“Bill's Bulge” – a 14.5
cm Femoral Aneurysm Case Report and Literature Review
Article Outline
Abstract
Introduction
True femoral aneurysms are a rare but important cause of groin swelling.
Report
We report a 79 year-old male, presenting with intermittent claudication and leg oedema after 25 years of a growing left groin swelling. On examination the mass was 14.5cm in diameter and pulsatile with an audible bruit. Distal pulses were absent. Perfusion was restored by interposition of a PTFE graft between CFA and PFA.
Discussion
This case presents the largest reported true common femoral aneurysm. Conventional open repair is recommended when diameter exceeds 2.5cm. Although endovascular techniques are evolving, they were not possible in this case.
Keywords: Femoral, Aneurysm, Swelling, Open repair
Introduction
An aneurysm is defined as a balloon-like dilatation of a blood vessel resulting from vessel wall weakness caused by disease or trauma. Common sites for the development of aneurysms include the circle of Willis and abdominal aorta (AAA) but they may also arise in femoral, popliteal and brachial arteries. True aneurysms involve all three layers of the vessel wall while pseudoaneurysms usually consist of a single fibrous layer that harbours pulsating haematoma. True femoral aneurysms are rare, risk factors for their development are age, smoking, male sex, other peripheral aneurysms and associated atherosclerosis.1 Other rare causes of true femoral aneurysm include Marfan's syndrome, vasculo-Behcet's disease and acromegaly.
Case Report
A 79-year-old Caucasian male presented with a 25-year history of left-sided true femoral aneurysm measuring 14.5cm (Fig. 2 C) associated with limb oedema and intermittent claudication. The patient delayed medical consultation because he was initially asymptomatic, and did not want doctors “cutting him about”. However with on going expansion the aneurysm started to cause difficulty in walking and sitting. The title “Bill's bulge” was actually suggested by the patient himself (Fig. 1 A, B). On examination, it was pulsatile with a bruit but no distal pulses were palpable.
Figure 1
Bill's Bulge. External appearance - anterior view (A) lateral view (B). PTFE graft in situ (C) and after skin closure (D).
Figure 2
CT images of the femoral aneurysm. Coronal view (A), Sagittal view (B), Cross-section view (C), 3-D reconstruction (D).
CT angiogram (CTA) confirmed the diagnosis of true femoral aneurysm (Fig. 2 A, B) and also demonstrated an infra-renal abdominal aortic aneurysm with a diameter of 5.4cm (Fig. 2 A, B, D). During repair, the aneurysm was exposed with a vertical skin incision over the swelling. The external iliac artery (EIA) was accessed through a separate transverse incision in the left iliac fossa using an extraperitoneal approach. Dissection around the aneurysm was particularly challenging due to size, distorted anatomy and calcification. Incision of aneurysm after clamping EIA and SFA revealed totally occluded SFA and back bleeding from two PFA branches that was controlled by Fogarty catheters. An 8mm PTFE graft (IMPRA Carboflo®) was stitched to the orifice of the PFA branches using 3/0 Prolene and to the femoral inflow with 4/0 Prolene (Fig. 1 C). The aneurysm sac and skin were closed with Vicryl and metal clips respectively (Fig. 1 D). Recovery was delayed by a lymph leak which reduced in volume after 10 days allowing discharge.
Discussion
Femoral artery aneurysms are uncommon and to our knowledge this is the largest reported case of CFA aneurysm in the literature. Previously, CFA aneurysms up to 8cm have been reported,2 while a recent review has reported the mean diameter of SFA aneruysms to be 8.4cm (range 3-24cm).3 The mean diameter of the femoral artery is 0.98cm in males and 0.82cm in females.4 Most authors suggest elective repair of femoral aneurysms if the arterial diameter exceeds 2.5cm, to avoid complications like thromboembolism, limb ischaemia, and rupture. The conventional treatment of femoral aneurysms is open repair joining distal external iliac artery or proximal CFA to the distal CFA with Dacron or polytetrafluoroethylene (PTFE) grafts above the CFA bifurcation. When the CFA bifurcation is involved it is imperative to preserve patency of the profunda which may require a branched graft. If the SFA is occluded, the CFA can be anastamosed to the PFA. Alternatively, a bypass from the CFA to the popliteal or tibial vessels may be considered.
Endovascular femoral aneurysm repair is evolving but the main limitation of this method is the close proximity of femoral aneurysms to the inguinal ligament and hip joint. This may result in compression of the stent during movement leading to early or delayed graft thrombosis, device migration and/or fracture.
Femoral aneurysms are commonly associated with multiple aneurysms at other sites such as popliteal artery, aorta and contralateral femoral artery.5 It is therefore imperative that patients presenting with femoral aneurysms are investigated for aneurysms elsewhere. Death from ruptured AAA has been reported when the repair was deferred to treat femoral aneurysm first,5 although the extreme nature of “Bill's Bulge” necessitated urgent femoral repair prior to aortic intervention.
Conflict of Interest
None.
References
- . Arteriosclerotic femoral artery aneurysms. A short review. J Cardiovasc Surg (Torino). 1997;38(4):335–338
- . Common femoral artery–uncommon aneurysms. Scand J Surg. 2003;92(3):203–205
- . Degenerative aneurysms of the superficial femoral artery. Eur J Vasc Endovasc Surg. 2008 Mar;35(3):332–340
- . The diameter of the common femoral artery in healthy human: influence of sex, age, and body size. J Vasc Surg. 1999;29(3):503–510
- . Surgical management of arteriosclerotic femoral aneurysms. Surgery. 1973;74(5):764–773
PII: S1533-3167(09)00034-X
doi:10.1016/j.ejvsextra.2009.09.006
© 2009 European Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.
Refers to article:
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“Bill's Bulge” – a 14.5cm Femoral Aneurysm Case Report and Literature Review
, 21 January 2010
