When good enough is better than perfect: a case of end stage visceral segment aortic occlusive disease

The patient is a woman in her 60’s who self referred for complaint of abdominal pain, weight loss, and rest pain of the lower extremities. She is a 40 pack year smoker and had severe COPD, hypertension, congestive heart failure with mitral regurgitation, chronic kidney disease stage IV, and ischemic rest pain of the legs. She had a 30 pound weight loss due to severe postprandial abdominal pain. She had bloody stools. Her kidney function was worsening, and dialysis was being planned for likely renal failure but she was against dialysis. She had consulted several regional centers but was felt to be too high risk for surgery and with her refusal of dialysis, would be a high risk for renal failure and death with intervention. Physical examination revealed weakened upper extremity pulses, and nonpalpable lower extremity pulses and a tender abdomen. In clinic, she developed hypoxia and dyspnea and was admitted directly to the ICU.

preop-cta

CTA (above) revealed severely calcified atherosclerotic plaque of her visceral segment aorta occluding flow to her mesenteric and renal arteries and to her leg. The right kidney was atrophic. The left kidney had a prior stent which looked crushed. The infrarenal aorta was severely diseased but patent and there were patent aortic and bilateral iliac stents.

Echocardiography revealed a normal ejection fraction of 60%, diastolic failure,  +2 to+3 mitral regurgitation, and pulmonary artery hypertension. She did respond to diuresis and stabilized in the ICU. Intervention was planned.

Options that I considered were an extranatomic bypass to her legs and revascularization from below. I have come across reports of axillo-mesenteric bypass, and I have performed ascending and descending thoracic aorta to distal bypass for severe disease, but concluded, as did the outside centers, that she was a formidable operative risk. Also, there was a high likelihood of great vessel occlusive disease. Looking at her CTA, I felt that she needed just a little improvement in flow -not perfect but good enough. The analogy is like drilling an airline through a cave-in. Also, her left kidney gave a clue -it was normal sized and survived the stress test of a contrast bolus for the CTA without dying. A discussion with the patient green lighted an attempt -she understood the cost of failure but did not wish to linger with this abdominal pain.

Access for intervention was via the left brachial artery. Aortography showed the severe stenosis at the origin of the SMA and the nearly occlusive plaque in the visceral segment aorta.

preintervention-aortogram

The plaque was typical of the coral reef type, and had an eccentric channel that allowed passage of a Glidewire. Access into the left renal artery was achieved. Its stent was patent but proximally and distally there were stenoses; this was treated with a balloon expandable stent. The path to it was opened with a balloon expandable stent to 8 mm from femoral access. This was the improvement the renal needed. A large nitinol stent was placed from this access in the infrarenal aorta when severe disease above the iliac stents was encountered.  The SMA was then accessed and treated with a bare metal stent.

post intervention.jpg
Renal stent was reaccessed and ballooned in this pentultimate angiogram

Her creatinine improved, as did her intestinal angina. She was discharged home. She later returned a month after the procedure with complaints of nausea and vomiting and right lower quadrant abdominal pain and was discovered to have an ischemic stricture of her small bowel. This was removed laparoscopically and she recovered well. She recovered her lost weight and now a year and a half later, remains patent and symptom free.

Discussion: Dr. Jack Wiley includes in the preface to his atlas of vascular surgery the words of Dr. Joao Cid Dos Santos, the pioneer of endarterectomy techniques, “Vascular surgery is the surgery of ruins.” And in that context, good enough is sufficient.

