Asclepiades – SurgeryPaedeia

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Introduction

The  development  of  the  IVC  involves  fusion,  regression, and establishment of midline anastomoses  between  parts  of three paired fetal venous systems: the two posterior cardinal veins,  the  two  subcardinal,  and  two supracardinal  νeins.  The  changes  in  the  abdominal venous  systems  that  produce  the  final  IVC  cover a long period from day 25 to day 50, mainly between days 29 and 41. Depending on the embryonic origin, four parts of the IVC have been recognized:  (1)  hepatic  segment,  (2)  prerenal segment,  (3)  renal  segment  and,  (4) postrenal segment. “Absent  IVC” normally designates absence of the prerenal segment of the IVC only, with azygos continuation being the most common variety of an interrupted IVC.  “Full IVC agenesis” should cover those cases in which all four parts of the IVC and the iliac venous system  are  absent  and blood return is accomplished by one or both of the following pathways: (1) vertebrolumbar pathway (anterior external vertebral plexus, ascending lumbar veins, and azygos  and  hemiazygos  veins), and  (2)  superficial  anterior  abdominal  wall collaterals. This definition  is  exemplified  by  the present  case  and  other  ones  previously reported. “Full IVC agenesis,” an extremely rare condition, may be compatible with normal adolescence, and such a congenital abnormality has never to our knowledge caused acute abdominal symptoms.

Absence of the entire inferior vena cava caused acute abdominal symptoms, and the patient, a twenty-year-old man, was operated on on an emergency basis. Subsequent ascending venography, abdominal computed tomographic scan, intraarterial digital subtraction angiography, and intra-osseous phlebography revealed full inferior vena cava and iliac venous system agenesis, up to and above the level of the hepatic veins, venous return from the lower limbs and the abdominal viscera being through a series of multiple collateral channels and the azygos-hemiazygos system.

Keywords

Inferior vena cava, full inferior vena cava agenesis, vena cava, agenesis of IVC, full agenesis of IVC, congenital anomalies of IVC, thrombosis of IVC

Discussion

There are at present no known therapeutic measures for this very  rare  anomaly.  In pure IVC  agenesis  disclosed  accidentally (eg, by chest x-ray), those cases revealed during investigation  of  patients  with  congenital  heart abnormalities, and those in symptomatic patients, the management should be focused on the prevention of complications, such as thromboses  in  the  distal drainage channels.

On the  other  hand, knowledge  of  this  condition  is important for surgeons to avoid ligation of the azygos vein in the  course  of pulmonary  or  cardiac  operation  because  prevention of the only  major  route  of  venous drainage  from  below  the  diaphragm may  result  in death. In complicated  cases, eg, hypertension due to a hypoplastic kidney, or ureteric obstruction from constricting venous  collaterals  as  in  the  present  case,  surgery is unavoidable. When thrombosis  occurs, a  life-threatening condition  for this type of patient, vigorous anticoagulant treatment  has  to  be  instituted  promptly  that  will last until sufficient venous return has been reestablished.

In  making  the  differential  diagnosis  the  following conditions should be taken into account:

1. Pathological mediastinal lesions and other vascular anomalies, when the IVC agenesis presents  as a mediastinal abnormality on the chest radiograph, to avoid mediastinoscopy  or  thoracotomy
2. Causes  of  dilatation  of  the  azygos-hemiazygos  venous system
3. The syndrome of obstruction of IVC in childhood
4. Abdominal wall venous collaterals and varicose veins because excision of these veins would interrupt a vital venous return or at least result in intractable ulcers
5. Retroperitoneal and para-aortic space-occupying structures
6. Causes of difficulty or prevention of catheterization of the heart from the IVC
7. Other causes of acute abdominal symptoms (although it should be last in the list)
8. Causes of ureteric obstruction
9. Causes of retroperitoneal hemorrhage
10. Causes of lower back pain
11. Causes of Klippel-Trenaunay syndrome

