Accepted Manuscript

Endovascular treatment of isolated degenerative superficial femoral artery aneurysm

H. Mufty, K. Daenens, S. Houthoofd, I. Fourneau

PII: S0890-5096(18)30090-6
DOI: 10.1016/j.avsg.2017.11.038
Reference: AVSG 3670

To appear in: Annals of Vascular Surgery

Received Date: 22 September 2017

Revised Date: 2 November 2017
Accepted Date: 7 November 2017

Please cite this article as: Mufty H, Daenens K, Houthoofd S, Fourneau I, Endovascular treatment of
isolated degenerative superficial femoral artery aneurysm, Annals of Vascular Surgery (2018), doi:
10.1016/j.avsg.2017.11.038.

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1 Title page

2 1/ Endovascular treatment of isolated degenerative superficial femoral artery aneurysm

3 2/ Type manuscript: case report

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4 3/ H. Mufty, K. Daenens, S. Houthoofd, I. Fourneau

5 Department of Vascular surgery, University Hospitals Leuven, Belgium

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6 4/ Correspondence to:

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7 Hozan Mufty; M.D., University Hospitals Leuven, Department of vascular surgery

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8 Herestraat 49, 3000 Leuven, Belgium
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9 Phone: 003216345102 Fax: 003216346852 Email: hozan.mufty@uzleuven.be
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10 5/ Word count main body manuscript: 1245 Number of pages: 10 Number of figures: 5
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11 6/ Scientific meeting: This paper was presented at the iMeet congress 1-2 June 2017, Nice,
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12 France.

13 7/ Key words: Superficial femoral artery aneurysm, endovascular treatment

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14 8/Abbreviations:
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15 SFA: superficial femoral artery; DCB: drug coated balloon; MRa: Magnetic resonance
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16 angiography

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19 Endovascular treatment of isolated degenerative superficial femoral

20 artery aneurysm

21 H. Mufty, K. Daenens, S. Houthoofd, I. Fourneau

22 Department of Vascular surgery, University Hospitals Leuven, Belgium

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23

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24 Isolated degenerative superficial femoral artery aneurysms are rare. One hundred and forty-two

25 cases are described in literature. Threshold for operative management varies in literature. In

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26 literature, only ten cases are treated in an endovascular way.

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27 We present a case of a 77-year old patient who presented with non-healing wounds on the right
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28 foot. Duplex ultrasound revealed an isolated aneurysm of the superficial femoral artery on the right

29 side as a source of emboli. The patient was treated in an endovascular way with a covered stent
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30 graft. The procedure was complicated by embolization in the peroneal artery as a single outflow

31 vessel.
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32 An overview of endovascular treatment of superficial femoral artery aneurysms in literature is

33 discussed.
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41 Introduction

42 Isolated degenerative aneurysms of the superficial femoral artery (SFA) are rare. [1-4] To our

43 knowledge, only 142 cases are described in literature. [2, 4-13] Threshold for operative management

44 varies in literature. Most cases reported in literature are treated by open surgical management.

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45 Endovascular repair is only described in ten cases.

46 We present the case of a 77-year old patient that was seen at our outpatient clinic with a

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47 symptomatic isolated aneurysm of the SFA on the right side. The patient was treated in an

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48 endovascular way with a covered stent graft, Viabahn® 6*100 (WL Gore, Flagstaff, AZ, USA) The

49 procedure was complicated by embolization in the peroneal artery as a single outflow vessel which

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50 could be solved by using a drug coated balloon (DCB). A brief overview of endovascular treatment of
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51 SFA aneurysms in literature is given.

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61 Case report

62 A 77-year old male caucasian patient presented at the outpatient clinic of vascular surgery with

63 trophic lesions at the right foot since 1,5 month. This was accompanied by a blue toe syndrome of

64 the fourth toe. His medical history included diabetes mellitus, arterial hypertension,

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65 hypercholesterolemia and atrial flutter which was treated by ablation two years earlier. The patient

66 was anti-coagulated with Eliquis ® 2.5mg, two times daily (Apixaban).

