A 54-Year-Old Man Who Developed a Femoral Pathologic Fracture from a Giant Popliteal Artery Pseudoaneurysm 7 Years After Ligation and Bypass of a Popliteal Artery Aneurysm: A Case Report and Literature Review.

BACKGROUND This case report describes a giant pseudoaneurysm that grew in size during the years following surgical treatment of a popliteal artery aneurysm, eventually causing a femoral fracture. Bone fractures secondary to vascular injuries are rarely described in the literature. CASE REPORT A 54-year-old man underwent surgical ligation and bypass for left popliteal artery aneurysm. Seven years later, he suffered a left distal femur pathologic fracture surrounded by a giant soft-tissue mass. The patient came to us with a diagnostic hypothesis of angiosarcoma from another hospital at imaging evaluation. After computed tomography angiography (CTA) and angio-magnetic resonance imaging (MRI), we made a diagnosis of femoral pathologic fracture caused by a giant pseudoaneurysm of a treated popliteal artery aneurysm refilled by an aberrant anterior tibial artery (IIA2, Kim classification). We performed excision of the mass and open reduction and internal fixation, with anatomic plate, of the fracture. Fracture healing and good functional outcome were observed at follow-up. CONCLUSIONS A possible complication of surgical treatment of popliteal artery aneurysms is refilling of the excluded aneurysm due to collateral blood flow or, such as in the present case, aberrant vessels. Therefore, the knowledge of anatomical variants of the vessels is important in surgery. Follow-up evaluation after surgery is advisable and a growing mass should be further investigated with an angio-CT scan. In case of a non-pulsating soft-tissue mass causing pathologic bone fracture, a biopsy is mandatory to exclude malignancy.

A comparative analysis of anatomical variations of popliteal artery and its branches in concomitant aneurysmal disease.

OBJECTIVES: Open or endovascular treatment of popliteal artery aneurysms (PAAs) is still debated. Data about the popliteal artery anatomy and its branches are essential to plan a surgical approach. The aim of this study was to report the anatomical variations of the popliteal artery and its branches in a population with aneurysmal disease and compare them with a standard population with non-aneurysmal disease. METHODS: A retrospective review of consecutive patients who underwent surgical PAA repair in our center between January 2011 and December 2020 was performed. One-hundred-forty-six limbs in 128 patients underwent PAA treatment (Group 1). Computed tomography angiography images using a 128-section configuration were reviewed for anatomical variations of the popliteal artery and its branches. A control population of 178 limbs in 89 patients with non-aneurysmal disease was used to compare the outcomes (Group 2). All limbs were classified according to Kim's classification. The two groups were analyzed and compared by means of nonparametric Pearson chi-square test. RESULTS: Both groups were homogeneous in terms of demographics, risk factors, and clinical presentation. In Group 1, the limbs with PAA were classified as type IA, 133 (91.1%); type IB, 2 (1.4%); type IC, 0; type IIA1, 1 (0.7%); type IIA2, 1 (0.7%); type IIB, 4 (2.7%); type IIC, 0; type IIIA, 3 (2.1%); type IIIB, 0; and type IIIC, 2 (1.4%). In Group 2 the limbs with non-aneurysmal disease were classified as type IA, 163 (91.6%); type IB, 5 (2.8%); type IC, 1 (0.6%); type IIA1, 1 (0.6%); type IIA2, 3 (1.7%); type IIB, 2 (1.1%); type IIC, 0; type IIIA, 3 (1.7%); type IIIB, 0; and type IIIC, 0. No difference in terms of anatomy of the popliteal artery and its branches was found between the two groups (P = NS). CONCLUSIONS: Knowledge of anatomical variations of the popliteal artery and its branches is mandatory in case of the surgical approach. Anatomy in PAA patients is not different. Studies with larger population size are needed to validate these outcomes.

Stability of the aneurysmatic sac post-EVAR could no longer be a reliable criterion of healing.

BACKGROUND: Evaluation of the impact of aneurysm sac behavior in terms of either stability or shrinkage after endovascular aneurysm repair (EVAR) on long-term clinical outcomes. METHODS: A retrospective study was conducted on 1483 consecutive patients who underwent EVAR from 1999 to 2021 at our institution. 1037 patients met inclusion criteria (1037/1483, 69.9%): abdominal aortic or aorto-iliac aneurysm, elective surgery, follow-up (FU) ≥12 months. Patients who had sac stability (330/1037, 31.8%) and patients who demonstrated sac shrinkage (542/1037, 52.2%) at FU were compared; patients who presented sac increase at FU were excluded (165/1037, 16%). PRIMARY ENDPOINTS: rupture rates, need for surgical conversion, and long-term aneurysm-related mortality. Secondary endpoints: all type endoleak rates and long-term reintervention rates. RESULTS: Mean FU was 61.2 months (IQ 26-85.7 months). In terms of comorbidities, the group of patients with stable sac showed greater association with polidistrectual atherosclerotic manifestations. Estimated 12-year survival was 42.9% in the stable sac group and 65% in the shrinked group (P<0.001), although there were no significant differences in terms of freedom from aneurysm-related death (97.3% vs. 95.4% estimated at 12 years, P=0.493). Patients with sac stability had higher rates of rupture (2.1% vs. 0.6%, P=0.035) and surgical conversion (2.1% vs. 0.6%, P=0.035). The stable sac group had significantly higher rates of all type endoleak during FU (45.8% vs. 24%, P<0.001). Estimated 12-year freedom from reintervention rates were 56.2% and 83.9% respectively (P<0.001). CONCLUSIONS: After more than 20 years of EVAR experience it is probably time to reconsider the procedure clinical success parameters as a patient with a stable sac cannot be considered healed.

Extravascular risk factors in the prognostic evaluation for spinal cord injury during thoraco-abdominal aortic aneurysm exclusion: a case report.

BACKGROUND: The etiology of delayed-onset spinal cord injury (SCI) following endovascular repair of thoraco-abdominal aortic aneurysms (TAAA) is still unclear and may be related to multiple factors. Extravascular factors, such as lumbar spinal stenosis (LSS), may play a significant role in the selection of patient at risk of SCI. In this report we describe a case of paraplegia following thoracic endovascular aortic repair (TEVAR) in a patient suffering from severe and symptomatic LSS and undergoing staged endovascular repair of a TAAA. CASE PRESENTATION: A 70-year-old man was admitted to our department with an asymptomatic type III TAAA in previous open repair for abdominal aortic aneurysm. The patient complained of buttock and thigh claudication in the absence of defects in the pelvic perfusion; a spinal magnetic resonance angiography (MRA) showed a severe narrowing of the lumbar canal.. After 24 h from first-step procedure (TEVAR) paraplegia was detected. A cerebrospinal fluid (CSF) drainage was then placed with incomplete recovery. CONCLUSIONS: Stenotic damage to the spinal cord is thought to be the result of direct compression of the neural elements and ischemic disruption of arterial and venous structures surrounding the spinal cord. This comorbidity may constitute an additional anatomic risk factor in those patients currently recognized as prognostically associated to the development of SCI.