 

The Cost of Success in Iliocaval Venous Thrombosis: Efficacy is Only One Aspect of Device and Procedural Innovation

preop-venous-duplex The patient is a young woman who three weeks prior to presentation developed sudden low back pain and left leg pain while exercising on an elliptical. This pain worsened through the subsequent weeks and she developed fevers, chills, and night sweats, and she came to the emergency department. There, she was found to have left thigh and leg swelling. Duplex revealed a left iliofemoral DVT starting from the iliocaval tributary and extending to her left femoral vein (figure above). A CT scan revealed a pulmonary embolism to the left lung (below). No precipitating factors were present. Vascular surgery was consulted.

ct-pe-left_1

Plan was for catheter directed thrombolysis. Venography from the patient’s popliteal vein via a short saphenous access revealed thrombotic occlusion from the left common femoral confluence to the iliocaval confluence. The thrombus was crossed, and ballooning showed there was chronicity to the occlusion in the pelvis evidenced by waisting of the balloon on inflation. A multihole infusion catheter was placed across the thrombus from the thigh to the inferior vena cava and recombinant tissue plasminogen activator was infused overnight.

pretpa-catheter-placement

The venogram from the popliteal vein showed a patent popliteal and femoral vein and the goal of this procedure became opening the common femoral  vein  and its confluence of multiple veins from the thigh, to connect it via stents to the vena cava (second image below).

femoral-vein-pre-tpa

pretpa-ivc

Clinically, there was no change overnight and when the patient was restudied next morning, there was still an occlusion starting at the common femoral vein.

post-lysis-cfv-occluded

At this point, I had a choice as to what to do next. First, I could stop, and have the patient start anticoagulation and return several months later -often, the common femoral vein returns to drain into pelvic collaterals. As I had discussed in an earlier post, venous interventions are no different from arterial ones in that inflow, draining vein, and outflow have to be considered. In the case of the veins, I like to think of it as connecting major confluences, and for a leg, the common femoral venous confluence is paramount.Confluences

Intervening from the popliteal vein to the vena cava is inferior to being able to connect draining veins at the common femoral confluence to the vena cava. So getting the common femoral vein to patency is critical, and can sometimes be achieved with anticoagulation and time. The second option is to break out a thrombectomy catheter and try to remove the thrombus by various machinations, ie. gadgets and novel catheter systems of which there are many. I felt that given the three week time course of the thrombus, the best we could get was some clearance of thrombus, leaving behind a complex network of chronic thrombus and fibrinous scar with the overnight lysis. I didn’t even try this second option and the thrombectomy machine stayed unplugged, the fancy (and expensive) catheters left hanging. The third option, surgery, was not indicated as the patient did not have signs of phlegmasia, and for the same reasons that the lysis didn’t work, opening the common femoral vein for an endovenectomy has uneven outcomes.

The fourth option, mechanical aspiration sheath thrombectomy (MAST), is a technique developed by Dan Clair, our former chair. As a concept, it is very simple. A large sheath (>12F) is introduced and the thrombus is aspirated while the bare sheath is advanced over a wire. The sheath is then removed and the contents emptied. For this case, an 18 F sheath was introduced into the femoral vein in mid thigh.

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The blood is ejected into a basin and a cell saver (in non-malignant cases) is used to salvage the whole blood.

thrombectomy-photo

This reopened the common femoral vein. This was for me a very important step as without achieving this, I would have had to stent into the femoral vein, excluding many smaller veins draining into the common femoral vein, and effectively basing my revascularization off the popliteal vein confluence, an inferior inflow source for venous revascularization.

post-mast-cfv
CFV post MAST

With the common femoral vein open, placing stents from the vena cava to the common femoral vein was straightforward and described elsewhere (reference). The iliac vein remained closed due to the chronic thrombosis, which was clinically May Thurner’s Syndrome, and was stented.

completion fluoro.jpg

Three things deserve comment: the vena cava and iliac veins need to be dilated up to 18mm, and larger for the cava. This is disconcerting, but size does matter. Second, IVUS is critical in confirming that everything is open. Third, the 14mm nitinol stent placed into the common femoral vein will stay open, unlike a stent placed into the artery across the inguinal ligament. It likely has to do with the deeper position of the vein in relation to the artery which protects the vein from the ligament. We don’t have the large diameter nitinol stents designed for iliocaval venous revascularization yet, but the available stents do a good job.

large-balloon-in-iliocaval-vein

The patient was discharged on anticoagulation with resolving edema in the left leg and thigh. At one month followup, duplex confirmed wide patency of the stents and IVC and no new DVT.