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67 On physical examination, we had a normal weight patient (Body mass index of 23.14). Only pulses at

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68 the level of the groin were palpable bilateral with absent distal pulsations. At the level of the foot, a

69 small ulcer was seen at the lateral side of the distal phalanx of digit 5 and a blue fourth toe as a sign

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70 of embolisation. Ankle brachial index was 0.8 in rest and lowered to 0.4 after 75 meters, which was
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71 the maximal walking distance.

72 Duplex ultrasonography revealed a high grade stenosis of the SFA (peak systolic velocity
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73 327cm/second) and an isolated SFA aneurysm with a maximal diameter of 2.45cm. (2.16*2.45)
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74 Because of chronic kidney insufficiency (creatinine 2.3mg/dl, eGFR 26), a magnetic resonance
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75 angiography (MRa) was performed, which illustrated an isolated aneurysm at the middle third of the

76 SFA and the peroneal artery as the single outflow vessel. (Figure 1).
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77 The patient was planned for an endovascular treatment. An antegrade puncture of the common
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78 femoral artery was performed. Five thousand IU of heparin were administered. Recanalisation was
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79 difficult and different attempts were needed. Eventually, we could pass the stenosis using a 0.035

80 stiff Terumo guidewire® (Terumo corporation, Tokyo Japan). A combination of carbon dioxide and

81 35cc of Visipaque® isotonic contrast was used. The stenosis was dilated wit a Lutonix® DCB 5*100

82 balloon (Bard Lutonix, New Hope, MN, USA) and the aneurysm was excluded using a Viabahn® 6*100

83 (WL Gore, Flagstaff, AZ, USA). The stent was post dilated using a balloon Armada® 6*40 (Abbott Park,

84 Illinois, USA). Control angiography showed complete exclusion of the aneurysm without residual
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85 stenosis. (Figure 2) Unfortunately, final angiography showed distal embolisation with complete

86 occlusion of the outflow vesssel. (Figure 3) The peroneal artery was recanalised using a 0.014

87 guidewire and a Quick-Cross support catheter® (Spectranetics Corporation, CO, USA). No additional

88 thrombolytics or thrombus aspiration was used. The vessel was dilated with a Lutonix® DCB 3*150.

89 An excellent end result was achieved. (Figure 4).

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90 The patient was discharged on the first postoperative day. Complete healing was obtained after 1.5

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91 month. Ten months postoperatively the patient is still completely asymptomatic.

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104 Discussion

105 Isolated degenerative SFA aneurysms are rare. Degenerative femoral artery aneurysms occur in

106 approximately five patients per 100 000.[1] Ten to 26% of these aneurysms are located in the SFA.

107 [2, 3, 4] According to our knowledge, since 1967, only 142 SFA aneurysms are described in literature.

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108 [2 ,4 ,5 , 6, 7,8 , 9, 10 ,11 ,12 , 13] In 45.9% of cases, the aneurysm is located in the middle third of the

109 SFA. Because of this, SFA aneurysms are less likely to be palpable and visible. The majority of SFA

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110 aneurysms will only be detected once they become symptomatic. Up to 52% of the patients will

111 present with rupture as a first symptom. [5] Acute ischemia comes on the second place with an

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112 incidence of 13-22%. Other symptoms are compression on the deep veins resulting in deep vein

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113 thrombosis and lower limb edema and the presence of a painful pulsatile mass in the thigh (each <
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114 1%). [2, 14] There is still no consensus on the threshold for operative repair. At least, as we did in our

115 case, every symptomatic aneurysm should be treated. Since they are only detected in a later phase,
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116 there is still no agreement on the threshold for operative repair in asymptomatic patients. The

