Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 441-443

Surgical correction of traumatic common femoral artery aneurysm in intravenous drug abuser


Department of Surgery, Dhulikhel Hospital, Dhulikhel, Kavrepalanchok, Nepal

Date of Submission20-Apr-2020
Date of Decision27-Apr-2020
Date of Acceptance19-May-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Prasesh Dhakal
Department of Surgery, Dhulikhel Hospital, Dhulikhel, Kavrepalanchok
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_39_20

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  Abstract 


Trauma is an uncommon cause of common femoral artery aneurysm (CFAA). We present a 31-year-old male with a history of intravenous drug abuse with an incidental finding of the right leg CFA aneurysm during ultrasonography Doppler for deep vein thrombosis. The aneurysm was surgically excised and repaired with polytetrafluoroethylene graft as good peripheral veins were not available due to the history of repeated puncture. Peroperative finding was a right-sided CFA aneurysm measuring about 3 cm × 1 cm with the distal end 1 cm below profunda femoris. In cases of growing CFAA, surgical excision and anastomosis between proximal and distal segments using a conduit are the treatment modality.

Keywords: Femoral artery aneurysm, intravenous drug abuse, peripheral bypass surgery, traumatic aneurysm


How to cite this article:
Dhakal P, Thapa P, Dahal S, Bhandari N, Bade S, Shrestha P, Karmacharya RM, Singh AK, Vaidya S. Surgical correction of traumatic common femoral artery aneurysm in intravenous drug abuser. Indian J Vasc Endovasc Surg 2020;7:441-3

How to cite this URL:
Dhakal P, Thapa P, Dahal S, Bhandari N, Bade S, Shrestha P, Karmacharya RM, Singh AK, Vaidya S. Surgical correction of traumatic common femoral artery aneurysm in intravenous drug abuser. Indian J Vasc Endovasc Surg [serial online] 2020 [cited 2021 Feb 26];7:441-3. Available from: https://www.indjvascsurg.org/text.asp?2020/7/4/441/304635




  Introduction Top


Aneurysms are formed when there is trauma to the tunica intima of the blood vessels. The patients may be asymptomatic and found incidentally or may present along with the complications such as ischemia. True aneurysm with dilatation of all three layers of blood vessels is not so common in the femoral artery unless there are risk factors such as old age, atherosclerosis, history of trauma, or smoking.[1] Inadvertent injury to vessels in intravenous (IV) drug abuser forms pseudoaneurysm. Groin is the most favorable site in patients using IV drugs. These types of aneurysm have high risk of rupture, distal embolization, local pain, and local skin ischemia.[2],[3]

Here, we present a case of bilateral common femoral artery (CFA) aneurysm (CFAA) with progressive dilatation of the right CFAA requiring bypass and excision.


  Case Report Top


A 31-year-old gentleman with a history of IV drug abuse had developed deep vein thrombosis in the right lower limb 2 years back, for which he took anticoagulants for a year and half. After stopping the anticoagulants 6 months back, he started to develop pain in his right leg, which was severe on prolonged standing or walking for a long time. He had an addiction to IV drug abuse, especially in the upper limb and groin vessels for 10 years, and according to him, he discontinued IV drug abuse for 2 years. Doppler ultrasonography (USG) performed when he had had symptoms for 6 months showed the right saccular CFAA measuring about 3 cm × 2.1 cm. The patient was reluctant to accept surgical intervention outright; thus, follow-up in a month was planned. The patient presented in 2 months, and the Doppler findings showed an increase in the diameter of the aneurysm measuring 3.4 cm × 2.4 cm [Figure 1] and [Figure 2]. Follow-up multidetector computed tomography (CT) angiogram of the aorta and bilateral lower limbs was done. It showed saccular pseudoaneurysm of distal right CFA at the level of bifurcation with above-mentioned size [Figure 3]. Based on the CT angiogram reports, surgical excision of the aneurysm was planned with end-to-end anastomosis between CFA to the superficial femoral artery (SFA) and profunda femoris. As good peripheral veins were not available due to repeated puncture while IV drug abuse, the conduit planned was polytetrafluoroethylene (PTFE) graft.
Figure 1: Color Doppler image of the aneurysm involving the right common femoral artery. The normal external iliac artery can also be seen

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Figure 2: Aneurysm with normal superficial femoral artery

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Figure 3: Computed tomography-angiogram showing right saccular pseudoaneurysm

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Preoperatively, marking was done under ultrasound guidance to identify the aneurysm and proximal and distal control sites. Under general anesthesia, two incisions were given above and below the right inguinal ligament. We found that the distal end of the aneurysm was at the level of bifurcation to profunda femoris artery. The aneurysm had dense adhesions over it, so it was difficult to isolate the whole of the aneurysm from the surrounding tissues. Following adequate exposure, SFA was clamped 1 cm below the bifurcation, and profunda was also clamped. The external iliac artery (EIA) was also clamped 1 cm above the aneurysm. The aneurysm was excised as much as possible. During excision of the aneurysm sac, profuse bleeding was noted probably from some collaterals, for which multiple buttresses suturing was done for adequate hemostasis.