Discussion: MAST illustrates a critical issue for all innovation in the current setting of resource limitation. Innovations must be made with not just a consideration to efficacy and potential market, but also cost. The large sheaths used in MAST are commonly available and cheaper by multiples of tens compared to the thrombectomy systems and catheters. Unpublished data reviewing 13 patients undergoing MAST with a mean followup showed 69% with complete thrombus removal, 31% with subsegmental removal, no operative mortality, and 92% primary patency at an average of 79 days of followup, all with symptom improvement (Clair, correspondence). Other groups have reported similiar results using “large catheters” (reference 2), but nothing can compare to an 18F sheath in clearing the iliocaval system.

The patient can expect to have excellent patency in the short to mid term (reference 1).

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References

  1. Titus JM et al. J Vasc Surg. 2011 Mar;53(3):706-12.
  2. Chung HH et al. Vasc Endovascular Surg. 2016 Jul;50(5):321-7

3D VR Images from CT Data Very Useful in Open Surgical Planning: Popliteal Venous Aneurysm

ct-3dvr-planning

Patient is a middle aged man with history of DVT and PE who in preoperative workup for another operation was found to have a popliteal venous aneurysm affecting his right leg. Unlike the recently posted case (link) which was fusiform, this aneurysm was saccular (CT above, duplex below). Popliteal venous aneurysms have a high risk of pulmonary embolism because: they tend to form clot in areas of sluggish flow and once loaded with clot, will eject it when compressed during knee flexion.

preop-duplex

When I perform open vascular surgery, I tend to get a CTA not just because it is minimally invasive and convenient, but because it gives important information for operative planning. The volume rendering function, which takes the 3 dimensional data set from a spiral CT scan, and creates voxels (3 dimensional pixels) of density information and creates stunning images such as the one featured on the current September 2016 issue of the Journal of Vascular Surgery. But these are not just pretty pictures.

In fact, I use these images to plan open surgery, even to the location of incisions. Vital structures are seen in 3D and injuries are avoided. Take for example the CT Venogram on the panel below. By adjusting the window level, you have first the venographic information showing the saccular popliteal venous aneurysm on the left panel, you can also see where it is in reference to the muscles in the popliteal fossa. The greater saphenous vein and varicose veins below are well seen.

ct-3dvr-planning

By adjusting the level, subcutaneous structures are better seen including the small saphenous vein which could be harvested to create a patch or a panel graft from a posterior approach. A final adjustment of the window level on the right shows the skin, and I can now plan the curvilinear incision.

By changing the orientation, I can also recreate the surgeon’s eye view of the leg in the prone position (below).

or-view_1

And you can see how well it matches up to the actual operation shown below:

Intraop Photo.png

This was treated with plication of the saccular aneurysm and unlike the fusiform aneurysm, I did not sew over a mandrill (a large 24F foley) inserted through a transverse venotomy, but rather ran a Blalock type stitch under and over a clamp.

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The several weeks postoperatively showed no further trace of the saccular aneurysm.

postop-duplex

The volume rendering software grew out of the 3D gaming industry. The voxel data that paints flesh and bone on skeletons and costumes and weapons is far more complex than what is applied for the 3DVR packages that are available. The images shown for this post comes from TeraRecon/Aquarius, but they are also available as open source software from Osirix, Vitrea, and various software packages sold with CT scanners. While those that are tied to the scanners are often tied to dedicated workstations -limiting you to going to Radiology and taking over their workstation, many will work in the cloud for both the DICOM data and for virtual desktop access through mobile. Contrast is not necessary if the patient has kidney dysfunction -the vessels can be manually centerlined -ie. a line can be dropped in the center of the artery to illustrate its course when viewing the VR images.

