R. L. Cornell, J. A. Murie
Vascular Surgery Department, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA
Correspondence to: R Cornell, Consultant Vascular Surgeon, Ward 105, Royal Infirmary of Edinburgh, Little France Crescent, Edinburgh EH16 4SA
Email: RachelCornell_505@hotmail.com
SMJ 2006 51(4): 49
Idiopathic aneurysms, occurring at multiple sites throughout the arterial tree, are rare. This report describes a case of multiple asymptomatic arterial aneurysms of uncertain origin, involving the aorta and lower limb vasculature, in a 70 year old man. The clinical presentation, vascular reconstruction and a brief review of the literature are described.
A 70 year old man, presented with rectal bleeding in 1999. This episode was fully investigated, including an abdominal ultrasound scan and an aortic aneurysm (4.2cm) and a right femoral artery aneurysm (2.2cm) were incidentally found. He was referred to the vascular surgery service. He was placed on the aneurysm surveillance programme and was ultrasound scanned every six months. Over time both aneurysms enlarged considerably and a suspicious popliteal pulse was identified. The patient remained entirely asymptomatic.
The aortic aneurysm increased to 6cm in diameter and, in 2003, an elective aorto-bifemoral graft procedure was performed. At this time, it was noted that there was also multiple ectatic vessels throughout the lower limbs. The patient was treated conservatively with respect to these findings. In view of his enlarging right femoral artery aneurysm review continued regularly as an outpatient and, in 2003, palpable popliteal artery aneurysms and a small increase in the size of the right femoral artery were found.
In 2005, magnetic resonance angiography revealed:
Aneurysmal dilation of the left renal artery
Ectasia of the right renal artery
Marked dilatation of the right internal iliac artery to 2.8cm
Aneurysmal dilatation of the left internal iliac
Marked aneursymal dilatation of the right common femoral artery of 3.3cm
Mild aneursymal dilatation of the left profunda
Diffuse ecstasia of both superficial femoral arteries
Mild aneurismal dilatation of both popliteal arteries.
A computerised tomography angiogram also demonstrated multiple renal cysts and a number of small irregularly shaped low attenuation lesions in the liver, not classical of simple cysts.
Right internal iliac 27mm
Left internal iliac 15mm
Right common femoral aneurysm 43mm
Left profunda femoris aneurysm 23mm
Right popliteal aneurysm 32mm
Surveillance continued in clinic until December 2005, when a considerable increase in the size of the right femoral aneurysm and the presence of a smaller left femoral aneurysm were noted. A decision to surgically repair the right femoral aneurysm was followed by an admission in January 2006. The procedure was uncomplicated and the patient was discharged within 3 days.
The patient’s past medical history includes:
Aortic valve replacement, 1986
Rheumatic fever, 1949
Hypertension
Cervical spondylosis
Atrial filbrillation
Graves’s thyrotoxicosis with subsequent hypothyroidism following treatment.
Idiopathic aneurysms occurring at multiple sites throughout the arterial tree are rare. Causes include connective tissue disorders (Marfan's or Ehlers-Danlos), arteritidies (Takayasu’s, polyarteritis nodosa or Kawasaki disease), tuberous sclerosis, trauma and infection. Arteriomegaly is a condition of diffusely enlarged arteries2. One study demonstrated the high incidence of arteriomegaly in patients presenting with femoral artery aneurysms and it also demonstrated that those who present with a femoral artery aneurysm are likely to have multiple aneurysms upon further investigation1.
Diffuse aneurysmal disease is also known as ‘aneurysmosis’, according to the proposal by Trippel, as reported by Beal3. Aneurysmosis is a term that originates from two Greek words: ‘aneurysm’ (dilatation) and ‘osis’ (condition of)4. Aneurysmosis has been classified into three types on the basis of location and extent of aneursymal disease:
Type I: Aneurysms of the aorta, iliac and common femoral arteries, with arteriomegaly of the aorta and popliteal arteries
Type II: Aneurysms of the common femoral, superficial and popliteal arteries, with arteriomegaly of the aorta and iliac arteries
Type III: Aneurysms of the aorta, iliac, femoral and popliteal arteries, with arteriomegaly of the arteries that are not aneurismal4.
Conclusion
Prevention of aneurysm-related complications is the primary goal of vascular reconstruction in these patients. However, repair is not without risk as there exists a high incidence of thrombotic and embolic complications5. The risk of aneurysm-related complications must therefore be compared to the risk of repair for each individual case.
References
Yamamoto N, Unno N, Mitsuoka H, Uchiyama T, Saito T, Kaneko H, Nakamura S. Clinical Relationship Between Femoral Artery Aneurysms and Arteriomegaly. Surgery Today; 32(11): 970-3, 2002.
Lee Thomas M. Arteriomegaly. British Journal of Surgery. 58: 690-694, 1971.
Beal JM. Aneurysmosis. Illinois Medical Journal. 133: 157-160, 1968.
Belardi P, Lucertini G. Regarding ‘Peripheral aneurysms and arteriomegaly: Is there a familial pattern?’ Journal of Vascular Surgery. 30; 3: 581, 1999.
Hollier LH, Stanson AW, Gloviczki P, Pairolero PC, Joyce JW, Bernatz PE, Cherry KJ. Arteriomegaly: classification and morbid implications of diffuse aneursymal disease. Surgery. 93(5): 700-8, 1983.