Overview
Definition:
A profunda artery aneurysm (deep femoral artery aneurysm) is a localized, abnormal dilatation of the deep femoral artery, a major artery supplying the thigh muscles
These aneurysms are less common than superficial femoral artery or popliteal artery aneurysms but can lead to significant morbidity due to limb ischemia, thrombosis, or rupture.
Epidemiology:
Profunda artery aneurysms are rare, accounting for a small percentage of all peripheral artery aneurysms
They are more frequently seen in older males, often associated with underlying risk factors for atherosclerosis such as hypertension, hyperlipidemia, diabetes mellitus, and smoking
Trauma and infection (mycotic aneurysms) are less common etiologies.
Clinical Significance:
Untreated profunda artery aneurysms pose a risk of limb-threatening complications including arterial thrombosis leading to acute limb ischemia, distal embolization causing critical limb ischemia or foot ischemia, and spontaneous rupture, which is a surgical emergency with high mortality
Accurate diagnosis and timely intervention are crucial for limb salvage and patient survival.
Clinical Presentation
Symptoms:
Pulsatile mass in the thigh, often deep and difficult to palpate
Pain in the thigh, calf, or foot, especially with exertion (claudication), suggestive of distal embolization or inflow obstruction
Signs of acute limb ischemia: coldness, pallor, paresthesia, paralysis, absent pulses distally
Less commonly, spontaneous rupture may present with sudden severe pain and hemodynamic instability.
Signs:
Palpable, expansile pulsatile mass in the adductor canal or groin region
Auscultation may reveal a bruit over the aneurysm
Distal pulses may be diminished or absent if there is associated arterial disease or thrombosis
Signs of limb ischemia: decreased skin temperature, capillary refill time > 2 seconds, sensory or motor deficits, pallor, dependent rubor.
Diagnostic Criteria:
Diagnosis is primarily based on imaging findings confirming a saccular or fusiform dilatation of the profunda femoris artery exceeding 1.5 times the diameter of the adjacent normal artery
A diameter of >2 cm or a significant increase from baseline measurements is generally considered diagnostic
Clinical suspicion combined with confirmatory imaging is essential.
Diagnostic Approach
History Taking:
Detailed history of claudication symptoms, onset and progression
Risk factors for atherosclerosis (smoking, diabetes, hypertension, hyperlipidemia)
History of trauma, infection, or connective tissue disease
Previous vascular interventions
Family history of aneurysms
Assess for symptoms of acute limb ischemia.
Physical Examination:
Thorough examination of the lower extremities, including palpation for peripheral pulses from the aorta to the dorsalis pedis and posterior tibial arteries
Inspect for skin changes indicative of ischemia
Palpate for any pulsatile masses in the groin and thigh, noting location, size, and compressibility
Assess for neurological deficits and muscle strength.
Investigations:
Duplex ultrasonography: Non-invasive, first-line investigation to assess aneurysm size, morphology, presence of thrombus, and flow dynamics
Computed Tomography Angiography (CTA): Provides detailed anatomical information of the aneurysm and surrounding structures, useful for surgical planning
Magnetic Resonance Angiography (MRA): Alternative to CTA, useful for patients with contrast allergies or renal insufficiency
Conventional Angiography: Gold standard for detailed luminal assessment, helps define extent of disease and plan intervention
Blood tests: Complete blood count, coagulation profile, renal function tests, lipid profile, and HbA1c are important for overall patient assessment and risk stratification.
Differential Diagnosis:
Inguinal lymphadenopathy
Femoral hernia
Hematoma
Soft tissue tumor
Pseudoaneurysm (e.g., post-catheterization)
Iliac artery aneurysm
Superficial femoral artery aneurysm.
Management
Initial Management:
For asymptomatic aneurysms, close surveillance with regular imaging may be considered if the aneurysm is small and without risk factors
For symptomatic or large aneurysms, prompt surgical or endovascular intervention is indicated
In cases of acute limb ischemia secondary to the aneurysm, emergent management is required, including anticoagulation and revascularization
Hemodynamic instability due to rupture necessitates immediate resuscitation and urgent surgical control.