I will plan the surgery while in the clinic with the patient, actually tracing out the incisions and dissections necessary to achieve success. It is a wonderful teaching tool for trainees. But most critically, it helps me imagine the operation and its successful completion.

Complex femoral pseudoaneurysm with arteriovenous fistula and large hematoma treated with novel hybrid therapy

wide avf and pseudo

The patient is a middle aged man who after an interventional procedure was referred to my clinic with an expanding hematoma due to a pseudoaneurysm complicated by an arteriovenous fistula. He was a week out from his procedure and had grown a hematoma roughly the size of a hard boiled egg in his left groin which caused him pain. A duplex scan showed a pseudoaneurysm (below) with fistula flow.

preduplex12

On examination, he had this well circumscribed indurated hematoma of hard boiled egg size with tenderness. There was a bruit on auscultation. Duplex showed a small chamber of flow adjacent to the proximal superficial femoral artery emptying into the femoral vein. Doppler in the common femoral vein showed relatively high fistula flow, and this is reported to be associated with failure of thrombin injection. CTA (top) demonstrated flow of contrast from femoral artery to vein through a pseudoaneurysm chamber that laid between. Angulation to an axial orientation showed this better (below).

axial AVF
Contrast flows from femoral artery (right) to the fistula chamber, then into the femoral vein.

axial CTA avf pseudo
Axial MPR
Operation was planned, but in the days leading up to the operation, I had a thought -the primary reason why ultrasound guided thrombin injection would fail is the AVF. It would be simple to fluoroscopically guide an angioplasty balloon on the arterial side to occlude the fistula inflow. The next step would be to get access to the pseudoaneurysm with a needle under ultrasound guidance, confirm location with a contrast injection. Once confirmed, the balloon is inflated and a small volume of thrombin would be injected. I discussed this with the patient in detail and he was enthusiastic about trying this before proceeding with an open repair.

 

pseudoaneurysm avf procedure sketch
Schematic of procedure
The procedure went as planned. Ultrasound guided access is aided with dual live display of B-mode and color flow (below)

Arteriography showed much of the contrast from injection of the pseudoaneurysm to preferentially go to the artery which made me worry less about creating a DVT/PE. With balloon inflated (below), thrombin was injected and balloon inflation held for about 30 seconds.

angio procedure31

There was resolution of flow in the pseudoaneurysm and in the fistula. Before and after duplexes are composited below.

prepost pseudo chamber

Repeat duplex on the following day showed resolution of the pseudoaneurysm and arteriovenous fistula.

In the days before ultrasound guided thrombin injection of pseudoaneurysms, open surgical repair of these was fraught with complications. First, these patients typically had cardiac disease. Second, they were usually anticoagulated often with multiple agents. And finally, they were  many times obese, making not only the operation fraught with complexity, but the ultimate wound healing a delicate and rare phenomena. Even now, we get emergency repairs when access hemostasis fails, and these patients are typically high risk. With hematoma evacuation, inflammation, lymph leaks, and infections may follow; the patient was correct in his enthusiasm for agreeing to proceed with a minimally invasive effort.

As to the techniques, they are all well established in the vascular surgeon’s toolbox. Ultrasound guided access of the pseudoaneursm should be obtained before arterial occlusion. This was  facilitated by general anesthesia which kept the patient from moving. Having access to excellent ultrasound and angiographic imaging made this possible. The patient felt much better and was discharged home the next day after his confirmatory duplex.

Nutcracker Syndrome: A Simplified Approach With Gonadal Vein Transposition

CTV_1

The patient is a young woman in her twenties who developed severe right sided abdominal and back pain about 4 months prior to presentation associated with bouts of bloody urine. Activity and standing exacerbated her pain and inactivity and recumbency relieved it. She gained 15 pounds because of her inactivity. Examination was significant for tenderness over her left kidney. Urinanalysis showed positive proteinuria and hemaglobinuria.

