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  • True aneurysms: Involves all 3 layers of vessel wall

    False aneurysm (pseudoaneurysm): Disruption of artery causing contained hematoma confined by fibrous capsule

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Lower Extremity

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  • • 70% of peripheral aneurysms are of popliteal artery; femoral artery next most common site

    • Persistence of sciatic artery

    • -Rare anomaly

      -Large embryonic sciatic artery (originates from internal iliac artery) communicates directly with popliteal artery;

      -Propensity for aneurismal degeneration

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Upper Extremity

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  • • Subclavian artery aneurysms: Rare

    • -Several causes: Pseudoaneurysms from drug addict injections increasing, poststenotic dilation from patient with cervical rib or thoracic outlet syndrome, congenital variant with aberrant artery arising from proximal descending thoracic aorta (Kommerell's diverticulum)

    • Radial artery pseudoaneurysms: Increased as a result of increased radial artery catheters, occasionally infected

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Epidemiology

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  • • 0.5-6% incidence of pseudoaneurysm of femoral artery after puncture

    • Popliteal aneurysms bilateral in 50%

    • 33% of patients with popliteal aneurysm have AAA

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Symptoms and Signs

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  • • Usually minimal until progressive thrombosis, stenosis occurs

    Femoral: Throbbing mass in groin often present

    Popliteal: Usually asymptomatic

    • -First symptom often acute ischemia

      -Thrombosis, peripheral embolization cause acute ischemia

      -Occlusion may occur from fragmentation of mural thrombus

      -Thrombus may occlude lumen of aneurysm or embolize

      -Can progress rapidly to gangrene

      -Recurrent embolization presents with sudden ischemia of toe or foot with gradual resolution

      -Popliteal aneurysms rarely cause symptoms from compression of vein or tibial nerve

      -Palpation suggests diagnosis

    Persistent sciatic artery aneurysms: Painful, pulsatile buttock mass

    Subclavian: Emboli to fingers, dysphagia lusoria (difficulty swallowing)

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Imaging Findings

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  • • US confirms size, diagnosis, flow

    • Arteriography advised before operation

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  • • Evaluate for multiple sites of aneurysm

    • Evaluate for distal ischemia or embolus

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  • • US confirms diagnosis

    • Arteriography may not demonstrate aneurysm but is advised before operative repair to define distal arteries

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  • • Immediate operation or thrombolytic therapy indicated when pregangrenous

    • Femoral pseudoaneurysm treated with US-guided compression

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Surgery

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  • Femoral artery: Replace diseased segment

    Popliteal artery: Exclude and bypass with saphenous vein

    Sciatic nerve: Exclude aneurysm and bypass with saphenous vein

    Subclavian: Resect first rib or cervical rib, divide scalenus anterior, replace aneurysm with graft

    Radial pseudoaneurysm

    • -Normal Allen test, excise and ligate

      -Abnormal Allen test, reconstruct artery

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Indications

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  • • Pregangreneous ischemia

    • Recurrent peripheral embolization

    • Symptomatic aneurysm

    • Asymptomatic aneurysm 3 × normal diameter

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Medications

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  • • Thrombolytics for occluded popliteal aneurysms should be considered

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Prognosis

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  • • Depends on outflow tract

    • Late graft failures less common than operations done for peripheral vascular occlusive disease

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References

Diwan A et al. Incidence of femoral and popliteal aneurysms in patients with abdominal aortic ...

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