117 lowest threshold is described by Perini et al (≥20mm). [2] In a large review concerning 61 case of SFA
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118 aneurysms by Leon et al, the most often used threshold diameter is 25mm in good-risk patients. [5]
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119 Lawrence et al included 236 femoral artery aneurysms in their study, whom 34 located in the SFA

120 (14,4%). They didn’t find any difference in behavior of the aneurysm whether located in the SFA, the
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121 deep femoral artery or the common femoral artery, as long as the aneurysm was isolated. They
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122 concluded that asymptomatic femoral artery aneurysms rarely develop complications unless they are
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123 ≥35mm and have intraluminal thrombus. [9]

124 Most cases described in literature are treated in an open surgical way. [5] Dietrich et al was the first

125 in 1995 to describe an endovascular treatment in two patients. [15] Since then, only ten cases were

126 described in literature to be treated also in an endovascular way. [7-9, 13,15,16] Viabahn is the

127 preferred endograft for treatment of SFA aneurysms. More details are illustrated in table 1.

128 Concerning postoperative anticoagulation, no consensus was seen in the different articles. This

129 varied from no anticoagulation [15] to a combination of acetyl salicylic acid and clopidogrel for life.
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130 [7, 13] Our patient received Apixaban due to atrial flutter. Except for one case, no long term follow-

131 up of these patients are available. (table 1) Pecoraro et al reported spontaneous stent graft expulsion

132 two years after the initial procedure. [7] As illustrated in table 1, the majority of the patients treated

133 endovascular was symptomatic and good postoperative results were achieved. In our case report,

134 the outflow ostium was not in a straight line with the proximal SFA, resulting in a difficult

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135 recanalization of the aneurysm complicated by distal embolization. Although this was not reported in

136 other studies, the presence of intra-aneurysmal thrombus, as confirmed on our preoperative duplex

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137 sonography, should be considered as a risk factor for distal embolization during guidewire

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138 manipulation.

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140 Conclusion
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141 Isolated degenerative SFA aneurysms are rare. Data are limited and threshold for operative repair
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142 remains uncertain. Endovascular repair is feasible in both asymptomatic and symptomatic patients.

143 Longer follow-up data concerning endovascular treatment of SFA aneurysms are needed.
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154 References

155 [1]Lawrence PF, Lorenzo-Rivero S, Lyon JL. The incidence of iliac, femoral, and popliteal artery

156 aneurysms in hospitalized patients. J Vasc Surg. 1995; 22(4):409-16.

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158 [2]Perini P, Jean-Baptiste E, Vezzosi M, et al. Surgical management of isolated superficial femoral

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159 artery degenerative aneurysms. J Vasc Surg. 2014; 59(1):152-8. doi: 10.1016/j.jvs.2013.07.011.

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160

161 [3]Ormstad K, Solheim K. Ruptured aneurysm of the superficial femoral artery. Scand J Thorac

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162 Cardiovasc Surg. 1975; 9(3):181-2.
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164 [4]Piffaretti G, Mariscalco G, Tozzi M, et al. Twenty-year experience of femoral artery aneurysms. J
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165 Vasc Surg. 2011; 53(5):1230-6. doi: 10.1016/j.jvs.2010.10.130.

166
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167 [5]Leon LR Jr, Taylor Z, Psalms SB, et al. Degenerative aneurysms of the superficial femoral artery. Eur
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168 J Vasc Endovasc Surg. 2008; 35(3):332-40.

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170 [6]Jarrett F, Makaroun MS, Rhee RY, et al. Superficial femoral artery
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171 aneurysms: an unusual entity? J Vasc Surg. 2002; 36(3):571-4.

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173 [7]Pecoraro F, Sabatino ER, Dinoto E, et al. Late Complication after Superficial Femoral Artery (SFA)

174 Aneurysm: Stent-graft Expulsion Outside the Skin. Cardiovasc Intervent Radiol. 2015; 38(5):1299-302.

175 doi: 10.1007/s00270-014-0970-6

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177 [8]Lyazidi Y, Abissegue Y, Chtata H, et al. Endovascular Treatment of 2 True Degenerative Aneurysms

178 of Superficial Femoral Arteries. Ann Vasc Surg. 2016; 30:307.e1-5. doi: 10.1016/j.avsg.2015.05.041.

