devices following needle cannulation contribute to the rising
incidence of infected femoral pseudoaneurysms..

Conventional recommendations for the treatment of femoral aneurysms include all symptomatic aneurysms of any
size, aneurysms with intramural thrombus, aneurysms greater than 2.5 cm, aneurysms that show growth with
surveillance, and those that change their baseline pulseexam, indicating embolization.(3),(4)

Aside from trauma and rare degenerative and congenital disorders, popliteal aneurysms are almost exclusively
atherosclerotic in origin.(5)&(6)

These aneurysms account for about,70% of peripheral aneurysms, occurring in about 1% of men aged 65 to 80 years
old, with a 20-to-1 male-to-female ratio.(7)&(8).

Popliteal aneurysms are primarily atherosclerotic in etiology, with occasional causes including trauma, cystic
degeneration of the adventitia, entrapment, and infection.Current recommendations for repair of popliteal aneurysms
include aneurysm size 1.5 to 2.0 cm with thrombus, all aneurysms of 2 cm or greater in size, all symptomatic
aneurysms, and those with evidence of occult distal embolization. This recommendation is based on the high
incidence of thromboembolic complications associated with these lesions, as detailed earlier, and the low morbidity
and mortality associated with repair.(9)

267
ISSN: 2320-5407 Int. J. Adv. Res. 11(10), 266-273

Patients with peripheral aneurysms are also at high risk for the development of future peripheral aneurysms. Dawson
showed that in patients with a popliteal artery aneurysm, new peripheral aneurysms were detected in 32% of these
patients after 5 years and in 49% of these patients after 10 years.(10).

Aneurysms of the tibial and pedal arteries are also uncommon. Although a small proportion are degenerative in
etiology, most are pseudoaneurysms that arise following trauma or infection or as a delayed complication of balloon
catheter embolectomy.(11-13)Tibial artery aneurysm has also been reported in association with polyarteritis
nodosa.(14).they may present as a painful mass or with digital or calf ischemia secondary to thromboembolism.
Small, asymptomatic aneurysms may safely be observed, Repair is indicated for aneurysms two times the size of
normal, adjacent artery, or for any symptomatic aneurysms, particularly those associated with pain and ischemic
symptoms. If the remaining tibial vessels are healthy, ligation of the aneurysm or percutaneous embolization are
acceptable. In the presence of diabetes or concomitant atherosclerosis in the remaining infrageniculate vessels,
however, ligation or excision with saphenous vein bypass is recommended. Both ligation in the presence of adequate
collateral circulation and repair are successful in the treatment of tibial aneurysms.(12)

Results:-
Total cases- Male -14/23- 60.8%,Female-9/23- 39.1%

SEX DISTRIBUTION

MALES FEMALES

Age Distribution

268
ISSN: 2320-5407 Int. J. Adv. Res. 11(10), 266-273

12

10

8
age
6 age2
age3
4
Series 4

0
0-20 21-40 41-60 61-60

• 0-20Y- 2/23(8.6%)
• >20-40Y- 11/23(47.8%)
• >40-60Y- 8/23(34.7%)
• >60-80Y- 2/23( 8.6%)

Complications –
Out of 23cases only 4 had complications(17.3%).

cases

complications

269
ISSN: 2320-5407 Int. J. Adv. Res. 11(10), 266-273

6
Column1
5
Column2
4
PFA
3
CFA
2

0
CFA SFA POP.A PFA

• CFA -5/23(21.7%)
• SFA-8/23(34.7%)
• Popliteal artery- 5/23(21.7%)
• PFA- 2/23(8.6%)
• TP trunk-1/23(4.3%)
• PTA- 2/23(8.6%)

ARTERY NUMBER OF ETIOLOGY MANAGEMENT COMPLICATIO

INVOLVED CASES NS
CFA 5 (right-4,left-1) •Coronary • Pseudoaneurysm • 1
5 pseudoaneyrysms angiogram- excision + primary • Recurrent
2/5(40%) closure of CFA rent- pseudoaneurys
• Coronary 2/5(40%). m involving
angioplasty & • Pseudoaneurysm distal
stenting- excision +vein patch anastomosis-
1/5(20%),RH repair-1/5(20%). pseudoaneurys
D S/P AVR & • Pseudoaneurysm m excision +
S/P MVR - excision + EIA to EIA to SFA
1/5(20%) distal CFA RGSV interposition
• Unknown- interposition graft - graft with IIA.
1/5(20 1/5(20%)
• Unknown- 1/5(20%)
•
SFA 8(right -8) • -Coronary • Pseudoaneurysm • 1
-pseudoaneurysms-7 angiogram – 4/8( excision + primary • wound
Aneurysms-1 50%) closure of SFA rent – debridement to
• 3/8( 37.5%) raw area of
• -P Popliteal • Pseudoaneurysm thigh
artery excision + vein patch
pseudoaneurysm closure of SFA rent –
excision + GSV 2/8 (25
Interposition • Pseudoaneurysm
graft – 1/8 excision + primary
(12.5%) closure of rent +
• proximal SFA to

