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A LARGE IDIOPATHIC PSEUDOANEURYSM OF THE POPLITEAL ARTERY--A CASE REPORT/VELIKA IDIOPATSKA PSEUDOANEURIZMA POPLITEALNE ARTERIJE--PRIKAZ SLUCAJA.

Introduction

Pseudoaneurysm, also known as a false aneurysm, is a collection of blood which passes through individual layers of the blood vessel or through all layers, but it is retained in the surrounding soft tissues [1].

Pseudoaneurysm may be pulsatile and resemble a real aneurysm. A true aneurysm is a permanent, localized dilation of all three layers of a blood vessel, by more than 50% of the usual diameter for the viewed segment [1].

The common causes of the pseudoaneurysms of the femoropopliteal segment include penetrating traumas [2], blunt traumas [3], fractures [4], previous medical procedures [5], infections [6], and in rare cases exostosis [7] and cystic adventitial diseases [8]. Since these rare lesions can be corrected, early detection and appropriate treatment should be a priority [9].

The main cause of false aneurysm is trauma and in the literature it has been reported that about 72.5% of limb loss is due to the trauma of the popliteal
Abbreviations
LL--latero-lateral
AP--anteroposterior
KK--cranio-candal
US--ultrasound
MRI--magnetic resonance imaging
CT--computeriuzed tomography
GSV--great saphenous vein
DUS--duplex ultrasonography
PAD--peripheral artery disease


artery. In our case, there were no anamnestic indications about injuries [10].

Traditionally, pseudoaneurysms were treated with surgical repair, but traditional surgical treatment is invasive and is often associated with significantly higher morbidity and mortality rates [11]. Over the past few years, minimally invasive radiologic treatments have been developed as alternatives to surgery, including ultrasound (US)-guided compression [12], direct percutaneous management (including US-guided thrombin injection) [13], and endoluminal management [14]. Larger and symptomatic pseudoaneurysms should be repaired [11].

There are still delays in the diagnosis and treatment, so we present a case of a pseudoaneurysm with slow progression caused by a disease of unknown etiology, and large nonpulsatile tumor mass that has not been recorded so far, with successful treatment of a large pseudoaneurysm of the second segment of the popliteal artery of the left leg.

Case Report

A 41-year-old patient was admitted to the Emergency Department, referred by an orthopedist where he was first sent for a suspected Baker's cyst. He had a magnetic resonance image of the left leg, and this was his first and only diagnostic method until then.

The patient's medical history showed that the pain behind the left knee started three weeks ago, and the tissue swelling about 6 months ago, and before that he had no problems with this leg. The clinical examination showed a large, painful, nonpulsatile tumor mass, resulting in a 90 degrees flexion contracture of the knee.

Baseline laboratory test results showed: leukocytes - 12x[10.sup.9]/l; neutrophils - 9.5x[10.sup.9]/l ;blood glucose - 5,2 mmol/l; urea - 6mmol/l; creatinine - 84 mmol/l; international normalized ratio (INR) - 0.96.

The patient is a smoker, without a history of trauma or serious illnesses, and previously had only an appendectomy. Magnetic resonance imaging (MRI) (Siemens Avanto 1.5T) showed a pseudoaneurysm of the left popliteal artery (Figure 1).

The computeriuzed tomography (CT) scan (Siemens Somatom Sensation 16) was performed urgently in the Emergency Department, which confirmed a pseudoaneurysm with 9.7 x 8 x 15 cm/latero-lateral (LL) x anteroposterio (AP) x craniocandal (KK) diameters of the second segment of the left popliteal artery without signs of peripheral arterial obliterative disease, so digital subtraction angiography (DSA) was not performed (Figure 2).

After adequate preoperative preparation and assessment of general operability, the patient underwent surgery. Standard anesthetic protocol, orotracheal intubation, and a posterior approach to the popliteal artery were performed, with pronounced periarterial inflammatory infiltrate, excessive fibrosis, but without signs of infection.

