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Leg Aneurysms
by Dr Panayiotopoulos, Consultant Vascular and General Surgeon Essex.

Femoral Aneurysm

1. What is a femoral aneurysm?

An aneurysm is an abnormal dilatation [swelling] of an artery. Aneurysms are not uncommon and affect mostly men after the age of 65 years. The commonest artery to be affected is the aorta [the main artery in your stomach] followed by the popliteal and the femoral artery. The latter is the artery in your groin that conveys blood to your thigh and leg. If you have an aneurysm of one femoral artery, in 40-60% of the cases the other leg has an aneurysm as well.

If you present with an aneurysm of your aorta, then the femoral and popliteal arteries should be examined to confirm or exclude the presence of an aneurysm. The opposite is also true [scan of the aorta in the presence of popliteal or femoral aneurysm 50%].

2. What is a false femoral aneurysm?

This is an aneurysm of the artery that develops following arterial surgery in the groin or trauma or even puncture in the artery from a cardiologist or radiologist. It develops only in a small of cases. It is different from the one described previously as it represents a cavity outside the artery with blood circulating into it.

3. How is it diagnosed?

In 30% it is found incidentally during In about 60% of patients the diagnosis is made by the patient or the doctor who some investigation, while in 10% it may present acutely with symptoms.

The diagnosis is confirmed by ultrasound and then angiography [x-ray of the arteries] if surgery is contemplated.

 

4. What is the danger from a femoral aneurysm?

The main risks are:

         rupture and bleeding

         thrombosis that will occlude the lumen and

         embolisation downstream into smaller arteries in the leg or foot.

The overall risk is about 10-25%, and depends as well on the size of the aneurysm. False aneurysms are more likely to cause complications and should be corrected surgically whenever discovered. For true femoral aneurysms surgery is indicated in complications or when the diameter of the aneurysm is more than twice the diameter of the normal artery above it.

5. What is the best treatment?

Surgery is the best treatment available! However, thrombolysis via an arterial catheter may be useful in acute stages. Only rarely an endovascular procedure [stent graft insertion] performed in radiology is feasible.

Surgery should be performed:

a.   In all symptomatic femoral aneurysms

b. In all aneurysms greater than 3cm in diameter [symptomatic or asymptomatic].

c.   In all false femoral aneurysms.

6. Are there any tests needed before surgery?

In most of the cases an ultrasound and an angiogram are the only tests needed. Of course, If you are not already in the hospital you will be asked to attend a pre-admission clinic about a week before the operation in order to allow time for tests required to make sure you are fit for the operation. An x-ray of the arteries [arteriogram] to find where the blockages are may be performed if it has not already been done.

Popliteal Aneurysm

1. What is a popliteal aneurysm?

An aneurysm is an abnormal dilatation [swelling] of an artery. Aneurysms are not uncommon and affect mostly men after the age of 65 years. The commonest artery to be affected is the aorta [the main artery in your stomach] followed by the popliteal artery. The latter is the artery behind your knee that conveys blood to the leg and foot. If you have an aneurysm of one popliteal artery, in 60-70% of the cases the other leg has an aneurysm as well.

If you present with an aneurysm of your aorta, then the popliteal arteries should be examined to confirm or exclude popliteal aneurysm. The opposite is also true [scan of the aorta in the presence of popliteal aneurysm 50%].

2. How is it diagnosed?

In about 60% of patients the diagnosis is made only when symptoms appear.

In the  rest  it is found incidentally [  a pulsatile mass behind the knee]  and  the diagnosis is confirmed by Ultrasound and then angiography [x-ray of the arteries].

3. What is the danger from a popliteal aneurysm?

As about two thirds to half of the popliteal aneurysms will present with serious complications, it is necessary to diagnose them early.

The complications include;

1. Rest pain due to thrombosis [blockage] of the arteries, threatening your limb [15%]

2.  Acute ischaemia of your leg [8%]

3. Venous thrombosis and venous insufficiency due to compression of the popliteal vein [20%]

4.  Foot drop and other neurological symptoms due to nerve compression [5%]

5.  Rupture of the aneurysm [5%]

In acute symptomatic cases, despite surgery, the foot is salvaged in 60-70% only.

