|Year : 2021 | Volume
| Issue : 1 | Page : 19-24
Review of the management of isolated superficial femoral artery aneurysms
Khalid Bashar1, Sana Sharafat Ali1, Andrew Garnham2
1 Queen Elizabeth Hospital Birmingham, Vascular Unit, Birmingham, UK
2 Black Country Vascular Unit, Co. West-Midlands, UK
|Date of Submission||19-Mar-2020|
|Date of Decision||27-Mar-2020|
|Date of Acceptance||07-Apr-2020|
|Date of Web Publication||20-Feb-2021|
Queen Elizabeth Hospital Birmingham, Vascular Unit, Birmingham
Source of Support: None, Conflict of Interest: None
Truly isolated aneurysms of the superficial femoral artery (SFA) are uncommon. The treatment options come from small case series and case reports. In the absence of definitive management guidelines, a revision of the available literature was carried out. True SFA aneurysms are more common in elderly male patients and tend to present late and can grow to significant sizes. Both open and endovascular options are available, which will depend on many factors highlighted in this review. Open repair should be offered to fit patients.
Keywords: Endovascular repair, false aneurysms, peripheral aneurysms, pseudo-aneurysms, superficial femoral artery aneurysms, true aneurysms
|How to cite this article:|
Bashar K, Ali SS, Garnham A. Review of the management of isolated superficial femoral artery aneurysms. Indian J Vasc Endovasc Surg 2021;8:19-24
| Introduction|| |
Isolated true femoral aneurysms are rare, and there is a lack of consensus in the management of those aneurysms. Therefore, we aimed to review the available evidence, which is largely based on case series with small numbers.
Arterial aneurysms are classified into true aneurysms with the aneurysm involving all three layers of the artery (intima, media, and adventia), and false aneurysms (pseudoaneurysms) that spare at least one layer from being involved. The first group includes atherosclerotic, syphilitic, and congenital aneurysms. The second group includes mycotic, anastomotic, and posttraumatic aneurysms.
The most common site of peripheral aneurysms is said to be the popliteal artery (PA) with an incidence of reference. Degenerative (atherosclerotic) aneurysms of the femoral arteries are uncommon, with the incidence reported as 5/100,000. Those aneurysms most commonly involve the common femoral artery (CFA), with isolated aneurysms involving the superficial femoral artery (SFA) and the profunda artery uncommon., Femoral aneurysms are commonly bilateral and frequently associated with other aneurysms, in particular aortoiliac and popliteal aneurysms.,,
| Types of Peripheral Aneurysms|| |
Peripheral aneurysms are rarely isolated; more commonly, aneurysms present as a manifestation of a systemic process that would affect other arteries and has the potential to predispose to multiple aneurysms. Etiological factors include atherosclerosis, connective tissue disease (such as Ehlers-Danlos syndrome and Marfan's syndrome), infectious arthritis (such as syphilis) and noninfectious arthritis (inflammatory or immunologic, such as Takayasu arteritis, Wegener's granulomatosis, Behçet's disease, and giant cell arteritis).,,, In addition to the potential for causing multiple aneurysms, systemic manifestations of those pathological disorders are usually present in the same individuals at the time of presentation with symptomatic peripheral aneurysms.
Truly isolated peripheral aneurysms are exceptionally rare, with around 140 cases reported in the literature. They are more common in elderly male patients and tend to be symptomatic at the time of presentation in most of the reported cases.,,,, We believe that there is not any convincing evidence that aneurysmal disease affects one limb more than the other in the legs. Those aneurysms are also commonly located in the middle third of the leg, are usually focal, and rarely extend beyond the adductor canal., Aneurysms in the SFA are more likely to rupture in comparison to aneurysms in the CFA or the PA.,,
In general, false aneurysms are more common peripherally. False aneurysms are usually caused by catheterization of the artery, most commonly following cardiac angiographic procedures, as the groin is a common access site. Other causes include infection, needling among intravenous drug abusers, and anastomotic leak. Pseudoaneurysms are more common following therapeutic procedures rather than diagnostic and are more common in obese patients. Inadequate manual compression is thought to be the single most important risk factor in the development of pseudoaneurysms. Katzenschlager et al. reported a decrease in the overall incidence of pseudoaneurysms in their series from 14% to only 1.1% after they introduced a new manual compression technique by continuing the compression for a full 5 min after the stopping of local bleeding.
