RUPTURE OF COMMON FEMORAL ARTERY ANEURYSM WITH CONCOMITANT ILIAC ARTERY ANEURYSMS IN POST RADIOTHERAPY PATIENT – CASE REPORT

Abstract

Femoral and popliteal aneurysms can be limb threatening because of their potential for distal embolization, acute thrombosis and rarely rupture. Aneurysms of the common femoral artery are especially rare (up to 10 times more seldom than aortic aneurysms. As spontaneous rupture of infrainguinal aneurysm is very rare, there is also a risk of such rupture after radiation therapy.
Case report: Seventy four year old female patient with history of pain and swelling of the right thigh and calf from 3 days. A hysterectomy due to cervical carcinoma with multiple chemo and radiotherapy courses was performed 3 years prior. Two computed tomography angiographies (CTAs) were performed to monitor for metastases. No relapse of the oncological disease was found, but the CTAs revealed multiple aneurysms of the iliac arteries, and one of the right common femoral artery. Clinical status: painful swelling of the right thigh with pulsatile mass in the groin, subfascial oedema of the calf. Palpable pulses on the tibial arteries. Doppler ultrasonography femoro popliteal phlebothrombosis, aneurysmal dilatation of the common femoral artery. Computer tomography angiography
aneurysm of the right common iliac artery 34mm diameter; aneurysm of the left common iliac artery 54mm diameter; aneurysm of the right common femoral artery 108mm diameter with contrast extravasation and oedema of the surrounding tissues. Compression of the right femoral vein. Operative treatment: A median laparotomy was undertaken under general anaesthesia. Aorta was clamped 2 cm proximal of its bifurcation, inferior mesenteric artery was preserved. The proximal anastomosis of the aortobifemoral bypass was constructed over the aortic bifurcation with silver knitted Dacron prosthesis 18/9mm. Tunnelling of the branches was extremely difficult due to severe adhesions of the retroperitoneum. Оperative access in the right inguinal area showed absence of arterial wall and capsule of false aneurysm. The ostial parts of superficial and deep femoral arteries were discovered in the cavity, approximately 10cm away from the most distal part of the external iliac artery. A neobifurcation was constructed and implanted to the right branch of the graft. In the left groin, a standard end to side anastomosis was constructed. The patient was discharged with therapy Edoxaban 30mg/daily and hypertension medications on the 15th postoperative day with primarily healing surgical wounds, actively mobilized with a bandage belt and elastocompression for the right leg. Bilateral foot pulses present.
Discussion: Radiation induced peripheral artery disease (RIPAD), after therapeutic irradiation of the abdomen, due to lymphoma, sarcoma or genitourinary malignancies has been reported by several studies. Clinical presentations of RIPAD in those cases vary from vase renal hypertonia, chronic claudication to acute limb ischemia. Rupture of major vessel after irradiation is uncommon, but acute complication of radiotherapy. Common femoral artery is rarely affected by spontaneous rupture after irradiation, but it has been reported several times, mostly in conditions of slowly or non healing wound, with death of haemorrhage as the most common outcome.
Conclusion: The presented clinical case demonstrates multiple vascular complications in irradiated patient, although we cannot fully associate those with the previous radiotherapy. Intraoperative challenges of tunnelling the right branch of the bypass were great, but the post radiotherapy adhesions prevented asymptomatic rupture of the common femoral artery aneurysm.