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EJVES Extra 23 (2012) e23ee24

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EJVES Extra
journal homepage: www.ejvesextra.com

Short Report

A Rare Case of Popliteal Venous Aneurysm


M. Dumantepe a, *, I.A. Tarhan a, A. Ozler a, I. Yurdakul b
a
Department of Cardiovascular Surgery, Memorial Atasehir Hospital, Istanbul, Turkey
b
Department of Radiology, Memorial Atasehir Hospital, Istanbul, Turkey

a r t i c l e i n f o a b s t r a c t

Article history: Objective: Popliteal venous aneurysms are uncommon but potentially fatal abnormalities, since they can
Received 21 September 2011 cause pulmonary emboli. Here, we report a case of a popliteal venous aneurysm of the right popliteal
Accepted 23 December 2011 fossa.
Method: In a 32-year-old healthy male complaining of a localised swelling and pain in his right popliteal
Keywords: fossa, duplex ultrasonography and angio-computed tomography revealed a giant popliteal vein aneu-
Venous aneurysm rysm. The popliteal fossa was surgically explored and aneurysm was resected partially and sutured
Pulmonary emboli
through posterior approach.
Doppler ultrasound
Results: Recovery was uneventful and patient still remains asymptomatic. Further duplex ultrasonog-
Surgery
raphy follow-ups revealed patency of popliteal vein without thrombotic changes in 1st, 6th, 12th and
15th months. Additionally, no dilatation of the operated vein segment has been observed in the follow-
up ultrasound studies.
Conclusion: Surgical repair of popliteal venous aneurysms can be performed safely. Partial aneurysm
resection together with lateral venorrhaphy is preferred. Due to pulmonary thrombo-embolic compli-
cation risks, we recommend surgery in early stages.
Ó 2012 European Society for Vascular Surgery. Published by Elsevier Ltd.
Open access under CC BY-NC-ND license.

Introduction computed tomography confirmed a 42  68 mm-oval mass in the


left popliteal fossa, involving popliteal vein. The popliteal fossa was
Primary popliteal venous aneurysms (PVAs) are rare. In total, explored through posterior approach by a vertical incision. A large
there are 164 reported cases.1 In general, first signs for diagnosis are popliteal vein aneurysm sac was incised longitudinally and, after
pulmonary embolism (PE) or other thrombo-embolic events. resection, the vein wall was repaired primarily (Fig. 2). An oral
Although rare, it is important to recognise this disease, in order to anticoagulant containing warfarin was prescribed for 6 months. The
prevent deaths due to pulmonary emboli.1 patient was discharged on the 4th post operative day. Further
follow-up duplex ultrasonography investigations showed patent
Case popliteal vein without thrombotic changes in 1st, 6th, 12th and 15th
months. Additionally, no dilatation of the operated vein segment has
The case presented here is a 32-year-old man with a local been observed in the follow-up ultrasound studies (Fig. 1B).
discomfort in the left popliteal fossa. On detailed physical exami-
nation, a soft, non-pulsatile and compressible mass was identified.
Discussion
Electrocardiogram and chest X-ray did not demonstrate any
pathology. Complete blood count and basic metabolic profile were
The first asymptomatic PVA was reported by May and Nissel in
normal. Color-Doppler ultrasonography was performed to identify
1968.2 According to a current review, respiratory symptoms caused
the origin of the lesion (Fig. 1A). Proximal, distal popliteal vein and
by pulmonary embolism are the predominating symptoms.1 The
aneurysmal segment diameters with Doppler ultrasonography
aetiology of venous aneurysm remains unknown but congenital
(DUS) were found as 12, 11 and 43 mm, respectively. Angio-
factors, inflammation, trauma or degenerative changes have been
proposed.3 Detailed microscopy reported destruction of the
DOI of original article: 10.1016/j.ejvs.2011.12.033. internal elastic lamina.4
* Corresponding author. Merit Life Göl Konakları Sitesi, A-5 Blok, Kat: 7 Daire: 20,
Serifali/Umraniye 34660, Istanbul, Turkey. Tel: þ90 216 508 2702; fax: þ90 532 377
Variety of diagnostic tools such as phlebography, duplex ultra-
1872. sonography, magnetic resonance imaging, computerised tomog-
E-mail address: mdumantepe@gmail.com (M. Dumantepe). raphy (CT) and surgical exploration are available. Venous duplex