| Presentation and Indications for Treatment|| |
The presentation depends on the type and site of the peripheral aneurysm. True femoral aneurysms in the groin present with local symptoms, such as pain, a growing mass, or localized tenderness in about one-third of the cases. They are asymptomatic in about 30%–40% of cases.,, The remaining one-third of patients present with complications (claudication pain in a background of chronic thrombosis, acute limb ischemia in a background of acute thrombosis and rupture). It needs to be highlighted that some series report the incidence of femoral aneurysms presenting with complications as high as 65%, whereas others found it to be around 10%.,, This fact means that a systematic approach to patients presenting with peripheral aneurysms should be recommended, with the use of arterial duplex ultrasound (DUS) considered adequate to assess patients for possible aortoiliac and other peripheral aneurysms; however, a cross-sectional scan – computed tomography (CT) or magnetic resonance imaging (MRI) provides more definitive details, in particular, if a repair procedure will be required or considered. Infected aneurysms can present with constitutional symptoms, such as fever or rigors. They can mimic the presentation of an abscess, acute phlebitis, or deep venous thrombosis, particularly when they are thrombosed with the lack of pulsatility, bruit, and thrill commonly found in expanding aneurysms.,
False aneurysms tend to present as an expanding mass, localized pain, and tenderness due to the size of the swelling, and the compressive neuropathy associated with the growing size is also a common presentation in pseudoaneurysms. Patches of necrotic or ischaemic skin can result from large false aneurysms, as well as external compression on the adjacent vein. They can also cause distal embolization and rupture. It has also been reported that anastomotic pseudoaneurysms– regardless of graft material-rarely present with massive bleeding (even when they do rupture), excluding retroperitoneal false aneurysms. Anastomotic aneurysms usually present with localized pain and a pulsatile mass. Similarly, distal ischemia is rare in anastomotic false aneurysms.,
Isolated aneurysms of the SFA are rare. A fact that can be attributed to the protection provided by the muscle mass surrounding those arteries and the lack of stress from repeated bending movements affecting the other arteries of the peripheral tree., This same fact can explain the late presentation of isolated SFA aneurysms, as they lie deep to the muscles. Those aneurysms are more prone to late presentation with complications such as distal embolization and rupture in comparison to aneurysms elsewhere in the lower limbs. Isolated aneurysms in the SFA represent around 15%–25% of femoral aneurysms, with those aneurysms usually reported in the literature as single cases or in small series.,,,,
SFA aneurysms are more likely to present with rupture compared to aneurysms in the PA and CFA, which more commonly present with symptoms related to thrombosis and distal embolization., Leon et al. reported a rupture rate of 52% at the time of presentation, which is similar to other reports in literature ranging from 30% to 50%.,, Thrombosis has been observed in 13%–19%, while distal ischemia – caused by embolization or compression on adjacent vessels– has been reported in 9%–14% in published literature.,,,
Symptomatic aneurysms (claudication pain, critical ischemia, acute limb ischemia, and rupture) should all be considered for repair procedures. In addition, large aneurysms that present with local symptoms (Pain, pulsatile mass, edema, skin changes, and infection) should also be considered for surgical repair. A definitive size for femoral aneurysms that is predictive of complications has not been agreed; however, most authors will recommend repairing aneurysms larger than 2.5 cm.,
| Diagnostic Imaging Modalities|| |
Depending on the location of the aneurysms, the physical examination might prove to be of little or no usefulness, as SFA aneurysms are known to be deep to the muscles, and usually are not expected to be readily palpable until they reach a significant size, and that is the main reason for the delayed presentation of isolated SFA aneurysms. Jarrett et al. found that up to 66% of their patients did not have a palpable SFA aneurysm at the time of presentation. Isolated distal SFA and proximal popliteal aneurysms in the lower third of the thigh are easier to assess by manual examination after the artery leaves Hunter's canal.
