Emergency Percutaneous Endovascular Stenting of a Spontaneous Ruptured Popliteal Aneurysm

Drummond RJ1, Murch C2, Kettlewell S2

Affiliations: 1: Monkland Hospital, Airdrie, Scotland. 2: Hairmyres Hospital, East
Kilbride, Scotland

Correspondance: Mr R Drummond – rdrummond@ntlworld.com

Abstract
Spontaneous rupture of a popliteal aneurysm is a relatively uncommon event with a significant risk of limb loss. The elderly patient with multiple co-morbidities presents a particular risk for surgical intervention in these cases.
In this case we present such a situation successfully treated by endovascular means with a satisfactory outcome.

Case
A 79 year old gentleman was admitted with dehydration and diarrhoea. At the time of admission he was noted to have a tender swollen right thigh which had gradually increased in size over the preceding week. His past medical history was of myocardial infarction, left ventricular hypertrophy, pulmonary hypertension and tricuspid regurgitation. He had been admitted to hospital 3 months previously following a fall down a flight of stairs with notes highlighting a complaint of right leg pain and calf swelling. Plain x-rays performed at the time were normal as were 2 venous duplex scans.

On this admission, he was haemodynamically stable with haemoglobin of 9.0 g/dl (unchanged from the previous admission). On physical examination he was found to have a large tender swelling on the medial aspect of his right thigh principally overlying the right adductor hiatus. Both femoral pulses were palpable with a bruit palpable on the right side. No distal pulses were present on the right. All pulses were present on the Left side, with a small palpable popliteal aneurysm. A 4cm abdominal aortic aneurysm was also palpable examination.

Ultrasound of the right thigh demonstrated a large aneurysm on the medial aspect of the right calf. CT angiogram demonstrated a 12 x 10 cm haematoma medial and posterior to the RSFA in the adductor canal. There was flow of contrast into this haematoma. Distal to this there was a popliteal aneurysm extending over several centimetres to the knee joint.

An urgent angiogram was performed with antegrade puncture of the right CFA. A large false aneurysm was demonstrated distal to the adductor canal with run-off via peroneal and posterior tibial (Fig1). A catheter was passed from SFA into distal popliteal and 3 Fluency stents (Bard Vascular) were deployed (8 x 60mm, 10 x 60mm, 10 x 60mm). Repeat angiogram showed a proximal leak thus a further balloon expandable Jostent (Abbott Vascular) was deployed. A further proximal leak was noted which required a balloon expandable iCAST stent (Atrium Medical) (10 x 60mm) to seal (Fig2).

A repeat CT angiogram was performed 3 weeks following the procedure showing the stents to be patent and intact with no evidence of leak. The leg remained viable throughout the subsequent admission.

Discussion

The popliteal artery is the second most common site of aneurysm formation after the aorto-iliac vessels. 5-10% of those with aortic aneurysms have co-existent popliteal artery aneurysms (PAA). Of patients presenting with PAA, 50% will have a contralateral PAA, and 37% will have a co-existent abdominal aortic aneurysm [1]. Spontaneous rupture of popliteal aneurysms is a relatively rare event, occurring in less than 5% of patients with known popliteal aneurysm [2]. It is often a difficult diagnosis with over 50% having an incorrect diagnosis made at the time of initial referral[3].

Following surgical management in non-ruptured PAA asymptomatic lesions are associated with a significantly higher limb salvage rate and lower amputation rate [4]. Due to the rarity of rupture, little is known regarding outcomes and frequency of complications, however it is expected that limb salvage and patency rates would be similar to those in patients following repair of symptomatic PAA. Several recent series have been published showing the suitability of endovascular stenting as a treatment modality for PAA[5], however, its role in the management following rupture is as yet undetermined.

Although ruptured PAA is an emergency vascular case with a high rate of limb loss, it is not an immediately life-threatening event. Thus the patient is often stable enough to allow for adequate imaging in order to demonstrate the suitability of an endovascular approach.

We have demonstrated that antegrade endovascular stenting of ruptured PAA is technically feasible and may be preferable in patients with multiple medical co-morbidities in order to avoid open exclusion and bypass. This does however rely heavily on the availability of both interventional equipment and expertise on an emergency basis.

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