Profunda femoris artery aneurysm (PFAA) is an extremely rare entity, with most cases being asymptomatic, which makes obtaining an early diagnosis difficult. We herein report a case series of PFAA, in which more than half of the PFAAs, which presented with no clinical symptoms, were discovered incidentally. All PFAAs were treated surgically with aneurysmectomy with or without vascular reconstruction. In cases involving a patent superficial femoral artery (SFA), graft replacement of the profunda femoris artery (PFA) is not mandatory; however, preserving the blood flow of the PFA is necessary to maintain lower extremity perfusion in patients with occlusion of the SFA. Therefore, the treatment of PFAAs should include appropriate management of both the aneurysmectomy and graft replacement, if possible.
Profunda femoris artery aneurysm (PFAA) is an uncommon condition, accounting for only 0.5% of peripheral aneurysms and only 1–2.6% of all femoral artery aneurysms [
A retrospective review was performed on all patients with a diagnosis of PFAA who underwent surgical treatment at Tokyo Medical and Dental University Hospital between January 2005 and December 2014. All subjects provided their informed consent, and approval was obtained from our Institutional Review Board for a retrospective review of the patients’ medical records and images. The inclusion criterion was aneurysmal dilatation of a PFA of more than 20 mm, based on preoperative imaging findings. Cases of pseudoaneurysms of PFAA due to trauma were excluded, and only true aneurysms were included. The medical records were abstracted to include basic demographic information, preoperative symptoms, aneurysm size measurements, intraoperative findings, perioperative complications, and long-term imaging findings. The characteristic features of the patients are given in Table
Patients characteristics.
Pt | Gender | Age | PFAA | Clinical symptoms | Diagnostic modality | Other aneurysms | Comorbidity | |
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Laterality | Size (mm) | |||||||
1 | M | 76 | Rt | 45 × 40 | None | MRI, angiography | AAA | HT, Af, CHF, smoker |
2 | F | 69 | Bil | (Rt) 25 × 22 |
(Rt) None |
CT | Bil CFAA | Smoker |
3 | M | 73 | Rt | 25 × 22 | None | CT | TAA, AAA, Bil CIAA | HT, smoker |
4 | F | 65 | Rt | 26 × 25 | None | US, CT | None | Smoker |
5 | M | 70 | Lt | 86 × 78 | Pulsatile mass, pain | CT | None | HT, smoker |
A 76-year-old asymptomatic male presented for follow-up magnetic resonance imaging (MRI) after open surgical repair of an abdominal aortic aneurysm (AAA). MRI showed a PFAA measuring 45 × 40 mm on the right side of the thigh. The aneurysm was successfully resected under general anesthesia without vascular reconstruction, as the superficial femoral artery (SFA) was patent, and the distal portion of the PFA was very small, making it unsuitable for revascularization. The patient’s postoperative course was uneventful, and the postoperative ankle brachial pressure was within the normal limits without any lower limb ischemia.
A 69-year-old female presented with pain and swelling of the left thigh. Computed tomography (CT) showed a left PFAA measuring 34 × 24 mm. Furthermore, CT detected a right PFAA measuring 25 × 22 mm, without clinical symptoms, and the bilateral common femoral arteries (CFAs) showed aneurysmal changes (Figure
Computed tomography showed bilateral common femoral artery aneurysms (a) and bilateral profunda femoris artery aneurysms (b).
A 73-year-old asymptomatic male presented for follow-up CT after open surgical repair of AAA and bilateral common iliac artery aneurysms and an assessment of an untreated thoracic artery aneurysm measuring 40 mm in size. CT exhibited a PFAA measuring 25 × 22 mm on the right side of the thigh (Figure
(a) Preoperative computed tomography exhibited a 22 mm right profunda femoris artery aneurysm with an intraluminal thrombus. (b) Postoperative computed tomography revealed a patent replaced prosthetic graft (white arrow).
