surgical management of isolated superficial femoral

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Surgical management of isolated supercial femoralartery degenerative aneurysms

Paolo Perini, MD,

a,b

Elixene Jean-Baptiste, MD, PhD,

b

Massimo Vezzosi, MD,

a

Jean-Luc Raynier, MD,

b

Francesca Mottini, MD,a Michel Batt, MD,b Rda Hassen-Khodja, MD,b and Pierfranco Salcuni, MD,a

Parma, Italy; and Nice, France

Objective:To investigate the mode of presentation, diagnosis, association with other aneurysms, operative management,and outcomes of supercial femoral artery (SFA) aneurysms.Methods:Records of all patients who underwent surgery for isolated, true SFA aneurysms (not due to infection, vasculitis,or tissue disorders) from 2002 to 2012 in two European centers were retrospectively analyzed. Demographic (sex, age),clinical (cardiovascular risk factors, location of the aneurysm, symptoms, presentation, emergency setting), surgical andradiological data (diameter, surgical technique, runoff vessels patency, presence of aneurysms elsewhere) were obtainedfor analysis. Follow-up was undertaken with clinical and ultrasound examinations at 1 month, 3 months, 6 months,12 months, and yearly thereafter. The patency of the graft and the status of the anastomoses and inow and outow

vessels were assessed. Main end points were represented by 30 days and long-term mortality and amputation-free survival.Results:A total of 27 cases of SFAaneurysm were analyzed.Mean age at operation was 78 years6 8.5. At presentation, SFA

aneurysms were often symptomatic (rupture was present in 7/27 cases andacutedistal ischemia in 6/27 cases), large (meandiameter,54 mm6 33.1 mm), bilateral (38%of the cases), and associated with aneurysms elsewhere (84%). Sixteen patientsunderwent resection of the aneurysm and polytetrauoroethylene interposition graft, seven patients exclusion of theaneurysm with a femoropopliteal bypass (autogenous bypass in ve cases, prosthetic in two), three patients simple ligation,and one patient underwent primary amputation. Mean follow-up was 41.47 months (range, 0.43-128.67 months). Early(


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isolated, true SFA aneurysms. Thus, patients in which adenitive etiologic factor other than degenerative oratherosclerosis was identieddsuch as false aneurysmssecondary to trauma, anastomotic aneurysms, mycoticaneurysms, vasculitis or connective tissue disordersd

were excluded. Patients with extension of femoral or popli-teal aneurysm into the Hunters canal were consideredfemoropopliteal aneurysms and, therefore, excluded, as

well as patients with a concomitant popliteal artery aneu-rysm with a diameter >20 mm that needed surgical repairat the same time. An aneurysm was dened as an arterialdilatation of two or more times the diameter of thenormalnative blood vessel, as suggested by Jarrett et al.1,6

Demographic (sex, age), clinical (cardiovascular riskfactors, location of the aneurysm, symptoms, presentation,emergency setting), surgical and radiological data (diameter,surgical technique, runoff vessel patency, presence ofaneurysms elsewhere) were obtained for analysis (Table I).

This study was approved by the Ethical Review Board

of our institutions, and written informed consent was ob-tained from all patients.

Diagnostic assessment and surgical management. Allpatients underwent ultrasound examination and computedtomographic angiography (CTA) or digital subtractionangiography (DSA) before surgery, and the diameter andthe localization (proximal, middle, or distal third of theSFA) of the aneurysms were assessed. Diameter measure-ments were recorded as the mean of three measurementsusing CTA (or ultrasound, if the patient underwentDSA), outer wall to outer wall. Runoff vessel patency wasalso analyzed on preoperative imaging.

Each symptomatic patient underwent surgery, and in

such case, the indication was unrelated to the diameter ofthe aneurysm. In asymptomatic cases, surgery was indi-cated when the diameter was $20 mm.

Patients were treated with different surgical techniquessuch as resection/interposition graft, ligation/exclusion

via a femoropopliteal bypass, or simple l igation, dependingon the availability of the great saphenous vein (GSV), condi-tions of the inow and outow vessels, and the operatorspreference.

The presence of aneurysms elsewhere was systemati-cally investigated on preoperative CT scan. If CTA wasnot performed, or considered insufcient for proper inves-tigation, patients underwent supplementary ultrasoundexaminations (contralateral lower limb, abdomen, supra-aortic trunks, and upper limbs) during the postoperativeperiod or during follow-up.

