Cardiovasc Intervent Radiol (2007) 30:1016–1019

DOI 10.1007/s00270-007-9077-7

CASE REPORT

Spontaneous Rupture of the Superficial Femoral Artery Treated

with Endovascular Stent-Grafting
James R. Ramus Æ Matthew Gibson Æ Timothy Magee Æ
Peter Torrie

Received: 13 December 2006 / Revised: 13 December 2006 / Accepted: 1 February 2007 / Published online: 29 May 2007

Springer Science+Business Media, LLC 2007

Abstract Spontaneous rupture of the superficial femoral Case Report

artery (SFA) is rare. It may occur in the presence of an SFA
aneurysm or in a nonaneurysmal, but usually atheroscle-
rotic, artery. Previously these ruptures have been treated by
surgical exclusion, often with bypass grafting. We report a
case of spontaneous rupture of a nonaneurysmal SFA
treated successfully with endovascular stent-grafting.
Keywords Superficial femoral artery
Rupture

Covered stent
Stent-graft
Femoral aneurysm

False aneurysm
Spontaneous rupture of the femoral artery is rare and is
most commonly due to rupture of true aneurysms [1].
Spontaneous rupture of nonaneurysmal atherosclerotic
superficial femoral arteries (SFAs) is even rarer and has
previously been treated surgically with excision or exclu-
sion of the rupture or aneurysm and either immediate or
delayed bypass grafting where necessary [2–8].
We describe the case of a 74-year-old man presenting
with a ruptured, nonaneurysmal, atherosclerotic SFA suc-
cessfully treated with endovascular stent-grafting.
J. R. Ramus
T. Magee
Department of General Surgery, The Royal Berkshire Hospital,
London Road, Reading RG1 5AN, UK
M. Gibson
P. Torrie
Department of Radiology, The Royal Berkshire Hospital,
London Road, Reading RG1 5AN, UK
J. R. Ramus (&)
Tree House, Church Lane, Chearsley, Bucks HP18, ODF
e-mail: jimramusuk@yahoo.co.uk
A 74-year-old man presented with a 24-h history of left
thigh pain and swelling. He had no history of peripheral
vascular disease, although there was a history of stroke (30
years previously), chronic renal impairment, and hyper-
tension and he was an ex-smoker. He was warfarinized for
atrial fibrillation and was taking antihypertensive medica-
tion.
On presentation the patient was mildly hypotensive,
with a systolic blood pressure of 90 and a pulse of 70.
There was a tense swelling in his left thigh which was not
pulsatile His left foot was cool but not critically ischemic.
The left foot had a delayed capillary refill of 4 s, but
sensation and motor function were normal. There were no
palpable pulses in either foot, but easily palpable femoral
and popliteal pulses bilaterally.
Initial investigations showed a hemoglobin of 10.7 g/dl,
which dropped to 8.8 g/dl within 6 h, requiring a 2-unit
blood transfusion. A duplex ultrasound demonstrated a
bilobed pseudoaneurysm arising from the lateral wall of the
left SFA. The proximal lobe had a diameter of 5 cm, and
the distal lobe, 4 cm. The SFA was noted to be ectatic and
atheromatous.
Magnetic resonance angiography (MRA) confirmed
generalized ‘‘arteria magna’’ with bilateral internal iliac
aneurysms. It demonstrated a patent right femoropopliteal
segment with single-vessel runoff and a similar appearance
on the left apart from a pseudoaneurysm arising from a
short stenosis in the upper SFA (Fig. 1).
After discussion among the vascular surgeons and
interventional radiologists it was decided to treat endo-
vascularly using a stent-graft. The patient was cardiovas-
cularly stable and stent-grafting was performed 3 days
after presentation. This delay was due to a combination of