After pseudoaneurysmectomy and evacuation, occlusive Fogarty catheters were temporarily placed to control bleeding, and a 2 cm rupture (laceration) of the popliteal artery was verified (Figure 3).

Due to the length of the laceration, a decision to create an autovenous graft interposition was made, followed by preparation of the proximal segment of the great saphenous vein (GSV) of the opposite leg.

Interposition of an autovenous graft was performed, without technical difficulties and complications (Figure 4). A part of the pseudoaneurysm wall was taken for pathohistological analysis. After correction of hemostasis, two active Redon drains and one passive ribbed drain were placed (Figure 5). The operation lasted 100 minutes. The post-operative period at the Clinic for Vascular Surgery and Transplantation Surgery was uneventful, with palpable peripheral pulses and good revascularization effect. The passive ribbed drain was extracted on the second, and the active drains on the third postoperative day.

Because of reduced knee mobility due to contracture, during hospitalization the patient was examined by a physiotherapist who carried out physical treatment to establish the full extent of movement in the joint.

The patient was discharged from hospital on the 10th postoperative day, mobile, in good general condition, with palpable distal pulses and equal ankle-brachial indices in the lower extremities, receiving an oral anticoagulant (Sintrom) and antiaggregation therapy (Aspirin).

The diagnosis of pseudoaneurysm was confirmed pathohistologically, without expected adventitial wall degeneration (Figure 6).

On the last checkup, six months after surgery, a control Duplex scan ultrasonography showed regular flow in the autovenous graft, the leg was without any recurrent vascular lesions, with palpable peripheral pulses, and with maximum mobility in the knee joint. The surgical wound healed per primam intentionem.

Discussion

The incidence of popliteal artery pseudoaneurysms is low, estimated to be 0~3.5% of all popliteal artery aneurysms of various etiologies, most commonly caused by trauma, but it can easily lead to instability [2, 15, 16].

A detailed medical history is of great importance, followed by physical examination. If the lesion is large or superficially located, it is generally palpable. The diagnostic procedures are important in order to set the final diagnosis. Duplex ultrasonography (DUS) should be considered as the first diagnostic method for early diagnosis. This technique is successfully used for detection and monitoring of pseudoaneurysms, but does not provide full visualization of the whole area and has limited accuracy [9].

Digital subtraction angiography has been the traditional first-line imaging technique in patients with peripheral artery disease (PAD), but in our case it was not indicated because PAD was not present [9].

MRI is useful and non-invasive, but it is expensive and does not provide such a good insight into the lumen of the artery like CT angiography, so CT remains the diagnostic procedure of choice for pseudoaneurysms [9].

In the diagnosis of the disease, the examiner must strictly follow the rules of the medical methodology for the diagnosis, which requires strict adherence to a certain order of examination of certain tissues, systems and organs. After medical history taking and physical examination, the next step is DUS, after which the need for further diagnostics is considered [9]. Masahiro and associates published a case with a small popliteal aneurysm and the first diagnostic procedure was radiographic examination, where they noticed exostosis of the femur bone, and after a CT was performed, a pseudoaneurysm was found [8]. Janssen and associates described a case of a patient with pain in the popliteal fossa, and Doppler examination was their first diagnostic procedure, after which MR-angiography revealed a pseudoaneurysm of the popliteal artery [17]. Woolgar and associates described a delayed diagnosis and treatment (24 months), in our case it was six months [2].

If the cause of the pseudoaneurysm is unknown, the pathohistological analysis of the wall verifies the cystic changes [8], inflammatory process in the artery wall and presence of giant cells [6] or complete lack of muscle layer in the media [18]. In our case, we did not find such changes, so the etiology remained unknown. Our opinion is that adventitial cystic disease is the cause of this false aneurysm, which may be a result of (1) repeated microtrauma; (2) ectopic ganglion cyst migrating from the adjacent joint; (3) systemic myxomatous degeneration; and (4) developmental rests of mucin-secreting mesenchymal cells derived from adjacent joints and development of obliterative disease, or it can rupture and cause a pseudoaneurysm, which may have happened in our patient [8].

