British Journal of Radiology (2007) 80, e147-e149
© 2007 British Institute of Radiology
doi: 10.1259/bjr/29913717
Endovascular therapy for a profunda femoris artery aneurysm which ruptured following intravenous thrombolysis
A Ganeshan, MBBCh, BSc, MRCP, FRCR
1
M Hawkins, MBBS, BSc, MSc, MRCS
1
D Warakaulle, MBBS, MRCP, FRCR
2 and
M C Uthappa, MBBS, FRCS, FRCR
2
1 Department of Radiology, John Radcliffe Hospital, Headley Way, Oxford OX3 9DU, 2 Department of Radiology, Interventional Radiology, Stoke Mandeville Hospital, Mandeville Road, Aylesbury, Bucks HP21 8AL, UK
Correspondence: Dr Arul Ganeshan, John Radcliffe Hospital, Oxford, Headley Way, Oxford OX3 9BD, UK. E-mail: aganeshan{at}hotmail.com
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Abstract
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Arterial aneurysms are a relative contraindication for systemic thrombolytic therapy due to the risk of rupture. This case report describes rupture of a rare profunda artery aneurysm (PFAA) following systemic thrombolysis for myocardial infarction. Subsequent imaging and endovascular management of this rare complication is presented with a brief discussion.
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Introduction
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Aneurysmal changes of the profunda femoris artery (PFAA) are rare. Presentations of PFAA vary from incidental findings in asymptomatic individuals to a variety of symptoms due to pressure on adjacent structures and, in the most extreme cases, rupture. We report a case where rupture of a previously unknown PFAA occurred following systemic thrombolytic treatment for myocardial infarction (MI) and discuss its subsequent endovascular management. To our knowledge this is the first description of a PFAA presenting in this way. This report also highlights the value of interventional radiological techniques in the management of this rare peripheral aneurysm.
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Case history
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A 76-year-old male patient with known intermittent claudication received thromblytic therapy with intravenous recombinant tissue plasminogen activator for an acute anterior MI. During the 24 h following thrombolysis, the patient developed ischaemic symptoms in the right foot. On examination the limb was pale with reduced capillary refill. The pulses below the groin were absent, but both femoral pulses were palpable. In addition transmitted pulsation was felt in the right groin through a 6 cm x 5 cm soft mass, which according to the patient had been present for several months. The presumptive diagnosis of an acute on chronic ischaemic event in the lower limb was made. Initially management consisted of intravenous heparin and during this period the patient's symptoms resolved.
Initial magnetic resonance angiogram (MRA) images although degraded by movement artefact showed bilateral common iliac and femoral artery aneurysms. A subsequent CT angiographic (CTA) examination revealed an additional PFAA with a maximum axial diameter of 6 cm x 5 cm with extensive surrounding haematoma (Figure 1
). Digital subtraction angiography (DSA) performed via an ipsilateral antegrade approach confirmed an aneurysm of the true profunda femoris artery with a single small branch vessel leaving the aneurysm sac. There was a proximal neck of approximately 3 cm. The superficial femoral artery was noted to be irregular with single vessel runoff via the posterior tibial artery (Figure 2). There was no evidence of emboli to account for the acute event. A percutaneous transcatheter coil embolisation of the PFAA was successfully performed using a contralateral retrograde approach. Due to the size of the draining vessel it was not possible to coil the "back door" and therefore the aneurysm sac was packed with 6 mm x 40 mm type 0.035 fibred platinum coils (Boston Scientific, Cork, Ireland) along with further coils in the proximal profunda femoris (Figure 2b). The patient made an uneventful recovery and no flow was demonstrated through the profunda at follow up CTA after 6 weeks. The patient remains under the care of the vascular surgical team for the coexisting iliac and femoral aneurysms.
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Figure 1. Contrast-enhanced CT showing the calcified profunda artery aneurysm (PFAA) (white arrow) surrounded by extensive haematoma (black arrow).
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Figure 2. (a) Digital subtraction angiography (DSA) showing a patent femoral artery with an aneurysm of the profunda artery (PFAA) (white arrow) and smaller draining vessel (black arrow). (b) DSA post-coil embolisation showing a good technical result with filling of the aneurysm sac and preservation of flow in the superficial femoral artery. Coils can be seen in the aneurysm sac (white arrow), with further coils located in the profunda artery (black arrow).