The  prognosis  of  this  rare  congenital  anomaly  seems to be directly related to the presence of  thrombosis  in  the retroperitoneal  venous collaterals and to any coexistent congenital anomalies  (cardiac  and  vascular  defects, situs  inversus). In  “full IVC agenesis”  thrombosis  is  the major cause of mortality and morbidity (paresthesias of lower legs and lower back pain  on  exertion,  retroperitoneal  hemorrhage,  hypertension,  ureteric  obstruction,  and  emotional  distress  due  to  dilated  superficial abdominal  wall veins).  Apart from this anomaly per se,  implicating  factors  favoring  thrombosis  in  this  category  of  patients have been reported such  as  (1)  oral  contraceptives  and  cigarette  smoking;  (2) increased intraabdominal pressure (constipation,  tumors,  pregnancy),  and  (3)  dehydration,  marasmus,  sepsis,  and  exertion. Therefore,  prevention  of  thrombosis  must  be  our  mainstay  in  helping  these patients.

Δημοσίευση Άρθρου

Το πλήρες άρθρο έχει δημοσιευτεί στο: [ Vascular Surgery, Vol. 27, No 2, March 1993; pp: 155-162 ]

Αρχείο Άρθρου

Για το πλήρες άρθρο  «Full inferior vena cava agenesis …» πατήστε:  Εδώ(.pdf αρχείο).

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Abstract

Internal hernias rarely cause intestinal obstruction, the reported incidence being between 1 and 1.7 %. The most common sites of herniation are the epiploic foramen and the transverse mesocolon, and hernias through defects in the greater or lesser omentum are rare. An even rarer occurrence is the presence of two or three such hernias in the same patient.

Discussion

Internal hernias can occur in various places and they have distinctive clinical and radiological features. Among the most common types are: omental, Treizt’s, mesenteric, caecal, retrocaecal, intersigmoid, sliding, and uterine hernias. Internal hernias account for less than 2 % of the cases of obstruction caused by herniation but the incidence of asymptomatic internal hernias found at necropsy was reported to be between 0.2 % and 0.9 %. Of these only about 1-4% are omental hernias. Our case shows that the aetiology of such hernias, which has previously not been clarified, must be congenital.

Δημοσίευση Άρθρου

Το πλήρες άρθρο έχει δημοσιευθεί στο: [ Eur J Surg 1992; 158:561-562 ]

Αρχείο Άρθρου

Για το πλήρες άρθρο «Multiple congenital internal hernias…» πατήστε: Εδώ (.pdf αρχείο).

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Purpose of study

This study compared patients with iatrogenic and noniatrogenic arterial injuries.

Conclusion

Retrospective assessment of the appropriateness of technique, made separately by two vascular surgeons, revealed instances of potentially avoidable iatrogenic arterial injury. The increasing incidence of iatrogenic arterial trauma may therefore be considered reducible.

Commentary

The paper states the expected conclusions: that iatrogenic injuries increase with the incidence of invasive procedures, that such injuries are nearly always related to the catheterization site and that in them thrombosis is a more frequent complication than hemorrhage. The noniatrogenic injuries (blunt trauma, motor vehicle accident and knife and gun injuries) had a predictably higher rate of associated and postoperative complications. The 14% mortality rate reported in the iatrogenic group is nearly 4-10 fold that reported in larger reviews. These results may be biased by the relatively few cases included in this report. – Ramon Berguer; Detroit

Δημοσίευση Άρθρου

Το πλήρες άρθρο έχει δημοσιευτεί στο:  [International Vascular Surgery 1991; 1:92-93]

Αρχείο Άρθρου

Για το πλήρες άρθρο «Iatrogenic and Noniatrogenic Arterial Trauma…» πατήστε:  Εδώ (.pdf αρχείο).

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Introduction

Purpose of study

Discussion

Conclusion

Δημοσίευση του Άρθρου

Αρχείου του Άρθρου

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Introduction

“Pulsatile veins” have been observed in the neck, forearm and forehead, and less commonly in other areas of the body. Venous pulsation is exaggerated when the pressure in the pulmonary artery is highly elevated as it happens when mitral stenosis coexists with tricuspid valve regurgitation.