A 65-year-old asymptomatic female presented for the ultrasonography to evaluate the varicose vein. US showed the 25 mm sized mass on her right groin. Further contrast enhanced CT scanning showed the right PFAA measuring 26 × 25 mm. Under general anesthesia, the SFA and the proximal and distal part of PFAA were well controlled; the aneurysmectomy was successfully performed with the interposed 8 mm prosthetic graft placed between the proximal and distal PFA (Figure
(a) The intraoperative findings showed the controlled profunda femoris artery (black arrow) and superficial femoral artery (white arrow), and (b) the aneurysmectomy was performed with graft interposition (black arrow). The patient’s head was to the right.
A 70-year-old male presented with a palpable mass and pain in the left thigh. Contrast enhanced CT revealed a left PFAA measuring 86 × 76 mm (Figure
Computed tomography showed a 78 × 86 mm left profunda femoris artery (PFA) (a), which extended to the distal part of the left PFA (white arrow) (b).
Surgical procedures and intra- and postoperative findings.
Pt | Surgical procedure | Conduit | Operative time (min) | Intraoperative blood loss (mL) | Pathology |
---|---|---|---|---|---|
1 | Aneurysmectomy | None | 149 | 122 | Degenerative |
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2 | (Rt) Aneurysmectomy + revascularization |
(Rt) 8 mm ePTFE + 6 mm ePTFE |
210 | 502 | (Rt) Degenerative |
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3 | Aneurysmectomy + revascularization | 8 mm Dacron | 87 | 15 | Degenerative |
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4 | Aneurysmectomy + revascularization | 8 mm ePTFE | 130 | 86 | Degenerative |
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5 | Aneurysmectomy | None | 81 | 594 | Degenerative |
Postoperative and long-term follow-up results.
Pt | Postoperative morbidity | Postoperative (<30 days) mortality | Follow-up (month) | Limb ischemia | Graft patency |
---|---|---|---|---|---|
1 | None | Alive | 8 | None | — |
2 | None | Alive | 76 | None | Patent |
3 | Wound infection, relief | Alive | 18 | None | Patent |
4 | None | Alive | 12 | None | Patent |
5 | None | Alive | 35 | None | — |
A total of six PFAAs were resected in five patients. The mean operative time was 130 minutes (range: 81–210 minutes) and the mean amount of intraoperative blood loss was 122 mL (range: 15–594 mL); therefore, none of the patients required a blood transfusion. Four of the six PFAAs were interposed with a prosthetic graft, and, in case 2, the bilateral PFAAs and CFAAs were resected simultaneously with revascularization. Two of the six PFAAs were treated with ligation without revascularization because the distal part of each PFAA was located too far to achieve revascularization. The pathological findings of the resected aneurysms showed degenerative and atherosclerotic changes in all six PFAAs.
None of the patients exhibited lower limb ischemia after the surgical procedures and all were discharged successfully. During the long-term follow-up period (median: 18 months, range: 8–76 months), no patients presented with signs of lower limb ischemia, and all of the interposed grafts remained patent.
Previous reviews of published cases have indicated that patients with PFAA often have synchronous aneurysms, occurring in 65–75% of cases, including AAA and popliteal artery aneurysms [
It has been reported that PFAAs are much more common in males (92–100%) than in females, and most PFAAs are discovered in the sixth to seventh decades of life [
Although patients with PFAAs usually remain asymptomatic and the lesions are discovered incidentally, such patients may present with symptoms related to local compression, thrombosis, or embolism, with consequent rupture. Compression-related symptoms include groin swelling, pain, and pulsatile masses [
Following the diagnosis of PFAA, elective surgical repair is recommended whenever the patient’s general condition allows for surgical intervention [
The aim of surgical treatment for PFAAs is to eliminate the risk of complications, including distal ischemia and rupture, and maintain perfusion to the lower extremities. Therefore, surgical repair consists of aneurysmectomy with or without graft replacement [
In conclusion, we herein reported a case series of PFAAs treated surgically with aneurysmectomy with or without graft replacement. Providing an early diagnosis and surgical treatment is necessary to prevent complications, and reconstruction of the PFA is recommended, unless the SFA is patent and performing graft replacement is technically difficult.
Kimihiro Igari and the other coauthors have no conflict of interests to declare.