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ESSENTIALS OF DIAGNOSIS

  • Widened, prominent pulses.

  • Acute leg or foot pain and paresthesias with loss of distal pulses.

  • High association of popliteal aneurysms with abdominal aortic aneurysms.

GENERAL CONSIDERATIONS

Like aortic aneurysms, peripheral artery aneurysms are silent until critically symptomatic. However, unlike aortic aneurysms, the presenting manifestations are due to peripheral embolization and thrombosis. Popliteal artery aneurysms account for 70% of peripheral arterial aneurysms. Popliteal aneurysms may embolize repetitively over time and occlude distal arteries. Due to the redundant parallel arterial supply to the foot, ischemia does not occur until a final embolus occludes flow.

Primary femoral artery aneurysms are much less common. However, pseudoaneurysms of the femoral artery following arterial punctures for arteriography and cardiac catheterization occur with an incidence ranging from 0.05% to 6% of arterial punctures.

CLINICAL FINDINGS

A. Symptoms and Signs

The patient may be aware of a pulsatile mass when the aneurysm is in the groin, but popliteal aneurysms are often undetected by the patient and clinician. Rarely, peripheral aneurysms may produce symptoms by compressing the local vein or nerve. The first symptom may be due to ischemia of acute arterial occlusion. The symptoms range from sudden-onset pain and paralysis to short-distance claudication that slowly lessens as collateral circulation develops. Symptoms from recurrent embolization to the leg are often transient, if they occur at all. Sudden ischemia may appear in a toe or part of the foot, followed by slow resolution, and the true diagnosis may be elusive. The onset of recurrent episodes of pain in the foot, particularly if accompanied by cyanosis, suggests embolization and requires investigation of the heart and proximal arterial tree.

Because popliteal pulses are somewhat difficult to palpate even in normal individuals, a particularly prominent or easily felt pulse is suggestive of aneurysm and should be investigated by ultrasound. Since popliteal aneurysms are bilateral in 60% of cases, the diagnosis of thrombosis of a popliteal aneurysm is often aided by the palpation of a pulsatile aneurysm in the contralateral popliteal space. Approximately 50% of patients with popliteal aneurysms have an aneurysmal abdominal aorta.

B. Imaging Studies

Duplex color ultrasound is the most efficient investigation to confirm the diagnosis of peripheral aneurysm, measure its size and configuration, and demonstrate mural thrombus. MRA or CTA is required to define the aneurysm and local arterial anatomy for reconstruction. Arteriography is not recommended because mural thrombus reduces the apparent diameter of the lumen on angiography. Patients with popliteal aneurysms should undergo abdominal ultrasonography to determine whether an abdominal aortic aneurysm is also present.

TREATMENT

To prevent limb loss from thrombosis or embolization, surgery is indicated when an aneurysm is associated with any peripheral embolization, the aneurysm is larger than 2 cm, or a mural thrombus is present. Immediate or urgent surgery is indicated ...

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