“Pulsatile varicose veins” may occur either in arteriovenous (AV) fistulae or in tricuspid valve insufficiency when it is combined with an incompetent valve at the sapheno-femoral junction. In the later case the wave of ventricular systole is conducted backwards along the inferior vena cava to the superficial venous system of the lower limb resulting in visible pulsation of the varicosities. The cardiac origin of the pulsatile varices necessitates differential diagnosis from an AV fistula, especially when cardiac catheterization has been performed via the ipsilateral femoral vessels. Furthermore the presence of a murmur does not exclude the cardiac component in cases of pulsating varicosities as Hollins and Engeset have reported.

We report an uncommon case of pulsatile varicose veins in a young woman caused by tricuspid valve insufficiency of rheumatic origin combined with an incompetent valve at the sapheno-femoral junction. She was treated with limited stripping of the great saphenous vein and local varicosities were excised. Postoperative recovery was complicated by a large haematoma in the thigh. Following our recent experience we believe that patients like this, with elevated venous pressure and requiring anticoagulant therapy for prosthetic valves, should be treated with sapheno-femoral dissociation alone.

Discussion

Although the clinical picture and etiology of pulsatile varicose veins have been fully described in previous reports, there is no information regarding the indications for surgical therapy, the preferable type of surgery and any possible complications thereof. Patients of this category with huge varicosities, complicated with bleeding, venous ulcer, eczema, lipodermatosclerosis, extensive hemochromatosis and ankle edema, should be offered surgical therapy. The postoperative haematoma in the thigh experienced by our patient following limited stripping of the long saphenous vein has convinced us that the therapy of choice has to be a “sapheno-femoral dissociation along with removal of local varicosities” and meticulous hemostasis only. Although limited stripping of the long saphenous vein is the treatment of choice for primary varicose veins, the elevated venous pressure in pulsatile varicosities along with the anticoagulant therapy given compulsorily to patients with prosthetic valves can cause serious postoperative haematoma in spite of preoperative discontinuation of anticoagulants and proper bandaging.

Δημοσίευση Άρθρου

Το πλήρες άρθρο έχει δημοσιευτεί στο: [ Phlebology (1990) 5; 189-191 ]

Αρχείο Άρθρου

Για το πλήρες άρθρο «Pulsatile varicose veins caused by tricuspid valve regurgitation» πατήστε:  Εδώ (.pdf αρχείο).

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Σύνοψη Άρθρου

Η συχνότητα της εκκολπωματικής νόσου της σκωληκοειδούς απόφυσης σε μια αναδρομική μελέτη 1092 σκωληκοειδεκτομών ευρέθη 1,1%. Όλες οι περιπτώσεις ταξινομήθηκαν σε 4 μορφολογικούς τύπους, με συνηθέστερο τύπο εκείνο της οξείας εκκολπωματίτιδας. Η οξεία εκκολπωματίτιδα της σκωληκοειδούς μπορεί να μιμείται κλινικά την οξεία σκωληκοειδίτιδα, εκδηλούμενη σαν μια μορφή κλινικής παραλλαγής της, εμφανιζόμενη ως επί το πλείστον μετά την 3η δεκαετία, εμφανίζοντας μακρότερο ιστορικό, λίγα γαστρεντερικά ενοχλήματα, ασυνήθη μετατόπιση του κοιλιακού πόνου και σημαντική αύξηση της συχνότητας διάτρησης της σκωληκοειδούς. Η εκκολπωματίτιδα της σκωληκοειδούς δεν είναι σπάνια νόσος και πρέπει να λαμβάνεται σοβαρά υπ’ όψη στις διαφορικές διαγνώσεις και θεραπεία των οξειών χειρουργικών παθήσεων της κοιλίας.

Abstract

«Diverticular disease of the appendix»

A retrospective study of diverticular diseases of the appendix was made in 1092 consecutive instances of appendectomies. A 1.1% incidence of diverticular disease was found.