Prior to consultation with me she had had an MR venogram showing compression of her left renal vein by the superior mesenteric artery (nutcracker phenomena). The presence of hematuria, proteinuria, and pain (albeit atypically right sided) made it nutcracker syndrome.

MRV color_Image006
Dilated left gonadal vein and pelvic varices indicate left renal vein (LRV) ouflow obstruction by the superior mesenteric artery (SMA)

I ordered a renal duplex and a CT venogram for procedural planning.

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On the duplex, the proximal left renal vein (LRV) was not visualized. The right kidney had normal parenchymal appearance and blood flows, while the left, the kidney appeared distended and had flows consistent with outflow obstruction.

spectral kidneys
Spectral Doppler flows show respirophasicity in right renal vein(RRV), outflow obstruction on left renal vein (LRV)
Duplex kidneys bmode
The left kidney is swollen and tender.

CT Venography showed the gonadal vein to be an important outflow vessel to the left renal vein with dilated proximal segment and reflux into pelvic varices.

CTV_1

CTA processed_5CTA processed_4

A left gonadal vein to iliac vein transposition was planned via a left lower quadrant retroperitoneal exposure. On the table, a venogram was performed with selective access of the left renal vein.

Venogram13

The injection from the LRV showed severe compression of the LRV with a channel only slightly larger than the sheath and avid reflux into the gonadal vein. Selective access into the gonadal vein and venography from a confluence in the pelvis showed that flow was one way from the LRV into the gonadal vein and this filled a large region of pelvic varices.

Venogram19

Venogram23

The gonadal vein was large caliber and refluxed into two large veins in the pelvis. The one that fed the varices was not selected for transposition, but rather the longer straighter tributary. A catheter was left for easier identification during the dissection.

A left lower quadrant incision was made and a retroperitoneal dissection performed exposing the gonadal vein and iliac vein.

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Prior to ligation of the tributaries, a sheath was inserted and through this a LeMaitre valvulotome was brought up to the left renal vein and carefully deployed and pulled back, cutting the valves. This greatly increased the outflow from the vein as evidenced by the height of the blood spout from the vein when the sheath was removed. The varices were ligated at their root -treating them definitively. Transposition was to the external iliac vein, and I could see the feasibility of a laparoscopic or robotic approach to this operation (ref 3).

Completion venography showed excellent flow from the LRV down the gonadal vein into the iliac venous system.

Venogram41

The patient lost less than 10mL of blood and was discharged on postop day 2. Gratifyingly, all of her preoperative pain resolved and her UA showed no more hemoglobinuria or proteinuria.

Discussion

The described treatment options for nutcracker syndrome include (ref 1):

  1. Medical therapy aimed at decreasing renal venous hypertension (for hematuria)
  2. Renal autotransplantation
  3. Left renal vein transposition
  4. Left renal vein to vena cava bypass (autologous or PTFE)
  5. SMA transposition
  6. Nephrectomy
  7. Gonadal vein to IVC bypass
  8. Exovascular stenting (wrap of renal vein with ringed PTFE graft)
  9. Endovascular stenting

Many of the operations are of historic interest. Stenting deserves some comment. The patient self referred because she had read multiple reports of cardioembolization on internet support group comments. The largest nitinol stent (self expanding) available is 14mm. Wall stents in larger diameters are available, but are stiff, poorly conformable, and will elongate if constrained by a non-dilating stenosis like the external compression by the SMA. While acceptable results have been reported, the long term results (20-70 years) for younger patients is unknown. Migration is highly morbid, and usually to the heart, requiring sternotomy and cardiotomy to retrieve the stent. Optimally, a conforming 16-28mm self expanding stent should eventually become available, but conformability is typically inversely proportional to radial strength, and it is the less conformable stents that migrate. Work is ongoing to bring larger diameter nitinol stents for venous indications. The difference between May-Thurner Syndrome and Nutcracker syndrome isn’t merely the size of the veins and stents. The iliocaval confluence is relatively static with some movement of the lumbosacral joints and well suited for treatment with the relatively nonconforming Wall Stents. The left renal vein under the SMA is a very dynamic environment with motion of the SMA and the kidneys with respiration, ambulation, and activity leaving stents vulnerable early to migration and later to fracture.

