Arteriosclerotic Femoral Artery Aneurysms Linda M. Graham and Sunita Srivastava Arteriosclerotic femoral artery aneurysms are relatively uncommon, but they are the second most commonly encountered peripheral arterial aneurysm. The exact incidence of femoral artery aneurysms in the general population has not been defined, but they are nearly as common as popliteal artery aneurysms and have been reported in 6.8% of patients with abdominal aortic aneurysms. Although limb loss is rarely attributed to complications of femoral artery aneurysms, their importance arises from their frequent association with potentially life-threatening abdominal aortic aneurysms and limb-threatening popliteal aneurysms. Pathogenesis The etiology of arteriosclerotic or degenerative femoral artery aneurysms is not clear. The multiplicity of aneurysms often found in patients with arteriosclerotic femoral artery aneurysms supports a systemic abnormality in the arterial wall or in the body’s response to injury. Arterial wall damage can occur at locations where hemodynamic or mechanical factors cause arterial wall stress, such as proximal to major branching vessels or distal to a relative stenosis at the inguinal ligament. Similar to aortic aneurysms, an inflammatory infiltrate is seen in the wall of femoral aneurysms. In addition, hereditary factors affecting collagen or elastin production or stability and arterial wall enzyme activity can contribute to aneurysm formation. None of these factors satisfactorily explains the predilection of the disease for men; femoral aneurysms, like popliteal aneurysms, are much more common in men, with a male-to-female ratio of 20:1 or greater. Pattern of Disease Aneurysms of the proximal femoral arteries almost always involve the common femoral artery with or without involvement of the superficial femoral and profunda femoris arteries. Common femoral artery aneurysms can be categorized as type 1, being femoral artery aneurysms limited to the common femoral artery, or type 2, being those with involvement of the orifice of the profunda femoris artery. Type 1 and type 2 aneurysms occur with nearly equal frequency. The anatomic differences become important when planning arterial reconstruction. Type 2 aneurysms usually require a more complex procedure to ensure continued patency of both the superficial femoral and profunda femoris arteries. Of great clinical significance is the common association of femoral artery aneurysms with life-threatening and limb-threatening aneurysms that can pose greater risk for the patient than the femoral aneurysm. In a series of 100 patients with arteriosclerotic femoral artery aneurysms seen at a single institution, aortoiliac aneurysms were detected in 85% of patients, thoracic aortic aneurysms in 6%, and popliteal aneurysms in 44%; 55% of the popliteal aneurysms were bilateral. In addition, 72% of patients had bilateral femoral artery aneurysms. Associated aortic aneurysms are more common in patients with bilateral femoral artery aneurysms. Aneurysms of the proximal superficial femoral or profunda femoris artery without an ipsilateral common femoral artery aneurysm are unusual. Aneurysms of the profunda femoris artery often manifest with rupture. Asymptomatic proximal superficial femoral or profunda femoris artery aneurysms are being recognized more often with the increasing use of imaging modalities. Similar to common femoral artery aneurysms, concomitant aortic aneurysms are common. Natural History The natural history of atherosclerotic femoral artery aneurysms has not been defined, because most series originate from a surgical service. However, in retrospective reviews including patients not undergoing surgery, it appears that the natural history of femoral artery aneurysms is more benign than that of popliteal artery aneurysms. Serious limb-threatening complications were documented in only 2.9% of 105 aneurysms managed nonoperatively and followed for an average of 28 months. Clinical Presentation The typical patient with an atherosclerotic femoral artery aneurysm is a man in the 7th decade of life. The strong male predominance in patients with femoral artery aneurysms is similar to that found with popliteal artery aneurysms, and it is much greater than that found in aortic aneurysms or peripheral arteriosclerotic occlusive disease. Patients with femoral aneurysms have the usual risk factors for atherosclerosis, with hypertension in 36%, cigarette smoking in 86%, and diabetes mellitus in 14%. Clinical manifestations of coronary artery disease are present in at least one third of patients, and 7% have symptoms of cerebrovascular disease. Associated aneurysmal disease is common, as mentioned earlier. Approximately 40% of patients with femoral artery aneurysms are asymptomatic at the time of diagnosis, but the majority present with local symptoms or with complaints of lower extremity ischemia. In one series, 40% of patients were asymptomatic at the time of diagnosis, 18% had only local symptoms such as pain or a mass, and 42% had symptoms of lower extremity ischemia. Ischemic symptoms, including claudication and rest pain and gangrene are not necessarily related to the femoral artery aneurysm and can result from concomitant aneurysmal or occlusive disease. Lower extremity swelling can occur as a result of local pressure on the femoral vein by the aneurysm; however, venous involvement is rarely the sole manifestation of the aneurysm. Femoral artery aneurysms can be complicated by embolization, thrombosis, or acute expansion or rupture, similar to other aneurysms, but the incidence of these events seems to be lower than with aortic or popliteal aneurysms. In the one series, 8% of patients had evidence of embolization of the peripheral artery, but the femoral artery aneurysm could not be established as the definite source owing to the presence of popliteal artery aneurysms in most of these patients. Acute thrombosis occurred in 2% of patients, and chronic thrombosis was encountered at presentation in 1% of patients. Enlargement of the femoral artery aneurysm was noted in 5% of patients, and 2% of patients experienced rupture of the femoral artery aneurysm. These findings are in sharp contrast with those reported in other series, which consist primarily of surgical cases, in which embolization, acute thrombosis, chronic thrombosis, and rupture occurred in as many as 14%, 16%, 16%, and 15% of patients, respectively, at the time of presentation. Only gold members can continue reading. 