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Radiol Case Rep
Radiol Case Rep
Radiology Case Reports
1930-0433
Elsevier

S1930-0433(24)00800-8
10.1016/j.radcr.2024.08.017
Case Report
Endovascular repair of true profunda femoris artery aneurysm using covered stent
Streck Elena MD elena.streck@gmail.com
⁎
Caballero Enrique Ramos
Hofmann Marcel MD
Claußnitzer Tim MD
Department of Cardiac and Vascular Surgery, Schön Klinik of Vogtareuth, Krankenhausstrasse 20, 83569 Vogtareuth, Germany
⁎ Corresponding author. elena.streck@gmail.com
04 9 2024
11 2024
04 9 2024
19 11 55235526
29 5 2024
4 8 2024
5 8 2024
© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.
2024

https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Profunda femoris artery aneurysms are extremely rare, and strongly associated with multiple synchronous or asynchronous aneurysms. In the literature, 2 types of the profunda femoris artery aneurysms were described. Pseudoaneurysms of the profunda femoris artery are mostly iatrogenic through fractures, catheterization, orthopedic injury, blunt trauma, or penetrating trauma. True profunda femoris artery aneurysm is idiopathic in nature. There is poor data related to the management of this type of aneurysm. This report is about the successful endovascular treatment of a 2.9 cm right asymptomatic true profunda femoris artery aneurysm using covered stents, with inconspicuous follow-up results after 3 and 6 months after implantation using contrast enhanced ultrasound. Endovascular repair is a good therapy to treat patients with true profunda femoris artery aneurysm, especially those with high morbidity.

Keywords

True profunda femoris artery aneurysm
Endovascular repair
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pmcIntroduction

The incidence of true profunda femoris artery aneurysm (TPFAA) is very rare with the occurrence of only 0.5% of all peripheral artery aneurysms, and 1%-2.6% of all femoral aneurysms [1], [2]. This is due to the deep covering of the profunda femoris artery (PFA) by the rich muscle layers in the upper thigh [2]. Most TPFAAs are asymptomatic, and associated with atherosclerotic wall degeneration in advanced age [1]. Symptomatic aneurysm may cause symptoms of venous compression with distal emboli, thrombose, neurologic compression of the femoral or tibial nerve, or rupture of aneurysm [3]. The rupture rate of TPFAA is 20%. Detection of an asymptomatic TPFAA is difficult without clinical signs [1], [4]. In the literature, it is suggested that patients with TPFAA >2 cm should be treated promptly, because of the increased risk of rupture. Most described cases were treated with an aneurysm resection and interposition bypass.

This case report describes in detail the endovascular approach for TPFAAs, which has rarely been reported in the literature. The endovascular repair of TPFAA could be good solution for the patients with high risk of open surgery and morbidity, because it is less traumatic for patients.

Case report

A 60-year-old male with a history of smoking, hypercholesterolemia, and chronic kidney disease due to solitary kidney was referred to our vascular surgery center for the treatment of intermittent claudication symptoms in the left leg. The diagnosis of a right asymptomatic TPFAA was detected in a computed tomography angiography (CTA) scan during the clarification of the vascular status of both lower extremities. The CTA scans showed aneurysmal changes of the bilateral popliteal arteries (right: 3.6 cm; left: 5.5 cm) with the partial thrombosis, and right profunda femoris artery with 2.9 cm. The aortic aneurysm and visceral artery aneurysms were excluded. The patient underwent surgical implantation of a femoropopliteal bypass in both legs because of the high risk of acute limb ischemia, with exclusion of the bilateral popliteal aneurysms without complications. After vein bypass implantation with reduced outflow in lower extremities, oral anticoagulant therapy with phenprocoumon was indicated.

After a detailed discussion of the imaging of TPFAA, we decided in favor of endovascular therapy.

The left common femoral artery (CFA) was accessed under ultrasound guidance, starting with the retrograde puncture of the CFA through a small incision. A long 7-Fr hemostatic sheath (Flexor Check-Flo Introducer, Cook Medical, Bloomington, Indiana, USA) was introduced in the crossover technique in the right groin. An angiogram clearly revealed the right TPFAA (Fig. 1). After catheterization of the PFA with an 4F interventional BER catheter (Cordis, Norderstedt, Germany), a 0.018 inch guidewire was introduced in the distal profunda artery side branch. A self-expandable covered stent 6mm in diameter und 50 mm in length (Gore® Viabahn® endoprosthesis with Propaten Bioactive Surface, W. L. Gore & Associates, Inc, Newark, Delaware, USA) was successfully delivered and deployed distal to the aneurysm to avoid an endoleak around the side branch of PFA. A subsequent dilatation of the stent was performed with a 7 × 40 mm balloon (Passeo-35 Xeo, Biotronic, Berlin, Germany) by 50% distal stent stenosis. The second self-expandable covered stent 8 mm in diameter und 100 mm in length (Gore® Viabahn® endoprosthesis with Propaten Bioactive Surface, W.L. Gore & Associates, Inc, Newark, Delaware, USA) was implanted, with an overlapping stent zone of 3 cm to exclude the PFA. The final angiogram showed complete exclusion of the PFAA without endoleaks, and good perfusion of the stent grafts (Fig. 2). The distal outflow into the 5 remaining side branches of the profunda femoris artery was satisfactory. The procedure lasted 45 minutes. A total of 45 mL of contrast medium was used. The patient had an uneventful outcome and was discharged the day after the procedure.Fig. 1 Patient with 2.9 cm asymptomatic true profunda femoris artery aneurysm (TPFAA). Arrow shows TPFAA.