4. What is the best treatment?

Surgery is the only treatment available! However, throbolysis via an arterial catheter may be useful in acute stages.

Surgery should be performed:

d.  In all symptomatic popliteal aneurysms

e. In all aneurysms greater than 2cm in diameter [symptomatic or non-symptomatic].

Your Leg Aneurysm Operation

1. Coming into hospital

Please bring with you all the medications that you are currently taking. You will be admitted to your bed by one of the nurses who will also note down your personal details in your nursing records. Prior to surgery you will undergo a number of investigations, if these have not been performed previously, including a heart tracing, a chest x-ray and blood tests. You will be visited by the surgical team who will perform your operation as well as the doctor who will give you the anaesthetic. If you have any questions regarding the operation please ask the doctors. You will be started on injections of heparin which will continue throughout your stay in hospital. This stops blood clots forming in the veins of your legs.

2. The operation

a) Femoral Aneurysm

The aim is firstly, to excise the aneurysm secondly to reestablish blood flow to your leg. You will be taken into the anaesthetic room and from there to theatres. You will either be put to sleep [a general anaesthetic] or you will have a small tube placed in your back [epidural] which can make numb the lower part of your body and  helps with pain relief following surgery, by injecting pain killers through it. Sometimes you will have this as well as general anaesthetic in order to provide pain relief after surgery. Whilst you are asleep, tubes will also be inserted into your bladder to drain your urine and into a vein in your arm or neck or both for blood pressure measurements and administration of fluids following surgery.

Aneurysmorrhaphy.  Through a vertical incision in your groin the aneurysm is prepared and dissected free till normal artery is found above and below it. Blood flow is then stopped, the aneurysm is opened and is replaced by plastic tube graft.

The wounds are closed with a stitch under the skin that dissolves by itself.

b) Popliteal Aneurysm

The type of surgery varies, but the aim is, firstly, to exclude the aneurysm by tying it at both its ends and secondly to perform some type of bypass to bring blood to your leg below the aneurysm. If the aneurysm is big and compresses the vein or the nerve, it will have to be excised. The surgeon will inform you about the procedure he plans to perform before you are taken to theatres.

You will be taken into the anaesthetic room and from there to theatres. You will either be put to sleep [a general anaesthetic] or you will have a small tube placed in your back [epidural] which can make numb the lower part of your body and helps with pain relief following surgery, by injecting pain killers through it. Sometimes you will have this as well as general anaesthetic in order to provide pain relief after surgery. Whilst you are asleep, tubes will also be inserted into your bladder to drain your urine and into a vein in your arm or neck or both for blood pressure measurements and administration of fluids following surgery.

a.  Bypass using your vein. The bypass will be usually performed by using your own leg vein [donít worry, you can manage without it].

b. Aneurysmorrhaphy. In this technique the aneurysm is approached from behind your knee with an S-shaped incision.

This procedure is accompanied by less morbidity, has the advantage of excising the aneurysm [in compression symptoms] but the result is slightly worse to the bypass if we look at the time the graft runs without blocking.

The wounds are closed with a stitch under the skin that dissolves by itself.

3. After the operation

After the operation  you will be given all the fluids you require in a drip in one of your veins until you are well enough to sit up and take fluids and food  by mouth. Most patients sit out in a chair on the first day after surgery and you will be encouraged to walk the second day.

The nurses and doctors will try and keep you free of pain by giving pain killers by injection via the tube in your back or by a machine that you are able to control by pressing a button.

As the days pass and you improve the various tubes will be removed and you will become gradually more mobile until you are fit enough to go home. This is usually 7-14 days after your operation. You will be visited by the physiotherapist before and after the operation who will help you with your walking and with your breathing to prevent you developing a chest infection.

