Overview
Definition:
A profunda femoris artery aneurysm is a localized, abnormal dilation of the profunda femoris artery (deep femoral artery), which is the largest and most proximal branch of the femoral artery, supplying the muscles of the thigh
Ligation is a surgical technique involving tying off the artery to occlude blood flow, typically performed when endovascular repair is not feasible or has failed, or as a salvage procedure.
Epidemiology:
Aneurysms of the profunda femoris artery are rare, accounting for less than 1% of all peripheral arterial aneurysms
They are more common in older men, often associated with risk factors for atherosclerosis such as hypertension, hyperlipidemia, smoking, and diabetes mellitus
Trauma can also be a causative factor.
Clinical Significance:
These aneurysms pose a risk of rupture, distal embolization leading to limb ischemia, or compression of adjacent structures
Prompt diagnosis and management are crucial to prevent severe morbidity and mortality, making it an important topic for surgical residents preparing for examinations.
Clinical Presentation
Symptoms:
Asymptomatic presentation is common, with incidental findings on imaging
Symptomatic patients may present with: A pulsatile mass in the groin or thigh
Pain in the thigh, groin, or buttock, especially with activity
Signs of distal embolization, including foot pain, numbness, coldness, or gangrene
Symptoms of limb ischemia, such as claudication or rest pain
Rarely, symptoms related to compression of surrounding nerves or veins, causing sciatica-like pain or deep vein thrombosis.
Signs:
A palpable, pulsatile, expansile mass in the femoral triangle or proximal thigh
Bruit may be auscultated over the mass
Signs of limb ischemia: decreased distal pulses, cool extremities, pallor, cyanosis
Neurological deficits if nerve compression is present
Edema if venous compression is present.
Diagnostic Criteria:
Diagnosis is primarily based on imaging
Clinical suspicion from physical examination findings, especially a pulsatile mass, prompts investigation
No specific diagnostic criteria exist beyond imaging confirmation of an aneurysm exceeding a certain diameter (e.g., >1.5-2 times the normal arterial diameter) with a demonstrable defect in the arterial wall.
Diagnostic Approach
History Taking:
Inquire about cardiovascular risk factors (hypertension, hyperlipidemia, diabetes, smoking history)
Ask about any history of trauma to the thigh or groin
Detailed questioning regarding onset, character, and progression of pain, numbness, or coldness in the limb
Assess for any history of previous arterial interventions or surgery.
Physical Examination:
Careful palpation of the femoral triangle and proximal thigh for a pulsatile mass
Auscultation for bruits
Comprehensive assessment of peripheral pulses in the affected limb and contralateral limb for comparison
Neurological and vascular assessment of the entire limb
Examination for signs of venous compression.
Investigations:
Duplex ultrasonography: The initial imaging modality of choice, providing anatomical detail, lumen diameter, flow characteristics, and thrombus assessment
Computed tomography angiography (CTA): Offers detailed anatomical information, especially useful for complex anatomy or planning surgical intervention
Magnetic resonance angiography (MRA): Alternative to CTA, particularly in patients with contrast allergies or renal insufficiency
Conventional angiography: Still considered the gold standard for detailed vascular anatomy but is invasive and less frequently used for initial diagnosis now.
Differential Diagnosis:
Femoral artery pseudoaneurysm (iatrogenic, post-traumatic)
Femoral vein thrombosis
Lymphadenopathy
Soft tissue tumors or masses
Femoral hernia
Saphenous varix.
Management
Indications:
Symptomatic aneurysms (rupture, embolization, limb ischemia, compression)
Asymptomatic aneurysms exceeding 2-3 cm in diameter or with rapid expansion
Aneurysms in young patients or those with high risk of rupture.
Preoperative Preparation:
Comprehensive vascular assessment and risk stratification
Optimization of comorbidities (hypertension, diabetes, cardiac status)
Preoperative antibiotics
Anesthesia planning (general or regional)
Planning for potential blood transfusion
Identification of suitable vascular grafts if needed.