Medical Management:
Medical management focuses on aggressive risk factor modification: smoking cessation, control of hypertension, diabetes, and hyperlipidemia
Anticoagulation (e.g., unfractionated heparin) may be used peri-operatively or in cases of thrombosis to prevent further clot propagation
Aspirin or clopidogrel may be prescribed as secondary prevention for embolic events.
Surgical Management:
Indications for repair include symptomatic aneurysms, asymptomatic aneurysms >2 cm, aneurysms with rapid growth, or those associated with critical limb ischemia
Open surgical repair: Traditionally involves proximal and distal ligation of the aneurysm with interposition graft (autogenous vein or synthetic graft, e.g., PTFE)
This is often performed via an incision in the adductor canal or groin
Endovascular repair: Minimally invasive approach using stent-grafts to exclude the aneurysm from circulation
Requires suitable anatomy for stent-graft deployment and adequate landing zones proximally and distally
This is often the preferred approach for select patients
Embolization: May be considered for small, isolated aneurysms or in high-risk patients where open or endovascular repair is not feasible.
Supportive Care:
Perioperative fluid management, pain control, and deep vein thrombosis prophylaxis
Postoperative monitoring for signs of bleeding, infection, limb ischemia, and graft occlusion
Nutritional support is important for wound healing and recovery, especially in elderly or comorbid patients.
Complications
Early Complications:
Graft occlusion or thrombosis
Distal embolization
Bleeding or hematoma formation
Infection of the graft or surgical site
Nerve injury leading to motor or sensory deficits
Deep vein thrombosis
Acute limb ischemia.
Late Complications:
Graft stenosis or pseudoaneurysm formation
Chronic limb ischemia
Aneurysm rupture (rare after repair)
Systemic complications of atherosclerosis
Recurrence of aneurysm at or near the repair site.
Prevention Strategies:
Meticulous surgical technique, careful patient selection for endovascular versus open repair, aggressive perioperative anticoagulation when indicated, and optimal wound closure
Aggressive medical management of cardiovascular risk factors and regular long-term surveillance with duplex ultrasound are crucial.
Prognosis
Factors Affecting Prognosis:
Presence and severity of atherosclerosis
Patient's comorbidities (e.g., heart disease, diabetes)
Presence of acute limb ischemia at presentation
Type of repair (open vs
endovascular)
Graft patency
Postoperative complications.
Outcomes:
With timely and appropriate repair, the prognosis for limb salvage is generally good, with high rates of patency for grafts
Open repair has excellent long-term durability
Endovascular repair offers lower morbidity but may have a higher reintervention rate compared to open repair
Ruptured aneurysms have a significantly higher mortality rate.
Follow Up:
Long-term follow-up is essential, typically involving clinical assessment and duplex ultrasonography at 1, 6, and 12 months post-operatively, and then annually thereafter, to monitor graft patency, detect pseudoaneurysms, and assess for disease progression or recurrent aneurysms
Patients should be advised to continue aggressive risk factor modification.
Key Points
Exam Focus:
Profunda artery aneurysms are rare but can cause limb ischemia or rupture
Risk factors are similar to other atherosclerotic aneurysms
Diagnosis relies on imaging (US, CTA, MRA)
Management options include open repair (ligation and graft) and endovascular repair (stent-graft)
Indications for repair are symptomatic aneurysms, large size (>2cm), or associated critical limb ischemia.
Clinical Pearls:
A pulsatile mass in the thigh that is deep and difficult to palpate should raise suspicion for a profunda artery aneurysm
Be aggressive with risk factor modification for all patients with peripheral aneurysms
Consider endovascular repair if anatomy is suitable to minimize surgical morbidity, but be prepared for open conversion if necessary.
Common Mistakes:
Attributing symptoms of distal embolization solely to peripheral arterial disease without considering an underlying aneurysm
Delaying intervention in symptomatic or large aneurysms, leading to critical limb ischemia or rupture
Inadequate risk factor assessment and management
Choosing the wrong repair modality based on incomplete imaging or patient selection.