Follow-up.Follow-up wasundertaken with clinicalandultrasound examinations at 1 month, 3 months, 6 months,12 months, and yearly thereafter. The patency of the graftand the status of the anastomoses, and inow and outow

vessels were assessed. Main end points were represented by30 days and long-term mortality and amputation-freesurvival.

Statistics. DatawererecordedandtabulatedinaMicro-soft Excel (Microsoft Corporation, Redmond, Wash)

database. Preoperative results are presented as mean 6 stan-dard deviation (SD) or median with range for continuous

variables, while categorical ones are presented as number(percentage). The homogeneity of the two groups fromthe two hospitals was evaluated by Mann-WhitneyUtestor with the Kruskal-Wallis test (for continuous variables) or

with the c2 or Fischer exact test (in case of dichotomousvariables). Peri- and postoperative results in terms ofmortality, graft patency, and limb loss were determined byunivariate and multivariate logistic regression analysis asappropriate. Long-term results (mortality, graft patency,and amputation-free survival) were analyzed by Kaplan-Meier curves. A P value of


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(68%). SFA aneurysms were bilateral in 38% of the cases(Table III).

Operative data. Aneurysms were treated with severaltechniques. Resection (aneurysmectomy) and polytetra-uoroethylene interposition graft was the most commonprocedure, and it was performed in 16/27 patients. Ifacute ischemia was present (5/27 limbs) and access todistal popliteal artery was necessary to eventually performthrombectomy of tibial vessels prior to revascularization,or if severe atherosclerosis was present in the distal SFAor at the level of the popliteal artery (2/27 limbs), wepreferred to exclude the aneurysm by performing

a femoropopliteal bypass (7/27 limbs). Among these,exclusion of the aneurysm with a femoropopliteal bypassusing the GSV was performed in 5/27 cases. The GSV

was not available or usable in 2/27 cases, therefore, a pros-thetic femoropopliteal bypass was performed.

Three cases underwent simple ligation of the aneurysm,with or without partial resection. We performed this treat-ment in patients at high surgical risk, who presented in anemergency context and if no distal acute ischemia waspresent. At the end of surgery, we systematically checkedif the leg was still well perfused by means of collaterals.

One patient underwent primary major limb amputa-tion resulting from the severity of ischemia on presentation

Fig 1. An 83-year-old man with a ruptured supercial femoralartery (SFA) aneurysm at presentation (patient 24).

Fig 2. Axial computed tomographic (CT) scan of the patientpresented in Fig 1 with a visible and palpable left supercialfemoral artery (SFA) aneurysm measured as 13 cm in diameter.

Table I. Preoperative data of all supercial femoral artery (SFA) aneurysms operated on in our two European centers

VariablesAll

(n 27)Center 1

(n 10; 37%)Center 2

(n 17; 63%) Pvalue

Age, years 78 6 8.5 74 610.2 81 66.4 .045Male sex 27 (100) 10 (100) 17 (100) NA Risk factors

CAD 19 (70) 8 (80) 11 (65) .35COPD 12 (44) 6 (60) 6 (35) .20Diabetes 6 (22) 3 (30) 3 (18) .39Hyperlipidemia 14 (52) 5 (50) 9 (53) .60Hypertension 22 (82) 10 (100) 12 (71) .08Smoking (ongoing) 9 (33) 1 (10) 8 (47) .06

PresentationSigns

Symptomatic 17 (63) 8 (80) 9 (53) .16Emergency 16 (59) 7 (70) 9 (53) .32Rupture 7 (26) 3 (30) 4 (24) .53Ischemia 6 (22) 4 (40) 2 (12) .11

Aneurysm location (right side) 13 (48) 5 (50) 8 (47) .60Aneurysm diameter, mm 54 633.1 51 6 33.3 55 633.9 .92Other aneurysms 23 (85) 7 (70) 16 (94) .13

Runoff vessels .210 4 (15) 3 (30) 1 (6)1 8 (30) 3 (30) 5 (29)2 or 3 15 (55) 4 (40) 11 (65)

CAD,Coronary artery disease; COPD, chronic obstructive pulmonary disease; NA, not applicable.

Continuous data are presented as mean 6 standard deviation and categoric data as number (%).