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Arteriosclerotic Femoral Artery Aneurysms Linda M. Graham and Sunita Srivastava Arteriosclerotic femoral artery aneurysms are relatively uncommon, but they are the second most commonly encountered peripheral arterial aneurysm. The exact incidence of femoral artery aneurysms in the general population has not been defined, but they are nearly as common as popliteal artery aneurysms and have been reported in 6.8% of patients with abdominal aortic aneurysms. Although limb loss is rarely attributed to complications of femoral artery aneurysms, their importance arises from their frequent association with potentially life-threatening abdominal aortic aneurysms and limb-threatening popliteal aneurysms. Pathogenesis The etiology of arteriosclerotic or degenerative femoral artery aneurysms is not clear. The multiplicity of aneurysms often found in patients with arteriosclerotic femoral artery aneurysms supports a systemic abnormality in the arterial wall or in the body’s response to injury. Arterial wall damage can occur at locations where hemodynamic or mechanical factors cause arterial wall stress, such as proximal to major branching vessels or distal to a relative stenosis at the inguinal ligament. Similar to aortic aneurysms, an inflammatory infiltrate is seen in the wall of femoral aneurysms. In addition, hereditary factors affecting collagen or elastin production or stability and arterial wall enzyme activity can contribute to aneurysm formation. None of these factors satisfactorily explains the predilection of the disease for men; femoral aneurysms, like popliteal aneurysms, are much more common in men, with a male-to-female ratio of 20:1 or greater. Pattern of Disease Aneurysms of the proximal femoral arteries almost always involve the common femoral artery with or without involvement of the superficial femoral and profunda femoris arteries. Common femoral artery aneurysms can be categorized as type 1, being femoral artery aneurysms limited to the common femoral artery, or type 2, being those with involvement of the orifice of the profunda femoris artery. Type 1 and type 2 aneurysms occur with nearly equal frequency. The anatomic differences become important when planning arterial reconstruction. Type 2 aneurysms usually require a more complex procedure to ensure continued patency of both the superficial femoral and profunda femoris arteries. Of great clinical significance is the common association of femoral artery aneurysms with life-threatening and limb-threatening aneurysms that can pose greater risk for the patient than the femoral aneurysm. In a series of 100 patients with arteriosclerotic femoral artery aneurysms seen at a single institution, aortoiliac aneurysms were detected in 85% of patients, thoracic aortic aneurysms in 6%, and popliteal aneurysms in 44%; 55% of the popliteal aneurysms were bilateral. In addition, 72% of patients had bilateral femoral artery aneurysms. Associated aortic aneurysms are more common in patients with bilateral femoral artery aneurysms. Aneurysms of the proximal superficial femoral or profunda femoris artery without an ipsilateral common femoral artery aneurysm are unusual. Aneurysms of the profunda femoris artery often manifest with rupture. Asymptomatic proximal superficial femoral or profunda femoris artery aneurysms are being recognized more often with the increasing use of imaging modalities. Similar to common femoral artery aneurysms, concomitant aortic aneurysms are common. Natural History The natural history of atherosclerotic femoral artery aneurysms has not been defined, because most series originate from a surgical service. However, in retrospective reviews including patients not undergoing surgery, it appears that the natural history of femoral artery aneurysms is more benign than that of popliteal artery aneurysms. Serious limb-threatening complications were documented in only 2.9% of 105 aneurysms managed nonoperatively and followed for an average of 28 months. Clinical Presentation The typical patient with an atherosclerotic femoral artery aneurysm is a man in the 7th decade of life. The strong male predominance in patients with femoral artery aneurysms is similar to that found with popliteal artery aneurysms, and it is much greater than that found in aortic aneurysms or peripheral arteriosclerotic occlusive disease. Patients with femoral aneurysms have the usual risk factors for atherosclerosis, with hypertension in 36%, cigarette smoking in 86%, and diabetes mellitus in 14%. Clinical manifestations of coronary artery disease are present in at least one third of patients, and 7% have symptoms of cerebrovascular disease. Associated aneurysmal disease is common, as mentioned earlier. Approximately 40% of patients with femoral artery aneurysms are asymptomatic at the time of diagnosis, but the majority present with local symptoms or with complaints of lower extremity ischemia. In one series, 40% of patients were asymptomatic at the time of diagnosis, 18% had only local symptoms such as pain or a mass, and 42% had symptoms of lower extremity ischemia. Ischemic symptoms, including claudication and rest pain and gangrene are not necessarily related to the femoral artery aneurysm and can result from concomitant aneurysmal or occlusive disease. Lower extremity swelling can occur as a result of local pressure on the femoral vein by the aneurysm; however, venous involvement is rarely the sole manifestation of the aneurysm. Femoral artery aneurysms can be complicated by embolization, thrombosis, or acute expansion or rupture, similar to other aneurysms, but the incidence of these events seems to be lower than with aortic or popliteal aneurysms. In the one series, 8% of patients had evidence of embolization of the peripheral artery, but the femoral artery aneurysm could not be established as the definite source owing to the presence of popliteal artery aneurysms in most of these patients. Acute thrombosis occurred in 2% of patients, and chronic thrombosis was encountered at presentation in 1% of patients. Enlargement of the femoral artery aneurysm was noted in 5% of patients, and 2% of patients experienced rupture of the femoral artery aneurysm. These findings are in sharp contrast with those reported in other series, which consist primarily of surgical cases, in which embolization, acute thrombosis, chronic thrombosis, and rupture occurred in as many as 14%, 16%, 16%, and 15% of patients, respectively, at the time of presentation. Only gold members can continue reading. 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