Delayed Rupture of a ligated Popliteal Aneurysm

In 1988, this male presented to the  emergency department with a 2 day history of (R)leg pain.He gave no history of claudication.The limb was pulseless below the groin and had all the classical signs of an acutely ischemic leg.The limb was cool to the knee,had no pedal or politeal pulse, was cadaveric , painful and had a decreased range of movement.The patient was heparinized and brought to the operating room with a tentative diagnosis of an acutely ichemic leg likely on the basis of an embolus.He had previous ECG evidence of  cardiac arrythmia.At this surgery the Fogarty catheter returned clot  but became "bent" from the memory of curling up in the popliteal area.With the return of flow an obvious aneurysm became evident.An on table angio was done and the aneurysm was identified and ligated  and a femoral popliteal bypass graft was performed.The patient subsequently developed a compartment syndrome in the immediate post- op period and was given the benefit of a fasciotomy.Despite the return of pulses the patient  developed gangrene of the distal forefoot.This was treated by guillotine transmetatarsal amputation and  skin grafting.
     The patient was  discharged and over  the next decade   had regular followup.  During this time he  had a resection of an AAA as well as repair of a popliteal aneurysm in the opposite limb.
              In 1997 the patient again presented with pain and swelling in the (R) limb and was initially felt to have a superficial phlebitis and treated  throught the emergency as such.After a week , the patient was referred for a vascular assessment..The patient did complain of pain and enlargement of  his (R) knee area.An ultrasound was done which showed the old large popliteal aneurysm but with color  flow and a possible secondary rupture entertained. Angiography was not helpful other than demonstrating flow in the venous phase A CT scan demonstrated the old aneurysm and a possible pseudoaneurysm from previous rupture.The patient now had a significant cardiac history and since he seemed to improve quickly and was asymptomatic with no threat to limb loss was treated conservatively
    One year later the patient presented with a similar presention again wth pain  and an enlarging mass.Now , however, the popliteal  graft was clearly displaced by the underlying mass which  had expanded. MRI showed the old aneurysm with the displaced graft as well as a secondary aneurysm around a femoral bony spur.The patient was brought to the  operating room and in a controlled environment  had the old aneurysm sac opened and all feeding geniculate vessels ligated .Exploration of the old sac did indeed confirm at  least one  secondary(false)aneurysm likely  from a contained leak and a repeat secondary rupture.The patient was discharged fully ambulatory and is seen on a regular basis.

B

  C

  A

(A)The limb at presentation as marked.An obvious mass,supported by excellent MRI images.The lobulated appearence above would confirm  clot of varying age in the secondary ruptured false aneurysm (B and C).Slide D confirms  both old and new activity.Slide E shows the  two  aneurysms and the displaced  graft.Slide F..the findings at surgery

   D

  F

  E