179

180 [9]Lawrence PF, Harlander-Locke MP, Oderich GS, et al. Vascular Low-Frequency Disease Consortium.

181 The current management of isolated degenerative femoral artery aneurysms is too aggressive for

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182 their natural history. J Vasc Surg. 2014; 59(2):343-9. doi: 10.1016/j.jvs.2013.08.090.

183

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184 [10]Varetto G, Castagno C, Ripepi M, et al. Rupture of giant superficial femoral artery aneurysm in a

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185 leukemic patient submitted to chemotherapy. Korean J Thorac Cardiovasc Surg. 2014; 47(4):413-5.

186 doi: 10.5090/kjtcs.2014.47.4.413.

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187
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188 [11]Naouli H, Jiber H, Bouarhroum A. A ruptured superficial femoral artery

189 aneurysm: A case report. J Mal Vasc. 2016; 41(1):69-73. doi: 10.1016/j.jmv.2015.09.001.
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191 [12]Dighe S, Thomas P. Ruptured superficial femoral artery aneurysm treated by

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192 simple ligation. Singapore Med J. 2008; 49(6):e151-2.

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194 [13] Endovascular today http://evtoday.com/2010/08/percutaneous-endovascular-repair-of-a-distal-

195 sfa-aneurysm/ (accessed August 2010). SE Peralta, J Calderin, KS Toufic Percutaneous repair of a
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196 distal SFA aneurysm. Endovascular today 2010; 40:140-142.

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198 [14]Atallah C, al Hassan HK, Neglén P. Superficial femoral artery aneurysm—an uncommon site of

199 aneurysm formation. Eur J Vasc Endovasc Surg. 1995; 10(4):502-4.

200

201 [15]Diethrich EB(1), Papazoglou K. Endoluminal grafting for aneurysmal and occlusive disease in the

202 superficial femoral artery: early experience. J Endovasc Surg. 1995; 2(3):225-39.
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204 [16]Troitskiĭ AV, Bobrovskaia AN, Orekhov PIu, et al. Successful percutaneous endovascular

205 treatment of a ruptured femoral aneurysm. Angiol Sosud Khir. 2005; 11(1):53-7.

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207 Table and figures

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208 Table 1: Overview of SFA aneurysms treated with stentgraft

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210 Figure 1: MRa illustrating the aneurysm in the right SFA

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212 Figure 2: Result after exclusion of the aneurysm
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214 Figure 3: Distal below the knee embolization after stenting

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216 Figure 4: Adequate runoff after using DCB

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Paper N Type stent Diameter (cm) Symptoms Follow-up

(months)

Diethrich et al, 2 Customized NR (aneurysm Combined stenotic – 83 +/- 5,5

1995 [15] Endoluminal PTFE length 18 en 40 aneurysmal lesions *

tube anchored cm)

with palmaz stents

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Troitskii et al, 2005 1 Viabahn 8.5 Rupture NR

[16]

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Peralta et al, 2010 1 Viabahn 4.5 Pain and swelling NR

[13]

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Lawrence et al, 3 NR 2.4+/- 0.2 NR 49

2014 [9] (range 1-93)

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*
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Pecoraro et al, 1 Viabahn 7.5 Pulsatile mass 24

2015 [7]
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Lyazidi et al, 2016 2 in 1 Fluency (BARD, 6.0 (right side) Rupture of the right 12

[8] patient Tempe AZ, USA) 3.5 (left side) side

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Asymptomatic left side

Mufty et al, 2017 1 Viabahn 2.45 Distal embolization 10

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*: only follow-up time of mixed data are reported in these studies. No further information was given.
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NR = Not recorded
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