Other Aneurysmal Disease

Carotid: see here

Popliteal
Intro
Typically 'true' aneurysms, involving all 3 vessel layers, unlike most femoral aneurysms.
Typically degenerative; due to atherosclerosis.
Often associated with other aneurysms (up to 50%), particularly AAA, contralateral popliteal.
--> screen carefully.
Presentation
Half are asymptomatic when discovered.
- be aert for AAA isk factors; same.
Most typical complication is thromboembolism
- blue to syndrome; digital artery emboli
- or acute limb ischaemia.
Rupture is rare
Carefully evaluate whole vascular system.
Duplex USS is useful, given information volume.
- CT and MRI give simlar but not as practicable.
- contrast CTA if operative planning.
Treatment
If acute limb ischaemia, treat with immediate operative therapy.
- vascular reconstruction and restoration of flow
- may need immediate guillotine amputation in advanced / severe cases
If thrombosed and asymptomatic, can be managed nonoperative.
Else controversial:
- observe vs surgery vs selective
= observe if reduced life expencancy
- 1/3+ will eventually develop symptoms so surgery may be justifiable.
- selective approach considers patient, disease factors (>2cm, mural thrombus, loss of runoff, significant distortion)
--> but little evidence base
Surgical strategy
As usual, consider inflow, outflow and conduit.
Autogenous vein prefered to prosthetic vein, as in other BK recons.
- outflow assessment by duplex and CTA.
Catheter-directed thrombolysis for patients with acute thrombosis in time-tolerant patients
- when time is insufficient, balloon catheter embolectomy +/- intraarterial thrombolytics.
Electively, repair through medial or posterior approchaes (see access; exclude aneurysmal portion, short bypass, end-end or end-side;
Generally excellent outcomes and limb-salvange rates (better than atheroma): 10y = 95% patency.
But 1/3+ patients develop other aneurysms (aortoiliac, femoral, contralateral popliteal) so follow-up advised.

Femoral
Most false pseudo-aneurysms.
Typically involve common femoral; localised to deep femoral or superficial femoral are rare.
Present asymptomatic or with symptoms due to size / compression (veins / nerves)
Pain, pulsatile swelling and bruising suggest iatrogenic aneurysm after access procedures.
Thromboembolism most concerning complication, but SFA and deep femoral can rupture.
Diagnosed by USS +/- CTA
Repaired regardless of size if symptomatic; else selective if asymptomatic
- no consensis to size but rapid expansion reuqires intervention.
- infection requirees repair, needing autogenous conduit.
Iatrogenic femoral pseudoaneurysms
USS-guided compression and thrombin injection = minimally invasive
If <1cm, often sponteanously thrombosis
Large haematoma, or skin necrosis warrant open repair.