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Endovascular Management for a Rupture of a Previously Ligated Popliteal Artery Aneurysm Following Redo Revascularization A Case Report
Hayden R. Caudill, Catherine Go, Mohammad Eslami, Andrew Lee
Charleston Area Medical Center, Charleston, WV
INTRODUCTION Popliteal artery aneurysms (PAA) are the most common peripheral aneurysm with an incidence of 1% in the general population. Patients with PAAs commonly present with ischemic symptoms as rupture is quite rare (2% incidence). In this case report, we discuss a unique case of rupture of a previously bypassed and ligated PAA months after a redo femoral-posterior tibial (PT) bypass.
HISTORY 76-year-old man who originally presented in 2016 with acute-on-chronic limb ischemia of his right lower extremity (RLE). He was found to have a 1.4 cm thrombosed PAA with PT and peroneal runoff. He underwent a right superficial femoral artery to below-knee popliteal artery bypass with in-situ great saphenous vein with ligation of the PAA. In 2023, he developed worsening symptoms with rest pain of his RLE and his bypass was occluded, ABI of 0.56. He underwent a right common femoral artery to PT artery bypass with a prosthetic graft as he did not have an adequate vein conduit. Two months after his operation, he presented to the emergency department due to RLE swelling and popliteal fossa pain. He underwent duplex testing which showed a 3.18 x 4.03 cm mass with arterial flow in the popliteal fossa. CTA was obtained which showed patent CFA-PT bypass and contrast extravasation from the native, thrombosed PAA in the popliteal fossa (Figure 1).
PLAN The patient underwent angiogram and was noted to have a rupture of the previously thrombosed PAA with active extravasation from a collateral vessel from the distal PT artery filling via retrograde flow (Figure 2). The patient underwent coil embolization of the major feeding vessel. All anti-platelets and anti-coagulation were held post-operatively, and the patient's symptoms and physical exam improved to near complete resolution post-intervention on his follow-up visit.
DISCUSSION This case describes a unique situation in which a thrombosed PAA previously treated with aneurysm exclusion/ligation and bypass, not only grew substantially in size, but became symptomatic with rupture two months after a redo revascularization. Rupture of a PAA is rare as evidenced by the paucity of literature surrounding this complication. However, this appears to be the first report of a ruptured PAA after redo revascularization following a previous bypass and ligation 7 years prior. This also highlights the importance of why these patients should undergo duplex evaluation of the popliteal artery post-operatively to evaluate collateral feeding vessels. This case demonstrates the presentation, diagnosis, and successful utilization of endovascular evaluation and intervention with coil embolization as a treatment modality for this clinical scenario.
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