The left renal vein transposition to the IVC is a nice operation with a good track record (ref 2). The downside is the long midline incision required with transperitoneal exposure. There is bleeding risk and postoperative complications of ileus, wound infection, and small bowel obstruction. Looking at the CTV, it seems obvious that the gonadal vein crosses over the iliac vein in the pelvis and would be a straightforward, less morbid, less invasive option. A review of the literature reveals only a single reference discussing three cases of left renal vein transposition (ref 3), and it was done with a surgical robot. I think that a laparoscopic approach would be simpler and less invasive and will consider developing this if volumes justify it. That said, the open retroperitoneal approach is very straightforward and well used exposure. Using venography to set up and then confirm the results of the transposition was helpful. I don’t think that measuring pressures and diameters and taking calipers to calculate stenoses is all that useful and in some instances a harmful method of justifying endovascular treatment of nutcracker phenomena in the absence of serious symptoms and a careful deliberate workup which includes a good history and physical, a UA, a duplex and CTV.

Intervening on the gonadal vein to iliac vein anastomosis should be straightforward from a groin or thigh venous access on the ipsilateral side. This operation doesn’t preclude any future interventions on the LRV. The pelvic varices were treated with direct ligation. The patient’s pain was successfully relieved in the short term.

Conclusion: Open retroperitoneal left gonadal vein to iliac vein transposition with gonadal vein valvulotomy is effecting in treating nutcracker syndrome.

References

  1. Kurklinsky AK, Rooke TW. Mayo Clin Proc. 2010 Jun; 85(6): 552–559.
  2. Reed NR et al. J Vasc Surg. 2009 Feb;49(2):386-93;
  3. White JV et al. J Vasc Surg Venous Lymphat Disord. 2016 Jan;4(1):114-8.

 

Dysphagia Lusoria -a simplified approach

Arrow points to the esophagus. Tension is maintained by the tether on either side of the esophagus. By releasing one side, the tension is relieved.

The patient had been suffering with dysphagia for over a decade and had had extensive head and neck work up which found a goiter. Medical treatment of this goiter failed to relieve the lingering sensation of food getting stuck and the constant feelingof choking. It was only after a search for mediastinal sources of dysphagia that an aberrant right subclavian artery was found. 


One of the advantages of working at the Clinics (I was a fellow at the Mayo, and currently on staff the the Cleveland) is that the infrequent is common while the common is rare. Recently in clinic, I had not one but two patients with dysphagia lusoria. It was the observation of Dan Clair’s,  chairman emeritus, that by simply transposing the aberrant and yet nonaneurysmal right subclavian artery, the tension on the esophagus and trachea are relieved. Or as the dictum might go: it takes two hands to garrote someone


The question is then what to do with the stump? The natural history of the untreated stump is unknown but may be more benign than one might assume. It certainly doesn’t degenerate into an aneurysm all the time -chest CT’s are fairly common and when these are discovered, they are not usually aneurysmal like persistent sciatic arteries which present typically as aneurysms with thromboembolism. Perhaps because we don’t sit on the subclavian artery as we would on a persistent sciatic artery that these aberrant right subclavian arteries don’t degenerate. 