The instances were classified into 4 morphologic types: 1, acute diverticulitis;2, acute appendicitis with acute diverticulitis; 3, acute appendicitis with diverticulum, and 4, appendix with diverticulum. The elements in each type were examined in detail. Diverticulitis of the appendix is presented as a clinically variant form of the inflamed appendix. Some followed the pattern of typical acute appendicitis. However, most were distinctive at a later age of onset, longer interval of disease, fewer or absent symptoms of the gastrointestinal tract, failure of typical abdominal pain progression, delay in surgical treatment and a remarkably high incidence of perforation. These findings of variant behavior and high incidence of perforation are cautionary features of this frequently overlooked disease.

Δημοσίευση Άρθρου

Το πλήρες άρθρο έχει δημοσιευτεί στο: [ Ιατρικά Χρονικά, Τόμος ΙΕ, Τεύχος 3, Σελ. 223-226 ]

Αρχείο Άρθρου

Για το πλήρες άρθρο «Εκκολπωματική Νόσος της Σκωληκοειδούς» πατήστε: Εδώ (.pdf αρχείο).

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Σύνοψη Άρθρου

Οι εσωτερικές κήλες συγγενούς αιτιολογίας στους ενηλίκους είναι πολύ σπάνιες, οι δε πολλαπλές εσωτερικές κήλες επίσης συγγενούς αιτιολογίας είναι εξαιρετικά σπάνιες. Παρουσιάζεται μια τριπλή εσωτερική κήλη του λεπτού εντέρου κατά την οποία το ήμισυ αυτού ευρίσκετο μεταξύ των πετάλων του μείζονος επίπλου, σημαντικό τμήμα του ήταν στον ελάσσονα επιπλοϊκό θύλακα, ενώ μια έλικα του εντέρου, μέσω χάσματος στον ηπατογαστρικό σύνδεσμο, είχε επανέλθει στην περιτοναϊκή κοιλότητα. Μόνο τέσσερεις περιπτώσεις έχουν ανακοινωθεί διεθνώς και μόνο για διπλές εσωτερικές κήλες και σε νέα άτομα, αλλά η παρούσα περίπτωση είναι μοναδική, επειδή εμφανίζεται: 1) σε ασθενή ηλικίας 60 ετών και 2) συμβάλλει αποφασιστικά στην αντίληψη της παθογένεσης και διάγνωσης αυτής της εξαιρετικά σπάνιας παθολογικής οντότητας.

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Abstract

«Triple Transomental small bowel hernias of congenital origin in the adults»

An unusual case of a triple transomental small bowel hernia causing mechanical ileus is presented. The small bowel was traversing between the two layers of the greater omentum through a defect in its posterior layer, then it was coursing the lesser omental sac via a second defect in the posterior layer of the gastrocolic ligament and finally, through a third aperture in the gastrohepatic ligament, the small intestine was re-entering the peritoneal cavity with strangulated that part protruding through the latter defect. Combined transomental hernias are extremely rare, only four additional cases have been reported, but this one is unique due to the fact that: 1) it is the only one affected a 60 year old man, 2) It is the first case of this type of hernia with a fully developed transomental hernia between the two layers of the greater omentum and 3) it contributes decisively to the understanding of the pathogenesis and diagnosis of the extremely rare clinical entity of transomental hernias.

Δημοσίευση Άρθρου

Το πλήρες άρθρο έχει δημοσιευτεί στο: [ Ιατρικά Χρονικά, Τόμος ΙΕ, Τεύχος 2, Σελ. 146-150 ]

Αρχείο ‘Αρθρου

Για το πλήρες άρθρο «Τριπλή Εσωτερική Κήλη Συγγενούς Αιτιολογίας στους Ενήλικες» πατήστε  Εδώ  (.pdf αρχείο)

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Εισαγωγή

«Σφύζουσες φλέβες» έχουν παρατηρηθεί στον τράχηλο, το άνω άκρο και στο μέτωπο και ολιγότερο συχνά σε άλλες περιοχές του σώµατος. Οι φλεβικές σφύξεις γίνονται εντονότερες όταν η πίεση στην πνευμονική αρτηρία αυξηθεί πάρα πολύ, όπως αυτό συμβαίνει όταν συνυπάρχει στένωση της μιτροειδούς βαλβίδας με ανεπάρκεια της τριγλώχινας βαλβίδας.