JOURNAL OF VASCULAR SURGERY

154 Perini et al January 2014


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and the lack of distal targets for revascularization. Nopatients were treated with endovascular techniques.

Early (


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a strong male predilection was calculated (85%)1; the re-ported male preponderance in our series is even greater(100% males). Rigdon et al noted that patients presenting

with popliteal or CFA aneurysms were younger thanpatients with SFA aneurysms.14 Pulli et al reporteda mean age of 68 years in their popliteal artery aneurysmseries, whereas we reported a mean age of 78 years inour SFA aneurysm series.15

Although popliteal and CFA aneurysms are most oftenidentied in an asymptomatic state, the majority of SFAaneurysms present with symptoms.1,16 Jarrett et al reported76% of symptomatic patients presenting with either limb-threatening ischemia or painful thigh mass, and even higherrates are described by other authors.6,17 In our series, SFAaneurysms were symptomatic in 63% of the cases. Theincreased number of asymptomatic SFA aneurysms in ourstudy may be due to the advancement in medical imagingtechnology that allows a smaller number of lesions toremain undetected.

The rst symptom is most frequently rupture (26% vs3% for popliteal aneurysms),5 followed by acute ischemia

(22% in our series). Other reported symptoms are the pres-ence of a pulsatile mass in the thigh, pain, DVT, lower limbedema, claudication, or bruising.10,18 The high incidenceof complications suggests that repair should be performedelectively when possible.

SFA aneurysms were frequently located in the distalthird of the artery (59%). Most often, the aneurysm seemedto be focal and rarely involved a long segment of the artery.These results are in agreement with previously reportedstatistics.1

A total of 84% of our patients presented with aneu-rysms elsewhere with a predominance of abdominal aorticaneurysms. SFA aneurysms were bilateral in 38% of thecases. For these reasons, we suggest that patients diagnosed

with SFA aneurysms should be systematically evaluatedwith ultrasound and/or CTA for other aneurysms at thetime of diagnosis and/or follow-up.

In the literature, the most often-reported diagnostictool is DSA.1 However, this is not only an invasive exami-nation bringing additional risks to these frail patients, but italso tends to underestimate the true size and the true inci-dence of the aneurysm (for instance, a presumed occlusionof an atherosclerotic SFA could be the result of a throm-bosed aneurysm). CTA can be performed in an emergency

Fig 3. Sixty-month estimated survival for all the supercial femoralartery (SFA) aneurysm population.

Fig 4. Sixty-month estimated limb salvage for all the supercialfemoral artery (SFA) aneurysm population.

Fig 5. Sixty-month estimated primary patency for all the supercialfemoral artery (SFA) aneurysm population that underwent bypasssurgery or interposition graft.

Table IV. Case series (>three patients) and case reportsreported in literature

Author YearNo. of

patients

Piffaretti etal5 2011 6Jarrett et al8 2002 13Kremen etal16 1981 8Cutler et al11 1973 5Case reports (no. of patients #3)1,7,8 1967-2011 44Present study 2012 27

Total 103


156 Perini et al January 2014


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context, shows the real diameter, length, and shape of theaneurysm, and provides information about the runoffstatus. Furthermore, it can be easily used to size the endog-raft if endovascular exclusion is planned. For these reasons,

we recommend CTA as the rst-choice diagnostic tool. Itis also important to note that sometimes diagnosis canonly be made during surgical exploration.19

The indications for repair of SFA aneurysms follow thesame principles applicable to the repair of aneurysms in anyother location: remove the embolic source, prevent or treatrupture, eliminate any mass effect, and restore limb perfu-sion.1 Repair is indicated for every symptomatic case, butthere is no agreement on asymptomatic cases.1,12,20,21

No specic aneurysm diameter has been identied at whichthe incidence of complications dramatically increases. Wesuggest treating an asymptomatic aneurysm of the SFA ifits diameter is $20 mm, if surgical risk is not elevated,and if the aneurysm is known to have been enlarged, since

we noticed that even small aneurysms had high complica-

tion rates in our series. Other authors, however, proposedto wait until the diameter reaches 25 mm.1