The old fashioned way I learned to treat these aneurysms (Kommerell Diverticula) was through a high thoracotomy and short graft repair of the aorta, replacing the origin of the diverticulum.  This is a dangerous operation for  an older, sicker, and often cachectic patient. The more recent reports involve a left carotid subclavian bypass or transposition and TEVAR after a right carotid subclavian revascularization. This second step may be unecessary if the non-aneurysmal stump proves to be benign. I don’t recommend coil embolization of the stump as mass effect of packed coils adjacent to the esophagus can cause dysphagia to recur, and this may necessitate an open resection and repair (observation, DC). 

The patient underwent a successful right carotid subclavian transposition and had immediate relief of her dysphagia for the first time in over a decade, especially because she had been told she may have been imagining the discomfort. Kudos to her physicians who ordered the CT of the chest that discovered her arch anomaly. Follow up at 6 weeks showed a stable subclavian stump and patent transposition (images above). My plan is for regular interval CT’s with increasing intervals as time passes. 

The Clot Gun: Popliteal Venous Aneurysms Are Not Varicose Veins

IMG_9819

The basics of this air rocket pictured above is the projectile, attached by tube to a large bladder which when compressed by external force, ejects the projectile upwards. These are the same features of a popliteal venous aneurysm. First, the large chamber predisposes to stasis and thrombus formation. This thrombus will form on the flaccid walls which are areas where stasis occurs. During activity, it likely dislodge but catch at the outflow, obstructing it. Pressure builds up in the calf veins below, and flexing the knee and pressing the venous aneurysm ejects the thrombus towards the heart and lungs. Clot Gun.

CTV_1

The patient is a young woman who was an active college athlete. She had her first pulmonary embolism occur during practice several years prior to presentation. A duplex noted residual thrombus in her right popliteal vein. Over the next several years, she had two more episodes of pulmonary embolism whenever her anticoagulation was stopped. No thrombophilia was detected on workup. She was referred to the Clinic and Dr. Jerry Bartholomew in the Department of Cardiovascular Medicine noted in her records a mention of a dilated popliteal vein. On examination, she had no historical or physical examination findings to suggest a predisposition to pulmonary embolism. A duplex was ordered.

preop duplex popliteal venous aneurysm.png

The duplex showed a 2.8cm popliteal venous aneurysm of the right leg. No acute DVT was seen but swirling rouleaux could be seen on the B-mode video. A CT venogram was ordered.

CTA summative

No other defect was detected. Operation was planned. Mapping showed no suitable superficial venous conduit, and venorrhaphy was planned. The patient was kept anticoagulated to the day of operation.

IMG_9702.jpg

A curvilinear incision (lazy S) was made across the popliteal fossa and careful dissection revealed the aneurysm. It was soft and the vein was normal below in the calf. Above it, there was a tight fibrous band that was contricting it -a popliteal venous entrapment. I released this band. Using a 24 French Foley catheter inserted through a transverse venotomy on the popliteal vein below, the aneurysm was plicated to approximately 1cm diameter, and the catheter removed and the venotomy repaired.

IMG_9703

The nerves were restored to their original position and the wound closed in layers. She recovered well and returned to followup about a month later. Duplex showed a patent vein and she had no symptoms of dyspnea.

pop venous aneurysm post18

The plan is to have her come off of her anticoagulation after a visit with Dr.Bartholomew. Reviewing the literature, my confreres at Mayo published their 15 year experience with popliteal venous aneurysms and found that 5 of their 8 patients presented with pulmonary embolism, and that most of their complications occurred with bypass repair while aneurysmorrhaphy fared well (reference). Because of their rarity, about 200 cases in the literature, it may be assumed that many are not found until complications occur or never found because pulmonary embolism, the most common complication, results in death. Also, it would be easy for unknowing physicians to assume that popliteal venous aneurysm falls under the umbrella of varicose vein which this is not. They should be treated when found, and in most cases, such as this, venorrhaphy is preferred.

 

Reference

Johnstone JK et al. Surgical treatment of popliteal venous aneurysms. Ann Vasc Surg 2015;29:1084-1089.