«Οι σφύζοντες κιρσοί της μείζονος σαφηνούς φλέβας» μπορούν να οφείλονται είτε σε αρτηριοφλεβικές επικοινωνίες είτε σε ανεπάρκεια της τριγλώχινας βαλβίδας, όταν αυτή συνδυάζεται με ανεπαρκή βαλβίδα κατά τη σαφηνομηριαία συμβολή. Στην τελευταία περίπτωση το κύμα της κοιλιακής συστολής άγεται αντίδρομα κατά μήκος της κάτω κοίλης φλέβας και του επιπολής φλεβικού συστήματος του κάτω άκρου και καταλήγει σε ορατές σφύξεις των κιρσών.

Παρουσιάζουμε μια περίπτωση σφυζόντων κιρσών σε μια νέα γυναίκα, η οποία πάσχει από ρευματική καρδιακή νόσο και η οποία αντιμετωπίστηκε με περιορισμένη εκτομή της μείζονος σαφηνούς καθώς επίσης και την εμπειρία μας από ένα μεγάλο μετεγχειρητικό αιμάτωμα στο μηρό, το οποίο δημιουργήθηκε λόγω των ειδικών συνθηκών σε αυτούς τους ασθενείς.

Συζήτηση

Μολονότι  η κλινική  εικόνα και αιτιολογία των σφυζόντων  κιρσών έχουν  πλήρως  περιγραφεί  σε  όλες  τις προηγούμενες ανακοινώσεις, εντούτοις δεν δίνεται επαρκής πληροφορία όσον αφορά τις ενδείξεις χειρουργικής θεραπείας, τον προτιμώμενο τύπο εγχείρησης και τις οποιεσδήποτε πιθανές επιπλοκές. Ασθενείς αυτής της κατηγορίας με πολύ μεγάλους κιρσούς που επιπλέκονται με αιμορραγία, φλεβικά έλκη, έκζεμα, λιποδερματοσκλήρυνση, εκτεταμένη αιμοχρωμάτωση και οίδημα στα σφυρά, πρέπει να χειρουργούνται. Η πρόσφατη εμπειρία μας με ένα μεγάλο μετεγχειρητικό αιμάτωμα στο μηρό μετά από περιορισμένη σαφηνεκτομή της μείζονος σαφηνούς μας έχει πείσει ότι η εγχείρηση εκλογής σε αυτές τις περιπτώσεις πρέπει να είναι η “σαφηνομηριαία αποσύνδεση” μόνο, με εκτομή των τοπικών κιρσών με χωριστές μικρές τομές καθώς επίσης και η επιμελής αιμόσταση. Μολονότι η “περιορισμένη σαφηνεκτομή” είναι η θεραπεία εκλογής για τους πρωτοπαθείς κιρσούς, η αυξημένη φλεβική πίεση στους σφύζοντες κιρσούς μαζί με την αντιπηκτική θεραπεία, η οποία σύντομα πρέπει να ακολουθήσει σε αυτή την κατηγορία των ασθενών με προσθετικές βαλβίδες, μπορούν να προκαλέσουν σοβαρό μετεγχειρητικό αιμάτωμα παρά τη σωστή και επαρκή ελαστική περίδεση του σκέλους.

Abstract

«Pulsatile varicose veins caused by tricuspid valve regurgitation»

Pulsatile varicose veins may occur either in arteriovenous or tricuspid valve insufficiency when it is combined with an incompetent valve at the sapheno-femoral junction. In the latter case the wave of ventricular systole is conducted backwards along the inferior vena cava to the superficial venous system of the lower limb resulting in visible pulsation of the varicosities. We report an uncommon case of pulsatile varicose veins in a young woman caused by tricuspid valve regurgitation of rheumatic origin combined with an incompetent valve at the sapheno-femoral junction. She was treated by limited stripping of the great saphenous vein along with excision of local varicosities. Postoperatively she was complicated by a large haematoma in the thigh. Following our recent experience we believe that patients of this category with elevated venous pressure and necessitating anticoagulant therapy for prosthetic valves, should be treated with sapheno-femoral dissociation only.

