Lower Extremity Aneurysms

Question 1

What is the men to women ratio of true lower extremity aneurysms (all types)?

Answer 1

30:1

Question 2

What are the main types of aneurysms and their definition?

Answer 2

• True aneurysm - focal, fusiform dilation of the artery to 1.5 times the normal diameter of the adjacent segment of artery.
• Pseudoaneurysm - a rim of fibrous tissue containing thrombus and arterial flow in continuity with a defect in the artery.

Question 3

What is the appeoximated normal size of CFA in men and women?

Answer 3

• 1 cm in men
• 0.8 cm in women

Question 4

What are the indication for aneurysmatic Femoral artery intervantion?

Answer 4

• All symptomatic aneurysms should be treated.
• Asymptomatic aneurysms of more than 2.5cm in good risk patients can be concidered for treatment.
• Recent study (by Lawrence et al. 2014) acute complications such as ischemia or rupture did not occur in patients with asymptomatic femoral artery aneurysms less than or equal to 3.5 cm.
• Size threashold can be reduced in the presence of intraluminal thrombuse.

Question 5

What is the most common etiology of true aneurysms in lower extremities?

Answer 5

Degenerative aneurysems.

Question 6

What is the major risk of lower limb aneurysms?

Answer 6

They can cause limb-threaening ischemia due to thrombose or emboly.
Rapture is a rear presentation!

Question 7

What is the rate of association between femoral aneurysms and aortic aneurysms?

Answer 7

50-90% chance of concurrent aortic aneurysm

Question 8

What is the rate of association between popliteal aneurysms and aortic aneurysms?

Answer 8

30-50% chance of concurrent aortic aneurysm
70% chances for aortic aneurysm if there is a bilateral popliteal aneurysms.

Question 9

What is the rate of bilateral femoral aneurysms?

Answer 9

25-50%

Question 10

What is the rate of bilateral popliteal aneurysms?

Answer 10

50-70%

Question 11

What is the rate of femoral or popliteal aneurysems in men with aortic aneurysms?

Answer 11

14%

Question 12

What is the rate of femoral or popliteal aneurysems in women with aortic aneurysms?

Answer 12

Rare

Question 13

what is tne major etiology of Pseudoaneurysm?

Answer 13

iatrogenic injury due to instrumentation

Question 14

What is the rate of the specific femoral arteries aneurysms (CFA, SFA, PFA)?

Answer 14

CFA 57%
SFA 27%
PFA 17%
Bilateral 26%
Associated with additional aneurysms 48%

Recent study showed higher percentage (81%) in the CFA, and lower percentage (14%, 5%) in the SFA and PFA, respectively.

Question 15

At which age group are femoral artery aneurysms predominantly found?

Answer 15

70 year or older

Question 16

What is the possible clinical presentaion of symptomatic femoral artery aneuryems and their rate (most common to less common)?

Answer 16

Lower extremity ischemia is the most common presentation in up to 65%.
30-40% locolized pain from compression.
Rupture (rear) 4%

Question 17

What is the rate of asymptomatic femoral artery aneurysms?

Answer 17

30-40% are asymptomatic and found on physical examination or Duplex US.

Question 18

What is the imaging modality of chioce for the diagnosis and assessment of lower extremities aneurysms?

Answer 18

Duplex ultrasound.

Question 19

What is the role of CTA and MRA in the assessment of lower extremities aneurysms?

Answer 19

Although the modality of chioce is Duplex US, CTA and MRA has a role in:

• Planning intervantion
• Measurment
• identify normal proximal and distal segments.

Question 20

What is the recommended treatment approch to femoral aneurysms?

Answer 20

Open surgery with exclusion and interposition graft is the prefarred approch.
In both emergency and elective repair there is a minimal morbidity and mortality.

Question 21

What type of graft is preffered for interposition in open surgical repair of the femoral artery?

Answer 21

Syntetic PTFE or Dacron graft are better size matches and have equivalent or better patency rates than vein grafts in the femoral artery.