123
J. R. Ramus et al.: Stenting of SFA Rupture
Fig. 1 Contrast-enhanced MRA showing the left SFA stenosis (short
arrow) and the false aneurysm arising from it (long arrow). Arteria
magna and bilateral internal iliac aneurysms noted (arrowheads)
factors including not having the appropriate size stent-graft
on the shelf and the need for accurate measurement for
stent sizing with MRA. The stent was ordered and deliv-
ered within 24 h.
Procedure
In the angio suite the left common femoral artery was
punctured percutaneously and a 10-F sheath inserted an-
tegradely. No anticoagulation was used. The angiogram
confirmed the presence of a stenosis in the upper SFA and a
false aneurysm arising from it (Fig. 2). The stenosis was
crossed using a Terumo guide wire and 5-F Cobra 2 glide
catheter (Terumo Corp., Tokyo). These were exchanged for
a 1.5-mm J heavy-duty guide wire (Cook, Denmark), and a
13.5 mm · 10-cm Fluency plus stent-graft (Bard GmbH/
Angiomed, Karlsruhe, Germany) was deployed across the
SFA stenosis. The appropriate size stent-graft was chosen
after measuring, from the MRA, the length required to treat
the stenosis and also have a good length of stent-graft,
above and below, to exclude the aneurysm. The ‘‘landing
zone’’ diameters were then measured on the MRA and the
stent-graft diameter was oversized by 2 mm. The stent-
graft was dilated with an 8 mm · 4-cm Powerflex P3
balloon (Cordis; Roden, the Netherlands). The subsequent
angiogram demonstrated the stent-graft to be in a good
position, with abolition of the SFA stenosis and no filling
of the false aneurysm (Fig. 3). The puncture site was
1017
Fig. 2 Angiogram showing the stenosis of the upper SFA (short
arrow) and the false aneurysm arising from it (long arrows)
successfully closed using an 8-F Angioseal device (St. Jude
Medical, Minnetonka, MN, USA).
After stent-grafting the leg was warm and well perfused.
Unfortunately the patient’s admission was complicated by
a mild myocardial infarction and a bleeding duodenal ul-
cer. He eventually made a full recovery and was discharged
with a well-perfused left foot and no further vascular
problems. At the time of writing there has been no follow-
up but a 6-month postprocedure CTA is planned.
Discussion
We describe the case of a ruptured nonaneurysmal SFA in
a patient with generalized peripheral ‘‘arteria magna’’ and
internal iliac aneurysms.
Spontaneous rupture of nonaneurysmal aortas has been
described [9–13], however, there are few reports of rupture
of nonaneurysmal femoral arteries. In 1970 King and Kaupp
[8] described the spontaneous rupture of a nonaneurysmal
SFA in a patient who had undergone aorto-bi-iliac grafting
14 months previously. Subsequent pathological examination
did not show the presence of mycotic organisms or evidence
123
1018
Fig. 3 The stent-graft has been deployed, abolishing the stenosis and
excluding the aneurysm
of dissection or complications from the previous surgery.
Cadier et al. [14], in 1993, described the case of a 37-year-old
man with Ehlers-Danlos syndrome presenting with sponta-
neous rupture of the common femoral artery in the presence
of ‘‘broadened femoral popliteal segments’’ and ‘‘aneurys-
mal segments in the ilio-femoral regions’’ but no discrete
femoral artery (CFA) aneurysm.
In 1996, Origuchi et al. [15] described the case of a
ruptured saccular femoral ‘‘aneurysm’’ requiring surgical
resection. Their paper does not specify whether this arose
from the CFA, SFA, or profunda femoris artery (PFA).
Subsequent histopathological examination demonstrated
that the aneurysm wall consisted only of adventitial tissue.
It was therefore concluded to have been a false aneurysm
arising from an atherosclerotic arterial wall.
Femoral artery rupture is more commonly associated
with true aneurysms. In a study by Pappas et al., of 115
patients with true femoral aneurysms from all sites (CFA,
SFA, and PFA), 5% ruptured spontaneously over 13 years
of follow-up [16]. Peripheral atherosclerotic aneurysms in
general, however, are rare. In a review by Dent et al. [1] of
1488 aneurysms, only 68 (4.6%) were found in the
peripheral arteries, with popliteal aneurysms making up
70% of these. Overall, femoral artery aneurysms (CFA,
SFA, and PFA) have been found to make up approximately
3% of all peripheral aneurysms [17], with true aneurysms
of the SFA making up about 26% of these [16].
123
J. R. Ramus et al.: Stenting of SFA Rupture
Reports of spontaneous rupture of aneurysmal SFAs,
although more common than aneurysmal rupture of the
PFA, are limited, with only a handful of cases described
over the last 40 years [2–8]; all were treated surgically. On
review of reported cases of spontaneously ruptured femoral
aneurysms from all sites (n = 25) we were only able to find
one that was treated endovascularly. This ruptured PFA
aneurysm was successfully treated with transcatheter
embolization [18].
As far as we are aware this is the first case of sponta-
neous rupture of an atherosclerotic SFA successfully trea-
ted with endovascular stent-grafting. It was fortunate that,
despite being borderline hypotensive and anemic on initial
presentation, our patient remained cardiovascularly stable
over the following days. This allowed time for imaging and
obtaining the appropriate stent-graft. If this had not been
the case, then urgent surgical intervention might have been
necessary. With the patient’s underlying cardiac condition,
which became evident after the procedure, avoidance of
general anesthesia and operative risks was advantageous.
Endovascular stent-grafting allowed exclusion of the
false aneurysm, with restoration of blood flow, without the
risks of invasive bypass procedure and the associated com-
plications of open operative procedures. Endovascular stent-
grafting should also be considered for the treatment of rup-
tured and nonruptured true femoral aneurysms when ana-
tomical considerations (size of artery and location) allow.
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