Δημοσίευση Άρθρου

Το πλήρες άρθρο έχει δημοσιευτεί στο: [ Ιατρικά Χρονικά, Τόμος ΙΕ, Τεύχος 4, Σελ. 319-321 ]

Αρχείο Άρθρου

Για το πλήρες άρθρο «Σφύζοντες κιρσοί» πατήστε: Εδώ (.pdf αρχείο).

Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Σύνοψη Άρθρου

Σκοπός αυτής της μελέτης είναι η ανάλυση όλων των περιπτώσεων Ανευρυσμάτων Κοιλιακής Αορτής (Α.Κ.Α) που χειρουργήθηκαν εκλεκτικά ή επειγόντως στο Αγγειοχειρουργικό Τμήμα του Νοσοκομείου μας κατά την τελευταία 10ετία με ιδιαίτερη έμφαση στους ασθενείς ηλικίας >75 ετών που χειρουργήθηκαν για Α.Κ.Α οξέως ή εκλεκτικά. Διαπιστούται στατιστικά σημαντική διαφορά στη θνητότητα μετά από εγχείρηση για ρήξη Α.Κ.Α μεταξύ υπερηλίκων (>75 ετών) και ασθενών ηλικίας (<75 ετών) που έχουν καλό προσδόκιμο επιβίωσης.

Abstract

«Surgical Treatment of Abdominal Aortic Aneurysms in the Elderly»

An increasingly growing incidence of abdominal aortic aneurysms has been observed in recent years resulting from the increase of life expectancy. Therefore aneurysmatectomy has become one of the most frequently performed operations in vascular surgery. From 1985 to 1989 seventy nine cases of abdominal aortic aneurysms were operated upon in the Department of Vascular Surgery of Athens General Hospital. 41 were elective whereas 38 were due to a ruptured abdominal aortic aneurysm. Group A (28 cases) included patients > 75 years of age (mean age = 79 years) and Group B (51 cases) comprised of patients <75 years of age (mean age = 67.3 years). There was a statistically significant difference in the mortality rate in the operated patients of groups A and B following rupture of their aneurysm whereas there was not such a difference among the patients of both groups when they had operated their aneurysm electively. Therefore elective surgery of abdominal aortic aneurysm should be undertaken in the elderly when life expectancy is anticipated to warrant the risks of the almost inevitable rupture of such an aneurysm.

Δημοσίευση Άρθρου

Το πλήρες άρθρο έχει δημοσιευτεί στο: [ Ιατρικά Χρονικά, Τόμος ΙΓ, Τεύχος 4, Σελ. 357-360 ]

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Συντάχθηκε από:

Αναστάσιος Λιάτας, MD, F.I.C.A. – Διευθυντής Χειρουργός

A C Liatas, MD, F.I.C.A. – Consultant Surgeon

Athens  General  Hospital  » EVAGELISMOS «

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Introduction

Aneurysms of the peripheral vessels are located in most cases in the popliteal arteries and are mainly atherosclerotic in nature. Popliteal artery aneurysms cause serious complications and they are the 2^nd most common ones after abdominal aortic aneurysms.

In contrast to the aneurysm of the abdominal aorta, with rupture being its main complication, the popliteal artery aneurysm causes primarily an acute or chronic ischemic syndrome. The morbidity of the popliteal artery aneurysm is high because it is mostly diagnosed and treated when complications have been established. Hence, during the first examination, Wychulis and Evans have identified evidence of a previous arterio-arterial embolism in 38% and 51% of their cases respectively and in 12% of the patients’ toes necrosis existed already.

In an effort to minimize morbidity, every attending doctor has to be proficient in both the natural course of the disease and the therapeutic alternatives in both the acute and chronic stage.

In this study, we present an analysis of our own patients with regard to the diagnosis, surgical treatment and interventional results of the acute and chronic course of atherosclerotic popliteal artery aneurysms.

