Open surgical repair of common femoral artery aneurysm: Case report and literature review

Kristine J S. Kwan; Hai-Lei Li; Yiu Che Chan; Dong-Zhe Cui; Stephen W Cheng

doi:10.4103/2589-9686.377615

CASE REPORT

Year : 2023 | Volume : 6 | Issue : 1 | Page : 16-19

Open surgical repair of common femoral artery aneurysm: Case report and literature review

Kristine J S. Kwan¹, Hai-Lei Li², Yiu Che Chan³, Dong-Zhe Cui², Stephen W Cheng³
¹ Clinical Medicine, International School, Jinan University, Guangzhou; Department of Surgery, Division of Vascular Surgery, University of Hong Kong – Shenzhen Hospital, Shenzhen, China
² Department of Surgery, Division of Vascular Surgery, University of Hong Kong – Shenzhen Hospital, Shenzhen, China
³ Department of Surgery, Division of Vascular Surgery, University of Hong Kong – Shenzhen Hospital, Shenzhen; Department of Surgery, Division of Vascular and Endovascular Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China

Date of Submission	04-Jan-2023
Date of Decision	01-Feb-2023
Date of Acceptance	02-Feb-2023
Date of Web Publication	26-May-2023

Correspondence Address:
Dr. Hai-Lei Li
West Wing, 4^th Floor A Block, 1^st Haiyuan Road, Futian District, Shenzhen 518053
China

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2589-9686.377615

Abstract

Common femoral artery (CFA) aneurysms are rare with an unknown exact incidence and often found in elderly males with chronic diseases. Early recommendations are to repair aneurysms with a maximum diameter of ≥2.5cm. We present the case of a 37-year-old male with a right CFA aneurysm. Open surgical repair (OSR) consisting of aneurysmectomy and reconstruction of the femoral artery with a bifurcated prosthetic graft was applied. Our study details this case and thoroughly reviews on the treatment of femoral artery aneurysms in the literature. OSR and vascular reconstruction with interposition prosthetic graft were durable and associated with favorable outcomes.

Keywords: Femoral artery aneurysms, open surgical repair, prosthetic graft

How to cite this article:
S. Kwan KJ, Li HL, Chan YC, Cui DZ, Cheng SW. Open surgical repair of common femoral artery aneurysm: Case report and literature review. Vasc Invest Ther 2023;6:16-9

How to cite this URL:
S. Kwan KJ, Li HL, Chan YC, Cui DZ, Cheng SW. Open surgical repair of common femoral artery aneurysm: Case report and literature review. Vasc Invest Ther [serial online] 2023 [cited 2023 Jun 8];6:16-9. Available from: https://www.vitonline.org/text.asp?2023/6/1/16/377615

Introduction

Femoral artery aneurysms (FAAs) are rarely encountered in clinical practice. As a result, current literature has not been able to define the threshold for the repair of this peripheral aneurysm. Treatment considerations are indicated when the patient is symptomatic (e.g., rupture, thromboembolism, and lower limb ischemia) or when the aneurysm exceeds 2.5 cm in diameter.^[1] The diagnosed majorities are males with an approximate mean age of 70 years and have atherosclerosis risk factors. This study describes a 37-year-old male with an isolated right common femoral artery (CFA) aneurysm who underwent open surgical repair (OSR).

Case Report

A 37-year-old male presented with a pulsatile right groin mass for a year that enlarged over the past 3 months. He has had good past health, negative smoking history, and denied trauma. Family history suggested consanguineous marriage for three generations, and his parents are cousins.

On physical examination, a pulsatile mass approximately 3 cm in diameter was palpable in the right inguinal region. Superficial varicosities and hyperpigmentation were seen throughout his right leg without associated pain. The right popliteal artery and dorsalis pedis artery (DPA) pulses were palpable. Laboratory results were normal. Contrast-enhanced computed tomography (CT) scan revealed a CFA aneurysm (maximum diameter 33 mm and 10 cm in length) with a mural thrombus. Angiography was performed due to suspected arteriovenous malformation, which revealed the right CFA aneurysm with involvement of the superficial femoral artery (SFA) and profunda femoris artery (PFA) origins. No concurrent aneurysm was detected in the aorta, bilateral iliac, popliteal, tibial, and peroneal arteries. Blood flow was patent, and no arteriovenous fistula was found.

Elective OSR was offered in view of the gradual enlargement of the aneurysm. Open surgical femoral aneurysm resection and reconstruction of the femoral artery using a bifurcated prosthetic graft were performed under general anesthesia. Color Doppler ultrasonography was used to locate the right CFA and its bifurcation before the operation. We approached the aneurysm through a vertical incision at the medial aspect of the right inguinal region. The CFA aneurysm was identified, which involved the origins of the SFA and PFA, but was difficult to isolate due to its adhesion toward the surrounding tissue. Part of the inguinal ligament had to be incised to expose the proximal CFA. A bifurcated prosthetic graft was made using an 8-mm Dacron graft (Intergard Woven, Intervascular SAS, France) by cutting a segment that was anastomosed in an end-to-side manner with 6-0 Prolene suture (Ethicon, US). After heparinization, the CFA, SFA, and PFA were controlled with vascular clamps. Aneurysmectomy and thrombectomy were performed. End-to-end anastomosis was performed with running suture using 5-0 Prolene (Ethicon, US) to reconstruct the CFA, SFA, and PFA [Figure 1]. After the procedure, the right DPA was palpable. Pathological analysis of the aneurysm sample revealed uneven dilatation of the vascular wall, focal neutrophil infiltration, fibrin deposition on the luminal surface, and multifocal intimal hyperplasia.