4. Going home

.  As dissolvable stitches have been used, these do not need to be removed. However, the stitch takes a long time to dissolve and if it comes to the surface it may be removed with a tweezers.

.  You will feel tired for many weeks after the operation but this should gradually improve as time goes by. Regular exercise such as short walk combined with periods of rest is recommended for the first few weeks after surgery, followed by a gradual return to your normal activity.

.  Driving: You will be safe to drive when you are able to move without pain and perform an emergency car stop.

.  Bathing: You may bathe or shower as normal, but do not soak in a bath until the wound is fully healed [i.e. no scabs as these may become soggy]

.  Work: You should be able to return to work within 1-3 months following your operation. If in doubt, please ask your doctor.

.  Medications: You will usually be sent home on a small dose of aspirin if you were not already taking it. This is to make the blood less sticky. If you are unable to tolerate aspirin an alternative drug may be prescribed. You should also continue taking your regular medications.

.   Sexual activity: You may resume sexual activity when you feel comfortable to do so.

5. Complications

. The main acute complication with this sort of surgery is embolisation downstream from debri inside the aneurysm [1-2%]. In such a case the surgeon may have to perform further surgery to re-establish blood flow to the rest of your leg.

.   Wound problems: Slight discomfort and twinges of pain in your wound is normal for several weeks following surgery, but wounds sometimes become infected and these can usually be successfully treated with antibiotics. Also the wound in your groin may fill with a fluid called lymph that may discharge between the stitches, but this usually settles down with time. If you had a long cut down your leg to harvest your leg vein, this wound may be red and swollen for 7-14 days and some fluid may ooze from it.

.  You may have patches of numbness around the wound or lower down the leg which is due to cutting small nerves to the skin. This can be permanent but usually gets better within a few months.

.  It is also common for the foot to swell due to improved blood supply. You must sit with your leg higher than your bottom until the swelling goes.

.   A late complication [5%] is blood clotting within the graft causing it to block, and if this occurs it will usually be necessary to perform another operation or a special x-ray procedure [thrombolysis] to clear the graft.

6. What is the success rate?

The success rate is excellent for non-symptomatic and symptomatic aneurysms without limb ischaemia.

As in all bypasses the results depend on the condition of the rest of your arteries.

About 95% remain open in a year and 80-90% in 3-5 years. The risk of surgery is small [2-4%] depending on your overall medical condition.

The risk of amputation is about 1%.

7. Follow-up?

Your vascular Surgeon will see you in the outpatients clinic 6 weeks after discharge. As these types of grafts do not last for ever, you will be entered into a surveillance program and a painless ultrasound scan of the graft will be performed after 3 months, then 6 months and after this at 6 or 12 monthly intervals. Thus we can detect early narrowings of the graft and proceed to angioplasty [ballooning of the narrowing in x-ray department] if there is a need to do so, extending thus graft survival.

Ultrasound performed in outpatients

to check both the operated groin and

the distal arteries in your leg.

The remaining of the arteries in your leg are also checked by the ultrasound in order to discover early narrowings [blockages] that have not yet caused you symptoms.

8. What can I do to help myself?

If you were previously a smoker you must make a sincere and determined effort to stop completely. Continued smoking will cause further damage to your arteries and your graft is more likely to stop working.

General health measures such as reducing weight, a low fat diet and regular exercise are also important.

 

       IF YOU DEVELOP ANY SEVERE PAIN IN THE LEG THE GRAFT MAY BE BLOCKED; THE SOONER YOU GET BACK TO THE HOSPITAL THE EASIER IT IS FOR IT TO BE UNBLOCKED.

       Please ring the Ward on 01245-514233 or

       The vascular lab on 01245-514145 or

       The Consultantís secretary on 01245-514095[NHS] or 01245-443379[Private]

 

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Please note:
A written referral from a general practitioner is helpful but is not essentially required in order to make an appointment to see a consultant specialist.

 

This page was last updated on 01/10/2006

Vascualr surgeon for varicose veins, renal and general surgical conditions and procedures