The excision of the aneurysm (aneurysmectomy) andthe reconstruction using prosthetic grafts were the mostcommon surgical treatments performed in our institutions(59%). This was our rst-choice technique, and it was used

when the SFA aneurysm was large, easily dissectible fromsurrounding tissues, or causing compression on veins and/or nerves or, above all, if no distal abnormality was present.If acute ischemia was present and access to the distal popli-teal artery was required to perform thrombectomy of tibial

vessels prior to revascularization, we preferred to excludethe aneurysm by performing a femoropopliteal bypass. In

this situation, our preference is to use autologous longsaphenous vein. Primary amputation is rarely necessary (4%in our series). Similar results are reported in the literature.1

Endovascular treatment has been reported only threetimes: two patients described by Diethrich et al and onepatient by Troitskii et al.22,23 Unfortunately, follow-up isunavailable for these cases, and no patient was treated

with endovascular techniques in our series. At present,therefore, no conclusion can be drawn. Finally, simple liga-tion of the aneurysm can be an option in vascular emergen-cies if no distal ischemia is present, and thelimb remains

viable despite the occlusion of the SFA.4,7,12

Despite their rarity and the frequent presentation in anemergency context with rupture or thrombosis, outcomesare typically favorable; the resection of the SFA aneurysmis easily accomplished in most of the cases, and the recon-struction can often be performed with a prostheticgraft.1,6,12,17 The estimated 5-year limb salvage rate andgraft patency rate are 88% and 85%, respectively.

Estimated 6-month and 12-month survival rates are88% and 84%, respectively. Nevertheless, the estimated5-year survival rate descends to 62%, signicantly lower ifcompared with thepopulation affected by popliteal arteryaneurysms (84%).15 This may be due to the fact that thepopulation affected by SFA aneurysms is signicantly olderat the time of operation.

Providing the largest case series ever published in liter-ature, this study suggests that degenerative SFA aneurysmsbehave differently than other lower extremity aneurysms.However, the treatment of these rare lesions is usuallyfeasible, and long-term outcomes are good.

CONCLUSIONS

True aneurysms of the SFA are rare. At present, there-fore, the natural history of these lesions is not well known.To date, only 76 SFA aneurysms have been reported in theliterature, and the most are small case series or case reports.Our study identied 27 additional cases, providing thelargest data collection ever reported in the literature.

SFA aneurysms are different from other peripheralaneurysms. In fact, they are often undetected and tend tobe large and symptomatic with rupture or ischemia atpresentation. These lesions preferentially affect elderlymen (in contrast to popliteal artery aneurysms) and aremost often located in the distal third of the artery. Thefrequent association with aneurysms elsewhere imposesa complete investigation at the time of diagnosis and a strictfollow-up for the surveillance of the appearance of otheraneurysms.

Aneurysmectomy and reconstruction with a prostheticgraft is the most performed treatment for this type oflesion, followed by exclusion with surgical bypass. Simpleligation should be reserved in vascular emergencies insome situations. Endovascular repair could be a valid alter-native, but the literature on this technique is too scant, andfurther studies are encouraged.

Even if SFA aneurysms are operated on in an emer-gency context, outcomes are usually good with an early

mortality of 4% and an estimated limb salvage rate at 5 yearsof 88%. The 62% estimated 5-year survival rate reects theold age of the population affected by this pathology(78 years old at the time of diagnosis).

AUTHOR CONTRIBUTIONS

Conception and design: PP, EJB, MV, RHK, PSAnalysis and interpretation: PP, EJB, MV, JR, FM, RHK, PSData collection: PP, MV, JR, FM

Writing the article: PP, EJB, FM, MB, RHK, PSCritical revision of the article: PP, EJB, JR, MB, RHK, PSFinal approval of the article: PP, EJB, MB, RHK, PSStatistical analysis: PP, EJB

Obtained funding: Not applicableOverall responsibility: PP

REFERENCES

1. Leon L Jr, Taylor Z, Psalms SB, Mills J Sr. Degenerative aneurysms of

the supercial femoral artery. Eur J Vasc Endovasc Surg 2008;35:

332-40.

2. Baird RJ, Gurry JF, Kellam J, Plume SK. Arteriosclerotic femoral artery

aneurysms. Can Med Assoc J 1977;117:1306-7.

3. Graham LM, Zelenock GB, Whitehouse W Jr, Erlandson EE,

Dent TL, Lindenauer SM, et al. Clinical signicance of arteriosclerotic

femoral artery aneurysms. Arch Surg 1980;115:502-7.

4. Hardy DG, Eadie DG. Femoral aneurysms. Br J Surg 1972;59:614-6 .


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surgical management of isolated superficial femoral

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