Patients and methods

28 patients with 48 popliteal artery aneurysms were treated as in-patients between 1982 and 1990. We found bilateral popliteal artery aneurysms in 19 (68%) patients whereas in 10 (36%) ones popliteal artery aneurysm coexisted with aneurysm elsewhere in the body. 36 (75%) of the popliteal artery aneurysms developed complications, specifically 15 (31%) developed peripheral arterio-arterial embolism, 16 (33%) had acute arterial thrombosis, 4 (8%) presented with non treatable ischemic damage of the affected extremity, 1 (2%) had ruptured and 2 (4%) had concomitant compression-caused venous thromboses. The severe complication of acute arterial occlusion resulted in amputation in 20% of the cases. Peripheral embolisms had caused obstruction of the outflow tract with persistence of incapacitating intermittent claudication even postoperatively. Severe ischemic complications occurred in cases of small aneurysms as well. In conclusion, all popliteal artery aneurysms regardless of their size must be treated promptly in order to avoid serious complications.

Clinical picture

The characteristic clinical and the diagnostic findings were as follows:

1. In all cases of non-thrombosed aneurysms, there was a striking palpable pulsating mass in the popliteal fossa, whereas in the thrombosed aneurysms there was a palpable non-pulsating mass in the area.
2. In cases of acute ischemia of a lower extremity along with a coexisting aneurysm in the ipsilateral popliteal fossa, the cause of the ischemia was also a popliteal artery aneurysm.
3. Aneurysms on both popliteal fossae were found in 19 (68%) patients. Like Brunner, we do observed significant differences between sides.

Diagnosis

The diagnosis was completed with the x-ray examinations. The simple radiogram showed in some cases the calcified aneurysmal border. Ultrasonography and computer tomography helped in establishing the diagnosis and determine the size of the popliteal aneurysm, in addition to investigate and localize further coexistent aneurysms elsewhere in the body. Furthermore, these examinations were helpful in the differential diagnosis regarding cystic formations or tumors. Unfortunately, these diagnostic modalities do not give sufficient information about the condition of the peripheral vessels distal to the aneurysm, which are however important for the surgical planning. The arteriography was almost in every case typical for the aneurysm, except for the cases with partial or total occlusion.

Surgical Method

In 34 surgeries a medial femoropopliteal access was chosen, while a dorsal one was chosen only in one surgery. The aneurysm (if small) was eliminated through proximal and distal ligation. Collaterals, if present, were ligated as well. Big aneurysms were clamped off at the proximal and distal end, were opened lengthwise and were evacuated from the thrombotic material. In order to avoid popliteal venous injuries, only a partly resection was performed, preserving the wall section adjacent to the vein. The re-establishment of the vascular continuity was effected in 21 cases with an autologous venous transplant of the contralateral great saphenous vein. In the remaining 14 cases, we used synthetic grafts, mostly PTFE. If the trifurcation was involved in the underlying disease or in the case of occlusion of the same, the distal anastomosis was usually performed without any difficulties, due to the general vascular dilation, in the central or distal part of the arteries of the lower leg.

In all cases with acute ischemia, a generous fasciotomy was performed following the completion of vascular continuity.

Discussion

Aneurysms of the popliteal artery are the most frequent ones among all peripheral aneurysms. They are mainly of atherosclerotic in origin and only 4% of the cases have different origin, such as: Marfan syndrome, syphilis, bacterial infection, Behçet-syndrome, trauma or entrapment syndrome of the popliteal artery. The medical condition usually becomes apparent in the 5^th-7^th decade of age and afflicts mainly men in a gender ratio of 30:1.

The most frequent severe complication of popliteal aneurysms is the acute thrombotic occlusion, which often has a dramatic course.

The timely diagnosis and treatment of the acute cases is decisive for the final result. Apart from the acute arterial occlusion, the popliteal aneurysm leads also to peripheral arterioerterial embolisms which can be asymptomatic.

We did not experience any amputation in the “a froid” operated cases, but we observed a persistence of the pre-existing intermittent claudication with invalidating consequences. The frequent permanent invalidity of patients operated upon in the complication stage, calls for timely surgery of all popliteal aneurysms, regardless of their size.

This paper was presented in «Aneurysma, Forum Angiochirurgicum», Innsbruck 4 – 6 October 1990

and has been published in: [ angio archv Bd. 20 (1991); 278-281 ]

The full article is free (.pdf) : Atherosclerotic aneurysm of the popliteal artery