EJVES Extra
Volume 12, Issue 1 , Pages 6-8, July 2006

Rapid Expansion of Popliteal Artery Aneurysm after Lower Limb Graduated Compression Bandaging for Varicose Ulcer

Regional Vascular Surgery Unit, Royal Victoria Hospital, Belfast BT12 6BA, Northern Ireland, UK

Accepted 6 April 2006.

Article Outline

We present the case of an 80-year-old woman who presented with rapid expansion of a right popliteal artery aneurysm. She had been treated with high-pressure graduated compression bandaging for a right lower leg ulcer prior to the sudden development of a painful swelling behind her right knee, diagnosed on ultrasound scan as a large non-ruptured popliteal artery aneurysm. She was treated successfully by reversed autologous vein graft bypass and exclusion of her popliteal artery aneurysm. This case suggests compression bandaging of the lower leg may be associated with rapid expansion of a previously undiagnosed popliteal artery aneurysm.

Keywords: Popliteal artery aneurysm, Graduated compression bandage, Ulcer

 

Back to Article Outline

Introduction 

Popliteal artery aneurysms, although rare, are the commonest peripheral artery aneurysm.1 When symptomatic they typically present with lower limb ischaemia from acute or chronic thrombosis, distal embolization, or rarely rupture. Outcomes following repair of symptomatic popliteal aneurysms presenting with acute ischaemia are poor, with series reporting limb loss, 20% to 59%, and operative mortality rates, 5.4% to 11.8%.2, 3

It is generally accepted that in most developed countries the life-time risk of developing a chronic venous ulceration is approximately 1%, and that the condition consumes approximately 1–2% of total healthcare spending.4 The cornerstone of treatment for venous ulcer is compression bandaging, using a single or multi-layer elastic bandage, which has been shown in a Cochrane collaboration meta-analysis to significantly improves ulcer healing rates.5 Whilst spontaneous rapid expansion can occur in popliteal artery aneurysms, in general they are slow growing.6 We report for the first time a case of rapid expansion of a popliteal artery aneurysm after treatment with compression bandaging for venous ulceration of the lower leg.

Back to Article Outline

Case Report 

An 80-year-old female presented to our institutions rapid access vascular examination (RAVE) clinic complaining of a non-healing ulcer on her right lower leg and the new onset of a painful swelling behind her right knee. She had a history of varicose veins affecting her right leg and had developed a non-painful varicose ulcer sited above the medial malleolus four months prior to this attendance. She had been treated in the community for the preceding three-months with graduated high-compression bandaging by a specialist nurse at her community ulcer clinic. She had no history of peripheral arterial occlusive disease (PAOD) and apart from her age had no cardiovascular risk factors. Over the preceding month she had developed a painful swelling behind her right knee. She had no history of local trauma and her contra-lateral leg was asymptomatic.

On clinical examination she was noted to have a large expansile swelling behind her right knee (Fig. 1), which on questioning she had noted over the last 3–4 weeks. She was noted to have a varicose ulcer above her right medial malleolus, with clinical signs of sapheno-femoral and long saphenous vein incompetence and associated varicose veins. Clinical impression was that of a large right popliteal artery aneurysm, which was non-tender and not ruptured. All peripheral pulse were palpable, and her ankle-brachial pressure index (ABPI), measured at the Doralis Pedis Artery, was 1.36 on the right, and 1.21 on the left, with triphasic waveforms noted. A venous duplex ultrasound scan diagnosed right sapheno-femoral junction incompetence with incompetence of her right long saphenous vein. Duplex ultrasound scanning also revealed a large true aneurysm of the right popliteal artery, measuring 4centimetres in maximum diameter, and a normal calibre left popliteal artery. Contrast-enhanced computerized tomography angiogram (CTA) scan demonstrated a large right popliteal artery aneurysm measuring 4centimetres in maximum transverse diameter and contained extensive thrombus (Fig. 2). Distal run-off vessels were of good quality. The patient was admitted for treatment of her symptomatic right popliteal artery aneurysm by exclusion and reversed autologous long saphenous vein bypass by a medial surgical approach (Fig. 3).

  • View full-size image.
  • Fig. 1. 

    This view of the medial aspect of the right knee was taken at outpatient clinic presentation and demonstrates the large swelling in the popliteal fossa, which was subsequently diagnosed on clinical and radiological testing to be a large right popliteal artery aneurysm. Also seen is the elastic graduated compression bandage she had been prescribed in the community for lower leg varicose ulceration.

  • View full-size image.
  • Fig. 3. 

    This intra-operative image demonstrates a reversed long saphenous vein interposition graft bypass with exclusion of a large right popliteal artery aneurysm by a medial surgical approach.

The patient made a full recovery with no major adverse event, and was discharged ten days postoperatively. At three-month review ultrasound flow characteristics in the vein graft bypass appear satisfactory, the popliteal aneurysm sac had reduced to less than 2cm, and the patient remains well.