Fig 1

Fig. 2 Endovascular repair of the 2.9 cm asymptomatic right true profunda artery aneurysm with the covered stents. (A) before intervention (B) after implantation of the 2 covered stents and (C) stent graft perfusion without endoleakage after intervention.

Fig 2

Three and 6 months after the procedure, contrast enhanced ultrasound approach revealed the patency of the covered stents without any endoleaks (Fig. 3).Fig. 3 Images of the color duplex ultrasound after the endovascular repair with the covered stents of the true profunda artery aneurysm. (A) stent graft inside of the 2.9 cm aneurysm (B) perfusion of the stent graft.

Fig 3

Discussion

This report presents the case of an asymptomatic TPFAA, which has been seen just once at our hospital over the last 20 years. The TPFAA is rare due to its deep anatomical location. The PFA benefits from the muscular protection from trauma [1]. The finding of TPFAA is much more common in men (92%) than in women [3].

The literature data about TPFAA is sparse. The systematic literature analysis revealed 82 cases of TPFAAs from 2002 to 2019 was published from Kibrik et al. [5] in 2020. In the systematic review, only 30 % of TPFAAs were asymptomatic [1]. Detection of TPFAA using ultrasound, and CTA scan, as well as the therapeutic approaches, have not changed over the years. At about 2 cm in size, it is recommended to treat a profunda femoris aneurysm due to high risk of rupture [1].

Association of TPFAAs with multiple aneurysms was described in the literature like in our case [1]. In this case, we treated first the popliteal aneurysms, followed by the profunda aneurysm after careful risk analysis, and considering patient symptoms.

The most common therapeutic approaches of treatment of TPFAAs consist of ligation, reconstruction with prosthetic graft material, or greater saphenous vein graft. Aneurysmectomy with ligation is then meaningful, if there is adequate femoral-popliteal outflow and limited atherosclerotic occlusive disease [3].

In the literature, there is no valid data related to the endovascular technique for the treatment of TPFAAs because of aneurysm factors and missing data pertaining to the patency of the stent graft [1]. There are only a few known cases of endovascular therapy for pseudoaneurysm of PFA [6].

This case report describes in detail, the implantation of a covered stent graft in crossover technique without any complications in a fit patient, with positive results in follow-ups (3 and 6 months after implantation). Contrast enhanced ultrasound was established in our hospital as a standard method to control the patency of the stent graft, and to exclude endoleakage. We cannot confirm that this technique can be considered only for aneurysms in which surgery is not tolerable. In our opinion, endovascular treatment is less traumatic for patients, with a little to no pain, and a short stay length of admission. In the event of complications, surgical therapy with ligation and bypass implantation is possible. Follow up of the patient after the endovascular repair of TPFAA is important.

Conclusion

Endovascular repair by stenting of the TPFAA is an efficient approach. In our opinion, endovascular treatment should be first line therapy to treat TPFAA. In Germany, the treatment costs in comparison to open surgical intervention are much less. The length of admission is significantly shorter, usually only 24 hours. In the future, complication rates of both techniques should be analyzed, as well as a cost comparison, when more data on TPFAAs exist.

Patient consent

Written informed consent was obtained from the patient for publication of this case report and accompanying images.

Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
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References

1 Elzawy G Eisenberg N Jaberi A Roche-Nagle G Vascular surgical management of profunda femoris artery aneurysms: a single center experience Vascular 1 4 2023 741 748 10.1177/17085381221084811
2 Harbuzariu C Duncan AA Bower TC Kalra M Gloviczki P Profunda femoris artery aneurysms: association with aneurysmal disease and limb ischemia J Vasc Surg 47 1 2008 31 34 10.1016/j.jvs.2007.09.040 discussion 4-5 18178452
3 Posner SR Wilensky J Dimick J Henke PK A true aneurysm of the profunda femoris artery: a case report and review of the English language literature Ann Vasc Surg 18 6 2004 740 746 10.1007/s10016-004-0116-4 15599634
4 Tripathi RK Verma H Giant true profunda femoris aneurysm: case series and literature review Indian J Vasc Endovasc Surg 4 1 2017 28 31 10.4103/0972-0820.198074
5 Kibrik P Arustamyan M Stern JR A Dua A. A systematic review of the diagnosis, management, and outcomes of true profunda femoris artery aneurysm J Vasc Surg 71 6 2020 2145 2151 10.1016/j.jvs.2019.10.086 31882317
6 Kouvelos GN Papas NK Arnaoutoglou EM Papadopoulos GS Matsagkas MI Endovascular repair of profunda femoral artery false aneurysms using covered stents Vascular 51 4 2011 51 54 10.1258/vasc.2010.cr0224