Figure 1: (a) Intraoperative finding of the common femoral artery aneurysm (b) Homemade bifurcated graft (c) Mural thrombus (yellow arrow) within the aneurysm sac (d) Reconstruction of the common, superficial, and profunda femoral arteries with the homemade bifurcated graft. CFA: common femoral artery; SFA: superficial femoral artery; PFA: profunda femoral artery

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The patient had an uneventful recovery and was discharged with an oral antiplatelet prescription. Follow-up CT scan at 6 months showed the CFA, SFA, and PFA were patent [Figure 2]. After 18 postoperative months, the patient remains healthy and color Doppler ultrasonography revealed patent blood flow in the right CFA, SFA, and PFA.

Figure 2: Follow-up CT at 6 months revealing patent common, superficial and profunda femoral arteries. CT: Computed tomography

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Discussion

FAA may be the second most common peripheral artery aneurysm, but a true FAA, defined as an isolated arterial dilatation that involves all three arterial wall layers and measures at least 1.5 times the diameter of the adjacent normal artery,^[1] is a rare clinical entity. A comprehensive literature search in MEDLINE from January 1973 to June 2022 using the keywords femoral artery aneurysm, prosthetic graft, and open surgical repair was performed. A total of 567 femoral arterial aneurysms have been identified. The clinical characteristics of the published studies on femoral aneurysms are summarized in [Table 1]. Most patients have an asymptomatic initial presentation. The aneurysm often presents as a painless, persistent, and pulsatile groin mass typically mistaken as an inguinal hernia. It can also be detected incidentally in supplementary examinations such as ultrasonography and contrast-enhanced CT. Angiography is invasive but helpful in determining other concurrent aneurysms and planning the appropriate management procedure.

Table 1: Summary of characteristics of published case series on femoral artery aneurysm

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The classification of FAAs is according to its anatomic relationship with the femoral bifurcation. There were originally two types: Type I aneurysm limited to the CFA and terminating proximal to the bifurcation and type II aneurysm extends to the origin of the SFA or PFA.^[2] Our patient had an isolated type II FAA with intramural thrombus, which was associated with higher complication rates and was more difficult to treat. Other than a strong male predilection (97%), our patient did not carry risk factors associated to FAA and was much younger than the mean age of 68.8 years.

Asymptomatic FAAs with a diameter smaller than 3 cm can be surveilled annually with ultrasonography. However, if a patient presents with complications such as rupture, thrombosis, or distal embolism, repair would be necessary regardless of the aneurysm diameter. These complications can be life-threatening, but their incidence is variable in prior studies. Levi and Schroeder studied the relationship between aneurysm diameter and the risk of rupture of FAA and found that the rupture rate for FAA <5 cm was 1.6% compared with 16% for those larger than 5 cm.^[7] Lawrence et al. found that acute aneurysm-related complications were associated with FAA diameter larger than 4 cm and intraluminal thrombus, but not location.^[1] Our patient complained of rapid aneurysm expansion in a course of 3 months and we found his maximum aneurysm diameter to be 3.3 cm with an intramural thrombus, which was indicated to be treated with OSR.

Angiography revealed no other aneurysm in our patient. However, there is a well-established association between FAAs and other aneurysms (i.e., abdominal aortic aneurysms and other peripheral arterial aneurysms). Piffaretti et al. concluded that FAA is rarely an isolated lesion, 26% of FAA were bilateral and 48% had additional aneurysms.^[10]

In this patient, endovascular repair with branched stent graft to exclude the aneurysm and preserve the PFA was another treatment option. In general, patients that undergo endovascular repair require frequent imaging follow-ups and more secondary interventions. As this patient was young, OSR was the treatment of choice. According to the literature, the general practice for surgical treatment of CFA aneurysms was partial excision of the aneurysm and interposition grafting as shown in [Table 1]. The most commonly used interposition graft is either polytetrafluoroethylene or Dacron.^[1],[10] The diameter of the interposition graft should be compatible to the healthy ends of the artery they are anastomosed to. We conducted the CFA reconstruction with a homemade bifurcated 8-mm Dacron graft (Intergard Woven, Intervascular SAS, France).

Outcomes of surgical treatment are favorable. Reported 30-day mortality was 0%–1.1% and 1-year survival was 88.6%–92%.^{[1],[2],[3],[4],[5],[6],[7],[8],[9],[10]} Lawrence et al. reported a patient who developed an open wound infection within 6 months of surgery, and 35 patients (27%) died of causes unrelated to an aneurysm during follow-up.^[1] Postoperative wound infection is the most common complication but is not observed in the case reports.

Advancements have been made in diagnostic and therapeutic vascular intervention. Therefore, the treatment of true FAAs may not pose a significant challenge. There is no standard treatment method, and outcomes of both surgical and hybrid repair are favorable. As aforementioned, the true prevalence of FAA and the incidence rate of its complications are unknown, and conducting a national screening study is neither economically feasible nor clinically possible as the aneurysm may be missed.

Conclusion

CFA aneurysm is a rare disease, and there remains a paucity of evidence on the treatment of asymptomatic CFA aneurysms. OSR and vascular reconstruction with interposition prosthetic graft were durable and associated with favorable outcomes.

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 initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed

Financial support and sponsorship

This study was supported by grants from the University of Hong Kong-Shenzhen Hospital Research Cultivation Program, China (No. HKUSZH201901013).

Conflicts of interest

There are no conflicts of interest.

References

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