Back to Article Outline

Discussion 

Varicose ulceration of the limb is an important cause of morbidity for which the cornerstone of treatment is elastic graduated compression bandaging, using a single or multi-layer elastic bandage, which has been shown to significantly improves ulcer healing.5 In recent times the majority of venous ulcer management in the British Isles has been conducted at specialized community leg ulcer clinics led by a specialist nurse, which has lead to significant improvements in outcomes in recent years.7 One recognised contraindication to the application of compression bandaging is the presence of significant peripheral arterial occlusive disease (PAOD), as the dressing can further reduce tissue perfusion pressure and precipitate critical limb ischaemia. Current standard practise at community ulcer clinics include the assessment of peripheral pulses and calculation of the ankle-brachial pressure index (ABPI), a ratio of less than 0.9, may indicate PAOD and suggest compression should only be considered with caution after referral to and assessment by a specialist vascular surgeon. Prior to the prescription of compression bandaging in this case the peripheral vascular system was thoroughly assessed and found to be normal by the General Practitioner, a local General Surgeon, and the specialist ulcer care nurse. Clinical assessment of the popliteal artery for aneurysmal change can be difficult even when conducted by a specialist and often require ultrasound imaging for confirmation.1 Whilst it is possible that this aneurysm was present but not diagnosed at initial presentation, this patient is exceedingly thin and this combined with the large size of the popliteal aneurysm at diagnosis strongly suggests rapid expansion of the aneurysm after initial medical assessment. Furthermore, the patient clearly identifies the development of pain and swelling in the region of the popliteal fossa after several months of compression bandaging therapy.

Whilst spontaneous rapid expansion can occur in popliteal artery aneurysms, in general they are slow growing. Penetrating and blunt trauma have been reported as a factor in the development of a true aneurysm of the popliteal artery.8 However, no previous report has highlighted the concern that elastic compression bandaging of the lower leg may be associated with the development and rapid expansion of a popliteal artery aneurysm. Chronic repetitive trauma has been implicated in the development of true arterial aneurysms, most notably the arteries of the upper limb artery in the presence of a thoracic outlet syndrome,9 a similar repetitive insult from tight elastic compression bandages may have caused aneurismal change in this case. The application of elastic graduated compression bandages induce increased peripheral resistance in the lower leg, and as such must be considered with caution in the presence of peripheral arterial occlusive disease, this increase in peripheral resistance may predispose to the development of a de-novo proximal arterial aneurysm or expansion of a previously unrecognised small popliteal artery aneurysm.

Outcomes following repair of symptomatic popliteal aneurysms presenting with acute ischaemia are poor as such many surgeons advocate elective repair, although debate still continues as to the diameter at which repair is considered, some authors recommending 2cm others 3cm. Conventional treatment has been aneurysm exclusion and autologous vein graft bypass, the treatment of choice in this case, although some question the durability of this approach in light of some reports of late aneurysm expansion and even rupture due to branch vessel perfusion of the aneurysm sac.10 More recently there have been many advocates for less invasive endovascular option such as covered-stent placement, and although some impressive results have been published concerns remain about the durability of this approach with respect to thrombosis, stenosis, aneurysm expansion, and stent fracture or migration.

We suggest that clinicians and other healthcare practitioners involved with the care of lower leg varicose ulcers should be alerted to the fact that distal graduated compression bandaging may be associated with rapid expansion of popliteal artery aneurysms. An examination of the peripheral vascular system in these patients should form an essential part of any community ulcer service with a low threshold for specialist vascular referral if concerning symptoms or signs develop.

Back to Article Outline

References 

  1. Trickett JP, Scott RA, Tilney HS. Screening and management of asymptomatic popliteal aneurysms. J Med Screen. 2002;9(2):92–93
  2. Aulivola B, Hamdan AD, Hile CN, Sheahan MG, Skillman JJ, Campbell DR, et al. Popliteal artery aneurysms: a comparison of outcomes in elective versus emergent repair. J Vasc Surg. 2004;39(6):1171–1177
  3. Mahmood A, Salaman R, Sintler M, Smith SR, Simms MH, Vohra RK. Surgery of popliteal artery aneurysms: a 12-year experience. J Vasc Surg. 2003;37(3):586–593
  4. Ragnarson TG, Hjelmgren J. Annual costs of treatment for venous leg ulcers in Sweden and the United Kingdom. Wound Repair Regen. 2005;13(1):13–18
  5. Nelson EA, Bell-Syer SE, Cullum NA. Compression for preventing recurrence of venous ulcers. Cochrane Database Syst Rev. 2000;4:CD002303
  6. Pittathankal AA, Dattani R, Magee TR, Galland RB. Expansion rates of asymptomatic popliteal artery aneurysms. Eur J Vasc Endovasc Surg. 2004;27(4):382–384
  7. Thomason SS. Management of patients with venous ulcers in the community setting. Home Care Provid. 1999;4(4):156–161
  8. Gupta S, Bedi AP, Malik VK, Mandal AK. True aneurysm of popliteal artery due to trauma: a case report. Indian J Pathol Microbiol. 2003;46(2):238–239
  9. McCarthy WJ, Yao JS, Schafer MF, Nuber G, Flinn WR, Blackburn D, et al. Upper extremity arterial injury in athletes. J Vasc Surg. 1989;9(2):317–327
  10. Antonello M, Frigatti P, Battocchio P, Lepidi S, Cognolato D, Dall'Antonia A, et al. Open repair versus endovascular treatment for asymptomatic popliteal artery aneurysm: results of a prospective randomized study. J Vasc Surg. 2005;42(2):185–193

PII: S1533-3167(06)00056-2

doi:10.1016/j.ejvsextra.2006.04.002

EJVES Extra
Volume 12, Issue 1 , Pages 6-8, July 2006

Article Tools

* Image Usage & Resolution