270
ISSN: 2320-5407 Int. J. Adv. Res. 11(10), 266-273

• -Central venous distal SFA synthetic

catheter graft bypass( dacron)
insertion- 1/8 – 1/8 (12.5%)
(12.5%) • Aneurysm resection
• + SFA to SFA RSV
• -Idiopathic- interposition graft –
1/8(12.5%) 1/8( 12.5%)
• Pseudoaneurysm
excision + SFA
Ligation + SFA to
Proximal popliteal
RGSV bypass – 1/8(
12.5%)

• 3)POPLITEA • 5 (Right- 1, • S/P • Popliteal artery 1( 20%)-

L ARTERY Left- 4 ) arthroscopic ligation + distal SFA surgical site
• Pseudoaneurysm ACL/PCL to distal PA RGSV infection
s-3 repair-1 bypass – 1
• Aneurysms-2 Tibial occlusion S- • Pseudoanurysm
P Distal popliteal excision + popliteal
artery to peroneal artery to popliteal
artery bypass – 1 artery RSV Bypass –
• Arthrotomy 1
knee for septic • Pseudoaneurysm
arthritis – 1 excision + primary
• Atheroscleroti repair of PA rent -1
c- 2 • Popliteal artery
exclusion bypass –
proximal popliteal
artery to ATA RGSV
bypass – 1
• Popliteal artery open
endoaneurysmoraphy
/Distal SFA--distal
popliteal RSV graft
bypass-1

• PROFUNDA • 2 CFV Central • PFA aneurysm NIL

FEMORIS • Left- 1, Right – 1 venous catheter ligation + excision –
ARTERY • (Aneurysm – 1, insertion – 1 1
• Pseudoaneurysm- • Pseudoaneurysm
1) excision + PFA
ligation – 1

• TP TRUNK • 1 • RTA / Tibia • Pseudoaneurysm NIL

• • R side fracture / S-P excision + primary
(Pseudoaneurysm) Intramedullar repair of rent
y nailing

• POSTERIOR • 2 • Unknown – 2 • Pseudoaneurysm • 1

TIBIAL • Right – 1, Left - 1 excision + primary • Hematoma-
ARTERY • Pseudoaneurysm – closure of rent in evacuated
• 2 PTA -1
• PTA ligation-1 •

271
ISSN: 2320-5407 Int. J. Adv. Res. 11(10), 266-273

Right Popliteal Artery pseudoaneurysm

Conclusion:-
Given the high rate of complications, early operative intervention with autologous saphenous vein is recommended
whenever possible and Careful monitoring of all patients with peripheral aneurysms is indicated given the high
prevalence of additional aneurysms. Peripheral Artery aneurysm’s that are larger than 2-2.5cm and symptomatic
should be considered for repair for medically fit patients .The decision to perform open or endovascular repair of
Peripheral Artery aneurysm’s should be individualized .

272
ISSN: 2320-5407 Int. J. Adv. Res. 11(10), 266-273

References:-
1.Dent TL, Lindenauer MS, Ernst CB, et al. Multiple arteriosclerotic arterial aneurysms. Arch Surg 1972;105:338-
344.
2.Diwan A, Sarkar R, Stanley JC, et al. Incidence of femoral and popliteal artery aneurysms in patients with
abdominal aortic aneurysms. J Vasc Surg 2000;31(5):863-869.
3.Hall HA, Minc S, Babrowski T. Peripheral artery aneurysm. Surg Clin North Am. 2013;93(4):911–923 [ix].
4.Lawrence PF, Harlander-Locke MP, Oderich GS, et al. The current management of isolated degenerative femoral
artery aneurysms is too aggressive for their natural history. J Vasc Surg. 2014;59(2):343–349
5.Szilagyi DE, Schwartz RL, Reddy DJ. Popliteal arterial aneurysms. Their natural history and management. Arch
Surg. 1981;116(5):724–728.
6.Vermilion BD, Kimmins SA, Pace WG, Evans WE. A review of one hundred fortyseven popliteal aneurysms with
long-term follow-up. Surgery. 1981;90(6):1009– 1014
8.von Stumm M, Teufelsbauer H, Reichenspurner H, et al. Two Decades of Endovascular Repair of Popliteal Artery
Aneurysm—A Meta-analysis. Eur J VascEndovasc Surg. 2015;50(3):351–359.
9.Poirier NC, Verdant A, Page A. Popliteal aneurysm: surgical treatment is mandatory before complications occur.
Ann Chir. 1996;50(8):613–618.
10.Dawson I, van Bockel JH, Brand R, et al. Popliteal artery aneurysms. Long-term follow-up of aneurysmal disease
and results of surgical treatment. J Vasc Surg. 1991;13(3):398–407.
11.Cronenwett JL, Walsh DB, Garret HE. Tibial artery pseudoaneurysms: delayed complication of balloon catheter
embolectomy. J Vasc Surg 1988;8:483-488.
12. Monig SP, Walter M, Sorgatz S, et al. True infrapopliteal artery aneurysms: report of two cases and literature
review. J Vasc Surg 1996;24(2):276278.
13. McKee TI, Fisher JB. Dorsalis pedis artery aneurysm: case report and literature review. J Vasc Surg
2000;31(3):589-591.
14. Borozan PG, Walker HSJ, Peterson GJ. True tibial artery aneurysms: case report and literature review. J Vasc
Surg 1989;10(4):457-459.

273