Spontaneous Rupture of a Non Aneurysmal Atherosclerotic Superficial Femoral Artery: A Case Report
Article Outline
Spontaneous rupture of a non aneurysmal atherosclerotic artery is very rare. We report the second case in the literature of a patient with spontaneous rupture of a non aneurysmal atherosclerotic superficial femoral artery. It has been described as a result of a penetrating atheromatous ulcer. Exclusion of arterial wall rupture is required. Open surgery and endovascular stent-graft placement has been successfully reported. Respective indications depend on anatomical considerations. We opted for open surgical treatment in preference to endovascular stent-graft placement.
Keywords: Penetrating atheromatous ulcer, Arterial wall rupture, Pseudoaneurysm, Stent-graft
Introduction
Spontaneous rupture of a non aneurysmal atherosclerotic artery is an exceptional occurrence. This is the second reported case in the femoral area. Post traumatic and iatrogenic perforations, or mycotic pseudoaneurysms are much more common.
Case Report
An 86 year old woman, with severe hypertension, presented a painful thigh and disabled right lower limb. Clinical examination revealed a huge pulsating mass, occupying the whole distal segment of the right thigh. It had been growing slowly for several months accompanied with localized pain for the previous months. Lower limb oedema was noted. Right popliteal and distal pulses were absent, but the leg was not ischemic. The other leg was asymptomatic. Patient denied previous trauma.
Contrast–enhanced CT scan (Fig. 1) suggested a pseudoaneurysm of the distal segment of the superficial femoral artery (SFA):
Fig. 1
Angiogram and contrast-enhanced CT-scan revealing huge pseudoaneurysm of the SFA, displaced intimal calcifications, and displacement of the SFA.
CT-scan and angiograms (Fig. 1) showed a patent, non aneurysmal and severely atherosclerotic SFA, with major calcifications. They also revealed a localised arterial wall rupture, suggested by the displaced intimal calcifications, but they were unable to pinpoint the size and exact localization of the rupture. Proximal and below knee arteries were free of atheromatous stenoses.
Emergency open repair was performed. A prosthetic femoro-popliteal graft was inserted using a lateral approach to the below knee popliteal artery and a sub-cutaneous and extra anatomic route of the graft. We subsequently resected the involved arterial segment and the haematoma through a medial approach once SFA had been excluded by proximal and distal ligatures. Surgical findings revealed a 15
×5mm arterial wall rupture and a compressed to thrombosis superficial femoral vein (Fig. 2). Post operative course was uneventful. Thrombi and arterial wall bacteriological cultures remained sterile. Histological examination showed only atheromatous arterial wall changes with severe calcifications.
Fig. 2
Resected segment of the involved SFA with a 15
×5mm perforation, and adjacent thrombosed superficial femoral vein.
Discussion
Spontaneous perforation of a non aneurysmal atherosclerotic artery is one of the potential fates of penetrating atheromatous ulcer (PAU). This rare arterial pathology is defined as ulceration of an atheromatous plaque that extends through the intima and into the media.1 Its potential outcomes are: infrequent spontaneous resolution, intramural haematoma, progression to dissection in aortic area, formation of pseudoaneurysm and transmural rupture. Hypertension and major arterial wall calcifications seem to be the two most common risk factors. The most common site is the thoracic aorta. PAU of the infra renal abdominal aorta is far less reported. Others locations are exceptional: only one rupture of coronary2 and femoral3 arteries. We report the second case of a spontaneous perforation of a non aneurysmal atherosclerotic femoral artery.
CT scan is useful to diagnose pseudoaneurysm and arterial wall rupture in all cases, since it has revealed haematoma outside the arterial wall and displaced intimal calcifications.
Definitive diagnose requires no previous trauma, sterile arterial wall bacteriological cultures, and severe calcified atherosclerotic arterial lesions in the involved arterial segment.
In case of arterial perforation, both open repair4 and endovascular stent graft placement1, 2 have been described.
We preferred an open repair in our case, as precise localization and size of arterial perforation were not determined by pre operative exams. Furthermore, removal of huge haematoma was required, and we felt that a short graft replacement has better long term results than SFA stenting. Prosthetic graft was preferred to venous bypass because the femoral vein was compressed due to thrombosis and great saphenous vein was compressed and therefore insufficient for a vascular graft. To get vascular graft out of potential mycotic aneurysm, we preferred extraanatomic route.
In such clinical situation, we argue that endovascular stent graft placement may only be considered as an adjuvant procedure, before open repair, to obtain exclusion of arterial perforation: this may reduce blood loss and facilitate dissection. Open repair should remain the gold standard.
Definitive exclusion of arterial perforation by endovascular stent graft placement may be considered as a valued technique in other clinical situations, such aortic rupture. Based on endovascular repair of PAU5 and aortic aneurysms, compared with conventional open surgery, especially for patients at high risk for open surgical repair, endovascular stent graft placement may improve results. This procedure is restricted by pre procedural assessment to reject unsuitable patients: the most excluding criteria may be diameter and stenosis of aorto-iliac arteries, arterial calcifications, visceral and renal arteries patency, atheromatous lesions of proximal neck and distal sealing zone. Careful and indefinite follow up is then required to detect complications.
References
- . Endovascular stent graft placement for non aneurysmal infra renal aortic rupture: a case report and review of the literature. J Vasc Surg. 2003;38:836–839
- . The first spontaneous coronary artery peforation due to disruption of atherosclerotic plaque. Heart Vessels. 2004;19(6):294–296
- . Spontaneous perforation of a non aneurismal atherosclerotic abdominal aorta or femoral artery. Cardiovasc Surg. 1996;4(3):351–355
- . Rupture of a non aneurismal atherosclerotic infrarenal aorta. J Vasc Surg. 1997;26:700–703
- . Multiple penetrating atherosclerotic ulcers of the abdominal aorta: treatment by endovascular stent graft placement. Heart. 2001;85:52
PII: S1533-3167(07)00004-0
doi:10.1016/j.ejvsextra.2007.01.001
© 2007 Elsevier Ltd. All rights reserved.
Refers to article:
- Spontaneous Rupture of a Non Aneurysmal Atherosclerotic Superficial Femoral Artery: A Case Report