Question 22

How often is FA aneurysm bilat?
Other associated aneurysm?

Answer 22

25% if true aneurysm (most False)
50%

Question 23

What diseases are associated with FA aneurysm?

Answer 23

degenerative, Behcet, parkes weber, wegners

Question 24

How often to pseudoaneuryms of FA occur with diagnostic and therapeutic interventions?

Answer 24

0.2%
8%

Question 25

When to intervene?

Answer 25

\>2.5cm symptomatic

Question 26

What does false aneurysm look like on US?

Answer 26

to and fro (ying-yang)

Question 27

What are therapeutic options for false aneurysm?

Answer 27

US guided compression 10-20 minutes, bedrest 6 hours success 70% blind compression can be as good as US guided US guided thrombin injection 1000units success reaching close to 100% open surgical repair

Question 28

What is normal diameter of popliteal? what is aneurysmal?

Answer 28

0. 5-1.1 1. 5 times the normal segment diameter (\>1.5-2)

Question 29

How common are popliteal aneurysm? how many bilat? how many have AAA

Answer 29

most common peripheral aneurysm but still rare 50% 30-50%

Question 30

How do they present? Which is most common presentation?

Answer 30

asympto rupture (rare) chronic ischemia (claudication) acute ischemia compressive (vein, nerve) lower limb ischemia 30% acute

Question 31

How do you treat endovascular?

Answer 31

convered stent oversize 10-15% LZ 2 cm

Question 32

How to treat open?

Answer 32

smaller medial approach posterior approach

Question 33

What is the difference between open and endo?

Answer 33

similar but reintervention rate higher in endo 5yr patency 70%, 80% if add plavix

Question 34

What are advantages/disadvantages of medial/posterior approach?

Answer 34

posteriro decompress aneurysm ligate geniculates medial avoid aneurysm familiarity

Question 35

What is a persistent sciatic artery aneurysm? what % anerysmal what artery hypo plastic? presentation? What do you pay attention to when operating?

Answer 35

rare anomaly prone to aneurysm 40% become aneurysm femoral large buttock mass, local compressive symptoms, distal ischemia avoid sciatic nerve (so don't expose the artery surgically)

Question 36

What is the most common peripheral aneurysm?

Answer 36

popliteal

Question 37

How many PA have coexisting AAA?

Answer 37

30-50%

Question 38

What are CSVS recommendations for screening in PA?

Answer 38

screen for AAA screen for contra PA

Question 39

How many PA are bilateral?

Answer 39

50%

Question 40

What structures pass through the adductor hiatus?

Answer 40

superficial femoral artery superficial femoral vein spahenous nerve saphenous branch of descending genicular artery

Question 41

Name 6 non-atheromatous causes of IC?

Answer 41

Pop entrapment syndrome Adventitial cystic disease Chronic compartment syndrome Kinking/endofibrosis of iliacs Arteritis Thrombosis of persistent sciatic artery FMD Aortic coarctation Takayasu Peripheral emboli Vascular tumor

Question 42

What are indications for treatment of PA?

Answer 42

\>2.0cm symptoms presence of aneurysm (low risk procedure) \>3.0 (if asympto)

Question 43

Between what two muscles is the popliteal vessels found in the infrageniculate medial approach?

Answer 43

sartorius vastus medialis

Question 44

In posterior approach, which side is the upper portion of the S incision directed?

Answer 44

medial

Question 45

What are three nerves encountered in the posterior exposure

Answer 45

medial sural nerve tibial nerve peroneal nerve

Question 46

Which patients to consider for thrombolysis with PA thrombosis?

Answer 46

patients without motor loss patients with no distal runoff

Question 47

How do you mix cathflo?

Answer 47

10mg in 1L of NS 10mg bolus infusion 0.5mg/hr

Question 48

What are results for thrombolysis in PA?

Answer 48

restore 1-2 vessel outflow in 80-90% failure results in amputation at 30d thrombi may have improved limb salvage