British Journal of Radiology (2003) 76, 195-198
© 2003 British Institute of Radiology
doi: 10.1259/bjr/32510074
Insertion of a covered stent for treatment of a popliteal artery pseudoaneurysm following total knee arthroplasty
R Vaidhyanath, DMRD, FRCR
and
K S Blanshard, FRCR
Department of Radiology, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester LE5 4PW, UK
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Abstract
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We report the use of a covered stent to successfully treat a pseudoaneurysm of the popliteal artery, which occurred following total knee arthroplasty. Percutaneous endovascular repair offers a safe alternative to surgical management of this condition.
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Introduction
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Vascular complications following total knee arthroplasty (TKA) are uncommon, with reported incidence ranging from 0.03% to 0.12% [1, 2]. They are associated with significant morbidity and can be limb-threatening. We present a rare case of popliteal artery injury following TKA, presenting as a false aneurysm, which was successfully treated by percutaneous placement of a covered stent.
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Case report
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A 74-year-old man presented with a 10-day history of a swollen left lower limb following TKA. He had received post-operative anticoagulation for a presumed diagnosis of deep vein thrombosis. A duplex ultrasound scan, however, identified a false aneurysm measuring 3.7 cm by 1.2 cm in diameter, arising from the popliteal artery anteriorly, with considerable overlying soft tissue swelling and haematoma. It was elected to treat this with covered stent deployment.
An antegrade left common femoral artery (CFA) puncture was performed under local anaesthetic and lower limb arteriography completed. The femoral and popliteal arteries were a little dilated and the popliteal artery measured 7 mm in diameter. A false aneurysm was confirmed arising from the anterior aspect of the popliteal artery approximately 1 cm below the joint line (Figure 1
). A 10 French introducer sheath was placed in the left CFA and a nominal 7 mm x 7 cm Wallgraft endoprosthesis (Boston Scientific Limited, St Albans, UK) was placed in a satisfactory position within the popliteal artery and covering the neck of the false aneurysm. An initial endoleak at the proximal end of the covered stent was successfully treated with remodelling with a 7 mm diameter angioplasty balloon (Figure 2, Figure 3).
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Figure 1. Confirmed false aneurysm arising from the anterior aspect of the popliteal artery about 1 cm below the join line.
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Post operatively, the swelling rapidly resolved and the patient mobilized. Warfarin anticoagulation for 3 months was commenced and the patient was discharged 8 days following the stent insertion. Prior to discharge, duplex ultrasound confirmed exclusion of the false aneurysm from the circulation (Figure 4).
At 18 months duplex ultrasound follow-up the stent remains patent with no significant stenosis, and in a satisfactory position with no endoleak. The false aneurysm was no longer present. Plain radiographs at 12 months show no fracture or displacement of the stent (Figure 5).
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Discussion
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TKA is a safe and effective procedure in the management of patients with limiting osteoarthritis and rheumatoid arthritis. The spectrum of vascular complications following TKA includes popliteal artery thrombosis, embolism, pseudoaneurysm, arteriovenous fistula and transection of the artery [1, 2].
The proximity of the popliteal artery to the site of operation during TKA exposes it to potential direct surgical injury [3]. During surgery, popliteal artery injury is most likely to occur during resection of the posterior femoral condyles or proximal tibia, or during release of the posterior capsule [1–3].
False aneurysms of the popliteal artery present clinically as an enlarging pulsatile mass and may have an audible bruit. However, presentation is often subclinical and remains undetected for weeks [1, 2]. They may be misdiagnosed as post-operative haematoma or deep vein thrombosis as occurred in our patient. Pseudoaneurysms of smaller arteries such as the geniculate artery following TKA have also been reported [4].
Colour Doppler flow ultrasound is a safe and accurate method to confirm the diagnosis. Once the diagnosis is confirmed the treatment is usually surgical, comprising excision and repair. Surgery is made more difficult if a large haematoma is present surrounding the false aneurysm, possibly compounded by anticoagulation for presumed deep vein thrombosis, as seen in our patient.
Ultrasound guided compression repair (UGCR) has been used to treat false aneurysms, but has been largely superseded by percutaneous thrombin injection in our centre and elsewhere [5–7]. UGCR was not considered appropriate in this case because of the size of the associated haematoma and the location of the pseudoaneurysm deep to the artery.
Percutaneous thrombin or fibrin injection is now well described and has a high success rate [6, 7], and was considered as a treatment option in this patient, but discarded as a viable treatment owing to the size of the overlying haematoma, the location of the false aneurysm deep to the artery and because there was a possibility on angiography of there being two separate feeding points to the false aneurysm. The extent of injury to the artery wall was therefore unclear.
Covered stents have been available for some time, and used for the treatment of a variety of vascular and non-vascular indications with some success [9–13]. We are aware of several published case reports describing the use of the larger endograft devices to repair both true and false popliteal artery aneurysms, but to our knowledge there are only three previous case reports describing the use of the lower profile covered stents to repair popliteal false aneurysms [9–11]. The use of an uncovered stent has also been described to exclude a popliteal false aneurysm from the circulation, but only because a covered stent was unavailable [8].
In our patient the use of a covered stent permitted exclusion of the false aneurysm from the circulation without recourse to surgery. It is recognized that surveillance will be required to detect a late endoleak but this can be simply completed using duplex ultrasound. Experience of covered stent deployment across joint lines is limited and surveillance for stent strut fracture and migration will be required. This is easily performed with plain radiography.
Covered stent deployment should be considered in the treatment of large false aneurysms with extensive surrounding haematoma that might otherwise have been considered only suitable for surgery. For smaller false aneurysms percutaneous thrombin or fibrin injection remains the present treatment of choice.
The possibility of pseudoaneurysm, although extremely rare, should be considered when patients present with popliteal fossa swelling following TKA. Endovascular stent deployment is not perhaps the first line treatment for pseudoaneurysms, but may be a viable alternative for the treatment of these lesions. Further evaluation and long-term follow-up is required.
Received for publication October 24, 2001.
Revision received August 14, 2002.
Accepted for publication September 23, 2002.
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References
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Abstract
Introduction