PTFE graft was prepared and the proximal end was anastomosed end to end to EIA using prolene 6–0. Similarly, end-to-end anastomosis was done to SFA [Figure 4]. Owing to dense adhesion around profunda femoris, we could not do a separate bypass to profunda. Doppler USG also showed good flow in the right profunda femoris, probably due to extensive collateral flow. His postoperative stay was well without any complications, and he was discharged on the 5th postoperative day. On 6 months of regular follow-up, there are no complications, and the patient is doing fine. He is managing a rehabilitation center that deals with IV drug abusers.
Figure 4: Completed bypass using polytetrafluoroethylene graft

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  Discussion Top


A clinical study by Luther et al. found the femoral artery as the common site for pseudoaneurysm with IV drug abuse as the leading cause.[4] CFA pseudoaneurysm can present as a complication of vascular access with an incidence ranging from 0.2% to 7%.[5] Pseudoaneurysm is encountered more in the SFA than in the junction points of superficial and deep femoral arteries and in CFA.[6] In our case, CT angiogram showed saccular pseudoaneurysm of the CFA extending till the bifurcation.

The increasing size of the femoral artery aneurysm indicates high risk of rupture and thrombosis.[7],[8],[9] The size of aneurysm more than 25 mm warrants intervention.[8],[10] In IV drug abusers, surgical repair with autologous graft is less feasible as the majority have long history of drug use with obliteration of the superficial venous system. Autologous graft is a better alternative; however, chances of infection are high.[2] Intraoperative findings in our case suggested dense adhesion preventing us to do separate bypass for the profunda femoris. However, good flow was noted. IV drug users often have a good collateral network following previous arterial injury.[11]

Many institutions also adopt ligating the artery; however, due to frequent occurrence of limb loss, this method is less preferred.[12] Endovascular treatment options in these cases are reserved for emergency situations in which it can act like a bridge therapy.[13]


  Conclusion Top


The femoral artery aneurysm can occasionally be seen in IV drug users. When indicated, a modality of treatment is surgical excision with interposition conduit such as peripheral veins or PTFE graft.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sharma S, Nalachandran S. Isolated common femoral artery aneurysm: A case report. Cases J 2009;2:7522.  Back to cited text no. 1
    
2.
Stevenson RP, Tolias C, Hussey K, Kingsmore DB. Mycotic pseudoaneurysm in intravenous drug users: Current insights. RRCC 2019;10:1-6.  Back to cited text no. 2
    
3.
Lenartova M, Tak T. Iatrogenic pseudoaneurysm of femoral artery: Case report and literature review. Clin Med Res 2003;1:243-7.  Back to cited text no. 3
    
4.
Luther A, Kumar A, Negi KN. Peripheral arterial pseudoaneurysms-a 10-year clinical study. Indian J Surg 2015;77:603-7.  Back to cited text no. 4
    
5.
Dalvin M, Dessecker B, Vitvitsky E. Treatment of common femoral artery pseudoaneurysm: A novel approach utilizing a VASCADE percutaneous closure device. Case Rep Surg 2019;2019:1397981.  Back to cited text no. 5
    
6.
Huseyin S, Yuksel V, Sivri N, Gur O, Gurkan S, Canbaz S, et al. Surgical management of iatrogenic femoral artery pseudoaneurysms: A 10-year experience. Hippokratia 2013;17:332-6.  Back to cited text no. 6
    
7.
Levi N, Schroeder TV. True and anastomotic femoral artery aneurysms: Is the risk of rupture and thrombosis related to the size of the aneurysms? Eur J Vasc Endovasc Surg 1999;18:111-3.  Back to cited text no. 7
    
8.
Posner SR, Wilensky J, Dimick J, Henke PK. A true aneurysm of the profunda femoris artery: A case report and review of the English language literature. Ann Vasc Surg 2004;18:740-6.  Back to cited text no. 8
    
9.
Piffaretti G, Mariscalco G, Tozzi M, Rivolta N, Annoni M, Castelli P. Twenty-year experience of femoral artery aneurysms. J Vasc Surg 2011;53:1230-6.  Back to cited text no. 9
    
10.
Leon LR, Taylor Z, Psalms SB, Mills JL. Degenerative aneurysms of the superficial femoral artery. Eur J Vascular Endovasc Surg 2008;35:332-40. [doi: 10.1016/j.ejvs. 2007.09.018].  Back to cited text no. 10
    
11.
Maltezos C, Kopadis G, Tzortzis EA, Pappas T, Marakis J, Hatzigakis P, et al. Management of femoral artery pseudoaneurysm secondary to drug abuse. EJVES Extra 2004;7:26-9. [doi: 10.1016/s1533-3167 (03) 00110-9].  Back to cited text no. 11
    
12.
Tripathi R, Verma H. Giant true profunda femoris aneurysm: Case series and literature review. Indian J Vascular Endovasc Surg 2017;4:28. [doi: 10.4103/0972-0820.198074].  Back to cited text no. 12
    
13.
Sadat U, Kullar PJ, Noorani A, Gillard JH, Cooper DG, Boyle JR. Emergency endovascular management of peripheral artery aneurysms and pseudoaneurysms – A review. World J Emerg Surg 2008;3:22.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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