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Discussion
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True PFAAs account for approximately 0.5% of peripheral arterial aneurysms. They are usually unilateral and often coexist with more widespread aneurysmal disease, most commonly involving the iliac and femoral arteries [1]. Pseudoaneurysms are more common than true PFAA and are often iatrogenic in origin; they have been reported following trauma, percutaneous access procedures and following orthopaedic operations involving the proximal thigh [2]. Emboli originating in the aorta and iliac vessels causing distal emboli are well known and it has been suggested that retrograde propulsion of clot from a PFAA into the superficial femoral artery (SFA) may also occur [3]; a small embolus from either of these sources could explain the initial ischaemic symptoms in the case described.
PFAA have a high rate of rupture with significant associated morbidity if left untreated [4]. Exclusion of the profunda artery from the circulation by ligation is a recognized form of management [5]. It is imperative to ensure that the ispilateral SFA is patent prior to this as the profunda artery may provide collateral circulation to the distal limb. If the SFA is not patent, more extensive procedures involving reconstruction of the SFA or profunda circulation is required. Open surgical procedures do, however, expose the patient to the risks of general anaesthesia and are often technically difficult operations due to problems associated with surgical exposure and control of the aneurysm neck. A number of techniques have been described that provide endovascular methods of excluding PFAA or pseudoaneurysms from the circulation [6]. Thrombin has been used in the management of pseudoanaeuryms of the profunda artery [7]. Thrombin has a central role in the pathogenesis of acute coronary syndromes and increased levels are associated with increased rates of restenosis in the immediate period following MI although the manufacturer lists no contraindication [7, 8]. Although the patient was not in the immediate post MI period it was felt that the use of coils would be more appropriate in this case. Although covered stents have been used with some success in the treatment of aneurysms at a number of sites there are no reported cases using a covered stent in this context. The size of the proximal profunda artery and the draining vessel would have made the use of a covered stent technically difficult. Packing coils in the aneurysm sac with further coils located in the proximal PFA occlusion was performed to avoid problems such as misplacement of coils with attempting a "front" and "back door" approach.
This case report illustrates a well-known complication of thrombolytic therapy involving a rare peripheral artery aneurysm. We also highlight the use of percutaneous techniques in the management of this complication, which may have advantages over traditional open surgery, particularly in patients with significant co-morbidity.
Received for publication November 8, 2005.
Revision received March 15, 2006.
Accepted for publication April 10, 2006.
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References
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- Amer N, Grocott E, Shami S. Time for a new classification of femoral artery aneurysm? Vasa 2004;33:170–2.[CrossRef][Medline]
- 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.[CrossRef][Medline]
- Markland CG. Primary atherosclerotic aneurysm of the profunda femoris artery associated with distal embolization. Ann Vasc Surg 1989;3:389–91.[Medline]
- Tait WF, Vohra RK, Carr HM, Thomson GJ, Walker MG. True profunda femoris aneurysms: are they more dangerous than other atherosclerotic aneurysms of the femoropopliteal segment? Ann Vasc Surg 1991;5:92–5.[CrossRef][Medline]
- Uzoigwe CE, Tang T, Gaunt M. Surgical repair of bilateral profunda femoris artery aneurysms. Vascular 2005;13:184–6.[CrossRef][Medline]
- Entwisle JJ, De Nunzio M, Hinwood D. Case report: transcatheter embolization of pseudoaneurysm of the profunda femoris artery complicating fracture of the femoral neck. Clin Radiol 2001;56:424–7.[CrossRef][Medline]
- Cantasdemir M, Kantarci F, Mihmanli I, Numan F. Embolization of profunda femoris artery branch pseudoaneurysms with ethylene vinyl alcohol copolymer (onyx). J Vasc Interv Radiol 2002;13:725–8.[CrossRef][Medline]
- Jindal R, Dhanjil S, Carrol T, Wolfe JH. Percutaneous thrombin injection treatment of a profunda femoris pseudoaneurysm after femoral neck fracture. J Vasc Interv Radiol 2004;15:1335–6.[CrossRef][Medline]
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Abstract
Introduction