Several imaging modalities are available to diagnose peripheral aneurysms. The main aim is to estimate the size of the aneurysm, the presence – or lack – of flow, the status of collateral vessels and the anatomy of the artery both proximal and distal to the aneurysm. Depending on local protocols and the mode of presentation, clinicians should choose the test that is most suited to the patient, while keeping in mind the potential for aneurysms elsewhere in the aortoiliac vascular tree. In the setting of acute presentation (ischemia or rupture), the use of cross-sectional scans will provide detailed information about the aneurysm, while facilitating the planning for open or endovascular interventions if required. US scans are useful to show the size, the extent of growth, and presence of thrombus, and can be used both in the acute setting or for follow-up of diagnosed aneurysms. In addition, the US is noninvasive and can be used to detect the potential presence of other aneurysms.
DUS is noninvasive, and gives reasonable details about the size and anatomy of the aneurysm, while at the same time allow for a noninvasive assessment of the other arteries that are commonly associated with femoral aneurysms, including contralateral aneurysms., The use of US can be extended to assess the anatomy of ipsilateral and contralateral veins that might be used as vascular conduits to repair the aneurysms. Thrombosed aneurysms can prove challenging to assess properly using US scans as they can resemble soft-tissue tumors.
This same limitation applies to the use of MRI scans as the appearances of the aneurysm – accurate size and/or presence of thrombus-will depend on the extent of thrombosis, with partially thrombosed aneurysms and those containing laminated thrombus more difficult to assess accurately as MRI scans depend on flow dynamics in reconstructing the images. In general, MRI gives better details when there is still flow within the aneurysms, allowing to differentiate between aneurysms and other pathologies, such as soft tissue tumors.
Catheter angiographic studies of the peripheral circulation of the lower limb were once considered the gold standard in the diagnosis of femoral aneurysms. However, those tests are invasive and give limited details of the effects on surrounding structures, in particular when planning for endovascular repair. Moreover, they cannot differentiate between a thrombosed aneurysm with limited flow and thrombosis within an atherosclerotic SFA, which can lead to misdiagnosis and also underestimates the true prevalence of SFA aneurysms.,
Although CT scanning is less invasive in comparison to catheter angiography, it involves the use of intravenous contrast, which can cause a deterioration in renal function. This modality gives substantial details in assessing the accurate size and anatomy of the aneurysm and gives clear details of the arterial wall with the extent of calcification as well as the anatomy of proximal and distal circulation to the aneurysm. This allows for confident preoperative planning for both open and endovascular repair procedures.
| Treatment Options|| |
Surgical treatment of femoral aneurysms can be divided into open and endovascular procedures. Both approaches have their own advantages and disadvantages. Conventioanally, an open repair is considered superior in terms of outcome, particularly when it comes to limb survival intervals, and avoiding the need for second procedures to maintain patency or salvage limbs. However, the treatment option depends on several factors. The individual patient fitness for a repair procedure should be considered carefully in terms of age, comorbid conditions, physiological status, mobility, and independence. For example, an old patient who is otherwise fit and independent should be considered for a surgical repair for isolated distal SFA aneurysms, rather than an endovascular option that might not give the same longevity. With low numbers of SFA aneurysms treated endovascularly, it is unrealistic to construct randomized trial comparing endovascular to open repair for SFA aneurysmal disease. In general, endovascular solutions do not tend to provide the same longevity, although they may seem superficially attractive in the SFA with a good seal zone at either end; however, vein bypass is also durable in this setting. Moreover, the length of follow-up in most of the reported cases of endovascular repair is short or not reported at all. Similarly, the location and type of the aneurysm should be carefully analyzed before opting for one treatment or the other. While the availability of new stents means that more patients can have endovascular treatment, consideration should be given to the anatomic location of the aneurysm. Stents crossing joints are still prone to complications. They do not offer the same reassurance compared to open surgical treatment in the form of bypass or jump grafts using veins, in particular, if the patient was relatively young and in good functional status.
| Open Repair|| |
Open repair procedures should be the first treatment option in the setting of infection, presence of arteriovenous fistula, skin, or soft-tissue ischemic changes. Open repair should also be considered when the patient will be having a general anesthetic for another procedure performed simultaneously, like coronary artery bypass.