Surgical Management:
Open surgical ligation is the definitive treatment when endovascular options are unsuitable or have failed
The procedure involves a surgical incision in the groin or thigh
The profunda femoris artery is carefully dissected proximally and distally to the aneurysm
It is then ligated securely with strong sutures, typically high and low to exclude the aneurysm sac
If significant thrombus is present within the aneurysm, thrombectomy may be performed
In some cases, if the aneurysm involves the origin of the profunda femoris artery and is large, ligation might lead to significant thigh claudication
In such scenarios, a bypass graft (e.g., synthetic or autologous vein) from the common femoral artery to a patent distal segment of the profunda femoris artery might be considered, although this is less common than simple ligation.
Postoperative Care:
Close monitoring for bleeding at the surgical site
Pain management
Wound care
Vigilant monitoring for signs of limb ischemia, including serial assessment of distal pulses and perfusion
Early ambulation as tolerated
Anticoagulation may be considered depending on the extent of thrombus or risk of venous stasis
Long-term follow-up to monitor for graft patency if a bypass was performed or for any contralateral arterial disease.
Complications
Early Complications:
Hemorrhage from the surgical site
Infection
Nerve injury (femoral nerve)
Deep vein thrombosis
Limb ischemia due to inadequate collateralization or distal embolization during surgery
Reperfusion injury.
Late Complications:
Chronic limb-threatening ischemia if collaterals are poor
Development of new aneurysms in other locations
Pain or weakness in the thigh due to impaired muscle perfusion
Stenosis or occlusion at the ligation site or graft failure if bypass was performed.
Prevention Strategies:
Meticulous surgical technique with careful dissection to avoid inadvertent injury to surrounding structures
Adequate proximal and distal control of the artery before ligation
Use of appropriate suture material
Careful consideration of patient's collateral circulation before ligation
Prompt recognition and management of limb ischemia
Prophylactic antibiotics and DVT prophylaxis.
Prognosis
Factors Affecting Prognosis:
Presence and severity of symptoms at presentation
Presence of limb ischemia
Patient's overall health status and comorbidities
Adequacy of collateral circulation to the limb
Success of surgical intervention in excluding the aneurysm and restoring perfusion.
Outcomes:
With timely and appropriate surgical management, the prognosis for profunda femoris artery aneurysm ligation is generally good, with a low risk of mortality and limb loss
Asymptomatic aneurysms successfully treated have excellent outcomes
Symptomatic patients, especially those with limb ischemia, may have a more guarded prognosis depending on the severity of ischemia and ability to restore adequate perfusion.
Follow Up:
Regular clinical follow-up is essential, particularly for patients who underwent bypass grafting, to monitor graft patency
Patients with known atherosclerotic disease should have ongoing surveillance for new aneurysms or arterial disease
Follow-up intervals are typically 6 months to 1 year initially, then annually, or as dictated by the patient's risk factors and overall vascular status.
Key Points
Exam Focus:
Profunda femoris aneurysms are rare
suspect in elderly males with pulsatile groin masses
High risk of rupture and embolization
Duplex ultrasound is the initial diagnostic modality
Open surgical ligation is the standard treatment for symptomatic or large aneurysms, especially when endovascular options are limited
Consider bypass if ligation might cause severe thigh claudication.
Clinical Pearls:
Always palpate for pulsatile masses in the groin and thigh, and auscultate for bruits, especially in patients with vascular risk factors
Remember the proximity to the femoral nerve
careful dissection is paramount to avoid injury
Post-ligation limb ischemia is a critical complication to watch for
adequate collateral circulation is key.
Common Mistakes:
Misdiagnosing a profunda femoris aneurysm as a simple hematoma or lymphadenopathy
Delaying diagnosis in asymptomatic patients until rupture or embolization occurs
Performing ligation without adequately assessing collateral flow, leading to limb ischemia
Inadequate proximal or distal control of the artery during ligation, leading to bleeding.