1533-3167 Ó 2012 European Society for Vascular Surgery. Published by Elsevier Ltd. Open access under CC BY-NC-ND license.
doi:10.1016/j.ejvsextra.2011.12.004
e24 M. Dumantepe et al. / EJVES Extra 23 (2012) e23ee24

Figure 1. (A) Color-Doppler ultrasonography revealed a 42  68 mm oval mass in the left popliteal fossa. (B) Post operative DUS showed popliteal vein, after aneurysmectomy and
lateral venorrhaphy. (C) Post operative follow-up DUS. There is not dilatation on surgical site.

scan is the preferred diagnostic method to assess the lower limb approach with partial resection and venorrhaphy is the most
deep vein aneurysm, and to define the size and morphology of the common method used to treat PVA.1 Total aneurysmectomy and
aneurysm. CT scan or ascending venography can be performed to venorrhaphy is a reasonable choice for saccular aneurysms, but
learn more about venous anatomy before any surgical repair. occasionally the aneurysm sac may be resected and a graft can be
Phlebography by far has been the dominant diagnostic test method, interposed. It is advised to resect fusiform aneurysms and anasta-
although case reports using duplex ultrasonography have started to mose end to end or to interpose with a graft depending on its size. A
increase recently.5 bypass with ligation of the proximal and distal vein is another
There is no consensus on the diameter of dilated veins to assist preferred method.1 In our opinion, partial resection procedure must
us in diagnosing an aneurysm. Some authors call it an aneurysm if be preferred. In the literature, there are no data on progressive
the diameter is twice its normal size.1 dilatation with this technique. Few would treat an arterial aneu-
Pulmonary embolic events are the most common clinical rysm this way because of the diseased wall.4 Histology showed
presentations of a venous aneurysm; the risks are unpredictable destruction of the internal elastic lamina, elastin insufficiency and
and may not be related to the presence or absence of thrombus on endophlebosclerosis.
imaging studies.3 In our case, a diagnosis was made before occur- We preferred partial aneurysm resection and lateral venor-
rence of a pulmonary embolus. rhaphy, instead of total resection of aneurysm. For cases of smaller
As use of anticoagulants alone may remain ineffective in pre- fusiform aneurysms (less than 20 mm) without thrombus we
venting for PVS cases, surgical repair is recommended for both recommend conservative monitoring approach.1
asymptomatic and symptomatic patients.3 Posterior genicular Recurrence of PVA is possible after surgical repair.5 We exercised
a follow-up of 15 months for our case. Late patency rates are
encouraging. There has been no pulmonary embolism and no
recurrence of aneurysm or thrombus formation at the surgical site
(Fig. 1C). Long-term patency without anticoagulation in a follow-up
of 40 months has been described.5 Despite current reviews we
suggest a more simple and less invasive surgical method.

Conclusion

Because of the risk of thrombo-embolic complications, simple


surgical treatment is recommended in all PVAs. Partial aneurysm
resection with lateral venorrhaphy is the preferred procedure. We
highlight that, evaluation of the lower extremity venous system by
duplex ultrasonography and early surgical repair of PVA are very
important in all cases with pulmonary embolism. PVAs are not rare.
Some of them are overlooked.

Conflict of Interest
None.
Funding
None.

References

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Jun 9.
Figure 2. (A) Surgical image showing the popliteal venous aneurysm. (B) Intra- 5 Sarlon G, Bartoli MA, Malikov S, Thevenin B, Branchereau A, Magnan PE. Long-
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