Accepted procedures for resolving popliteal pseudoaneurysms are percutaneous induction of thrombin [13], stent grafting [14], Duplex ultrasound-guided compression [12], as well as surgical excision by placing a patch, graft or ligature with interposition and creating a bypass [11].

Earlier investigations of pseudoaneurysms show that the patients are mostly males, like in our case [2, 5, 6, 17], aged from 55 - 60 years [6, 18], and our patient was 41 years of age. Although pulsatile masses were found in all cases, mostly up to 6 cm in diameter, with knee contracture up to 40% on the right leg, described by Woolgar and associates [2], in our case there was a nonpulsatile mass, 9 cm in diameter, with knee contracture of 90% in the left leg.

A small number of cases were reported with different reconstruction techniques, but as in our case, the approach was posterior and GSV from the opposite leg was used. The final diagnosis was made using CT and MR, like in our case. The most important information is the size of arterial defects and its location, followed by the decision of reconstruction [7, 17, 19].

Jansen and associates published a case where an autovenous bypass between supra-genicular popliteal artery and tibio-peroneal trunk was created with GSV from the opposite leg, because of a large arterial defect and deep location [17]. In our case this was not necessary, because of a minor defect and a good exposure of the II segment of the popliteal artery.

Masahiro and associates performed an embolectomy of the distal popliteal artery because of a 5 mm diameter defect on the popliteal artery, and using this hole, an autovenous patch with GSV was created [7]. In our case it was not possible because of a bigger defect of the artery.

Perez and associates decided to perform a direct suture due to a 1mm artery defect, and a resection of the artery was not necessary [19]. As in the previous case, direct suture was not possible in our case because of a bigger defect of the artery.

Postoperative complications are possible after each operation, so Kirkpatrick and associates published a case with symptomatic enlargement of the aneurysm, with continued expansion [20], whereas Halidday and associates published a case with bove-knee amputation because of a distal arterial occlusion [21]. Huang and associates published a case with perioperative myocardial infarctions and graft thrombosis [19]. We did not have any complications.

Because of anamnestic and physical findings we assumed that the cystic adventitial disease was the cause of the pseudoaneurysm, but the pathohistological analysis showed no cysts, so the etiology remained unknown. The etiology of this disease is unclear. Four hypotheses have been proposed, including developmental, ganglionic, microtraumatic and degenerative causes [8].

After establishing control of the proximal part of the femoral and distal parts of the popliteal artery, intraoperatively we entered the pseudoaneurysm. Two occlusive Fogarty balloon catheters were used to occlude blood vessels, and repaired the artery. This technique offers numerous advantages: 1) adherent surrounding structures are not damaged; 2) veins and arterial branches remain untouched, thereby reducing the risk of bleeding; 3) the best possible anastomosis is provided because the lumen is not surrounded by pressure; 4) the balloon catheter provides a dry operating field and shortens the duration of the surgical procedure; and 5) thrombectomy of the distal blood vessel with a balloon catheter can be performed to prevent acute ischemia [23].

Conclusion

Early diagnosis plays an important role in avoiding temporary and permanent complications. Arterial reconstruction with autovein grafting is a gold standard and a method of choice in the surgery of the pseudaneurysm of the popliteal artery. The temporary setting of occlusive Fogarty catheters reduces damage to the surrounding tissue, accelerates bleeding control, which together shortens the time of surgery.

References

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Slavko BUDINSKI, Dragan NIKOLIC and Janko PASTERNAK

University of Novi Sad, Faculty of Medicine,

Clinical Center of Vojvodina, Novi Sad,

Clinic for Vascular and Transplantation Surgery

Corresponding Author: Dr Slavko Budinski, Klinicki centar Vojvodine, Klinika za vaskularnu hirurgiju, 21000 Novi Sad, Hajduk Veljkova 1-7, E-mail: slavko.budinski@unc.ac.rs; janko.pasternak@mf.uns.ac.rs

https://doi.org/10.2298/MPNS1804125B
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Author:Budinski, Slavko; Nikolic, Dragan; Pasternak, Janko
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Date:Mar 1, 2018
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