In cases with infected aneurysms, surgical management should be aimed at debriding the infected tissue, including the aneurysm sac, dead muscles, and necrotic tissue and drainage of the accompanying abscess. If a healthy segment of the artery can be identified, both proximal and distal to the aneurysm, a bypass procedure-possibly with a vein harvested from the contralateral limb – should be considered. Proximal control can be achieved via a separate incision in the abdomen if the aneurysm involved the CFA or the external iliac artery. Balloon occlusion and manual pressure are possible alternatives to achieve proximal control. Extra-anatomic bypass procedures can be considered in the presence of extensive infection and tissue damage, using the iliac artery through the obturator canal or axillary artery. The Sartorius flap technique can be used to cover the bypass. Ligation of the CFA can be considered; however, this carries a significant risk for both amputation and severe short distance claudication symptoms.,, The use of antibiotics that would cover staphylococcus and Salmonella species should be started before the surgical treatment, and continued for at least 6 weeks after the procedure.
In their series of 27 isolated SFA aneurysms, Perini et al. used a combination of various surgical techniques. The preference was to perform an aneurysectomy by resecting the aneurysm and then placing a polytetrafluoroethylene (PTFE) interposition graft, a technique used in 59% of their patients. In patients that presented with acute limb ischemia, they preferred to exclude the artery by performing a femoropopliteal bypass procedure using the great saphenous vein, an approach that would allow the simultaneous thrombectomy of the infragenicular vessels. Similarly, in the setting of severe atherosclerosis of the distal SFA or PA, they preferred to bypass the aneurysm. This approach was used in 26% of patients. Simple ligation was performed in 11% of cases and was reserved for those that presented acutely and were considered high risk for a more extensive surgical treatment, and when there was no evidence of distal ischemia. They reported a survival rate of 88% at 6 months, ad 62% after 5 years of follow-up. A limb salvage rate of 88% was recorded at 5 years, with patency rates of 90% and 85% at 6 months and 5 years consecutively. Diabetes and the presence of acute limb ischemia at the time of presentation were the only factors associated with the loss of limb and graft thrombosis.
| Endovascular Repair|| |
Endovascular repair is feasible for both true and false aneurysms of the femoral artery; however, little is known about the long-term outcomes, in addition, no data were available from randomized controlled trials in the endovascular management of peripheral aneurysms, particularly isolated aneurysms of the SFA. Considering the rarity of truly isolated SFA aneurysms, randomized trials are not likely to be feasible, even in the setup of large multi-center trials. Currently, endovascular procedures to treat femoral aneurysms are being reserved in most centers – at least in the UK – for patients who are considered high risk for open repair, or when a bypass procedure is technically challenging. The two most common techniques used are coil embolization and stent exclusion of the involved aneurysm, either alone or in combination., Endovascular techniques are not suitable in the setting of infection or skin ischemia.
The use of stents in femoral artery aneurysms is hindered by the dynamic nature of the artery, and are subjected to complications when placed across joints limiting their use in proximal and distal aneurysms where they have been shown to have low patency rates (43%–87%), which remains inferior to what is expected from open repair procedures in similar anatomic locations.,, The use of covered stent means – at least theoretically – that those stents can be considered in aneurysms that are complicated with the formation of arteriovenous fistulae. In addition, covered stents have shown better patency rates, in particular when used in isolated SFA aneurysms compared to patency rates conventionally expected from bare-metal stents. Stents in the aneurysms involving the middle third of the SFA are expected to perform better as they will not be subjected to the same repetitive stress forces.
Aneurysmal disease of the lower extremity is a different entity to occlusive disease of the same arteries; therefore, published data from studies showing comparable patency rates from the use of expanded PTFE/nitinol self-expanding stent graft – namely Viabahn – to bypass procedures should not be used to justify similar approaches in dealing with the peripheral aneurysmal disease.,
Findings from series with five or more cases are summarisedon [Table 1].
|Table 1: Series with ≥5 cases of isolated superficial femoral artery aneurysms|
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| Conclusion|| |
Isolated true aneurysms of the SFA are rare, and so far, most of the evidence regarding their management comes from small series and case reports. Those aneurysms are more common in elderly male patients and tend to present symptomatically either with localized pain, rupture, or symptoms of distal ischemia from embolization or compression of adjacent arteries. Patients fit to withstand open surgery and general anesthetic, should be offered an open repair option. Aneurysectomy should be considered in the presence of compression symptoms. Limited use of endovascular options for peripheral true aneurysms.
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Conflicts of interest
There are no conflicts of interest.
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