Endovascular Stent Graft Management of a Ruptured Profunda Femoris Artery Aneurysm

Introduction 

We describe the first reported case of a ruptured profunda femoris artery (PFA) aneurysm managed successfully with an endovascular stent graft.

Report 

An 87-year-old man presented with pain and swelling in his right thigh resulting in impaired mobility. There was no history of any injury. He was an ex-smoker. His past medical history included hypertension and recurrent suspected deep venous thrombosis for which he was being anticoagulated with warfarin. On examination there was diffuse ecchymosis and a pulsatile swelling in his right thigh. The femoral and popliteal pulses were palpable but the posterior tibial and dorsalis paedis pulses were absent, although, the foot was warm and well perfused. Blood test results revealed an INR of 4.7 and deteriorating renal function. The haemoglobin dropped from 11.2 g/dL to 8.0 g/dL within 24 h of admission. Plain x-rays demonstrated a calcified superficial femoral artery but no other significant abnormality. An ultrasound scan showed a large complex mass measuring 5 cm × 5 cm in the right upper thigh. This had a mixed reflectivity and demonstrated turbulent flow on Doppler. It was considered to represent an aneurysm containing some thrombus. A right femoral angiogram was performed confirming a large saccular aneurysm arising from the mid PFA with contained rupture in the mid thigh (Fig. 1). Significant atherosclerotic disease was also noticed. There was a very tight stenosis from an atheromatous plaque proximal to the aneurysm requiring balloon dilatation to 5 mm prior to deploying a 6 × 100mm Viabahn stent graft (W L Gore & Associates). This was seen to be well sited with successful exclusion of the aneurysm and good flow of contrast into the distal PFA on conventional angiography (Fig. 2). The access site was closed successfully with Angio-seal (St. Jude Medical) despite an INR of over 4. The patient made a good recovery post procedure with an improvement in his renal function and steadily increasing mobility.

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Figure 1 Right femoral angiogram showing the ruptured mid PFA aneurysm.

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Figure 2 Right femoral angiogram post endovascular stent graft deployment with good flow of contrast into the distal PFA.

Discussion 

Aneurysms of the PFA are rare with pseudoaneurysms being much more frequent than true aneurysms. Pseudoaneurysms are usually secondary to fractures or orthopaedic operations and occasionally secondary to penetrating or blunt injuries or arterial catheterisation. Less than seventy cases of true aneurysmal dilatation of the PFA have been previously reported. In our case the absence of any history relevant to a pseudoaneurysm and the angiographic findings make us believe that this was most likely a true aneurysm.

Rupture is a common presentation of PFA aneurysms. In the only case series of PFA aneurysms the incidence of rupture was 13%.1 A literature review of case reports of PFA aneurysms demonstrated a high incidence of rupture at 44%; this was probably the result of publication bias. PFA aneurysms tend to be larger at presentation than superficial femoral artery (SFA) aneurysms. The reported size of PFA aneurysms at presentation is 1.8–7.4cm.2 The diameter of ruptured PFA aneurysms has been reported to range between 1.5 and 7.5cm.1 It has been proposed that because size alone may not be an adequate predictor of rupture, low risk patients with PFA aneurysms over 2 cm should have elective repair.1

The standard treatment of PFA aneurysms is open surgery in the form of either ligation or vascular reconstruction.2 Ligation is simpler but has a higher risk of subsequent major amputation in the presence of significant atherosclerotic disease of the superficial femoral artery (SFA). In the presence of rupture, reconstruction is much more difficult and ligation is usually preferable. Our patient's significant co-morbidities rendered him a poor candidate for conventional open surgery.

There are two studies of true PFA aneurysms managed successfully with endovascular coil embolisation.3, 4 There are several other reports of PFA pseudoaneurysms being treated with various embolisation techniques.5 Unless selective aneurysm ablation with distal PFA preservation can be accomplished, embolisation may not be appropriate in the setting of pre-existing occlusive disease of the SFA.4 Given the elevated INR and active bleeding in our case, coil embolisation was deemed unlikely to rapidly achieve haemostasis. An endovascular stent graft was therefore chosen as the most appropriate treatment option.

To the authors knowledge this is the first reported case of a successful exclusion of a PFA aneurysm by endovascular deployment of a stent graft. This case demonstrates that PFA aneurysms, when ruptured, can be managed successfully by endovascular stent graft in the high-risk patient.

Conflict of Interest/Funding 

None.